Risk factors for massive bleeding based on angiographic findings in patients with placenta previa and accreta who underwent balloon occlusion of the internal iliac artery during cesarean section

Application of Uterine Artery Embolization in Patients With Placenta Accreta Spectrum After Abdominal Aortic Balloon Occlusion

OBJECTIVE

To evaluate the application of different uterine artery embolization procedures under balloon occlusion of the abdominal aorta in patients with Placenta Accreta Spectrum (PAS) undergoing cesarean section.

MATERIALS AND METHODS

A retrospective analysis was performed on clinical data from 72 patients who underwent uterine artery embolization for hemostasis during cesarean section with PAS. The patients were divided into two groups according to the embolization method used during surgery: group A (n = 43) underwent uterine artery embolization by withdrawing the balloon and inserting a Cobra catheter into the uterine artery for embolization, while group B (n = 29) underwent uterine artery embolization with a Cobra catheter inserted via contralateral puncture of the femoral artery and balloon occlusion. General information, surgical data, and postoperative recovery were compared between the 2 groups.

RESULTS

The bleeding and transfusion volumes were lower in group B than in group A and the differences between the 2 groups were statistically significant. There were no significant differences in surgical duration, number of embolized vessels, length of hospital stay, postoperative complications, or menstrual recovery between the 2 groups.

CONCLUSION

For patients with PAS undergoing cesarean section, uterine artery embolization for hemostasis is preferably performed by inserting a Cobra catheter via contralateral puncture of the femoral artery under abdominal aortic balloon occlusion.

Collateral Round Ligament Arterial Supply of Placenta Accreta Spectrum and Considerations for Prophylactic Balloon Occlusion Catheter Placement

Internal iliac artery (IIA) balloon occlusion catheters have been commonly inserted to decrease the risk of postpartum hemorrhage in placenta accreta spectrum disorders; however, there has been mixed success in clinical studies. Placement of an infrarenal aortic balloon has shown more consistent effectiveness in recent studies. A possible reason for this is collateral arterial supply to the placenta from external iliac artery branches. Retrospective chart review was conducted of angiography images during prophylactic IIA balloon occlusion catheter insertion over a 7-year period. Sixty-two individual cases were identified. Digital subtraction angiography (DSA) was performed in 32 (52%) cases, and 20 (62%) showed collateral blood supply from branches of the external iliac arteries, namely the round ligament artery. In conclusion, a high proportion of placenta accreta spectrum cases have arterial blood supply from branches of the external iliac artery, which may explain the discrepancy in effectiveness seen between IIA and infrarenal aortic sites of balloon occlusion catheter placement.

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.

MRI-Based Risk Factors for Adverse Maternal Outcomes in Prophylactic Aortic Balloon Occlusion for Placenta Accreta Spectrum and Placenta Previa

PURPOSE

We previously reported that T2 dark bands and placental bulges observed in magnetic resonance imaging (MRI) can predict adverse maternal outcomes in patients with placenta accreta spectrum (PAS) and placenta previa undergoing prophylactic balloon occlusion of the internal iliac artery. On the other hand, the risk factors associated with the use of prophylactic aortic balloon occlusion (PABO) have not been sufficiently investigated. This retrospective study aimed to identify MRI-based risk factors associated with adverse maternal outcomes in the context of PABO during a cesarean section (CS) for PAS and placenta previa.

MATERIALS AND METHODS

Ethical approval was obtained for a data analysis of 40 patients diagnosed with PAS and placenta previa undergoing PABO during a CS. Clinical records, MRI features, and procedural details were examined. The inclusion criteria for the massive bleeding group were as follows: an estimated blood loss (EBL) > 2500 mL, packed red blood cell (pRBC) transfusion (>4 units), and the need for a hysterectomy or transcatheter arterial embolization after delivery. The massive and nonmassive bleeding groups were compared.

RESULTS

Among the 22 patients, those in the massive bleeding group showed significantly longer operative durations, a higher EBL (p < 0.001), an increased number of pRBC transfusions (p < 0.001), and prolonged postoperative hospital stays (p < 0.05). T2 dark bands on MRI were significant predictors of adverse outcomes (p < 0.05).

