Retrospective observational case series of management of placenta accreta at tertiary care institution

Yogita Patil; Abhilasha Motghare; Dhwani Sanjiv Walavalkar; Indrani Chincholi

doi:10.4103/JOACC.JOACC_4_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 13 | Issue : 1 | Page : 71-74

Retrospective observational case series of management of placenta accreta at tertiary care institution

Yogita Patil, Abhilasha Motghare, Dhwani Sanjiv Walavalkar, Indrani Chincholi
Department of Anaesthesiology and Critical Care, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission	12-Jan-2022
Date of Acceptance	11-Apr-2022
Date of Web Publication	09-Mar-2023

Correspondence Address:
Dr. Dhwani Sanjiv Walavalkar
B 605, Manish Mahal, Off Veera Desai Road, Andheri West, Mumbai - 400 053, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/JOACC.JOACC_4_22

Abstract

Introduction: Placenta accreta is a general term, when part of the placenta or the entire placenta invades and is inseparable from the uterine wall. The incidence is considerably higher in women with both a previous caesarean delivery and placenta praevia, occurring in around 1 in every 20 such women. Resorption of the retained, poorly perfused placenta can be augmented by concurrent treatment with methotrexate when fertility is desired. In cases where operative measures are required, placement of Internal Iliac artery (IIA) balloons preoperatively and their inflation intraoperatively, reduces maternal morbidity and mortality. Materials and Methodology: We present a case series of 14 patients with placenta accreta diagnosed preoperatively, 7 of whom had IIA balloons placed before undergoing Caesarean section and 7 did not have such an intervention. The maternal and foetal morbidity and mortality were studied, including the need for blood and blood product transfusions. Results: Internal Iliac Balloon placements did not change the requirement for blood and blood product transfudion in both groups. The group who had IIA balloon placed preoperatively had better maternal and fetal outcome as compared to the group who had no such intervention.

Keywords: Internal iliac artery balloon, obstetric hysterectomy, placenta accreta, post partum hemorrhage, uterine artery embolization

How to cite this article:
Patil Y, Motghare A, Walavalkar DS, Chincholi I. Retrospective observational case series of management of placenta accreta at tertiary care institution. J Obstet Anaesth Crit Care 2023;13:71-4

How to cite this URL:
Patil Y, Motghare A, Walavalkar DS, Chincholi I. Retrospective observational case series of management of placenta accreta at tertiary care institution. J Obstet Anaesth Crit Care [serial online] 2023 [cited 2023 Mar 25];13:71-4. Available from: https://www.joacc.com/text.asp?2023/13/1/71/371314

Introduction

The incidence of placenta accreta of 1.7 in 10,000 pregnancies has been reported in UK, for the period of 1982–2002.^[1],[2] A conservative approach in the management of placenta accrete, when the placenta may be left in place followed by selective uterine artery embolization or inflation of angioballoons is well practised.^[3],[4],[5] Arterial balloon occlusion and embolization of bleeding vessels of the uterus and genital tract have emerged as a disruptive innovation that is very effective for decreasing blood loss in placental abnormalities and obviating the need for blood transfusion and hysterectomy. In turn, this may reduce the need for intensive care admission and decrease maternal morbidity and mortality.^[6],[7],[8] It not only saves lives but also preserves the fertility of women. In a confidential inquiry conducted in the United Kingdom recently, all patients who underwent radiological embolization preoperatively survived.^[6] Balloons are placed in the internal iliac or uterine arteries before delivery in an interventional radiology suite by a radiologist. The balloons can be inflated to occlude the vessels in the event of postpartum hemorrhage inside the operation theatre. Embolization can be performed via the balloon catheters if bleeding continues despite the inflation of balloons after delivery. Even if hysterectomy is still required, blood loss, blood transfusion, and number of admissions to intensive care units (ICU) can be reduced. Here we are presenting our experience of management of 14 cases of placenta accreta where seven patients had internal Iliac artery balloon (IIA) insertion done before delivery and in seven patients no intervention was done.

