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Original Report |
1
Department of Radiology, University of California Irvine Medical Center, 101
The City Dr., Orange, CA 92868-3298.
2
Department of Obstetrics and Gynecology, University of California Irvine
Medical Center, Orange, CA 92868-3298.
3
Present address: Facey Medical Group, 11211 Sepulceda Blvd., Mission Hills, CA
91345.
4
Present address: Regional Radiological Associates, 2020 Court St., Redding, CA
96001.
Received May 26, 2000;
accepted after revision December 4, 2000.
Address correspondence to D. D. Kidney.
Abstract
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CONCLUSION. We conclude that balloon occlusion of the hypogastric arteries is a safe and effective adjunct to cesarean hysterectomy in an attempt to minimize blood loss in patients with abnormal placentation.
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We report five patients with the antenatal diagnosis of placenta accreta, placenta percreta, or placenta increta who had prophylactic placement of balloon occlusive catheters in the hypogastric arteries to minimize blood loss before cesarean delivery and hysterectomy.
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Particular attention was paid to ensuring minimal fetal radiation exposure during the procedure, using appropriate shielding and intermittent low-dose fluoroscopy. Total fluoroscopy time ranged from 4 min 30 sec to 8 min 12 sec. Dosimetry studies were available for three patients and ranged from 108 to 294 mR (from 2.79 x 105 to 7.59 x 105 C/kg).
Using a standard Seldinger technique, both femoral arteries were punctured, and both internal iliac arteries selectively catheterized via a contralateral approach. Once access to both internal iliac arteries was gained, 7-French catheters with 11.5-mm occlusive balloons were placed (Boston Scientific, Watertown, MA). Contrast-enhanced angiography confirmed placement in each hypogastric artery (Fig. 1). With arterial sheaths and balloon catheters secured in place, patients were transferred to the operating room for cesarean delivery. After the delivery of the baby, the balloons were dilated, and cesarean hysterectomy was performed. After achieving hemostasis in the patient, the balloon catheters were deflated and removed. The patients' cases are briefly summarized here.
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Patient 1
A 34-year-old woman, gravida 4 para 1, with a history of one cesarean
delivery and two prior dilation and curettage procedures, was diagnosed as
having anterior placenta previa with placenta percreta at 37 weeks' gestation.
She was admitted at 38 weeks with intermittent vaginal bleeding with a large
retroplacental and subchorionic hemorrhage. A classic cesarean delivery and
total abdominal hysterectomy were performed with prophylactic balloon
placement. She remained hemodynamically stable with an estimated blood loss of
1600 mL and did not require intraoperative transfusion. Final pathology showed
placenta accreta and complete previa.
Patient 2
A 25-year-old woman, gravida 5 para 4, with history of two previous
cesarean deliveries, presented at 36 weeks' gestation with a complete anterior
placenta previa after a second episode of vaginal bleeding. Amniocentesis
performed on the patient's first hospital day showed fetal lung maturity, and
she was scheduled for cesarean delivery. However, she was found to have a
thinned lower uterine segment at the placenta implantation site suggestive of
a probable placenta accreta. A classic cesarean delivery with occlusive
balloons in situ and total abdominal hysterectomy were performed without
complication. The patient's estimated blood loss was 1100 mL, and she did not
require any blood products. Final pathology showed placenta previa but no
other placental or uterine abnormality.
Patient 3
A 34-year-old woman, gravida 10 para 4, presented at 30 weeks with twin
gestation complicated by an episode of vaginal bleeding at 20 weeks. Her
history was notable for four previous cesarean deliveries, three terminated
abortions, two spontaneous abortions, preterm methamphetamine use, and active
tobacco use. Her antepartum sonographic findings were suggestive of placenta
accreta with possible vessel involvement of the bladder. A fetal deceleration
noted during her examination prompted hospital admission for monitoring.
Because of the probable placenta accreta and a 15-min deceleration found for
twin B at admission, the patient underwent another classic cesarean delivery
of viable twins and subsequent elective hysterectomy with balloons inflated.
Her estimated blood loss of 2000 mL required 2 units of packed RBC. Final
pathology showed placenta percreta.
Patient 4
A 23-year-old woman, gravida 4 para 3, with history of three cesarean
deliveries underwent sonography, which revealed complete anterior placenta
previa at 35 weeks' gestation. Given her multiple cesarean history and
sonographic findings, it was thought that she had a 25-50% risk of placenta
accreta. She was subsequently admitted at 36 weeks 5 days' gestation after the
most recent of three episodes of vaginal bleeding. A classic cesarean delivery
with an intraoperative hysterectomy and balloon occlusion was performed
because of persistent lower uterine segment bleeding. The estimated blood loss
was 2500 mL, and she received 2 intraoperative units of packed RBC. Final
pathology showed placenta previa, cystic cervicitis, and focal fibrosis of
myometrium.
Patient 5
A 34-year-old woman, gravida 3 para 2, was transferred at 30 weeks'
gestation from another hospital for persistent nausea, abdominal pain, and
ascites of unknown etiology. Her history was notable for two classic cesarean
deliveries performed because of failure to progress. A sonogram showed a
complete placenta accreta with possible increta or percreta as well as vessel
involvement to the bladder. She was well until 31 weeks' gestation when she
experienced vaginal bleeding, and her hematocrit slowly dropped to 28%. She
then underwent another classic cesarean delivery at 35 weeks 4 days' gestation
with a subtotal hysterectomy. Despite balloon occlusion, she received 7 units
of packed RBC after an estimated blood loss of 4000 mL. Final pathology showed
placenta accreta.
