Prophylactic hypogastric artery ballooning in a patient with complete placenta previa and increta

Complete placenta previa and increta after radical trachelectomy: A case report

Background

Placenta accreta spectrum (PAS) disorders are increasing in incidence and represent a significant contributor to severe maternal morbidity in the US. Prior uterine surgeries other than cesarean section are important, yet less common, risk factors for PAS.

Case

This is a case of a 43-year-old woman with a prior history of cervical cancer necessitating radical trachelectomy. She was subsequently diagnosed with a complete placenta previa with a high degree of suspicion for PAS. Multidisciplinary teams convened to plan for delivery. A cesarean hysterectomy was performed at 32 weeks. Final surgical pathology confirmed the presence of morbidly adherent placenta invading the vaginal cuff.

Conclusion

Patients who are diagnosed with early-stage cervical cancers have the option of fertility-preserving surgical management. Serial ultrasound evaluations, specifically looking for PAS, might be warranted in post-trachelectomy pregnancies.

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 clinical evaluation of preoperative abdominal aortic balloon occlusion for patients with placenta increta or percreta

OBJECTIVE

To evaluate the efficacy and safety of abdominal aortic balloon for pregnant women with placenta increta or percreta (PIP).

METHODS

Retrospective analysis of the parameters containing estimated blood loss, red cell suspension (RCS) transfusion volume, hysterectomy, surgery time, postoperative hospital days, neonatal status and complications between the two groups.

RESULTS

The patients with preoperative abdominal aortic balloon occlusion (AABO) had significant reduction in blood loss volume, red cell suspension transfusion volume and plasma transfusion volume compared to patients without balloon. Similarly, the surgery time and hysterectomy were obviously reduced in the AABO group. However, there were no difference in the Apgar scores and neonatal complications between the two groups, indicating that the abdominal aortic balloon has little adverse effect on the newborns.

CONCLUSION

AABO plays dramatic roles on reducing blood loss volume and blood transfusion volume and it is also a safe and effective technology providing new insight into the therapy of patient with PIP.

SYNOPSIS

Preoperative abdominal aortic balloon occlusion (AABO), as a new intravascular interventional therapy, is safe and effective in patients with placenta increta or percreta.

Postpartum Hemorrhages: Prevention

The strict correlation between abnormal invasive placentation and postpartum hemorrhage suggests that a widespread antenatal diagnosis of placental anomalies would improve the management of these challenging patients; acting preventive solutions at the moment of delivery reduces blood loss and avoid hysterectomies. The role of endovascular procedures in this field has been encouraged by multiple studies reporting prophylactic uterine arteries embolization and iliac/aortic balloon catheters positioning. This paper aims to review the main imaging diagnostic findings of placental implant anomalies and summarize the principal preventive endovascular strategies proposed in literature.

Estimating the radiation dose to the fetus during prophylactic internal iliac occlusion in patients with abnormal placentation

AIMS

To evaluate the estimated fetal radiation dose during prophylactic internal iliac arterial occlusion in patients with abnormal placenta and to estimate the risk of radiation induced cancer in child age.

METHODS

Prophylactic occlusion of the internal iliac arteries during Caesarean section was performed in 42 patients with placenta praevia and/or placenta accreta spectrum. Fogarty embolectomy catheters were used for prophylactic occlusion of the internal iliac arteries. All procedures were performed in the hybrid operating room using Philips Allura Xper FD 20 X-ray system. Low dose X-ray fluoroscopy (7.5 frames per second) was used. The CODE (Conceptus dose estimation) Software was used to estimate the fetal dose and the risk of radiation induced carcinoma.

RESULTS

Fluoroscopy times required for insertion of Fogarty catheters were 0.5-4.2 min (mean: 1.7 min, median: 1.5 min). The estimated radiation dose to the fetus was 0.26-3.36 mGy (mean: 1.49 mGy, median: 1.25 mGy). The risk of radiation induced cancer in child age was 0.01-0.04% (mean 0.02%, median 0.01%). One patient developed thrombosis of a common femoral artery.

