SIR 2009: Treatment of Invasive Placenta Before Delivery Reduces Hysterectomy Rate

Kristina Rebelo

March 13, 2009

March 13, 2009 (San Diego, California) — The prophylactic use of a special occlusion balloon catheter ready to be inflated if needed at the time of cesarean delivery to block potentially perfuse blood flow significantly reduces the need for hysterectomy, according to a retrospective study presented here at the Society of International Radiology (SIR) 34th Annual Scientific Meeting.

Dr. Robert Beecroft

"The procedure is planned ahead of time," study coauthor J. Robert Beecroft, MD, FRCPC, from the Department of Interventional Radiology, University Health Network, Mount Sinai Hospital, in Toronto, Ontario, said during a news conference. "The patient gets an epidural first thing in the morning, then reports to the interventional radiology department, goes back to the obstetric floor for a C-section, and then she is brought back to us."

The interventional radiologist makes a small nick in the skin in both groins and places occlusion balloons inside the arteries in the body under X-ray guidance to control bleeding from within. There is no need for general anesthesia with this procedure, Dr. Beecroft said. The balloons are inflated after the infant is removed from the uterus, as needed.

The bilateral internal iliac-artery balloon is combined with uterine-artery embolization and is safe and effective, according to researchers, in cases of postpartum hemorrhage. It occurs in 1 in 1000 deliveries; however, numbers are increasing because of increased numbers of cesarean deliveries. It is the most common maternal morbidity in developed countries. The technique blocks blood flow through the arteries that supply the uterus, facilitating a smoother delivery.

There are 3 classifications of placental abnormalities: placenta accreta — the mildest (into uterine muscle); placenta increta (through uterine muscle); and placenta percreta — the most severe and life threatening (into adjacent organs).

The retrospective study looked at 14 women (mean age, 34 years; range, 23 – 40 years) between 2002 and 2008 who were diagnosed with the more severe forms of invasive placenta (6 had placenta increta, 8 had placenta percreta) and who underwent the preoperative and postoperative procedures.

Of the 14 study participants, 2 had planned hysterectomy and 12 had planned on preserving the uterus. Mean gestational age was 35 weeks (range, 30 – 38 weeks). Mean fluoroscopy time for the predelivery balloon insertions was 5.4 minutes; strict protocol was in place, Dr. Beecroft said, to absolutely minimize fluoro-radiation exposure.

Within the group of women who had planned uterine preservation, 4 of 12 women (33%) had a major complication: 1 required repeat embolization for delayed postpartum hemorrhage and a D&C procedure for endometritis; and 3 required hysterectomy for delayed postpartum hemorrhage at 2 to 4 months. The population with the intervention also needed fewer blood transfusions (28% vs 90%). In the uterine-preservation group, the hysterectomy rate was 25% (3 of 12 women); uterine preservation was 75% (9 of 12 women).

"Patients who had interventional radiology treatment had a significantly lower hysterectomy rate: only 33% of women had hysterectomy in the [interventional radiology] group, compared with a typical average of 80%," said Dr. Beecroft.

Donna L. D'Souza, MD, the study's lead author, also from the University Health Network in Toronto, told Medscape Radiology that previously, obstetricians knew about the technique worldwide from articles or colleagues, but that they have been waiting for solid research data.

"This relatively new technique will become more accepted and more widely available now that we have given them that data — it's up to them to refer the patients to us," she said. "If the obstetricians will incorporate interventional radiologists' procedures, they will provide greater safety and enhanced care with better outcomes for their patients — and for themselves. C-sections in women with invasive placenta will be easier deliveries with less bleeding."

Session moderator, Robert L. Vogelzang, MD, interventional radiologist and professor of radiology at Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine, in Chicago, Illinois, told Medscape Radiology that imaging helps treating physicians make more determinations in the rare cases of placental invasion. "So that's a big benefit and once again, it saves lives and saves uteruses," he said. "It has to do with the fact that when things go bad in the delivery room, they go bad very, very quickly and the ability to be in a controlled environment is critical."

Dr. Vogelzang added: "The goal of never having the uterus removed for postpartum bleeding is met with the techniques utilized by the interventional radiologist."

The study did not receive commercial support. The investigators and commentator have disclosed no relevant financial relationships.

Society of Interventional Radiology (SIR) 34th Annual Scientific Meeting: Abstract 181. Presented at a news conference March 10, 2009.


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