Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta

doi:10.1016/j.ijoa.2011.06.006

International Journal of Obstetric Anesthesia

Volume 20, Issue 4, October 2011, Pages 282-287

https://doi.org/10.1016/j.ijoa.2011.06.006 Get rights and content

Abstract

Background

Placenta praevia and accreta are leading causes of major obstetric haemorrhage and peripartum hysterectomy. Detection is largely based on a high index of clinical suspicion, though the diagnostic accuracy of radiological imaging is improving. Interventional radiological techniques can reduce blood loss and the incidence of hysterectomy.

Methods

We have reviewed our experience with bilateral prophylactic uterine artery balloon occlusion in the management of women with suspected placenta accreta. Thirteen women at high risk of major haemorrhage due to placenta praevia or suspected placenta accreta were retrospectively studied. Uterine artery balloons were placed prophylactically under neuraxial anaesthesia in the angiography suite followed by caesarean delivery in the obstetric operating theatre.

Results

Intraoperative blood loss and transfusion requirements were low in our case series. There were no hysterectomies or admissions to the intensive care unit. Fetal bradycardia necessitating immediate caesarean delivery occurred in two women (15.4%).

Conclusion

In our case series in women with suspected placenta accreta, prophylactic use of uterine artery balloons was associated with a low requirement for blood transfusion but with possible increased risk of fetal compromise. Performing the interventional procedure at a different site from the operative room complicated management.

Introduction

Placenta praevia and placenta accreta are important causes of obstetric haemorrhage and leading causes of peripartum hysterectomy.¹ The incidence of placenta accreta has increased with rising caesarean delivery (CD) rates and could be as high as 1 in 500 deliveries.² Transcatheter arterial embolisation has been used to manage obstetric haemorrhage since 1979 and is associated with decreased blood loss and lower rates of hysterectomy compared with conventional techniques.[3], [4] Evidence for the efficacy of predelivery prophylactic pelvic artery balloon occlusion in patients at high risk of peripartum haemorrhage is weak and has largely considered only maternal outcome.[5], [6], [7] The lack of randomised clinical trials or large cohort studies precludes a consensus on the ideal management of placenta accreta.

Caesarean hysterectomy remains the prevailing surgical approach,⁸ although a number of uterine sparing procedures have been described.[9], [10] However, the significant associated morbidity, uncertainties in antenatal diagnosis and desire for fertility preservation, require continued efforts to improve outcome from conservative management of placenta accreta, with the aid of interventional radiology.[11], [12] Uterine artery occlusion, first described in 1998 for control of haemorrhage from fibroids, has been used successfully for managing postpartum haemorrhage secondary to placenta accreta.[13], [14] We present our experience of prophylactic bilateral uterine artery (UA) balloon occlusion in 13 women with suspected placenta accreta.

Section snippets

Methods

The records of women who had bilateral UA balloons inserted before elective CD, between March 2004 and January 2008, were reviewed retrospectively. Each case was conducted in a similar manner although no formal protocol was prescribed. A method evolved with experience which was rooted in our standard institutional practice for elective CD. A presumptive diagnosis of placenta accreta was based on a history of previous uterine surgery and an anterior low-lying placenta in the current pregnancy,

Results

The personal and obstetric characteristics of the 13 women studied are shown in Table 1. Eleven women had one or more CD and two women had previous surgical terminations of pregnancy (Cases 3 and 9). Placenta accreta was confirmed surgically in four women (31%). Uterine artery balloons were inflated in 12 women.

Mean [range] estimated blood loss (EBL) was 800 mL [300–2100]. Transfusion requirements ranged from 1–4 units of packed red blood cells and up to 600 mL of salvaged blood. One woman (Case

Case 4

Following insertion of the second UA balloon the FHR dropped rapidly to 70 beats/min. The woman was immediately placed in the full left lateral position and supplemental oxygen administered but without improvement in the FHR. The balloons were then partially withdrawn resulting in rapid recovery of FHR to >140 beats/min. The woman was transferred urgently to the obstetric operating theatre maintaining the left lateral position. On arrival, the FHR was non-reassuring and immediate delivery was

Case 12

Insertion of the first femoral sheath was complicated by a groin haematoma. Following the second balloon insertion the woman complained of lower abdominal cramp at which time the FHR was 140 beats/min. The spinal catheter was topped-up with 0.5% plain bupivacaine 1 mL. Shortly after, the FHR dropped to 50 beats/min. As UA spasm was suspected, glyceryl trinitrate 300 μg was administered through the UABC. There were no significant effects on maternal cardiovascular variables but the FHR increased to

Discussion

Transcatheter embolisation has been used in the management of postpartum haemorrhage for 30 years as a sole technique or as an adjunct to surgical ligation. Surgical ligation of the internal iliac arteries (IIA) is successful in controlling bleeding in about 50% of cases,⁹ with bilateral IIA ligation reducing distal flow by only 50%, and pulse pressure by about 25%.¹⁵ Ligation of the UA is effective in reducing the blood supply to the uterus and can avoid hysterectomy.¹⁶

