Intermittent aortic balloon occlusion combined with cesarean section for the treatment of patients with placenta previa complicated by placenta accreta: A retrospective study

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.

Timing of intra-abdominal aortic balloon occlusion for prevention of hemorrhage in patients with placenta previa and placenta accreta spectrum

OBJECTIVE

Placenta accreta spectrum (PAS) has been linked to severe negative maternal-fetal pregnancy outcomes, including a high risk of maternal death. The goal of this study was to determine whether an abdominal aortic balloon block performed before fetal birth lowered intraoperative bleeding and the risk of severe bleeding, as opposed to a block performed after fetal birth.

METHODS

In this retrospective cohort study, patients who underwent pre-delivery or post-delivery inflation were compared for intraoperative hemorrhage, transfusion rate, hysterectomy rate, intensive care unit (ICU) hospitalization, and newborn indices. To ensure the robustness of our findings, we applied multivariate logistic regression, propensity score analysis, and an inverse probability-weighting model.

RESULTS

This study included 168 patients who underwent balloon occlusion (62 pre-delivery, 106 post-delivery). The overall probability of major bleeding was 56.5% (95/168), and the pre-delivery and post-delivery probabilities for major bleeding were 64.5% (40/62) and 51.9% (55/106) (P = 0.112), respectively. In the multivariable-adjusted model, post-delivery inflation was associated with a 33% numerically higher probability of massive bleeding (odds ratio 1.33, 95% confidence interval 0.54-3.25, P = 0.535). However, the difference was not statistically significant.

CONCLUSION

According to our findings, pre-delivery inflation did not significantly reduce the risk or amount of severe bleeding.

Current state of interventional procedures to treat pernicious placenta previa accompanied by placenta accreta spectrum: A review

Pernicious placenta previa (PPP) accompanied by placenta accreta spectrum (PAS) is a life-threatening placental implantation that causes a variety of complications, including antepartum hemorrhage, postpartum hemorrhage, hemorrhagic shock, preterm birth, and neonatal asphyxia. Along with continuous improvements in medical technology, interventional procedures have been widely used to prevent intraoperative hemorrhage associated with PPP. The commonly used interventional procedures include abdominal aorta clamping, prophylactic balloon occlusion of the internal or common iliac arteries, and uterine artery embolization. The above-mentioned interventional procedures have their respective advantages and disadvantages. The best procedure for different situations continues to be debated considering the complex pattern of blood supply to the uterus in patients with PPP. The specific choice of interventional procedure depends on the clinical situation of the patient with PPP. For grade III PAS, the need for uterine artery embolization is assessed based on blood loss and preoperative hemostatic effect following abdominal aorta clamping. Repair or hysterectomy may be performed following uterine artery embolization if there is a hybrid operating room for grade III PAS patients with extensive sub-serosal penetration of the uterus and repair difficulty. For grade II PAS (shallow placental implantation), prophylactic balloon occlusion may not be necessary before surgery. Uterine artery embolization can be performed in case of postoperative hemorrhage.

Use of an aortic balloon to achieve uterine conservation in a case of placenta accreta spectrum: A case report

Placenta accreta spectrum (PAS) is a rare complication of pregnancy associated with a high risk of massive haemorrhage and caesarean hysterectomy. This is a case report of abdominal aortic balloon occlusion, using intravascular ultrasound, to achieve uterine conservation in a case of severe PAS. The patient was a 34-year-old woman, G2P1, with one prior caesarean section. Antenatal imaging, consisting of transabdominal and transvaginal ultrasound, and magnetic resonance imaging, showed features of PAS. The risk of caesarean hysterectomy with PAS was explained, but the patient declared a desire to retain fertility. Following multi-disciplinary discussion, it was considered appropriate to attempt uterine conservation using en-bloc myometrial and placental resection. An elective caesarean delivery was performed at 36 weeks of gestation. An aortic balloon was inserted prior to surgery using intravascular ultrasound, which allowed for radiation-free, point-of-surgery, accurate balloon sizing, by measuring the aortic diameter, and correct placement of the balloon in the abdominal aorta below the renal vessels. Intraoperative findings confirmed PAS, and a myometrial resection was performed. There were no intraoperative complications. Estimated blood loss was 1000 mL and the patient had an uncomplicated postoperative course. This case demonstrates how the use of an intravascular intraoperative aortic balloon can facilitate uterine conservation in a case of severe PAS.

Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.

Spiral Suture of the Lower Uterine Segment with Temporary Aortic Balloon Occlusion in Morbidly Adherent Placenta Previa Cases

Purpose

We aimed to investigate the combined effect of spiral suture of the lower uterine segment with intraoperative aortic balloon occlusion in morbidly adherent placenta previa cases.

Patient and Methods

This retrospective, single-center study involved patients from 2017 to 2020. The study considered 68 cases of morbidly adherent placenta previa cases from medical records retrospectively with age ranging from 23 to 42 years. Bilateral uterine artery embolization was performed, to control excessive bleeding. Perioperative blood loss, hysterectomy rate, amount of blood transfusion, balloon occlusion time, fetal and maternal radiation dose, and postpartum complications were assessed.

Results

A total of 68 patients underwent surgery. Hysterectomy was performed in three patients and uterine artery embolization in 21 patients. Of 53 patients who required blood transfusions, the amount of packed red blood cells given was 800 mL and the amount of plasma given was 400 mL. Median abdominal aortic balloon occlusion time was 17 minutes. Fetal and maternal radiation doses were 5 mGy and 12 mGy, respectively. One patient experienced surgery-related complications, a bladder injury. No major catheterization-related and postpartum complications were observed.

Conclusion

Fertility-sparing surgery for women with morbidly adherent placenta could include abdominal aortic balloon occlusion and spiral suture of lower uterine segment.

Application of Abdominal Aortic Balloon Occlusion Combined with Tourniquet in Pregnant Women with Severe Placenta Accreta Spectrum

OBJECTIVE

Abdominal aortic balloon occlusion (AABO) is a vascular intervention method that has been widely used in the treatment of severe placenta accreta spectrum (PAS). The aim of this study was to investigate the benefits, potential risks, and characteristics of AABO combined with tourniquet binding of the lower uterine segment (LUS) in treatment of pregnant women with PAS.

METHODS

In this study, 64 pregnant women with PAS scores greater than 5 were enrolled as research subjects and divided into two groups. Group A (n=34) underwent normal operative procedures including tourniquet binding of the LUS. Group B (n=30) underwent AABO combined with tourniquet binding of the LUS. General clinical characteristics, ultrasonography PAS score, intraoperative blood loss (IBL), blood loss within 24 h after surgery (24-h BL), postoperative complications, and neonatal data of the two groups were retrospectively reviewed. The influencing factors of IBL for the two groups were analyzed.

RESULTS

The amounts of IBL, 24-h BL, total input red blood cell, and the incidence of disseminated intravascular coagulation were significantly lower in group B than in group A (P<0.05), and this difference was even more significant in the subgroup of placenta percreta (PAS scores ≥10). Further multivariate linear analysis showed that the combined therapy of AABO and tourniquet could independently predict lower IBL than normal operative procedures did (P=0.001).

CONCLUSION

AABO combined with tourniquet binding of the LUS could improve the outcomes of pregnant women with severe PAS and reduce serious peripartum complications of AABO.

The effect of prophylactic balloon occlusion in patients with placenta accreta spectrum: a Bayesian network meta-analysis

OBJECTIVES

Placenta accreta spectrum (PAS) can induce severe life-threatening obstetric hemorrhage. Herein, we conducted a Bayesian network meta-analysis of previous studies to evaluate the relative benefits of different prophylactic balloon occlusion (PBO) procedures.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to July 2021. Blood loss volume, blood transfusion volume, and hysterectomy rate were regarded as the primary endpoints. The data were pooled using a Bayesian network and traditional pairwise meta-analysis.

