Intra-abdominal aortic balloon occlusion in the management of placenta percreta

Prophylactic Radiologic Interventions for Postpartum Hemorrhage Control in Women With Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis

OBJECTIVE

To quantify the association between prophylactic radiologic interventions and perioperative blood loss during cesarean delivery in women with placenta accreta spectrum disorder through a systematic review and network meta-analysis.

DATA SOURCES

On January 3, 2023, a literature search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Science. We also checked ClinicalTrials.gov retrospectively. Prophylactic radiologic interventions to reduce bleeding during cesarean delivery involved preoperative placement of balloon catheters, distal (internal or common iliac arteries) or proximal (abdominal aorta), or sheaths (uterine arteries). The primary outcome was volume of blood loss; secondary outcomes were the number of red blood cell units transfused and adverse events. Studies including women who received an emergency cesarean delivery were excluded.

METHODS OF STUDY SELECTION

Two authors independently screened citations for relevance, extracted data, and assessed the risk of bias of individual studies with the Cochrane Risk of Bias in Non-randomized Studies of Interventions tool.

TABULTATION, INTEGRATION, AND RESULTS

From a total of 1,332 screened studies, 50 were included in the final analysis, comprising 5,962 women. These studies consisted of two randomized controlled trials and 48 observational studies. Thirty studies compared distal balloon occlusion with a control group, with a mean difference in blood loss of -406 mL (95% CI, -645 to -167). Fourteen studies compared proximal balloon occlusion with a control group, with a mean difference of -1,041 mL (95% CI, -1,371 to -710). Sensitivity analysis excluding studies with serious or critical risk of bias provided similar results. Five studies compared uterine artery embolization with a control group, all with serious or critical risk of bias; the mean difference was -936 mL (95% CI, -1,522 to -350). Reported information on adverse events was limited.

CONCLUSION

Although the predominance of observational studies in the included literature warrants caution in interpreting the findings of this meta-analysis, our findings suggest that prophylactic placement of balloon catheters or sheaths before planned cesarean delivery in women with placenta accreta spectrum disorder may, in some cases, substantially reduce perioperative blood loss. Further study is required to quantify the efficacy according to various severities of placenta accreta spectrum disorder and the associated safety of these radiologic interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022320922.

Nomogram based on clinical characteristics and ultrasound indicators for predicting severe postpartum hemorrhage in patients with anterior placenta previa combined with previous cesarean section: a retrospective case-control study

BACKGROUND

Placental accreta spectrum disorders (PAS) are a high-risk group for severe postpartum hemorrhage (SPPH), with the incidence of PAS increasing annually. Given that cesarean section and anterior placenta previa are the primary risk factors for PAS, therefore, our study aims to investigate the predictive value of clinical characteristics and ultrasound indicators for SPPH in patients with anterior placenta previa combined with previous cesarean section, providing a theoretical basis for early prediction of SPPH.

METHODS

A total of 450 patients with anterior placenta previa combined with previous cesarean section were retrospectively analyzed at Shengjing Hospital affiliated with China Medical University between January 2018 and March 2022. Clinical data and ultrasound indicators were collected. Patients were categorized into SPPH (blood loss >2000mL, 182 cases) and non-SPPH (blood loss ≤ 2000mL, 268 cases) groups based on the blood loss within 24 h postpartum. The population was randomly divided into training and validation cohorts at a 7:3 ratio. LASSO and multifactorial logistic regression analyses were utilized to identify independent risk factors for SPPH. Accordingly, a nomogram prediction model was constructed, the predictive performance was assessed using receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA).

RESULTS

Among the 450 patients, 182 experienced SPPH (incidence rate, 40.44%). Preoperative systemic immune-inflammatory index, preoperative D-dimer level, preoperative placenta accreta spectrum ultrasound scoring system (PASUSS) score, and one-step-conservative surgery were identified as independent risk factors for SPPH in patients with anterior placenta previa combined with previous cesarean section. A nomogram was constructed based on these factors. The areas under the ROC curves for the training and validation cohorts were 0.844 (95%CI: 0.801-0.888) and 0.863 (95%CI: 0.803-0.923), respectively. Calibration curves and DCA indicated that this nomogram demonstrated good predictive accuracy.

