The efficacy of pre-delivery prophylactic trans-catheter arterial balloon occlusion of bilateral internal iliac artery in patients with suspected placental adhesion

Internal iliac artery balloon occlusion in the management of placenta accreta: A systematic review and meta-analysis

PURPOSE

To examine the effectiveness and safety of prophylactic internal iliac artery balloon occlusion for hemorrhage control in placenta accreta.

METHOD

EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials data-bases were searched through November 2020. Clinical trials comparing the management of placenta accreta with and without internal iliac artery balloon occlusion were included. The meta-analysis results were expressed as the risk ratio (RR) or mean difference, with 95 % CIs.

RESULTS

Fifteen studies including 1098 women were eligible. No statistically significant difference was found between the internal arterial balloon occlusion group and the control group with respect to estimated blood loss volume (-0.525 mL, [95 % CI, -1.112 to -0.061], p = 0.079.), red blood cells (RBCs) transfused in observational studies (-0.682 mL, [95 % CI, -1.540 to 0.176], p = 0.119.) and in randomized controlled trials (0.134 mL, [95 % CI, -0.214 to 0.482], p = 0.451.), intensive care unit admission (p = 0.197), hysterectomy in observational studies (p = 0.969) and in randomized controlled trials (p = 0.323), urinary system injury in observational studies (p = 0.182) and in randomized controlled trials (p = 0.956), Apgar score at 5 min (p = 0.641), and neonatal intensive care unit admission (p = 0.973).

CONCLUSIONS

The currently available data demonstrate no significant differences between the internal iliac artery balloon occlusion group and the control group in blood loss and packed RBCs transfused for women with placenta accreta. Further large randomized controlled studies are needed to confirm our findings.

Experience of Managing Suspected Placenta Accreta Spectrum with or without Internal Iliac Artery Balloon Occlusion in Two Lithuanian University Hospitals

Background and objectives: Placenta previa and placenta accreta spectrum are considered major causes of massive postpartum hemorrhage. Objective: To determine whether the placement of an occlusion balloon catheter in the internal iliac artery could reduce bleeding and other related complications during cesarean delivery in patients with placenta previa and placenta accreta spectrum. Materials and Methods: A retrospective analysis was conducted at two tertiary obstetric units of Lithuania. From January 2016 to November 2019 patients with placenta previa and antenatally suspected invasive placenta were included in the intervention group and underwent cesarean delivery with endovascular procedure. From January 2014 to December 2015 patients with placenta previa and suspected placenta accreta spectrum were included in the non-intervention group. The primary outcomes were reduction in intraoperative blood loss and transfusion volumes in the intervention group. Secondary outcomes were the incidence of hysterectomy and maternal complications. Results: Nineteen patients underwent cesarean delivery with preoperative endovascular procedure, and 47 women underwent elective cesarean delivery. The median intraoperative blood loss (1000 (400-4500) mL vs. 1000 (400-5000) mL; p = 0.616) and the need for red blood cell transfusion during operation (26% vs. 23%; p = 0.517) did not differ significantly between the patients groups. Seven patients in the intervention group and two patients in the non-intervention group underwent perioperative hysterectomy (p = 0.002). None of the patients had complications related to the endovascular procedure. Conclusion: The use of intermittent balloon occlusion catheter in patients with placenta pathology is a safe method but does not significantly reduce intraoperative blood loss during cesarean delivery.

The intraoperative use of internal iliac artery balloon catheters in cesarean deliveries for abnormal invasive placentation: A 3-year retrospective cohort review in Doha, Qatar

Background: Abnormal invasive placentation leads to massive intraoperative hemorrhage and maternal morbidity. This study aimed to assess the impact of the preoperative use of internal iliac artery balloon occlusion (IIABO) catheters in patients who had a cesarean delivery (CD) for invasive placentation, commonly known as the placenta accreta spectrum.

Methods: This retrospective cohort study reviewed 67 pregnancies complicated by abnormal invasive placenta and confirmed intraoperatively. Preoperative planned placement of IIABO was performed in 33 women who underwent elective CD. Senior Obstetricians with the necessary expertise performed all CDs. The primary outcome measures were: intraoperative blood loss, blood transfusion requirement, duration of surgery and the need for hemostatic measures. Univariate comparison between the groups and regression analysis of the primary outcome and controlling for confounders, were performed.

Results: No statistically significant difference was observed between the groups with intraoperative hemorrhage volume of above 3000 mL (unadjusted odds ratio [OR] 0.94 [no-IIABO group as the reference]; p = 0.895) and the median duration of surgery (median 107, interquartile range [IQR] 80–135 vs. median 96, IQR 75–121; p = 0.3508). More than 40% of the IIABO group required intraoperative transfusion of packed red blood cells above six units (14 [42.4%] vs. 10 [29.4%]; p = 0.357]), and 30% required additional postoperative transfusion (10 [30.3%] vs. 8 [23.5%]; p = 0.706]), although not statistically significant. Multivariate logistic regression analysis showed that the difference remained nonsignificant after covariate adjustment (adjusted OR 0.585, p = 0.456). Cesarean hysterectomy was performed in fewer cases (seven [21.1%]) in the IIABO group than in the no-IIABO group (10 [29.4%]), although this difference was not significant (unadjusted OR 0.65, p = 0.442).

