Figure 1. A. Angiografía selectiva de ambas arterias uterinas. Se visualiza la tortuosidad de sus ...

Figure 2. Catéter balón Wedge 6 Fr (ARROW®, Arrow International, Inc. 2400 Bernville Road Reading...

Table 1. Characteristics of the population.

Table 2. Revista Argentina de Cardioangiología Intervencionista 2022;13(1):16-20.

INTRODUCTION

Placenta accreta is a serious complication during pregnancy that can be associated with massive bleeding during and after delivery with the potential risk for the patient’s life.[1] Currently, the rate of accretism is 1 for every 1000 deliveries (0.04% to 0.9%) [2]. Accretism is the most common indication for peripartum hysterectomy due to the increase of C-sections seen over the last 50 years.[3] It has become the leading cause of emergency hysterectomy.[4] However, the most common cause of postpartum bleeding is uterine atony. C-section and hysterectomy to treat accretism have been recommended since 1972. A total of 38 patients with a diagnosis of placenta accreta were admitted to the unit of hemodynamics of our center between January 2012 and January 2020 to be treated with percutaneous balloon occlusion of uterine arteries and/or embolization after the C-section and prior to hysterectomy. These are the results of our experience.

ENDPOINT

This represents our experience with the endovascular treatment of 30 patients with placenta accreta spectrum disorders treated with scheduled C-section. We will be describing the endovascular techniques used, the immediate results reported, and the in-hospital follow-up.

MATERIAL AND METHODS

Cross-sectional, descriptive, and observational study conducted from January 2012 through January 2020. A total of 38 patients with a diagnosis of placenta accreta were admitted to the unit of hemodynamics of our center. Each case was approached by a multidisciplinary team including obstetricians, neonatologists, urologists, anesthesiologists, and interventional cardiologists who were experts in the management of patients in their 34th-35th gestational week. Procedures were performed on an eligibility and scheduled basis. Ultrasound-guided prenatal diagnosis was achieved in all the patients. When the ultrasound was inconclusive an MRI was performed in 3 of these patients.

First, the urology unit inserted the ureteral catheters into the patient who was, then, transferred to the hybrid cath lab where the patient was treated with the Seldinger technique under local anesthesia. Two 6-Fr introducer sheaths were placed in both common femoral arteries retrogradely and then followed by the infusion of a bolus of 2500 IU of sodium heparin. Both introducer sheaths were connected to pressurized permanent cleaning with a heparinized physiological solution (2500 IU of sodium heparin in 500 mL of physiological solution) during the entire procedure at an acceptable rate to prevent access site thrombosis due to the, sometimes, extended surgical times.

The anesthesiology unit then administers general anesthesia with the corresponding intubation and connection to a ventilator.

Using the AP projection, using radiography, and with an average dose administered, 2 5-Fr Cobra angiographic catheters were mounted on a 0.035 in guidewire. Using the crossover technique at L4 level both catheters were placed next to both uterine arteries and then advanced towards the hypogastric artery anterior branch. Sometimes the contralateral oblique projection was used to select the uterine artery (25º to 40°) and see the partition between the anterior and posterior branches of the hypogastric artery. A baseline angiography was performed to assess the patient’s uterine vascular anatomy.

Patients from group #1 (n = 28 - 73%) were treated with embolization. Patients from group #2 (n = 10 - 26%) were treated with temporary balloon occlusion of the uterine arteries.

In group #1, once the insertion of the catheters has been confirmed into the uterine arteries Tegaderm and Lino dressings are used for catheter fixation and immobilization. Afterwards, the C-section is performed by the obstetrics team. The newborn is examined by the neonatologist and later hospitalized. Prior to the hysterectomy, embolization with gelatin sponge is performed (Spongostan® Curamedical B.V., Amsterdam, The Netherlands). Once the surgical act is completed the patient is extubated, and a control angiography is performed to confirm the patency of both iliofemoral axes.

In group #2, using a 180 cm-long 0.014 in guidewire, the Cobra catheters are exchanged for 6-Fr balloon wedge-pressure catheters (ARROW®, Arrow International, Inc. 2400 Bernville Road Reading, PA, United States) with distal orifice that will be inflated after starting the hysterectomy (Figure 2). Once the procedure is completed both the catheters and the introducer sheaths are removed. The patient is then extubated and transferred to the ICU where she will remain for the next 24 hours to be eventually transferred to the obstetrics ward. Table 1 shows the characteristics of the population treated.

RESULTS

The ultrasound revealed the presence of total occlusive placenta previa in 52.64% of the patients (20/38), anterior previa in 28.95% (11/38), posterior previa in 5.26% (2/38), anteroposterior in 5.26% (2/38), marginal previa in 5.26% (2/38), and lateral left previa in 2.63% (1/38).