CONCLUSION

T2 dark bands on MRI were crucial predictors of adverse maternal outcomes in patients undergoing PABO for PAS or placenta previa during a CS. Recognizing these MRI features proactively indicates the need for effective management strategies during childbirth and emphasizes the importance of further prospective studies to validate and enhance these findings.

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.

Complex Blood Supply Patterns in Cesarean Scar Pregnancy: Insights from Digital Subtraction Angiography Imaging

BACKGROUND Understanding the blood supply pattern of cesarean scar pregnancy (CSP) can effectively help to determine the best choice of treatment. The aim of this study was to investigate the blood supply pattern and outcomes of patients with CSP through digital subtraction angiography (DSA) imaging. MATERIAL AND METHODS This was a retrospective cohort study. Patients were divided into 2 groups according to the type of CSP. The DSA images of these patients were reviewed, including the type of blood supply, dominant vessel, and collateral blood supply to the gestational sac. The clinical outcomes were analyzed between the 2 groups. RESULTS Thirty-seven patients with type I and 29 patients with type II CSP were enrolled in this study. Type II CSP showed a higher proportion of rich blood supply than type I (44.83% vs 29.72%, P>0.05). Compared with type II CSP, type I CSP tended to have bilateral dominant blood supply predominance (67.57% vs 41.38%, P<0.05). The incidence of collateral blood supply was 5.41% in the type I CSP group and 31.03% in the type II CSP group (P<0.05). In the type II CSP group, multiple collateral blood vessels were found in 4 patients. The superior vesicle artery was the most common source of collateral blood supply in both groups. Two patients with type II CSP suffered massive bleeding during surgery after uterine artery embolization (UAE). None of the patients received a hysterectomy. CONCLUSIONS UAE is safe and effective for both types of CSP. The blood supply pattern is more complex and abnormal in type II CSP. More attention should be paid to the collateral blood supply to achieve complete embolization during the UAE procedure in the case of type II CSP.

Risk factors of MRI findings for predicting patient outcomes of placenta accreta spectrum and placenta previa after prophylactic balloon occlusion of the internal iliac artery

PURPOSE

Our study aimed to identify the risk factors of magnetic resonance imaging (MRI) findings for predicting patient outcomes of placenta accreta spectrum (PAS) and placenta previa after prophylactic balloon occlusion of the internal iliac artery (PBOIIA).

MATERIALS AND METHODS

This retrospective analysis was performed using the clinical records of 46 patients diagnosed with PAS and placenta previa who underwent PBOIIA during caesarean section (CS). The possible clinical risk factors for adverse maternal outcomes were evaluated by consulting patients' clinical records. The inclusion criteria for the massive bleeding group were as follows: estimated blood loss (EBL) > 2500 mL, packed red blood cell (pRBC) transfusion (>4 units), and need for hysterectomy or transcatheter arterial embolization after delivery. The MRI features were compared between the massive and non-massive bleeding groups.

RESULTS

Patients in the massive bleeding group (n = 22) had a significantly longer operation time (p < 0.001), more EBL (p < 0.001), more pRBC transfusions (p < 0.001), and a prolonged postoperative hospital stay (p < 0.05). MRI features showed a T2 dark bands, placenta bulge, and abnormal blood vessels in the placental bed more frequently in the massive bleeding group (p < 0.05). In the multiple logistic regression analysis, T2 dark bands (odds ratio 9.1, p = 0.048) and placental bulge (odds ratio 5.1, p = 0.014) remained statistically significant.

CONCLUSION

T2 dark bands and placental bulges observed on an MRI can predict adverse maternal outcomes in patients with PAS and placenta previa undergoing PBOIIA. If these findings are observed on a preoperative MRI, effective management strategies should be prepared for the possibility of massive hemorrhage during CS.

Red Blood Cell Transfusion in Patients With Placenta Accreta Spectrum: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate red blood cell use during delivery in patients with placenta accreta spectrum.

