Utilizations and outcomes of intra‐arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum

AbstractWhen cesarean hysterectomy is scheduled in cases of placenta previa accreta/increta/percreta, it is necessary that the departments of obstetrics, anesthesiology, blood transfusion, urology, and radiology hold a preoperative conference to assure full preparation for the surgery. A ureteral stent inserted just before cesarean section serves as a marker. A uterine incision should be made at a site free of placental contact. The presence/absence of bladder invasion by villi, adhesions, and the degree of vascularization greatly influence the amount of bleeding, and bleeding control is a key point. For prevention of massive hemorrhage, methods of blood flow blockage, such as balloon occlusion catheterization of the aorta or common iliac artery, should be considered. Stored autologous blood and Cell Saver should be prepared. When hysterectomy is performed with the placenta left in situ, handling of the elongated cardinal ligament, ureteric injury, and bladder injury are important issues because the lower uterine segment is enlarged with the placenta. If blood flow is not blocked, separation of the bladder at the area of placenta percreta should be performed as the last step, to reduce bleeding (Pelosi's method). At this time, after handling of the cardinal ligament, bladder separation can be performed more safely if the posterior vaginal wall is incised and exposed first.In cases of placenta accreta or partial placenta accreta/increta/percreta, a diagnosis of morbidly adherent placenta may not be obtained until separation of the placenta is performed. If bleeding from the placental separation surface cannot be controlled, total hysterectomy should be performed without hesitation.

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Prophylactic aortic balloon occlusion for placenta accreta spectrum disorders: Occlusion where?

Archives of Gynecology and Obstetrics ◽

10.1007/s00404-020-05434-4 ◽

2020 ◽

Vol 302 (6) ◽

pp. 1553-1554 ◽

Cited By ~ 1

Author(s):

Shigeki Matsubara ◽

Hironori Takahashi ◽

Yuji Takei ◽

Hiroyasu Nakamura ◽

Takashi Yagisawa

Keyword(s):

Placenta Accreta ◽

Balloon Occlusion ◽

Aortic Balloon Occlusion ◽

Placenta Accreta Spectrum ◽

Spectrum Disorders

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Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum

The Journal of Maternal-Fetal & Neonatal Medicine ◽

10.1080/14767058.2020.1802717 ◽

2020 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Julie R. Whittington ◽

Megan E. Pagan ◽

Bryan D. Nevil ◽

Kyle J. Kalkwarf ◽

Nadir El Sharawi ◽

...

Keyword(s):

Placenta Accreta ◽

Vascular Complications ◽

Balloon Occlusion ◽

Placenta Accreta Spectrum ◽

Endovascular Balloon Occlusion

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When is the ideal time to remove cerclage in cases requiring cesarean hysterectomy for placenta accreta spectrum?

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20190972 ◽

2019 ◽

Vol 8 (4) ◽

pp. 1668

Author(s):

Futa Ito ◽

Shinya Matsuzaki ◽

Masayuki Endo ◽

Tadashi Kimura

Keyword(s):

Preterm Birth ◽

Maternal Morbidity ◽

Birth Rate ◽

Placenta Accreta ◽

Cervical Insufficiency ◽

Short Cervix ◽

Cesarean Hysterectomy ◽

Preterm Birth Rate ◽

Placenta Accreta Spectrum ◽

The Ideal

Placenta accreta spectrum (PAS) presents one of the highest risks to pregnancy and often requires a cesarean hysterectomy for management, but the challenges associated with this surgery often cause severe obstetric haemorrhaging and high rates of maternal morbidity. Shirodkar cerclage is usually performed in cases with cervical insufficiency, a short cervix with previous preterm birth, etc., to decrease the preterm birth rate. It is recommended that Shirodkar cerclage is removed when the patient approaches term, but the ideal timing of removal for patient for whom cesarean hysterectomy is planned is not clear. Here, authors present a case of PAS in whom Shirodkar cerclage that was difficult to remove at the timing of cesarean hysterectomy. After cesarean hysterectomy, the patient had a vaginal abscess and required antibiotic therapy for approximately two weeks. In the light of our case, authors discuss the timing of removal of cerclage in the cases of PAS.

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A new scoring system for placement of abdominal aortic balloon in Placenta accreta spectrum patients with placenta previa: A retrospective cohort study

10.21203/rs.3.rs-898065/v1 ◽

2021 ◽

Author(s):

Fusen Huang ◽

Jingjie Wang ◽

Qiuju Xiong ◽

Wenjian Wang ◽

Yi Xu ◽

...