Over the past 15 years

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Cited by (49)

Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial
2020, American Journal of Obstetrics and Gynecology
Citation Excerpt :
The possible reasons for the failure of internal iliac artery balloon occlusion to show benefits could be because surgical hemostasis was adequate for most of the placenta previa cases, and because collateral circulation such as ovarian arterial supply could not be controlled by internal iliac artery occlusion. A concern of internal iliac artery catheterization is procedure-related complications, which was reported to have an incidence ranging from 7.7% to 36%.53–56 In our study, none of the patients had procedure-related complications.
Placenta previa remains one of the major causes of massive postpartum hemorrhage and maternal mortality worldwide.
To determine whether internal iliac artery balloon occlusion during cesarean delivery for placenta previa could reduce postpartum hemorrhage and other maternal complications.
This was a prospective randomized controlled trial conducted at a tertiary university obstetric unit in Hong Kong. Pregnant women who were diagnosed to have placenta previa at 34 weeks (defined as lower placenta edge within 2 cm from the internal os) and required cesarean delivery were invited to participate. Eligible pregnant women were randomized into internal iliac artery balloon occlusion (Occlusion) group or standard management (Control) group. Those randomized to the Occlusion group had internal iliac artery balloon catheter placement performed before cesarean delivery and then balloon inflation after delivery of the baby. The primary outcome was the reduction of postpartum hemorrhage in those with internal iliac artery balloon occlusion. Secondary outcome measures included hemoglobin drop after delivery; amount of blood product transfusion; incidence of hysterectomy; maternal complications including renal failure, ischemic liver, disseminated intravascular coagulation, and adult respiratory distress syndrome; length of stay in hospital; admission to intensive care unit; and maternal death.
Between May 2016 and September 2018, 40 women were randomized (20 in each group). Demographic and obstetric characteristics were similar between the 2 groups. In the Occlusion group, 3 women did not receive the scheduled procedure, as it was preceded by antepartum hemorrhage that required emergency cesarean delivery, and 1 woman had repeated scan at 36 weeks showing the placental edge was slightly more than 2 cm from the internal os. Intention-to-treat analysis found no significant differences between the Occlusion and the Control groups regarding to the median intraoperative blood loss (1451 [1024–2388] mL vs 1454 [888–2300] mL; P = .945), the median length of surgery (49 [30–62] min vs 37 [30–51] min; P = .204), or the need for blood transfusion during operation (57.9% vs 50.0%; P = .621). None of the patients had rebleeding after operation, complication related to internal iliac artery procedure, or any other maternal complications. Reanalyzing the data using on-treatment approach showed the same results.
The use of prophylactic internal iliac artery balloon occlusion in placenta previa patients undergoing cesarean delivery did not reduce postpartum hemorrhage or have any effect on maternal or neonatal morbidity.
Application of ultrasound-guided balloon occlusion in cesarean section in 130 cases of sinister placenta previa
2020, Journal of Interventional Medicine
To investigate the clinical utility of ultrasound-guided balloon occlusion in cesarean section in patients with sinister placenta previa.
The Interventional and Ultrasound Departments of the authors’ center assisted obstetrics to complete cesarean section in cases of sinister placenta previa. A total of 130 patients with implanted sinister placenta previa were diagnosed using obstetrical ultrasound and magnetic resonance imaging (MRI). Before cesarean section, the balloon was positioned in the bilateral radial or abdominal aorta. Immediately after delivery of the fetus, the balloon was temporarily filled to transiently seal the target vessel. According to the obstetrician’s assessment of hemostasis, the balloon was withdrawn at the appropriate time. Among the 130 patients, there was one case of abdominal aortic occlusion, with 129 cases blocked by the bilateral common iliac artery.
All 130 cases were successfully blocked, with an average blocking time of <15 min, while intraoperative blood loss was 800–1500 ml.
Ultrasound-guided balloon blocking treatment before cesarean section can mitigate the dangers of placenta previa and significantly reduce blood loss with no exposure to X-ray radiation. Thus, the technique merits serious consideration.
Abnormally adherent placenta: Current concepts and anesthetic management
2019, Trends in Anaesthesia and Critical Care
Thrombosis after aortic balloon occlusion during cesarean delivery for abnormally invasive placenta
2018, International Journal of Obstetric Anesthesia
Citation Excerpt :
However, the risks associated with ABO cannot be ignored. In reports describing internal iliac artery or uterine artery balloon occlusion in AIP patients during cesarean delivery, balloon catheterization-associated complications included claudication,15 catheter displacement,18,19 groin hematoma,17 arterial thrombosis,19,22–25 pseudoaneurysm,22 arterial rupture,22 and sciatic nerve ischemia.26 In addition, ABO may potentially cause severe complications such as lower limb and pelvic organ ischemia, necrosis, and aortic rupture.