CONCLUSION

Prophylactic occlusion of the internal iliac arteries is a simple and safe procedure with minimal risk of complications and with a very low estimated radiation dose to the fetus.

Preoperative Prophylactic Balloon-Assisted Occlusion of the Internal Iliac Arteries in the Management of Placenta Increta/Percreta

Background and Objectives: Preoperative prophylactic balloon-assisted occlusion (PBAO) of the internal iliac arteries minimizes blood loss and facilitates surgery performance, through reductions in the rate of uterine perfusion, which allow for better control in hysterectomy performance, with decreased rates of bleeding and surgical complications. We aimed to investigate the maternal and fetal outcomes associated with PBAO use in women with placenta increta or percreta. Material and Methods: The records of 42 consecutive patients with a diagnosis of placenta increta or percreta were retrospectively reviewed. Of 42 patients, 17 patients (40.5%) with placenta increta or percreta underwent cesarean delivery after prophylactic balloon catheter placement in the bilateral internal iliac artery (balloon group). The blood loss volume, transfusion volume, postoperative hemoglobin changes, rates of hysterectomy and hospitalization, and infant Apgar score in this group were compared to those of 25 similar women who underwent cesarean delivery without balloon placement (surgical group). Results: The mean intraoperative blood loss volume in the balloon group (2319 ± 1191 mL, range 1000–4500 mL) was significantly lower than that in the surgical group (4435 ± 1376 mL, range 1500–10,500 mL) (p = 0.037). The mean blood unit volume transfused in the balloon group (2060 ± 1154 mL, range 1200–8000 mL) was significantly lower than that in the surgical group (3840 ± 1464 mL, range 1800–15,200 mL) (p = 0.043). There was no significant difference in the postoperative hemoglobin change, hysterectomy rates, length of hospitalization, or infant Apgar score between the groups. Conclusion: PBAO of the internal iliac artery prior to cesarean delivery in patients with placenta increta or percreta is a safe and minimally invasive technique that reduces the rate of intraoperative blood loss and transfusion requirements.

Prophylactic uterine artery embolization during cesarean delivery for placenta previa complicated by placenta accreta

OBJECTIVE

To evaluate the efficacy and safety of prophylactic uterine artery embolization (UAE) during cesarean delivery for women with placenta previa complicated by placenta accreta.

METHODS

A retrospective analysis of women with placenta previa admitted to The Second Affiliated Hospital of Soochow University, Suzhou, China, for elective cesarean between February 2003 and July 2016. Postpartum estimated blood loss, blood transfusion, hysterectomy, disseminated intravascular coagulation (DIC) incidence, intensive care unit (ICU) duration, and postoperative stay were compared between control women who underwent cesarean delivery only and women who underwent prophylactic intraoperative UAE during cesarean.

RESULTS

There were 28 and 26 women in the UAE and control group, respectively. There were no differences in hysterectomy incidence (P=0.291), or duration of ICU stay (P=0.085), or postoperative hospitalization (P=0.668) between the groups; however, the incidence of DIC was lower in the UAE group (P=0.035). Mean estimated blood loss (P=0.018) and blood transfusion (P=0.011) were also lower in the UAE group. No serious complications were associated with the endovascular procedures.

CONCLUSION

Prophylactic intraoperative UAE seemed to effectively reduce blood loss, need for blood transfusion, and incidence of DIC among women with placenta previa complicated by placenta accreta.