Methodology

This is a retrospective analysis of data collected over a period of one year in King Edward Memorial Hospital, Parel, Mumbai from January 2017 to December 2017. Total 14 patients with known placenta accreta were operated on for cesarean delivery electively. After suspected placenta accreta on ultrasonography (USG), magnetic resonance imaging (MRI) was done to confirm the diagnosis in 11 patients. After confirmation of diagnosis, patients were planned with a multidisciplinary approach for IIA insertion, and then they were immediately taken for delivery. IIA insertion is done under local anesthesia, but an anesthesiologist is needed for monitored anesthesia care. General anesthesia was planned in 13 patients. For all the patients, classical cesarean section was planned for better visualization and management. IIA balloons were inflated on the table once the baby was delivered and the cord was clamped. Depending upon blood loss, blood products were ordered and replaced. The decision to leave the placenta in loco where percreta was suspected was taken in one patient and injecting oxytocin was avoided to prevent augmentation of separation of placenta. In our hospital, primary obstetric hysterectomy is done on the table if peripartum hemorrhage (PPH) continues and in one patient delayed hysterectomy was done due to endometritis after 10 days after uterine artery embolization was done post cesarean delivery. After delivery depending upon blood loss and hemodynamic parameters blood products were replaced and number of packed red blood cells (PRBC), fresh frozen plasma (FFP) and Cryoprecipitates (CRYP) transfused were noted. All patients were shifted to the ICU for monitoring and their course in ICU was noted. The maternal and fetal outcome was noted in all the patients. One maternal mortality and one neonatal mortality were noted in 14 patients and the mortality was present in the patient in whom no intervention was planned.

Results

Data were collected for 14 patients. Seven patients had internal iliac artery balloon (Group A) insertion done preoperatively and in the other seven IIA balloon insertion was not done (Group B). All patients had a history of previous cesarean delivery, one patient had a history of placenta accreta in previous delivery with placenta percreta in the current pregnancy. The mean age of patients was 26.4 years (24 – 42 years). Out of 14 patients, 10 patients had documented placenta accrete on MRI and USG scan, rest had USG confirmation for diagnosis of placenta accreta.

In group A, blood loss was 2000 ml (1300 to 4000 ml) and five patients underwent obstetric hysterectomy (OH) on the table due to excess blood loss. One patient out of the five undergoing obstetric hysterectomy underwent uterine artery embolization as a secondary treatment for PPH prevention.

Seven patients did not receive IIA balloon insertion, Group B, treatment and average blood loss was 2207 ml (1200 ml to 4500 ml). Out of seven patients in Group A, six patients required transfusion of blood and blood products, while in group B, all seven patients required transfusion. Therefore, the odds ratio calculated using the Altman formula is 0.288 with P value of 0.47, which is insignificant. This shows that statistically, patients in group B had a 0.28% higher chance of requiring blood and blood product transfusions as compared to Group A.

Two patients in Group B had prolonged their ICU stay and one patient died due to septicemia and multiorgan failure. Only one patient out of seven in group A required OH. But secondary intervention like B Lynch suturing and cystoscopic clot evacuation and secondary suturing due to wound infection was needed in one patient in each group. One neonatal death was reported in group B due to Ante Partum Hemorrhage and prematurity.

Discussion

Post partum haemorrhage (PPH) is a leading cause of maternal mortality.^[1] Numerous women suffer significant morbidity in the form of pituitary necrosis, renal insufficiency, coagulopathy, and respiratory failure and require blood transfusions and hysterectomy due to excessive blood loss because of placental abnormality.

Intervention Radiology (IR) is a minimally invasive treatment modality in which temporary balloon occlusion of the internal iliac artery is done electively before delivery. The advantage of balloon catheter placement are that it can be planned electively so the emergency situation is avoided for delivery. The balloon can be deflated, resuming normal flow when hemostasis is confirmed. Peripheral circulation from ovarian, vaginal, and other arteries is untouched and ischemic complications can be avoided. If balloon occlusion is used prophylactically, quick conversion to embolotherapy (intentional blockage of an artery with an object such as a balloon) is possible in case of need. The disadvantage of balloon placement is that peripheral circulation is preserved which may still lead to hemorrhage and blood loss. Prophylactic catheter placement in cases of placental abnormality has the distinct advantage of prompt commencement of embolization if hemostasis is difficult to achieve after balloon inflation has failed.^[9]

The Royal College of Obstetrics and Gynaecology recommends the use of IR in elective cases of placenta praevia as well as in emergency cases of postpartum hemorrhage.^[10] Recent studies are indicating good fertility outcomes following conservative surgical or radiological treatment of PPH.^[11] It has been proposed that a second (or even a third) uterine sparing procedure such as uterine tamponade or B lynch suturing can be performed in case of a failed first procedure before considering hysterectomy in a hemodynamically stable patient. Hysterectomy should represent the last resort in the management of PPH owing to uterine cause when all other options of management have been exhausted.^[5],[12]

Different embolic materials are used depending on the type of treatment: temporary embolotherapy (pledgets of absorbable gelatine sponge or nonbovine sponge, etc.) and definitive vascular occlusion therapy (microparticles of several sizes, coils, etc.). To minimize the complications due to IR procedures (thrombus, ischemia, and necrosis)^[9] embolization should be performed as selectively as possible. The occlusion of the distal uterine artery bed is, however, temporary and it will re-canalize after 4 to 6 weeks. Successful pregnancies have been reported after IIA embolization.^[12],[13]

In our study, two patients underwent uterine artery embolization after cesarean delivery for excess bleeding out of 14 patients. Even if hysterectomy is required post internal iliac artery balloon inflation, blood loss, blood transfusion, and prolonged ICU admissions were less in group A. Prenatal diagnosis improves maternal and neonatal outcomes through treatment at tertiary centers with experienced multidisciplinary teams.^[14],[15] The multidisciplinary team approach permits a controlled operation with earlier recognition of blood loss and fewer attempts to remove the adherent placenta. So ideally such patients should be referred to centers where this facility is available. Many authors have reported having low blood loss and low hysterectomy rate, with the exception of Mok et al.^[16] who found no decrease in hysterectomy rate which was consistent with our study. Our uterine preservation rate was less than 40% while in other studies it ranged from 71%-86%. This supports the idea that the success of conservative management depends on the amount of placental tissue left behind.^[17] We observed a low successful uterine preservation rate in spite of IIA insertion but less maternal complication rate in our study. Hsiu et al. recommend that primary cesarean hysterectomy should be used as the treatment of choice for mild to severe abnormally invasive placenta to prevent complications of delayed hysterectomy.^[18] However, a survey conducted by Webster et al.^[13] in the UK revealed that only 31% of responding units had the experience with IR in the management of obstetric hemorrhage and only 29% of units had 24-hour availability of an intervention radiologist. Similarly in India IR facility is not commonly available in all the hospitals. Also, balloon insertion and embolization is a very expensive treatment so they may not be recommended for all the patients.

The treatment strategy should be individualized as per institution protocols and expertise available in that particular hospital. The current consensus among experts is that a planned cesarean delivery around 35 weeks of pregnancy and if fertility is not desirable primary hysterectomy is the recommended approach in such cases.^[18]

Anesthesia's concern for such surgeries is that IR suits are generally away from the OT complex. So, patients need to be shifted to IR suits, then again they are wheeled in for cesarean delivery to OR, so, during this shifting possibility of balloon misplacement is there. Then depending upon anesthesiologists' protocol anesthesia is induced. Once the delivery is done internal iliac artery balloons can be inflated on the table. Anaesthesiologist has to be vigilant to estimate correct blood loss and has to gear up for massive transfusion if the need arises. Depending upon blood loss invasive monitoring has to be done. For uterine artery, embolization patient has to be shifted to IR suit again when patients may or may not be hemodynamically stable. Such patients need postoperative ICU care due to the complexity of the procedure and nature of pathology.

The limitation of our study is that it is a retrospective audit and a small number of patients were studied. No randomization was done for any intervention and just an audit was done. So, for any recommendation, a larger sample size with randomization for intervention should be planned. Long term follows up of patients is needed for the safety and efficacy of each intervention to be proven and then offered to the patients for management of adherent placenta.

Conclusion

A multidisciplinary approach along with the combination of bilateral Internal Iliac Artery balloon occlusion and immediate postoperative uterine artery embolization is safe and may be effective in controlling blood loss. The adoption of this approach in routine clinical practice may cause a decrease in morbidity and mortality in women undergoing scheduled cesarean delivery for the invasive placenta.

Legends

*[Table 1], 1-14 patients with placenta accrete in whom for 7 IIA balloon insertion done (Group A) and for 7 no intervention (Group B). Following table shows whether IIA balloons were inflated intraoperatively, Obstetric Hysterectomy done, blood loss, requirement for transfusion and outcomes.

Table 1: Fourteen patients with placenta accrete in whom seven IIA balloon insertions were done (Group A) and for seven no intervention (Group B). The following table shows whether IIA balloons were inflated intraoperatively, Obstetric Hysterectomy done, blood loss, requirement for transfusion, and outcomes

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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