RESULTS

Fifty-nine articles with a total sample size of 5150 patients were included. Compared with no PBO (non-PBO) intervention, PBO of the abdominal aorta (PBOAA, mean difference(MD) - 1.02, 95% credible interval (CrI) - 1.4 to - 0.67), common iliac artery (PBOCIA, MD - 0.84; 95%CrI - 1.36 to - 0.06) and internal iliac artery (PBOIIA, MD - 0.42; 95%CrI - 0.72 to - 0.13) significantly lowered blood loss volume, with PBOAA being more effective than PBOIIA (MD - 0.60; 95%CrI - 1.05 to - 0.17). PBOAA and PBOIIA also significantly decreased blood loss volume (MD - 2.33; 95%CrI - 3.74 to - 0.94, MD - 1.57; 95%CrI - 2.77 to - 0.47 respectively) and hysterectomy rate (OR 0.31; 95%CrI 0.16 to 0.54, OR 0.53; 95%CrI 0.29 to 0.92 respectively). PBOAA has the highest probability of being more effective in reducing the blood loss volume, blood transfusion volume, and hysterectomy rate.

CONCLUSIONS

Performing PBOAA, PBOCIA, or PBOIIA in PAS patients is an effective way to minimize blood loss volume, while PBOAA and PBOIIA also reduce blood transfusion volume and hysterectomy rate. PBOAA is a notably more effective strategy to reduce blood loss volume than PBOIIA.

KEY POINTS

• PBOAA, PBOCIA, and PBOIIA procedures can significantly reduce the blood loss volume compared to non-PBO intervention in PAS patients, of which PBOAA was more effective than the PBOIIA procedure. • PBOAA and PBOIIA could significantly reduce the blood transfusion volume and hysterectomy rate in contrast to the non-PBO intervention in patients with PAS. • According to our statistical treatment ranking, PBOAA was statistically superior in reducing blood transfusion volume, blood transfusion volume, and hysterectomy rate than other PBO procedures.

Comparison of the safety and efficacy of PABO above or below the ovarian artery during cesarean delivery in patients with coexisting placenta accreta and placenta previa

Purpose

To determine the effect of ovarian arteries on the use of prophylactic abdominal aortic balloon occlusion (PABO) in patients with coexisting placenta accreta and placenta previa.

Methods

Thirty-two pregnant women with coexisting placenta accreta and placenta previa treated with PABO in our hospital during 2013-2020 were retrospectively analyzed. The patients were divided into two groups: one with infra-renal abdominal aortic balloon occlusion above the ovarian artery (Group A, n = 15) and the other with occlusion below the ovarian artery (Group B, n = 17). Medical records and relevant imaging of all patients were reviewed. All Cesarean deliveries were scheduled and we decided to perform hysterectomy based on the surgical findings.

Results

Patients in both groups were similar in terms of age, gravidity history, and status of placenta. Regarding their outcomes, estimated blood loss was not significantly different in both groups, although it was lower in Group B than in Group A (3949.5 vs. 4333.8 ml). The other tested parameters did not show any difference. The uterus was preserved in 13 (41%) patients. No access-related or balloon occlusion-related complications occurred in either group.

Conclusions

PABO was safe. However, the balloon location (above or below the ovarian arteries) did not influence the outcomes. Further evaluation and prospective studies are required to evaluate the safety and efficacy of balloon occlusion above or below the ovarian artery in patients with coexisting placenta accreta and placenta previa.

High-intensity focused ultrasound in management of placenta accreta spectrum: A systematic review

BACKGROUND

High-intensity focused ultrasound (HIFU) is a non-invasive procedure that has been studied in the management of placenta accreta spectrum (PAS).

OBJECTIVE

To appraise HIFU in the management of PAS and highlight the restrictions on converting uterus-preserving studies into evidence-based practice.

SEARCH STRATEGY

A search on Scopus, Cochrane, PubMed and Web of Science was conducted from date of inception to January 2020.

SELECTION CRITERIA

Studies on using HIFU in the management of PAS were eligible. Review articles, conference papers, and case reports were excluded.

DATA COLLECTION

A standardized sheet was used to abstract data from eligible studies. CON-PAS registry was used to include studies on other conservative modalities.