Experience of a Colombian center in the endovascular management of lifethreatening postpartum hemorrhage

Introduction: Postpartum hemorrhage is a world-leading cause of morbidity and mortality. Lacerations are the second most frequent cause. Early management with appropriate treatment is essential to obtain adequate outcomes; the endovascular occlusion of pelvic vessels is among the management options. Objective: To describe the management experience with the arterial embolization of pelvic vessels. Materials and methods: We conducted a retrospective case series study based on the institutional registry of Fundación Valle del Lili (Cali, Colombia), which included patients with postpartum hemorrhage admitted between January 1st, 2011 and October 31st, 2016. Results: Out of 430 patients diagnosed with PPH, 11 were subject to embolization of pelvic vessels. Within our group, 10 patients had a vaginal delivery with severe vaginal lacerations; most of them (9 cases, 82%) were referred from other lower-complexity institutions after 20.5 hours. Occlusion was more frequent in the superior vaginal and the internal pudendal arteries. No patients showed complications associated with the procedure and only 2 showed recurrent bleeding while 3 required a hysterectomy, but no deaths occurred. Conclusion: Percutaneous management is a safe and effective third-line method for difficult-management bleedings control in patients with postpartum hemorrhage after a severe perineal tear. These results are similar to case reports published in the worldwide literature available to date.

Recent Update of Embolization of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.

Prophylactic temporary abdominal aorta balloon occlusion in women with placenta previa accretism during late gestation

BACKGROUND

To evaluate the clinical efficacy of prophylactic temporary balloon occlusion of the abdominal aorta in patients with placenta previa accretism during cesarean section.

METHODS

Twenty-three consecutive patients, prenatally confirmed with placenta previa accretism were retrospectively analyzed in our center from August 2012 to October 2014. All 23 subjects underwent cesarean section with prophylactic balloon occlusion of the abdominal aorta.

RESULTS

All of the 23 subjects experienced singleton pregnancies leading to the birth of live infants. Of these subjects, the following problems were diagnosed: placenta accrete (n = 10), placenta increte (n = 10), and placenta precrete (n = 3). Mean intraoperative hemorrhage was 1170.0 mL. Fifteen patients received red blood cell transfusion with a mean transfusion volume of 2.3 units. The incidence of hysterectomy was 21.74% (5/23) with blood loss ranging from 2000 to 5000 mL (mean 3360.0 mL). One complication encountered in this retrospective study was lower extremity arterial thrombosis. Eighteen patients were followed-up by telephone to 14 months following discharge, all babies were noted to be healthy.

CONCLUSION

Prophylactic abdominal aorta balloon occlusion (ABO) was relatively safe in the treatment of patients with placenta previa accretism. This approach could represent a key aspect in a multidisciplinary algorithm in reducing hemorrhage in abnormal placentation.

Outcome of Pregnancies After Balloon Occlusion of the Infrarenal Abdominal Aorta During Caesarean in 230 Patients With Placenta Praevia Accreta

Purpose

To explore the efficacy and safety of prophylactic temporary balloon occlusion of the infrarenal abdominal aorta during caesarean for the management of patients with placenta praevia accreta.

Methods

Two hundred and sixty-eight cases of placenta praevia accreta from January 2012 to June 2015 were retrospectively reviewed. Group A included two hundred and thirty patients who underwent prophylactic temporary balloon occlusion of infrarenal abdominal aorta followed by caesarean section. Group B included thirty-eight patients who underwent caesarean without endovascular intervention. The parameters including operating room time, estimated blood loss, blood transfusion volume, PT (prothrombin time) during operation, days in the intensive care unit, and total hospital days were compared between the two groups.

Results

The operating room time, estimated blood loss, PT, the incidence of hysterectomy, blood transfusion volume, postpartum haemorrhage, and days in intensive care unit were lower in group A than in group B, with statistical significance (P < 0.05). There was no significant difference in the Apgar scores of the neonates and the incidences of thrombosis in lower limbs between the two groups (P > 0.05). No patient in the group with prophylactic temporary balloon occlusion of the infrarenal abdominal aorta was performed hysterectomy, while three patients in group B were performed hysterectomy because of uncontrollable haemorrhage.