DATA SOURCES

We searched MEDLINE, EMBASE, CINAHL, Cochrane Central, ClinicalTrials.gov, and Scopus for clinical trials and observational studies published between 2000 and 2021 in countries with developed economies.

METHODS OF STUDY SELECTION

Abstracts (n=4,275) and full-text studies (n=599) were identified and reviewed by two independent reviewers. Data on transfused red blood cells were included from studies reporting means and SDs, medians with interquartile ranges, or individual patient data. The primary outcome was the weighted mean number of units of red blood cells transfused per patient. Between-study heterogeneity was assessed with an I2 statistic. Secondary analyses included red blood cell usage by placenta accreta subtype.

TABULATION, INTEGRATION, AND RESULTS

Of the 599 full-text studies identified, 20 met criteria for inclusion in the systematic review, comprising 1,091 cases of placenta accreta spectrum. The number of units of red blood cells transfused was inconsistently described across studies, with five studies (25.0%) reporting means, 11 (55.0%) reporting medians, and four (20.0%) reporting individual patient data. The weighted mean number of units transfused was 5.19 (95% CI 4.12-6.26) per patient. Heterogeneity was high across studies (I2=91%). In a sensitivity analysis of five studies reporting mean data, the mean number of units transfused was 6.61 (95% CI 4.73-8.48; n=220 patients). Further quantification of units transfused by placenta accreta subtype was limited due to methodologic inconsistencies between studies and small cohort sizes.

CONCLUSION

Based on the upper limit of the CI in our main analysis and the high study heterogeneity, we recommend that a minimum of 6 units of red blood cells be available before delivery for patients with placenta accreta spectrum. These findings may inform future guidelines for predelivery blood ordering and transfusion support.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021240993.

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.

Placenta Accreta Spectrum Outcomes Using Tourniquet and Forceps for Vascular Control

Objective: To evaluate the use of tourniquet and forceps to reduce bleeding during surgical treatment of severe placenta accreta spectrum (placenta increta and placenta percreta). Methods: A tourniquet was used in the lower part of the uterus during surgical treatment of severe placenta accreta spectrum. Severe placenta accreta spectrum was classified into two types according to the relative position of the placenta and tourniquet during surgery: upper-tourniquet type, in which the entire placenta was above the tourniquet, and lower-tourniquet type, in which part or all of the placenta was below the tourniquet. The surgical effects of the two types were retrospectively compared. We then added forceps to the lower-tourniquet group to achieve further bleeding reduction. Finally, the surgical effects of the two types were prospectively compared. Results: During the retrospective phase, patients in the lower-tourniquet group experienced more severe symptoms than did patients in the upper-tourniquet group, based on mean intraoperative blood loss (upper-tourniquet group 787.5 ml, lower-tourniquet group 1434.4 ml) intensive care unit admission rate (upper-tourniquet group 1.0%, lower-tourniquet group 33.3%), and length of hospital stay (upper-tourniquet group 10.2d, lower-tourniquet group 12.1d). During the prospective phase, after introduction of the revised surgical method involving forceps (in the lower-tourniquet group), the lower-tourniquet group exhibited improvements in the above indicators (intraoperative average blood loss 722.9 ml, intensive care unit admission rate 4.3%, hospital stays 9.0d). No increase in the rate of complications was observed. Conclusion: The relative positions of the placenta and tourniquet may influence the perioperative risk of severe placenta accreta spectrum. The method using a tourniquet (and forceps if necessary) can improve the surgical effect in cases of severe placenta accreta spectrum.

Risk factors for poor hemostasis of prophylactic uterine artery embolization before curettage in cesarean scar pregnancy

Objective

To observe the hemostatic effect of prophylactic uterine artery embolization (UAE) in patients with cesarean scar pregnancy (CSP) and to examine the risk factors for poor hemostasis.

Methods

Clinical data of 841 patients with CSP who underwent prophylactic UAE and curettage were retrospectively analyzed to evaluate the hemorrhage volume during curettage. A hemorrhage volume ≥200 mL was termed as poor hemostasis. The risk factors of poor hemostasis were analyzed and complications within 60 days postoperation were recorded.