The angiography of uterine vessels performed revealed the presence of a dominant uterine artery in 76.31% of the patients (29/38) being the left uterine artery in 44.73% of the cases (17/38), and the right uterine artery in 31.57% of the patients (12/38). In the remaining cases it was codominant in 23.70% of the patients (9/38). The dominant uterine artery was embolized in a patient since the contralateral one could not be selected, which required 2 intraoperative RBCUs. No correlation between the anatomical distribution of the arteries and the location of the placenta was seen.

The Apgar test score in the newborns was 9-10 in 78.95% (30/38), 9-9 in 10.53% (4/38), 8-9 in 5.26% (2/38), 6-10 in 2.63% (1/38), and 6-7 in 2.63% (1/38). The newborns were not affected by general anesthesia, and the mother had no complications whatsoever.

Both arteries were embolized in 71% of the patients (27/38), the left uterine artery (dominant) in 1 patient because the right artery could not be selected in 2.6% of the cases (1/38), and only occluding balloons were used in both arteries in 16.6% of the patients (10/38).

A total hysterectomy was performed in 97.37% of the patients (37/38). Conservative treatment was used in a patient with uterine preservation.

The mean radiography time in groups #1 and #2 before the C-section (fetal radiation) was 3.9 minutes (+/- 1.5) with an average dose of 0.032 Gy = 3.23 rads. The overall radiography time was 14.2 minutes (+/-10) with an average dose of 0.11 Gy = 11 rads (table 2).

The mean volume of contrast used was 179 mL (+/-117). The contrast agent used was Ioversol (Optiray® - Mallinckrodt Inc., St Louis, MO, United States) in 92.1% of the cases (35/38) while Triyosom® (Gobbi Novag S.A, Bs.As., Argentina) was used in 3 patients (7.9%). None of the patients treated developed contrast-induced nephropathy (table 2).

Regarding the intraoperative transfusion requirements, 42.10% of the patients (16/38) did not require transfusion of hemoderivatives, 18.42% (7/38) required 2 RBCUs, 15.79% (6/38) required 1 RBCU, 7.89% (3/38) 4 RBCUs, 5.26% (2/38) 2 RBCUs, and 1 patient required 6 RBCUs (2,63%). In 7.89% of the patients (3/38) the Cell-Saver red blood cell recirculation system (Haemonetics Cell-Saver 5) was used to recirculate 300 mL of blood in these patients, which is equivalent to a single red blood cell unit (table 2).

A total of 10 patients were treated with coadjuvant therapy with balloon wedge-pressure catheters in both uterine arteries. The mean volume of contrast used in these patients was 30 mL (+/-10). No radiographies were obtained after the C-section. A total of 5 patients did not require the transfusion of hemoderivatives during the procedure or during the hospital stay. Two patients required a single red blood cell unit intraoperatively, 2 patients required 2 red blood cell units, and 1 patient required 3 units.

The levels of hemoglobin prior to the surgical act were 11.03 (+/-1.1). These levels dropped 23.49% at the follow-up with, on average, lowest hemoglobin levels of 8.44 (+/- 1.9). The patients had mean hemoglobin levels of 10.01 (+/- 1.47) at discharge, which would account for the 9.2% drop reported compared to admission levels without any clinical signs.

Balloon group: previous Hb levels (11.74 +/-1.1), lowest Hb levels (9.21+/-0.49), Hb at discharge (11.02+/-1.84). Reduced Hb levels after treatment: 21.6%.

Embolization group: Previous Hb levels (10.86+/-1.08), lowest Hb levels (8.28+/-2.09), Hb at discharge (9.8+/-1.3). Reduced Hb levels after treatment: 23.7%.

During admission and after the C-section, 47.37% of the patients (18/38) did not require transfusions, 21.06% (8/38) received 1 RBCU, 23.68% (9/38) 2 RBCUs, and 7.89% (3/38) 3 or more RBCUs.

A total of 92.10% of the patients (35/38) were hospitalized 4 days (+/-1.9) before the C-section waiting for fetal maturity. A total of 4 patients remained at the hospital for over 2 weeks also waiting for fetal maturity. After the procedure, 84.21% of the patients (32/38) were hospitalized for 6.5 +/-2.66 days until they were discharged. The remaining 15.79% (6/38) had complications that extended the hospital stay for 2 to 4 more weeks. Table 2 summarizes the comparative results of both techniques.

COMPLICATIONS

Only 1 patient required re-embolization due to bleeding after the hysterectomy (incomplete embolization).

The obstetrics unit performed new surgeries in 3 patients (7.9%): the laparotomy evacuation of hemoperitoneum without decompensation in 2 patients, and surgery due to hypovolemic shock in 1 patient (2.63%). All patients responded well to the surgical procedures performed. One patient had a longer hospital stay due to a concomitant in-hospital pneumonia.