Keyword(s):

Blood Transfusion ◽

Blood Loss ◽

Scoring System ◽

Placenta Accreta ◽

Placenta Previa ◽

Operation Time ◽

Balloon Occlusion ◽

Abdominal Aortic ◽

Placenta Accreta Spectrum ◽

New Scoring

Abstract Background In recent years, abdominal aortic balloon occlusion is considered an effective method for placenta accreta spectrum patients with placenta previa. However, not all patients in this category require abdominal aortic balloon placement. This study aims to investigate whether the new scoring system is effective for the placement of the abdominal aortic balloon in Placenta accreta spectrum (PAS)patients with placenta previa. Methods PAS patients with placenta previa diagnosed by color Doppler ultrasound were included, and divided into three groups according to their scores graded by a new scoring system (grade Ⅰ group ≤ 5 points, 6 points ≤ grade Ⅱ group ≤ 9 points, grade Ⅲ group ≥ 10 points). Patients with grade Ⅲ were placed with an abdominal aortic balloon unless their families and patients strongly refused. Those with grade I were not placed with an abdominal aortic balloon. Those with grade II generally were not placed with an abdominal aortic balloon unless their families and patients strongly request. Indicators were analyzed, including postpartum hemorrhage, transfusion requirements, operation time, and the ability to preserve the uterus and fertility. Results Estimated blood loss, the number of intraoperative transfused patients, postoperative days were different among the three groups. In group 2 (grade II), there was no significant difference in other observation indexes༈intraoperative blood loss 629 ± 214 vs 758 ± 749, P = 0.488, packed red blood cells47 ± 194 vs 154 ± 445, P = 0.488, admission to ICU 0/7 vs 3/71, P = 1.000, total hysterectomies 0/7 vs 2/71, P = 1.000༉(except for the operation time81.4 ± 19.5 vs 61.7 ± 30.6, P = 0.013) between the abdominal aortic balloon and non-abdominal aortic balloon groups. In group 3 (grade III), significant differences were found in intraoperative blood loss (950 ± 390 vs 2238 ± 1052, P༜0.001), packed red blood cells(213 ± 311 vs 662 ± 528, P༜0.001), postoperative blood transfusion volume(105 ± 181 vs 300 ± 321, P = 0.008), operation time(90.0 ± 25.9 vs 115.9 ± 45.3, P = 0.013), the proportion of people who need blood transfusion(14 in the IABO vs 11 in the NIABO, P = 0.002) and the total Hysterectomies (0 in the IABO vs 2 in the NIABO, P = 0.011) between the abdominal aortic balloon and non-abdominal aortic balloon groups. Conclusion With the new scoring system, not all patients with PAS and placenta previa need a preventive temporary balloon occlusion of the subrenal abdominal aorta. We recommend placing an abdominal aortic balloon in patients with grade III, for it can control intraoperative bleeding and reduce intraoperative blood transfusion, and reduce the risk of hysterectomy. For patients with grade I and II, abdominal aortic balloon placement is not recommended.

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When the balloon goes up, blood transfusion goes down: a pilot study of REBOA in placenta accreta spectrum disorders

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000750 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000750

Author(s):

Yevgeniya J M Ioffe ◽

Sigrid Burruss ◽

Ruofan Yao ◽

Beverly Tse ◽

Alicia Cryer ◽

...

Keyword(s):

Postoperative Ileus ◽

Placenta Accreta ◽

Vascular Complication ◽

Balloon Occlusion ◽

Surgical Intensive Care Unit ◽

Retrospective Case ◽

Surgical Intensive Care ◽

Level Of Evidence ◽

Perioperative Morbidity ◽

Placenta Accreta Spectrum

BackgroundPatients with placenta accreta spectrum (PAS) disorders often suffer massive hemorrhage during cesarean hysterectomies (CHyst). A novel strategy to decrease blood loss and minimize perioperative morbidity associated with PAS is utilization of ER-REBOA Catheter intraoperatively. In this study, we explore the use of ER-REBOA Catheter during CHyst with the goal of minimizing perioperative morbidity and packed red blood cell (PRBC) transfusions.MethodsWe conducted a retrospective case–control study at a regional referral center of consecutive patients with PAS undergoing CHyst. The primary outcomes were PRBC transfusions of ≥4 units. Secondary outcomes included surgical intensive care unit admissions, postoperative length of stay (LOS), postoperative ileus, and vascular complication rate. We also explored utilization of manual palpation and omission of precesarean fluoroscopy for resuscitative endovascular balloon occlusion of the aorta (REBOA) placement verification in distal aortic zone 3.Results90 patients were included in the study. REBOA and non-REBOA cases were similar in clinicodemographic characteristics. 17.7% of REBOA cases received ≥4 units of PRBC compared with 49.3% of non-REBOA cases (p=0.03). Zero REBOA patients developed postoperative ileus, whereas 18 (25%) non-REBOA patients did (p=0.02). LOS was reduced in the REBOA group. Postplacement fluoroscopy was omitted in all REBOA cases. Two postoperative arterial thrombotic events (2 of 19, 11% of REBOA patients) were identified in the REBOA group, one requiring a thrombectomy (1 of 19, 5%).DiscussionDecrease in blood transfusions of ≥4 units of PRBC is demonstrated when ER-REBOA Catheter is placed in distal aortic zone 3 during CHyst performed for severe PAS disorders. The incidence of postoperative ileus and LOS are reduced in the ER-REBOA Catheter group. Placement and utilization of ER-REBOA Catheter during CHyst may be feasible without fluoroscopy when manual placement verification is performed by an experienced operator. Protocol modifications focusing on reducing thrombotic rate are ongoing.Level of evidenceIV.

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