Results

Among the 841 patients, 6.30% (53/841) had poor postoperative hemostasis. The independent risk factors of poor hemostasis were gestational sac size, parity, embolic agent diameter (>1000 μm), multivessel blood supply, and incomplete embolization. The main postoperative complications within 60 days after UAE were abdominal pain, low fever, nausea and vomiting, and buttock pain, with incidence rates of 71.22% (599/841), 47.44% (399/841), 39.12% (329/841), and 36.39% (306/841), respectively.

Conclusions

Prophylactic UAE before curettage in patients with CSP is safe and effective in reducing intraoperative hemorrhage. Gestational sac size, parity, embolic agent diameter, multivessel blood supply, and incomplete embolization of all arteries supplying blood to the uterus are risk factors of poor hemostasis.

Prophylactic temporary abdominal aortic balloon occlusion for patients with pernicious placenta previa: a retrospective study

BACKGROUND

Pernicious placenta previa (PPP) can increase the risk of perioperative complications. During caesarean section in patients with adherent placenta, intraoperative blood loss, hysterectomy rate and transfusion could be reduced by interventional methods. Our study aimed to investigate the influence of maternal hemodynamics control and neonatal outcomes of prophylactic temporary abdominal aortic balloon (PTAAB) occlusion for patients with pernicious placenta previa.

METHODS

This was a retrospective study using data from the Peking University People's Hospital from January 2014 through January 2020. Clinical records of pregnant women undergoing cesarean section were collected. Patients were divided into two groups: treatment with PTAAB placement (group A) and no balloon placement (group B). Group A was further broken down into two groups: prophylactic placement (Group C) and balloon occlusion (group D).

RESULTS

Clinical records of 33 cases from 5205 pregnant women underwent cesarean section were collected. The number of groups A, B, C, and D were 17, 16, 5 and 12.We found that a significant difference in the post-operative uterine artery embolism rates between group A and group B (0% vs.31.3%, p = 0.018). There was a significant difference in the Apgar scores at first minute between group A and group B (8.94 ± 1.43 vs 9.81 ± 0.75,p = 0.037),and the same significant difference between two groups in the pre-operative central placenta previa (29.4% vs. 0%,p = 0.044), complete placenta previa (58.8% vs 18.8%, p = 0.032),placenta implantation (76.5% vs 31.3%, p = 0.015). We could also observe the significant difference in the amount of blood cell (2.80 ± 2.68vs.10.66 ± 11.97, p = 0.038) and blood plasma transfusion (280.00 ± 268.32 vs. 1033.33 ± 1098.20, p = 0.044) between group C and group D. The significant differences in the preoperative vaginal bleeding conditions (0% vs 75%, p = 0.009), the intraoperative application rates of vasopressors (0% vs. 58.3%, p = 0.044) and the postoperative ICU (intensive care unit) admission rates (0% vs. 58.3%, p = 0.044) were also kept.

CONCLUSIONS

PTAAB occlusion could be useful in reducing the rate of post-operative uterine artery embolism and the amount of transfusion, and be useful in coping with patients with preoperative vaginal bleeding conditions, so as to reduce the rate of intraoperative applications of vasopressors and the postoperative ICU (intensive care unit) admission. In PPP patients with placenta implantation, central placenta previa and complete placenta previa, we advocate the utilization of prophylactic temporary abdominal aortic balloon placement.

The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences

Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment option for which highest degrees of evidence are available. However, other techniques have been tested, including prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion. In this systematic review, we provide an overview of the currently reported interventional radiology procedures that are used for the treatment of postpartum hemorrhage due to AIP and suggest recommendations based on current evidences. Owing to a high rate of adverse events, prophylactic occlusion of internal iliac arteries should be used with caution and applied when the endpoint is hysterectomy. On the opposite, when a conservative management is considered to preserve future fertility, uterine artery embolization should be the preferred option as it is associated with a hysterectomy rate of 15.5% compared to 76.5% with prophylactic balloon occlusion of the internal iliac arteries and does not result in fetal irradiation. Limited data are available regarding the application of systematic prophylactic embolization and no comparative studies with arterial embolization are available.