RESULTS

Four studies were eligible (399 patients). Average residual placental volume was 61.74 cm³ (6.01-339 cm³ ). Treatment was successful in all patients. Normal menstruation recovered after 48.8 days (15-150 days). No major complications were encountered. Sixty-one studies were retrieved from the CON-PAS registry; uterine artery embolization (23 studies), balloon placement (15 studies), compression sutures (10 studies), placenta in situ (7 studies), and uterine resection (6 studies) were successful in 83.7%, 92.9%, 87.9%, 85.2%, and 79.3% of cases, respectively.

CONCLUSIONS

HIFU may fit certain clinical situations in the management of PAS. A global research strategy is recommended to incorporate conservative approaches within a comprehensive management protocol.

Interventional radiology for the obstetric patient

PURPOSE OF REVIEW

To discuss the recent results of the use of interventional radiology modalities treating postpartum hemorrhage (PPH).

RECENT FINDINGS

PPH still is a leading cause of maternal morbidity and mortality. An important risk factor for the development of PPH is the placenta accreta spectrum. In patients with placenta accreta, we can use prophylactic balloon occlusion of the common or internal iliac artery or abdominal aorta to prevent PPH. Balloon occlusion of the abdominal aorta seems to ensure better results than balloon occlusion of the iliac artery in terms of blood loss, transfusion rate and hysterectomy rate reduction with a minimal risk of complications. To treat PPH uterine artery embolization can be effective and potentially fertility-sparing, while having a low complication rate.

SUMMARY

The use of aortic balloon occlusion catheters for the prevention of PPH and uterine artery embolization for the treatment of PPH are well tolerated and feasible options for patients with placenta accreta spectrum.

The application of prophylactic balloon occlusion of the internal iliac artery for the treatment of placenta accreta spectrum with placenta previa: a retrospective case-control study

Background

Severe obstetric haemorrhage caused by placenta accreta spectrum (PAS) results in significant maternal morbidity and mortality. The effectiveness of prophylactic balloon occlusion of the internal iliac artery in PAS patients remains controversial. Therefore, we conducted a retrospective case-control study to investigate the clinical effectiveness of this treatment.

Methods

The clinical data of 104 patients with PAS complicated with placenta previa who delivered by caesarean section between January 2016 and January 2019 were collected, and the patients were divided into two groups. The study group (48 cases) underwent internal iliac artery preset balloon occlusion before caesarean section and uterine artery embolisation according to the bleeding status after surgery, while the control group (56 cases) did not undergo internal iliac artery preset balloon occlusion before caesarean section.

Results

The operation and hospitalisation times in the study group were longer than those in the control group. Additionally, the hysterectomy rate in the study group was significantly higher than that in the control group. No significant differences in blood loss, blood transfusion volume, urinary system injury, postoperative ICU transfer rate, or neonatal scores were identified between the groups. Among the patients without invasive placenta (placenta increta and percreta), blood loss was lower in the study group, and the caesarean hysterectomy rate did not significantly differ between the groups. Among the patients with invasive placenta, blood loss and the caesarean hysterectomy rate did not significantly differ between the groups. The risk of hysterectomy in the study group was related to invasive placenta penetration, a large area of placental invasion, or abnormal vascular filling. One patient in the study group had a thrombus in the left lower extremity artery.

Conclusions

Balloon occlusion of the internal iliac artery is effective for haemostasis of placenta previa in the absence of invasive placenta. For patients with invasive placenta, especially placenta percreta, a large area of placental invasion or abnormal vascular filling suggests the need for hysterectomy. The risks of the prophylactic use of internal iliac artery balloon occlusion include vascular injury and thrombus formation.

Uterine arteries prophylactic occlusion balloon placement in pregnancies with placenta praevia

INTRODUCTION

To evaluate the feasibility of uterine arteries prophylactic occlusion balloon placement (POBP) to reduce hemorrhagic complications associated with placenta praevia.