CONCLUSIONS

This nomogram presents an effective and convenient prediction model for identifying SPPH in patients with anterior placenta previa combined with previous cesarean section. It can guide surgical planning and improve prognosis.

Efficacy and safety of prophylactic balloon occlusion in the management of placenta accreta spectrum disorder: a retrospective cohort study

OBJECTIVE

Placenta accreta spectrum disorder (PAS) is a serious obstetric complication associated with significant maternal morbidity and mortality. Prophylactic balloon occlusion (PBO), as an intravascular interventional therapies, has emerged as a potential management strategy for controlling massive hemorrhage in patients with PAS. However, current evidence about the clinical application of PBO in PAS patients are still controversial. This study aimed to evaluate the effectiveness and safety of PBO in the management of PAS.

METHODS

A retrospective cohort study including PAS patients underwent cesarean delivery was conducted in a tertiary hospital from January 2015 to March 2022. Included PAS patients were further divided into balloon and control groups by whether PBO was performed. Groups were compared for demographic characteristics, intraoperative and postoperative parameters, maternal and neonatal outcomes, PBO-related complication and follow up outcomes. Additionally, multivariate-logistic regression analysis was performed to determine the definitive associations between PBO and risk of massive hemorrhage and hysterectomy.

RESULTS

A total of 285 PAS patients met the inclusion criteria were included, of which 57 PAS patients underwent PBO (PBO group) and 228 women performed cesarean section (CS) without PBO (control group). Irrespective of the differences of baseline characteristics between the two groups, PBO intervention did not reduce the blood loss, hysterectomy rate and postoperative hospital stay, but it prolonged the operation time and increased the cost of hospitalization (All P < 0.05) Additionally, there were no significant differences in postoperative complications, neonatal outcomes, and follow-up outcomes(All P > 0.05). In particular, patients undergoing PBO were more likely to develop the venous thrombosis postoperatively (P = 0.001). However, multivariate logistic regression analysis showed that PBO significantly decreased the risk of massive hemorrhage (OR 0.289, 95%CI:0.109-0.766, P = 0.013). The grade of PAS and MRI with S2 invasion were the significant risk factors affecting massive hemorrhage(OR:6.232 and OR:5.380, P<0.001).

CONCLUSION

PBO has the potential to reduce massive hemorrhage in PAS patients undergoing CS. Obstetricians should, however, be aware of potential complications arising from the PBO. Additionally, MRI with S2 invasion and PAS grade will be useful to identify PAS patients who at high risk and may benefit from PBO. In brief, PBO seem to be a promising alternative for management of PAS, yet well-designed randomized controlled trials are needed to convincingly demonstrate its benefits and triage the necessity of PBO.

Effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III caesarean scar pregnancy: a prospective cohort study

BACKGROUND

Caesarean scar pregnancy (CSP) is a special type of ectopic pregnancy with a high risk of massive haemorrhage. Few studies have focused on the efficacy of prophylactic abdominal aortic balloon occlusion as a minimally invasive method in caesarean section. This study aimed to evaluate the effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III CSP.

METHODS

This was a prospective cohort study. Patients with type III CSP in the First Affiliated Hospital of Zhengzhou University from January 2020 to June 2022 were enrolled. Eligible patients received prophylactic abdominal aortic balloon occlusion (defined as the AABO group) or uterine artery embolization (defined as the UAE group) before laparoscopic surgery. Clinical outcomes included intraoperative blood loss, body surface radiation dose, hospitalization expenses, and time to serum β-hCG normalization, and safety were also assessed.