One patient (2.63%) died due to arterial thrombosis of both lower limbs. Thrombectomy using Fogarty catheter was attempted twice with poor clinical course and shock associated with disseminated intravascular coagulation (DIC). Because of the prolonged time we believe that catheters remained inserted into both iliac arteries with an approximate hysterectomy time of nearly 5 hours.

Vesical reconstruction due to severe infiltration was performed in 1 patient (2.63%). During the immediate puerperium and the hospital stay 1 patient developed acute arterial ischemia in her right lower limb. The angiography performed confirmed the occlusion of the right external iliac artery that was treated with stent implantation. The patient’s clinical course was favorable.

DISCUSSION

Brown et al. performed the first embolization back in 1979. The maternal mean age was 34 years, and the mean parity, 2.5. The maternal morbidity and mortality rates sit at around 60% and 7%, respectively. The rate of perinatal complications is higher particularly due to the short gestational age of the fetus.[5]

Antenatal diagnosis is key regarding clinical management. In most cases it is ultrasound guided. To prevent emergency C-section and minimize complications performing the C-section between week 34 and week 35 is advised [6].

Maternal death in the placenta accreta setting can occur despite optimal planning, surgical care, and the transfusion of hemoderivatives. Using a multidisciplinary approach and a high-complexity center reduces the maternal and neonatal morbidity and mortality rates.

The risk of accretism is directly associated with the number of previous C-sections performed.[7] The higher rate of accretism reported at the follow-up was confirmed in patients in whom 2 or 3 C-sections had previously been performed. We should mention that 44.7% (17/38) of the total number of patients had suffered previous miscarriages with eventual curettage, which may have been an additional contributing factor.

Up to 90% of the patients with placenta accreta require blood transfusions, and 40% over 10 red blood cell units. Maternal mortality has been reported in 7% of these patients associated with surgical and/or conservative treatment, but not with the endovascular procedure performed.[8] A total of 42.1% of the patients (16/38) required intraoperative blood transfusions at the follow-up of whom only 1 patient required 6 units while 44,7% (17/38) needed between 1 and 3 red blood cell units. One patient eventually died (2.63%).

The bladder is an extrauterine organ most frequently involved in the presence of percretism and is associated with significant morbidity and mortality rates.[9] One patient required vesical reconstruction with good disease progression.

In selected cases and when fertility is desired conservative treatment can be used. Ours was a multiparity population. Only 1 patient required conservative treatment without any complications being reported.

Balloon occlusion of iliac arteries is still a matter of discussion. In a controlled and retrospective study of 69 patients, Shrivastava et al. [10] could not confirm fewer bleedings in the cesarean-hysterectomies performed with intra-arterial balloons (n = 19). However, the control group without balloon (n = 50) showed selection bias (18%; n = 9 patients had not been treated with a previous C-section), less risk of accretism, and fewer chances of bleeding, which attenuated the benefit anticipated in the study group.

The simultaneous and temporal occlusion technique of both hypogastric arteries proved to be a highly effective treatment to prevent massive bleeding in placenta accreta and reduced the maternal morbidity and mortality rates significantly.[11]

In an observational study conducted at Hospital Santojani in Buenos Aires, Argentina that included a total of 44 patients, 94.4% of the these were embolized bilaterally. Gelatin sponge (Spongostan®) was used in all cases with satisfactory outcomes in 97.15% of the patients (n = 34) and unsatisfactory outcomes in 1 of these patients (2.85%) [12].

According to the current studies on the preoperative placement of intravascular balloon catheters this treatment is feasible for the management of placenta accreta and particularly useful for the management of placenta percreta.[13] Our heart team decided to use coadjuvant therapy with balloons following our non-inferiority experience in the results reported regarding the embolization of both uterine arteries.

The catheters advance under fluoroscopy guidance is associated with fetal exposure to radiation. It has been reported that during this procedure the fetus is exposed to nearly 3 to 6 rads of radiation into the uterus. A child’s risk of developing cancer after fetal radiation exposure > 10 rads is around 0.5%[14,15] In our case, it was 3.23 rads without any differences being reported between both groups.

The hemodynamics procedure can be easily performed within 30 min with less than 5 to 8 minutes of fluoroscopy time. An exposure dose of 2 rads/min of fluoroscopy resulted in 10 to16 rads of radiation exposure to the pelvis and the fetus [16]. Our overall radiography time was 15.4 minutes (+/-9.7) with mean levels of 12 rads in the embolization group and 4.8 min in the percutaneous balloon occlusion group with mean levels of 3.9 rads.