MATERIAL AND METHODS

A retrospective analysis was carried out from January 2014 to November 2018. Only women with a diagnosis of placenta praevia and gestational age at delivery between 33 and 40 weeks were included. All women were diagnosed using transvaginal ultrasound scan (TVS) and confirmed with magnetic resonance imaging (MRI). All women underwent uterine arteries POBP before caesarean delivery (CD). All patients underwent clinical and instrumental follow-up with semestral outpatient TVS for 2 years after the surgery.

RESULTS

Forty-eight pregnant women were recruited and analyzed. 32/48 patients (66%) had positive anamnesis for previous CDs. Mean blood loss was 510 ± 222 mL. 15/48 patients (31.6%) were supported with RBC concentrate transfusion. In 10 (20.8%) cases, an intrauterine haemostatic balloon (Bakri-Balloon, Cook Medical, Spencer, USA) was used to control the intra-operative hemorrhage. Hysterectomy was performed in eight cases (16.6%). No cases of hemodynamic instability or urinary complications were reported. No postoperative complications occurred. During follow-up, no long-term complications were observed and nine patients had a successful pregnancy.

CONCLUSIONS

Uterine arteries POPB is a promising technique that may be adopted in women with placenta praevia to prevent hemorrhagic complications.

Epidural analgesia for the treatment of colic attack with retrocaval ureter in late pregnancy complicated with marginal placenta previa: a case report

Background

Retrocaval ureter was diagnosed in a woman complaining of ureteric pain in the last trimester of pregnancy. We describe the rationale behind the administration of epidural analgesia for her colic attack.

Case presentation

A 41-year-old pregnant woman was hospitalized with a diagnosis of a marginal placenta previa at 34 weeks and 5 days of pregnancy. Her right ureter encircled the dorsal aspect of the inferior vena cava (IVC) and was compressed by a growing fetus, causing hydronephrosis. Her right lower back pain was exacerbated every day, till an epidural catheter was inserted. Her estimated glomerular filtration rate (eGFR) and hematocrit worsened, and an elective cesarean section was performed.

Conclusion

Epidural analgesia only provided pain relief for a few days. When a pregnant woman presents with a retrocaval ureter and severe pain, short-term epidural analgesia should be considered after evaluating the complex medical condition and size of the fetus.

Clinical analysis of uterine artery embolization combined with double balloon catheter plus curettage for patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester: Three case reports

RATIONALE

It is very difficult to treat patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester.

PATIENT CONCERNS

In this study, case 1 was with fetal malformation of 18-trisomy syndrome at gestation of 19 weeks + 2 days, case 2 was with fetal malformation of 18-trisomy syndrome at gestation of 22 weeks + 1 day, and case 3 was for intrauterine fetal death at gestation of 27 weeks. All the 3 cases were completely placenta previa.

DIAGNOSES

For the 3 patients, completely placenta previa was confirmed by ultrasound examination after hospitalization and underwent pregnancy termination for fetal death or fetal malformation in the 2nd trimester.

INTERVENTIONS

The 3 patients with placenta previa underwent pregnancy termination by mifepristone combined with ethacridine lactate in the 2nd trimester for intrauterine fetal death or fetal malformation from June 2017 to May 2018, and suffered antenatal massive hemorrhage during termination. Uterine artery embolization (UAE) was immediately performed to achieve hemostasis, then double balloon catheter (DBC) was carried out to promote cervical ripen, at last curettage was implemented with the help of ultrasound. After all these procedures, the clinical outcomes were observed.

OUTCOMES

The antenatal bleeding volume of these 3 patients were about 500, 600, and 550 mL. After implementing the combined treatment, all patients completed the abortion. The UAE-DBC time interval and DBC-curettage time interval were 58.4 and 6.0 hours, respectively, for case 1, whereas almost 0 (i.e., immediately) for cases 2 and 3. Case 1 had a fever lasting for 3 days, and the maximum body temperature was up to 39°C after UAE. Moreover, the blood culture was positive for Escherichia coli after curettage in case 1, whereas it was negative in the other 2 cases.

LESSONS

The UAE-DBC-curettage combined treatment is safe and effective for patients with placenta previa who undergo pregnancy termination and suffered massive antenatal hemorrhage in the 2nd trimester. Future studies are needed to advance our observation.