The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences

Abstract

Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment option for which highest degrees of evidence are available. However, other techniques have been tested, including prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion. In this systematic review, we provide an overview of the currently reported interventional radiology procedures that are used for the treatment of postpartum hemorrhage due to AIP and suggest recommendations based on current evidences. Owing to a high rate of adverse events, prophylactic occlusion of internal iliac arteries should be used with caution and applied when the endpoint is hysterectomy. On the opposite, when a conservative management is considered to preserve future fertility, uterine artery embolization should be the preferred option as it is associated with a hysterectomy rate of 15.5% compared to 76.5% with prophylactic balloon occlusion of the internal iliac arteries and does not result in fetal irradiation. Limited data are available regarding the application of systematic prophylactic embolization and no comparative studies with arterial embolization are available.

Vascular control by infrarenal aortic cross‐clamping in placenta accreta spectrum disorders: description of technique

“…Therefore, the benefit of preoperatively placed balloon occlusion catheters into a limited numbers of pelvic arteries for PAS disorders is still controversial 1,2 . Risk of serious maternal thromboembolic events associated with the use of balloon occlusion was reported to be 5–15.8% 10,11,15,16 …”

“…1,2 Risk of serious maternal thromboembolic events associated with the use of balloon occlusion was reported to be 5-15.8%. 10,11,15,16 The duration of aortic cross-clamping can be at least 1 hour in surgery for abdominal aortic aneurysm. Although the aorta is clamped, it is well-known that collateral circulation is well-developed through three systems outside the vascular control provided by aortic crossclamping.…”

“…Reducing uteroplacental blood flow provides a clear, dry surgical field, makes the surgery technically easier and results in less operative blood loss. Several studies describing balloon occlusions of the internal iliac arteries, common iliac arteries and abdominal aorta have been published, [10][11][12][13][14][15][16] but none has considered blocking the aorta from its outside. In 2010, we reported the first successful management of a woman with placenta increta/ percreta using infrarenal aortic cross-clamping for vascular control at the time of caesarean hysterectomy.…”

Accurate prenatal discrimination of placenta accreta spectrum from uterine dehiscence is necessary to ensure optimal management

“…In view of this, uterine dehiscence misdiagnosed as PAS generates inappropriate obstetric anxiety and over-treatment (such as interventional radiology, vertical abdominal incision and hysterectomy) all of which carry risk of iatrogenic injury. In placenta previa with uterine scar dehiscence, the placenta spontaneously detaches from the uterus at caesarean delivery; there is no need for a classical uterine incision or hysterectomy, and blood loss is significantly lower, compared to placenta accreta spectrum (PAS) which is managed by a classical uterine incision during caesarean delivery [3], and may necessitate interventional radiology (IR) or surgical pelvic devascularisation to control haemorrhage [4].…”

Placenta Accreta Spectrum: A Continuously Evolving Challenge for Radiologists

“…The secondary objectives are to induce thrombosis of intervillous space, reduce the risk of further bleeding and improve the speed of placental resorption when conservative management is performed. 4 The third objective is to preserve fertility and potential further pregnancies by avoiding uterine necrosis. However, prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion are now commonly used but at the penalty of a high rate of complications compared to arterial embolization.…”