Vascular and Interventional Radiology.

Vascular and Interventional Radiology / Radiologie vasculaire et radiologie d’intervention

Conservative Management of Invasive Placenta Using Combined

Prophylactic Internal Iliac Artery Balloon Occlusion and Immediate

Postoperative Uterine Artery Embolization

Donna L. D’Souza, MBBSa,b

, John C. Kingdom, MDc

, Hagai Amsalem, MDc

,

John R. Beecroft, MDa

, Rory C. Windrim, MDc

, John R. Kachura, MDa,

*

a

Department of Medical Imaging, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada b

University of Minnesota, Minneapolis, Minnesota, USA c

Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada

Abstract

Purpose: The objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery

balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with

invasive placenta undergoing scheduled caesarean delivery.

Methods: Ten women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative

insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery

embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome

measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications,

and postoperative morbidity.

Results: All women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was

36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of

the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There

were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed

postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was

successful in 70%.

Conclusion: Combined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control

intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery.

R
esum
e

Objet : L’
etude avait pour objectif d’
evaluer l’efficacit
e et la s
ecurit
e d’une occlusion prophylactique perop
eratoire de l’artere iliaque interne

par ballonnet jumel
ee a une embolisation postop
eratoire des arteres ut
erines dans un contexte de prise en charge conservatrice (pr
eservation

de l’ut
erus) de femmes pr
esentant un placenta invasif et devant subir un accouchement programm
e par c
esarienne.

M
ethodes : Les interventions suivantes ont
et
e pratiqu
ees chez 10 femmes (^age moyen de 35 ans) pr
esentant un placenta invasif et ayant opt
e

pour un accouchement par c
esarienne sans hyst
erectomie : insertion pr
eop
eratoire de ballonnets d’occlusion dans l’artere iliaque interne,

gonflement perop
eratoire des ballonnets et embolisation postop
eratoire imm
ediate des arteres ut
erines a l’aide d’
eponge de g
elatine

r
esorbable. Un examen r
etrospectif a
et
e r
ealis
e apres avoir
et
e approuv
e par le comit
e d’examen de l’
etablissement. Les mesures des

r
esultats englobaient les saignements perop
eratoires, la n
ecessit
e de recourir a une transfusion, le taux d’hyst
erectomie, les complications

endovasculaires, les complications chirurgicales et la morbidit
e postop
eratoire.

R
esultats : Toutes les femmes pr
esentaient un placenta increta ou percreta, ainsi qu’un placenta praevia total. L’^age gestationnel moyen
etait

de 36 semaines a l’accouchement. Le placenta a
et
e laiss
e tel quel dans l’ut
erus de six femmes. Il a toutefois
et
e partiellement retir
e chez

deux patientes et extrait completement morceau par morceau chez deux autres. Selon les estimations, la perte sanguine moyenne a
et
e de 1,2 l

* Address for correspondence: John R. Kachura, MD, Division of Vascular and

Interventional Radiology, Department of Medical Imaging, Toronto General Hospital,

585 University Avenue, NCSB 1C-568, Toronto, Ontario M5G 2N2, Canada.

E-mail address: john.kachura@uhn.ca (J. R. Kachura).

0846-5371/$ - see front matter
2015 Canadian Association of Radiologists. All rights reserved.

http://dx.doi.org/10.1016/j.carj.2014.08.002

Canadian Association of Radiologists Journal 66 (2015) 179e184

www.carjonline.org

au cours de la c
esarienne. Seules deux patientes (20 %) ont n
ecessit
e une transfusion sanguine. Aucune complication chirurgicale

perop
eratoire, aucune complication endovasculaire, aucune mortalit
e chez la mere ni aucune mortalit
e p
erinatale n’ont
et
e relev
ees. Trois

femmes ont pr
esent
e des complications a la suite de l’accouchement et ont d^u subir une hyst
erectomie post-partum. Le taux d’hyst
erectomie

s’
eleve donc a 30 %. L’ut
erus a par ailleurs
et
e pr
eserv
e dans 70 % des cas.

Conclusion : L’occlusion bilat
erale de l’artere iliaque interne par ballonnet jumel
ee a l’embolisation des arteres ut
erines peut se r
ev
eler une

strat
egie efficace pour ma^ıtriser les saignements perop
eratoires et pr
eserver l’ut
erus des patientes qui pr
esentent un placenta invasif et qui

subissent un accouchement par c
esarienne.

2015 Canadian Association of Radiologists. All rights reserved.

Invasive placenta is defined as abnormal adherence of the

placenta to the uterine wall [1,2]. It is classified into placenta

accreta (76%) where placenta embeds directly onto the

myometrium, placenta increta (18%) where it penetrates into

the myometrium, and placenta percreta (6%) where it penetrates

though the myometrium to the serosa or beyond it [3].

In the latter, the placenta may invade adjacent structures such

as bladder or bowel [2,4].

Known risk factors forinvasive placentainclude concomitant

placenta previa, prior caesarean delivery, prior uterine curettage

or other uterine surgery, prior invasive placenta, multiparity, and

advanced maternal age [3,5,6]. The

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