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Few studies have reported the adjunctive use of balloon occlusion of hypogastric vessels for abnormal placentation before cesarean delivery and hysterectomy. In this study, bilateral occlusive catheters were used to temporarily tamponade the hypogastric arteries and to minimize uterine blood loss during cesarean hysterectomy of five patients. Abnormal placentation in two of the patients proved to be limited to placenta previa at pathology. The hypogastric arteries were chosen for the ease and speed of balloon deployment and also for the potential decrease of inflow from other hypogastric collaterals. Good hemostasis was achieved via suture ligation of the uterine vessels in all patients. Although previous data showed success rates for surgical ligation of uterine or internal iliac arteries varied widely from 40% to 100% [7], balloon occlusion before ligation was successful for all patients in this series.
Occlusion of the internal iliac arteries does not halt blood flow to the uterus because there is a rich supply of collaterals [3, 5]. However, the technique does reduce pulse pressure distal to the site of occlusion, thus minimizing blood loss during hysterectomy. Surgical internal iliac artery ligation is often used to attempt to control otherwise intractable obstetric hemorrhage. Therefore, a great amount of blood loss has already occurred before hemorrhage is controlled by arterial ligation.
Endovascular embolization has been used in other studies to control active and severe obstetric bleeding because it provides more distal occlusion and has the added advantage of preserving fertility [8]. Although in this study, embolization was a viable option for both controlling severe bleeding and preserving fertility, bleeding was well controlled, and each patient requested sterilization by hysterectomy. Consequently, it is unknown whether all the hysterectomies were medically necessary. Hansch et al. [3] reported two patients with placenta accreta who required postdelivery Gelfoam (Upjohn, Kalamazoo, MI) embolization of the internal iliac arteries to reduce bleeding; each patient's estimated blood loss was 3300-4000 mL [3]. Dubois et al. [1] reported two similar patients with placenta percreta in whom balloon occlusion with embolization limited hemorrhage. The final estimated blood loss of each was 1500-2000 mL [1]. The success rate of angiographic embolization in patients with normal clotting systems is reportedly more than 90% [3, 9]. However, complications of balloon occlusion with embolization occur in about 7% of patients. These include complications of angiography, pelvic infection (i.e., pelvic abscess), and ischemic phenomena such as bladder gangrene and a postembolization syndrome, a self-limited condition of fever, elevated WBC, and pain from tissue necrosis or vascular thrombosis [3, 7, 10].
A review of the literature suggests that most blood loss in patients occurs as a result of the time and efforts of physicians to avoid performing hysterectomy [4]. In one study of 22 patients, the average blood loss during delivery and the immediate postpartum period was reported as 3826 mL for patients with placenta accreta, with a mean number of blood transfusion of 7.9 units for the entire group [11]. Miller et al. [12] reviewed the records of 62 patients with placenta previa and accreta who underwent hysterectomies; the estimated blood loss was more than 2000 mL in 41 patients, 5000 mL in nine, 10,000 mL in four, and 20,000 mL in two. Transfusions were required in 55% of the patients with more than 5 units packed RBC in 13 patients, 20 units in five, and 70 units in three.
Although we report only five patients who had balloon occlusion without embolization, it is notable that the estimated blood loss for each patient ranged from 1100 to 4000 mL. The patient with the greatest blood loss required 7 units of packed RBC, two patients needed 2 units, and the remaining two patients did not require any blood products. Thus, angiographic balloon occlusion may not only limit blood loss, but it may also minimize the risk of transfusion reactions and blood-borne illness such as hepatitis C and HIV.
For optimal use of preoperative balloon occlusion procedures, a team approach to patient care and timely action by the interventional radiologist are essential. After diagnosing abnormal placentation with potentially critical hemorrhage in a patient, the obstetrician should discuss with the interventional radiologist their upcoming work before the scheduled operation to ensure time efficiency for both parties on the day of delivery. In our institution, access to the internal iliac arteries via a bilateral common femoral artery approach was obtained within 30 min, a time comparable with those of other institutions [3].
In summary, abnormal placentation such as placenta accreta or percreta is a potentially life-threatening hemorrhagic condition. The use of occlusive arterial catheters during cesarean hysterectomy offers several advantages to the patient. Bilateral insufflation of the catheters allows hemodynamic stability and optimal exposure of pelvic organs during surgery. The potential need for blood products is therefore reduced. The technical aspects of the procedure are straightforward with minimal procedure-associated risks. In addition, it is performed quickly with minimal fetal radiation exposure, which in this study was 4 min 30 sec—8 min 12 sec of total fluoroscopy time. The maternal and perinatal morbidity of this procedure has yet to be studied, and patients should be selected carefully.
In conclusion, with early collaboration between the obstetrician and interventional radiologist, perioperative bilateral balloon occlusion of the hypogastric arteries is a safe and simple option that may minimize blood loss in patients with abnormal placentation.
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