Conclusions

The results indicate that prophylactic temporary balloon occlusion of infrarenal abdominal aorta followed by caesarean section is safe and effective to control intraoperative blood loss and greatly decreases the risk of hysterectomy in patients with placenta praevia accreta.

Morbidly Adherent Placenta: Its Management and Maternal and Perinatal Outcome

OBJECTIVES

The aim of the study was to identify the risk factors predisposing to morbidly adherent placenta and to study the different modes of management and the obstetric and neonatal outcome of these patients.

METHODS

This was a retrospective cum prospective observational study conducted in the Department of Obstetrics and Gynaecology in a tertiary care referral hospital in Mumbai from January 2012 to November 2014.

RESULTS

The incidence of morbidly adherent placenta was 1.32 per 1000 pregnancies with patient profile comprising second gravida in the age group 26-28 years; 90 % of the patients in this study had previous Caesarean section and co-existing placenta praevia was diagnosed in 63 %. Fifty-three per cent of the women delivered between 35 and 38 weeks and 40 % had elective deliveries. Caesarean section was the mode of delivery in 90 % of the patients. Prophylactic balloon placement in the internal iliac artery followed by classical Caesarean section, uterine artery embolization and post-operative methotrexate was done in 27 % which preserved the uterus and was associated the blood loss of 1000-2000 mL.

CONCLUSION

Antenatal diagnosis of morbidly adherent placenta allows for multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality.

Urological Manifestations of Placenta Percreta

Placenta percreta is a condition of pregnancy associated with abnormal decidua placenta. It is characterized by invasion of chorionic villi past the myometrium and serosa, towards urogenital organs. Complications include massive hemorrhage, bladder dysfunction, and severe infections during delivery. Reports suggest an increasing prevalence of this condition. From a urological perspective, this review suggests how early diagnostic modalities, effective treatment plans, and appropriate surgical methods may aid in decreasing the morbidity and mortality of placenta percreta. The importance of maintaining bladder integrity during hysterectomy is emphasized.

Estimating the Radiation Dose to the Fetus in Prophylactic Internal Iliac Artery Balloon Occlusion: Three Cases

Background. Although radiation exposure is of great concern to expecting patients, little information is available on the fetal radiation dose associated with prophylactic internal iliac artery balloon occlusion (IIABO). Here we estimated the fetal radiation dose associated with prophylactic IIABO in Caesarean section (CS). Cases. We report our experience with the IIABO procedure in three consecutive patients with suspected placenta previa/accreta. Fetal radiation dose measurements were conducted prior to each CS by using an anthropomorphic phantom. Based on the simulated value, we calculated the fetal radiation dose as the absorbed dose. We found that the fetal radiation doses ranged from 12.88 to 31.6 mGy. The fetal radiation dose during the prophylactic IIABOs did not exceed 50 mGy. Conclusion. The IIABO procedure could result in a very small increase in the risk of harmful effects to the fetus.

Intraoperative uterine artery embolization without fetal radiation exposure in patients with placenta previa totalis: Two case reports

Embolization of the uterine arteries is a valuable method for controlling postpartum hemorrhage. There have been recent attempts to apply this tool as a means of controlling bleeding during Cesarean section, especially in patients with placenta previa. However, the benefits are controversial due to lack of randomized controlled studies, no evidence of significant improved outcomes, and potential harm including radiation exposure. This paper includes two case reports of intraoperative uterine artery embolization without fetal radiation exposure in patients with placenta previa totalis.

Transfundal uterine incision performed with prophylactic common iliac artery balloon occlusion for patient with placenta previa totalis

A 37-year-old primigravida at 35 weeks of gestation presented with known anterior wall dominant placenta previa totalis and suspected placenta accreta was successfully treated with transfundal uterine (transverse) incision performed with prophylactic common iliac artery balloon occlusion. This new surgical approach could be an alternative procedure for avoiding excessive blood loss during caesarean delivery.