RESULTS

A total of 68 patients met the criteria for the study, of whom 34 patients were in the AABO group and 34 patients were in the UAE group. The median intraoperative blood loss in the AABO and UAE groups was 17.5 (interquartile ranges [IQR]: 10, 45) and 10 (IQR: 6.25, 20) mL, respectively (P = 0.264). The body surface radiation dose of the AABO group was much lower than that of the UAE group (5.22 ± 0.44 vs. 1441.85 ± 11.59 mGy, P < 0.001). The AABO group also had lower hospitalization expenses than the UAE group (2.42 ± 0.51 vs. 3.42 ± 0.85 *10^5 yuan, P < 0.001). The average time to serum β-hCG normalization in the AABO group was 28.9 ± 3.21 d, which was similar to that in the UAE group (30.3 ± 3.72 d, P = 0.099). In addition, the incidence of adverse events in the AABO group was lower than that in the UAE group (5.9% vs. 58.8%, P < 0.001).

CONCLUSION

Prophylactic AABO was equally as effective as UAE in patients with type III CSP but was safer than UAE during and after the operation.

Novel concepts and improvisation for treating postpartum haemorrhage: a narrative review of emerging techniques

BACKGROUND

Most treatments for postpartum haemorrhage (PPH) lack evidence of effectiveness. New innovations are ubiquitous but have not been synthesized for ready access.

NARRATIVE REVIEW

Pubmed 2020 to 2021 was searched on 'postpartum haemorrhage treatment', and novel reports among 755 citations were catalogued. New health care strategies included early diagnosis with a bundled first response and home-based treatment of PPH. A calibrated postpartum blood monitoring tray has been described. Oxytocin is more effective than misoprostol; addition of misoprostol to oxytocin does not improve treatment. Heat stable carbetocin has not been assessed for treatment. A thermostable microneedle oxytocin patch has been developed. Intravenous tranexamic acid reduces mortality but deaths have been reported from inadvertent intrathecal injection. New transvaginal uterine artery clamps have been described. Novel approaches to uterine balloon tamponade include improvised and purpose-designed free-flow (as opposed to fixed volume) devices and vaginal balloon tamponade. Uterine suction tamponade methods include purpose-designed and improvised devices. Restrictive fluid resuscitation, massive transfusion protocols, fibrinogen use, early cryopreciptate transfusion and point-of-care viscoelastic haemostatic assay-guided blood product transfusion have been reported. Pelvic artery embolization and endovascular balloon occlusion of the aorta and pelvic arteries are used where available. External aortic compression and direct compression of the aorta during laparotomy or aortic clamping (such as with the Paily clamp) are alternatives. Transvaginal haemostatic ligation and compression sutures, placental site sutures and a variety of novel compression sutures have been reported. These include Esike's technique, three vertical compression sutures, vertical plus horizontal compression sutures, parallel loop binding compression sutures, uterine isthmus vertical compression sutures, isthmic circumferential suture, circumferential compression sutures with intrauterine balloon, King's combined uterine suture and removable retropubic uterine compression suture. Innovative measures for placenta accreta spectrum include a lower uterine folding suture, a modified cervical inversion technique, bilateral uterine artery ligation with myometrial excision of the adherent placenta and cervico-isthmic sutures or a T-shaped lower segment repair. Technological advances include cell salvage, high frequency focussed ultrasound for placenta increta and extra-corporeal membrane oxygenation.

CONCLUSIONS

Knowledge of innovative methods can equip clinicians with last-resort options when faced with haemorrhage unresponsive to conventional methods.

Ultrasound-guided prophylactic abdominal aortic balloon occlusion for placenta accreta spectrum disorder: A case series

Placenta accreta spectrum (PAS) disorder is one of the most dangerous conditions that can affect pregnancy and its incidence is increasing secondary to rising cesarean section rates worldwide. The standard treatment is frequently elective hysterectomy at the time of cesarean delivery; however, uterine and fertility preserving surgery is becoming more common. In the pursuit of a reduction in blood loss and associated maternal morbidity, occlusive vascular balloons are increasingly used at the time of surgery, usually placed with fluoroscopic guidance. Occlusive balloons placed in the infrarenal aorta have been shown in the literature to be superior in terms of blood loss and hysterectomy rates than those placed more distally, such as within iliac or uterine arteries. We present the first five cases performed in Europe of ultrasound-guided infrarenal aortic balloon placement before cesarean for PAS disorder, and describe the technique we used, which provided reduced blood loss, a clearer operating field and avoided fetal and maternal exposure to radiation and intravenous contrast.