Conclusions: The placement of IIABO catheters is an invasive procedure, which consumes time and resources. Its value as a means of reducing intraoperative blood loss or preserving the uterus in patients with abnormal placental adherence appears questionable. In this cohort study, there was no statistical difference in blood loss, and the need for other steps to control hemorrhage between women with and without IIABO catheters.

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.

A new non-invasive procedure for refractory PPH after vaginal delivery and caesarean section

Worldwide, the incidence of postpartum haemorrhage (PPH) is ∼6% and it is the leading cause of maternal mortality. The present study introduces a non-invasive procedure called bilateral cervix apex clamping (BCAC) as a new treatment for refractory PPH. A total of 13 vaginal deliveries and 5 caesarean section patients received the BCAC procedure to stop bleeding. During the procedure, the anterior and posterior walls of the cervical apex were clamped using toothless ovum forceps from the left and right side. The procedure was terminated when the bleeding had nearly stopped without clamping. The success rate of the procedure was 94.4% (17/18) overall, and 92.3% for vaginal delivery and 100% in caesarean section patients. Only one case of vaginal delivery did we resort to exploratory laparotomy and hysterectomy as amniotic fluid embolism occurred. The time spent on the procedure was 2-4 min for vaginal delivery cases and 5-7 min for caesarean section patients. The blood loss reduced significantly after the procedure, before the BCAC and after it was 875(450) ml versus 100(80)ml (p < .0001). There was a reduction in the need for UAE (uterine artery embolisation) from 13 in 22,817 deliveries (2013-2015) to 0 in 18,212 deliveries (2016-2017 (p < .001). But no change in the rate of hysterectomy (5/22817 versus 5/18212) (p = .76). BCAC is a simple, easy, safe, effective and non-invasive procedure that can decrease bleeding in patients with PPH.Impact statementWhat is already known on this subject? The BCAC clamping procedure was first described in Russia 80 years ago as the Genkel-Tikanadze method. But a PUBMED search did not identify and previous studies published on use of the technique.What do the results of this study add? The results of this study show that the BCAC clamping procedure can reduce bleeding significantly in refractory postpartum haemorrhage, when the uterine body is well contracted. The procedure can be performed after both in vaginal delivery and caesarean section. It can also reduce the necessity for UAE and balloon tamponade.What are the implications of these findings for clinical practice and/or further research? BCAC can be used after the failure of regular first line therapy for postpartum haemorrhage.

Management of massive hemorrhage in pregnant women with placenta previa

Patients with placenta previa are at risk for intra- and postpartum massive blood loss as well as increased risk of placenta accreta, a type of abnormal placental implantation. This condition can lead to serious obstetric complications, including maternal mortality and morbidity. The risk factors for previa include prior cesarean section, multiparity, advanced maternal age, prior placenta previa history, prior uterine surgery, and smoking. The prevalence of previa parturients has increased due to the rising rates of cesarean section and advanced maternal age. For these reasons, we need to identify the risk factors for previa and identify adequate management strategies to respond to blood loss during surgery. This review evaluated the diagnosis of placenta previa and placenta accreta and assessed the risk factors for previa-associated bleeding prior to cesarean section. We then presented intraoperative anesthetic management and other interventions to control bleeding in patients with previa expected to experience massive hemorrhage and require transfusion.

The role of supracervical hysterectomy in reducing blood products requirement in the management of placenta accreta: a case-control study

Objective: While surgical management is the treatment of choice for abnormally invasive placenta, the role of supracervical hysterectomy in this setting is not well established. We aimed to compare supracervical versus total cesarean hysterectomy as a surgical option for abnormally invasive placenta.Methods: We carried out an 8-year retrospective case-control study. Six cases of a patient treated by total hysterectomy were matched and compared to 30 controls treated by supracervical hysterectomy. Matching of cases with controls was based on coexisting placenta previa, a number of previous cesarean sections, and age, with five controls per case. Cases and controls were comparable in placental invasion topography. We compared the operative approach in all histologically identified cases of abnormally invasive placenta.Results: Overall, 36 women with histologically proven abnormally invasive placenta were identified. Composite blood products morbidity was higher among total hysterectomy patients (p = .02). Freshly frozen plasma utilization was greater among total hysterectomy patients (p = .01). Median operative time (142 ± 48 versus 136 ± 58 minutes) and hospitalization time (8.9 ± 3.1 versus 7.3 ± 1.5 days) were comparable between those who underwent supracervical versus total hysterectomy (p > .05). No case of maternal or neonatal death was encountered.Conclusion: The favorable maternal and perinatal outcomes observed in our study, suggest that supracervical hysterectomy should be considered as the first-line approach in cases of abnormally invasive placenta managed operatively.