To solve the problem of fetal radiation there is a case report that says that catheters should be placed after the C-section has been performed. The interventional radiologist should rapidly prepare the embolization where the presence of abundant bleeding was seen.[17] Further studies are needed to establish techniques and determine more accurate indications for embolization without fetal exposure to radiation.

CONCLUSIONS

The multidisciplinary approach is key in both scheduled and emergency procedures. The obstetrician is the one responsible for coordinating physicians from different medical specialties. Endovascular treatment as coadjuvant therapy in the management of placenta accreta spectrum disorders is useful reducing the maternal morbidity and mortality rates. Based on our own results, we believe that the selective temporary occlusion of both uterine arteries is advised. Less maternal radiation, fewer contrast agents used, shorter cath lab times, and lack of complications have been associated with embolization. Transfusion requirements were almost the same with both techniques. No differences were reported regarding more bleeding or intraoperative bleeding complications or at the in-hospital follow-up.

1. R. Faranesh, R. Shabtai, S. Eliezer, and S. Raed, Suggested approach for management of placenta percreta invading the urinary bladder, Obstetrics and Gynecology, vol. 110, no. 2, pp. 512–515, 2007

2. S. Wu, M. Kocherginsky, J. U. Hibbard. “Abnormal placentation: twenty-year analysis,” American Journal of Obstetrics and Gynecology, vol. 192, no. 5, pp. 1458–1461, 2005.

3. B. E. Hamilton, J. A. Martin, S. J. Ventura, P. D. Sutton, and F. Menacker, “Births: preliminary data for 2004,” National vital Statistics Reports, vol. 54, no. 8, pp. 1–17, 2005.

4. G. Daskalakis, E. Anastasakis, N. Papantoniou, S. Mesogitis, M. Theodora, and A. Antsaklis, “Emergency obstetric hysterectomy,” Acta Obstetricia et Gynecologica Scandinavica, vol. 86, no. 2, pp. 223–227, 2007.

5. T. H. Hung,W. Y. Shau, C. C. Hsieh, T. H. Chiu, J. J. Hsu, and T. T. Hsieh, “Risk factors for placenta accreta,” Obstetrics and Gynecology, vol. 93, no. 4, pp. 545–550, 1999.

6. J. M. O’Brien, J. R. Barton, and E. S. Donaldson, “The management of placenta percreta: conservative and operative strategies,” American Journal of Obstetrics and Gynecology, vol. 175, no. 6, pp. 1632–1638, 1996.

7. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Obstet Gynecol 2006;107:1226–32.

8. O’Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996;175:1632–8.

9. D. Levine, C. A. Hulka, J. Ludmir, W. Li, and R. R. Edelman, “Placenta accreta: evaluation with color Doppler US, power Doppler US, and MR imaging,” Radiology, vol. 205, no. 3, pp. 773–776, 1997.

10. Shrivastrava V, Nageotte M, Major C, Haydon M, Wing D. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol 2007;197:402.e1-5.

11. Oclusión endovascular temporal de arterias hipogástricas para el tratamiento del acretismo placentario A. Rodríguez Saavedra, G. Samaja, M. Acosta, J. Lukestik, N. urday, A. Vega Revista Argentina de Cardioangiología Intervencionista 2015;6(4):204-206.

12. Tratamiento del acretismo placentario: experiencia de un hospital público de Buenos Aires G. Dionisio, L. Puerta, N. Ruiz, S. Brandeburgo, C. Etcheverry, P. Olmedo, R. Luca, C. Simancas, R. Kevorkian, S. Centeno. Revista Argentina de Cardioangiología Intervencionista 2016;7(3):136-140.

13. Eur J Obstet Gynecol Reprod Biol. 2014 Aug;179:36-41. doi: 10.1016/j.ejogrb.2014.05.007. Epub 2014 May 21. Prophylactic use of intravascular balloon catheters in women with placenta accreta, increta and percreta. Cali G1, Forlani F2, Giambanco L1, Amico ML1, Vallone M3, Puccio G4, Alio L1.

14. Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters. Levine AB, Kuhlman K, Bonn J J Matern Fetal Med. 1999 Jul-Aug; 8(4):173-6.

15. Cousins C. Medical radiation and pregnancy. Health Phys. 2008 Nov; 95(5):551-3.

16. Huda W, Stone R: Review of Radiation Physics (ed 2). Philadelphia, PA: Lippincott Williams & Williams, 2003, p 165.

17. Hae Jeng Lim, Ju Yeong Kim, Young Dae Kim, Jee Yoon Park, Joon-Seok Hong. Intraoperative uterine artery embolization without fetal radiation exposure in patients with placenta previa totalis: Two case reports,. Gynecol Obstet Sci 2013; 56 (1): 45-49.

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Transient percutaneous balloon occlusion vs uterine artery embolization as coadjuvants in the management of placenta accreta spectrum disorders during C-section

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