Abnormally invasive placenta is a major cause of postpartum hemorrhage and cesarean hysterectomy. An increasing number of obstetricians worldwide employ prophylactic aortic balloon occlusion to manage bleeding during cesarean delivery in these patients. However, the safety of this procedure in pregnant women has not been confirmed.
The clinical records of patients who were suspected of having abnormally invasive placenta and who received prophylactic aortic balloon catheterization before cesarean delivery were retrospectively studied for thrombotic complications.
There were 121 patients with suspected abnormally invasive placenta who received prophylactic aortic balloon catheterization before surgery and 115 had the balloon inflated during surgery. Twelve of these 121 patients (10%) developed thrombotic complications. Except for one case of venous thrombosis, all other patients exhibited arterial thrombosis in the limbs on the catheterization side and 11 cases (92%) of thrombosis were discovered within 24 hours of delivery. Eventually, eight patients received arterial thromboembolectomy, and four patients received conservative anticoagulation treatment.
Aortic balloon occlusion for the management of bleeding in women with an abnormally invasive placenta may not uncommonly result in thrombosis. Therefore, the risks and benefits of the procedure must be carefully weighed before it is utilized in these patients.
Prophylactic Internal Iliac Artery Occlusion Balloon Placement to Reduce Operative Blood Loss in Patients with Invasive Placenta
2018, Journal of Vascular and Interventional Radiology
To evaluate efficacy and safety of prophylactic internal iliac occlusion balloon placement before cesarean hysterectomy for invasive placenta.
A retrospective analysis was performed of patients with invasive placenta treated with and without occlusion balloon placement. Preoperative occlusion balloons were placed in 90 patients; 61 patients were treated without balloon placement (control group). Baseline demographics, including patient age, gestational age at delivery, gravidity, parity, and number of previous cesarean sections, were not significantly different (P > .05). Of the balloon placement group, 56% had placenta percreta compared with 25% in the control group (P < .001), and 83% had placenta previa compared with 66% in the control group (P = .012).
Median blood loss was 2 L (range, 1.5–2.5 L) in the balloon placement group versus 2.5 L (range, 2–4 L) in the control group (P = .002). Patients with occlusion balloons were transfused a median of 2 U (range, 0–5 U) of packed red blood cells versus 5 U (range, 2–8 U) in patients in the control group (P = .002). In the balloon placement group, 34% had large volume blood loss > 2,500 mL versus 61% in the control group (P = .001), and 21% required blood transfusion > 6 U versus 44% in the control group (P = .002). Eight complications (9%) were attributed to occlusion balloon placement.
Prophylactic internal iliac artery occlusion balloon placement reduces operative blood loss and transfusion requirements in patients undergoing hysterectomy for invasive placenta.
Anaesthesia for abnormally invasive placenta: a single-institution case series Abnormally invasive placenta
2017, International Journal of Obstetric Anesthesia
Abnormally invasive placenta describes a spectrum of disorders resulting in pathological placental implantation. It is associated with the potential for severe maternal haemorrhage and poor fetal outcome. Increasing numbers of women are at risk owing to the rising incidence of uterine surgery and increasing maternal age. We report data over a five-year period describing anaesthetic management of cases of abnormally invasive placenta in a UK tertiary-referral maternity unit and assess how management has developed.
Surgically confirmed cases of abnormally invasive placenta were identified from January 2011 to January 2016. Cases were identified using standard ICD-10 codes and by review of departmental records, with surgically-confirmed cases included following review of medical records.
Forty cases of abnormally invasive placenta were identified. Eighteen (40%) women had significant medical co-morbidity. All parturients were delivered by caesarean delivery. Caesarean hysterectomy occurred in 24 (60%) cases, delayed hysterectomy in two (5%) and the uterus was preserved in the remaining 14 (35%). Thirty-eight (95%) caesarean deliveries were commenced under neuraxial anaesthesia with 17 (45%) converted to general anaesthesia intraoperatively. Interventional radiology was undertaken in 23 (58%) cases. Median [range] estimated blood loss was 1700 mL [500–12000 mL]. Intraoperative transfusion of packed red cells occurred in 14 (35%) cases. Intraoperative cell salvage was used in 26 (65%) cases. Four (10%) women were admitted to critical care postoperatively. There were no maternal deaths.
Our data illustrate the burden on healthcare resources associated with management of abnormally invasive placenta, underlining the continued need for centralised services for treatment of these complex cases. An integrated multidisciplinary approach to case planning, case management and service provision is key to a successful outcome in these cases.

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ORIGINAL ARTICLERole of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Case 4

Case 12

Discussion

Am J Obstet Gynecol

Tech Vasc Interv Radiol

Int J Obstet Anesth

Am J Obstet Gynecol

Int J Gynaecol Obstet

Int J Obstet Anesth

J Vasc Interv Radiol

J Vasc Interv Radiol

Int J Gynaecol Obstet

Am J Obstet Gynecol

Clin Radiol

Int J Obstet Anesth

Br J Anaesth

Int J Obstet Anesth

Br J Anaesth

ORIGINAL ARTICLE
Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta