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

Abstract

ObjectiveProphylactic trans-catheter arterial balloon occlusion (PTABO) before cesarean section of placenta previa totalis has been introduced to prevent massive hemorrhage. The purpose of this study is to evaluate the clinical usefulness of PTABO in cases of suspected placental adhesion and to examine antepartal risk factors and perinatal outcomes in women with placental adhesion.MethodsBetween January 2012 and December 2015, 77 patients who had undergone ultrasonography for evaluation of placenta previa were enrolled in this study. Seventeen of these patients with suspected placental adhesion by ultrasonography and Pelvic MRI underwent PTABO before cesarean section and another 59 patients underwent cesarean section without PTABO. Antepartal risk factors and peripartum maternal and neonatal outcomes were compared between patients with PTABO and those without PTABO.ResultsMore advanced maternal age, longer in gestational weeks at delivery, and more common previous cesarean section history were observed in the PTABO group. Placenta adhesion, abnormal Doppler findings, and frequency of transfusion were more common in the PTABO group. However there was no significant difference in estimated blood loss, hospital days, and neonatal outcome. It had occurred 3 cases of hysterectomy and 1 case of uterine artery embolization after cesarean section in the PTABO group.ConclusionClose surveillance of antepartum risk factors for placental adhesion using ultrasonography and pelvic magnetic resonance imaging is important to prevention of massive hemorrhage during cesarean section. PTABO before cesarean section might result in reduced blood loss and requirement for transfusion during the operation.

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

“…The temporary placement of OBCs is a preventive measure to control hemorrhage in these cases. Although the latest reviews have shown controversial results, some studies have confirmed that this preventive procedure reduced perioperative blood loss, blood transfusion rate, and incidence of cesarean hysterectomy and improved visualization of the operating field [ 13 , 14 , 15 , 16 ]. However, these studies are limited by their retrospective nature and nonrandomized design.…”

Management of massive hemorrhage in pregnant women with placenta previa

“…Although some studies have reported a lack of benefits or complications related to radiologic intervention [ 54 , 55 ], most were case reports or case studies. However, no differences in complications were observed among other large studies or prospective studies, in which prophylactic transcatheter arterial balloon occlusion resulted in reduced blood loss and transfusion requirement for parturients at risk for massive hemorrhage [ 56 – 59 ]. In the clinical application of the radiologic interventions mentioned above, there are various difficulties such as the catheterization timing, intervention and CS location, patient movement, anesthetic method, and fluoroscopic equipment.…”

高度救命救急センターに緊急転院搬送された10年間の産後出血症例の検討(Clinical characteristics of patients who were transferred to our tertiary care center for an emergency due to severe postpartum hemorrhage: a retrospective observational study)

“…産後出血への治療として1979年にTAEが初めて報告され，それ以降，有用性の報告は数多くされている 11), 12), 13)。当院の治療戦略では，子宮破裂など外科的介入が望ましい症例を除き，造影CT検査で活動性出血が認められた際，輸液蘇生に対する反応性が乏しい場合でも厳格な全身管理のもとで積極的にTAEを第一選択としている。救急医は統括者として全身管理や輸血療法を担い，産科医が診断と意思決定，放射線科医がTAEを担当する診療チームを組んでいる。なお，当院放射線科は365日24時間体制の対応が可能であり，産後出血症例の搬入要請時点で招集をかけるため比較的短時間で治療開始することができる。基本的にカテーテル検査室の滞在時間は1時間以内を目指しており，それ以上経過しても塞栓が完了しない場合は集中治療室に入室して輸血療法などの集中治療を行ったうえで，再度TAEを行うこともありうる。さらにTAEだけでは止血完了できない場合や，静脈出血により血行動態が改善しない場合には，開腹止血術や単純子宮全摘術を検討する必要がある。当院では約10年間で8例（2.9%）の子宮全摘術を施行しているが，その内訳は止血術としての子宮全摘術が7例（TAEを複数回行っても止血困難であったものが3例，修復不能な子宮破裂が2例，最重症例が2例）であり，デブリードマン術としての子宮全摘術が1例（TAE後に子宮壊死したものが1例）である。過去の報告では，大量の輸血を要した例や頻脈，低ヘモグロビン値，DIC併発，傍腟壁血腫，胎盤卵膜遺残などがTAEに関連して出血コントロールの失敗因子であることがわかっている 12), 13), 14), 15)。またabnormally invasive placenta（AIP）の産後に予防的TAEを行うことで子宮摘出率や平均在院日数，輸血必要量が減少したという報告 16)やMRI検査で胎盤卵膜遺残が疑われた患者に帝王切開前にprophylactic trans–catheter arterial balloon occlusion（PTABO）を行うことで出血量減少が示唆された報告 17)があり，産前に判明している失敗因子がある場合には予防的な塞栓や血流遮断も考慮される。緊急での血流遮断に対してもREBOAの使用は過去にいくつか報告があり，近年では非透視下でも安全に挿入できるとの報告も存在する 18), 19)。ただし当院での使用症例数は少なく，これはTAE開始までの時間をできるだけ短縮するため非透視での挿入をほぼ行っていないことが関与していると考えている。…”