The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta
Introduction
Morbidly adherent placenta (MAP) is a condition that causes significant maternal morbidity and mortality from primary postpartum haemorrhage (PPH).1 It occurs when there is invasion of the chorionic villi into the myometrium and its incidence is increasing, in line with the increase in caesarean delivery.2 This is a potentially life-threatening condition, which has traditionally required peripartum hysterectomy with or without bowel or bladder resection,3 depending on the degree of infiltration of these organs. Alternative therapies have included compression sutures and balloon tamponade with the placenta remaining in situ4, 5, 6; however, this carries a risk of sepsis and delayed haemorrhage.7
Placenta percreta is the most severe but least common form of MAP, whereas placenta accreta is the commonest but least severe. MAP can be diagnosed before delivery using ultrasound and magnetic resonance imaging (MRI),8 and so women at risk of developing haemorrhage from this condition can be identified before delivery.
In 2007, the authors commenced a programme of prophylactic occlusion balloon catheter (POBC) insertion into both internal iliac arteries before caesarean delivery in women suspected of having the most severe form of MAP, placenta percreta. The aim was to reduce blood loss, preserve the uterus, reduce maternal and foetal morbidity, and prevent mortality by reducing blood flow in the uterine arteries immediately after caesarean delivery. However, if haemorrhage occurred despite inflation of the occlusion balloons, the presence of intra-arterial catheters in the internal iliac arteries allowed rapid progression to arterial embolization.9, 10, 11, 12
Section snippets
Materials and Methods
Between December 2007 and June 2013, pregnant women diagnosed with placenta percreta by ultrasound or MRI, were referred to Interventional Radiology (IR) for POBC on the morning of elective delivery. All patients were fully counselled and gave informed consent. The study was based on service development, and therefore, local ethics committee approval was not required.
An epidural catheter was inserted by the anaesthetists before the patient was transferred to the IR suite for insertion of the
Results
Twenty-seven patients of mean age 36 years and 34 weeks + 2.6 days of gestation (±4 weeks + 2.3 days) with a diagnosis of placenta percreta were treated with POBC and caesarean delivery. All deliveries apart from one were performed electively. The non-elective patient went into labour 4 days before the booked elective caesarean delivery, but the standard treatment protocol was performed as usual, and so she was included in the study. In all cases, occlusion balloons were successfully placed
Discussion
MAP describes a range of conditions where the chorionic villi directly adhere to or invade the myometrium resulting in massive PPH during attempts at placental separation.13 It is increasingly recognized due to better antenatal diagnosis by ultrasound and MRI,14 but its incidence is also increasing as a result of previous uterine surgery and advanced maternal age.2 In England, the incidence of MAP is estimated at 6.3 per 1000 births.15
Primary PPH is defined as an estimated blood loss of >500 ml
Acknowledgments
M.T. is indebted to the Fundacion Alfonso Martin Escudero for the award of a grant. M. T. is envolved in the PhD program of the U.A.B. The authors thank all the members of the obstetrics, interventional radiology, and anesthetics teams for their dedication, support, and enthusiasm.
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A theoretical analysis of prophylactic common iliac arterial occlusion for potential massive bleeding during cesarean delivery: Decision-making considerations — A 2-year retrospective study
2022, Taiwanese Journal of Obstetrics and GynecologyCitation Excerpt :Hybrid suites comprised a full operating room with advanced imaging, providing equipment for both angiography and surgery. During this therapeutic intervention, high-quality imaging is crucial both for the placement of the occlusion balloons and for any ensuing embolization [17]. This also enabled intraoperative common iliac artery occlusion immediately after delivery, which was preferable because the postoperative transfer of patients to the radiology department could increase maternal mortality and morbidity [18,19].
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2021, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :It is performed using low-dose fluoroscopic guidance under local anaesthesia prior to caesarean section. In the authors' institution, the balloon catheters are inserted into the anterior divisions of each internal iliac artery but various other anatomical locations have been reported including the main trunk of the internal iliac arteries and the common iliac arteries [8] (Fig. 1a). In our practice, brief test occlusion is performed to estimate the volume of contrast medium required to inflate each balloon.
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