Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
C-2445
Congress:
ECR 2013
Type:
Scientific Exhibit
Authors:
Keywords:
DOI:
10.1594/ecr2013/C-2445
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Page 1 of 18
Purpose
Morbidly adherent placenta (MAP) is a condition which causes significant maternal
morbidity and mortality from post partum haemorrhage. It occurs when there is invasion
[1]
of the chorionic villi into the myometrium and its incidence is increasing , in line with the
increase in caesarian delivery. There are three types of MAP: Placenta percreta, increta
and acreta. Placenta percreta is the most severebut less common.
This is a potentially life threatening condition. It requires a radical treatment such as
peripartum hysterectomy with or without bowel or bladder resection depending on the
degree of infiltration of these organs
[2]
[3]
MAP can be diagnosed before delivery by ultrasound (US) and magnetic resonance
[4]
imaging (MRI) .
This led us to commence a programme in 2007 of prophylactic occlusion balloon insertion
into both internal iliac arteries before caesarian delivery in women with the most severe
forms of morbidly adherent placenta increta and percreta.
The purpose of the occlusion balloons is to reduce blood flow in the uterine arteries
after caesarian delivery and so reduce blood loss, transfusion requirements and need for
caesarian hysterectomy.
Following the success of this programme, in July 2010 our institution developed a
[5]
Page 2 of 18
Page 3 of 18
Fig. 1: Contrast injected through the catheters confirms their correct position.
References: radiology, Saint George's Hospital - London/UK
Test occlusion was performed to ensure reduction/stasis in uterine artery blood flow and
the volume of half strength contrast medium and normal saline solution required was
recorded in the patient's notes and luer lock syringes with the required volume were
attached to the catheters.
Page 4 of 18
Fig. 2: Contralateral placement of occlusion balloon catheters into both internal iliac
areries. Only fluoroscopic images are obtained.
References: radiology, Saint George's Hospital - London/UK
The balloons were then deflated, and the catheter and the sheath flushed, stitched and
dressed to minimize the possibility of movement during the patient's transfer.
In the obstetric theatre a mobile image intensifier was in position so that the interventional
radiologist could check the final position of the balloon catheter and change it if necessary
before caesarian section commenced.
After the baby was delivered and the umbilical cord clamped, the interventional radiologist
was responsible for inflating each balloon to reduce blood flow whilst the obstetrician
closed the uterus.
If there was no evidence of haemorrhage, the balloon catheters were deflated after four
hours and the patient observed for bleeding overnight. If the patient remained stable, the
sheaths and occlusion balloon catheters were removed by the interventional radiologists
the next morning.
Page 5 of 18
If bleeding commenced, then the occlusion balloons could be rapidly re-inflated and the
patient transferred for embolization. If significant hemorrhage occurred immediately in
theatre, either the patient could be transferred to the IR suite or if deemed too unstable for
transfer, the IR could proceed immediately to embolization with gelatin sponge through
the occlusion balloon catheters.
The following parameters were recorded for each procedure: radiographic exposure,
volume of blood loss, transfusion requirements, uterine artery embolization, peri-partum
hysterectomy, APGAR scores and any maternal complications including length of stay
on ITU.
Page 6 of 18
Page 7 of 18
Fig. 1: Contrast injected through the catheters confirms their correct position.
Page 8 of 18
Fig. 2: Contralateral placement of occlusion balloon catheters into both internal iliac
areries. Only fluoroscopic images are obtained.
Page 9 of 18
Page 10 of 18
Results
Twenty two patients were diagnosed with morbidly adherent placenta between December
2007 and September 2012.
All caesarean deliveries apart from one were performed electively. In all cases occlusion
balloons were successfully placed prior to caesarian delivery.
The clinical characteristics of the patients of both groups are summarized in Table 1.
Table 1: The clinical characteristics of all the patients included in the study and for
both groups are summarized in the table.
Page 11 of 18
Page 12 of 18
Fig. 5: BLOOD LOST DURING THE PROCEDURE: The boxplots represents the
smallest and largest observation, lower and upper quartile and median of blood lost
during the procedure. Group 1 had patients outliers and the group is less uniform in
blood lost. The graphic 1 showed than more than 50% of patients treated in Group 2
bled less than the median of blood lost in Group 1.
References: radiology, Saint George's Hospital - London/UK
There was no significant difference between the number of women requiring a transfusion
in both groups (45.5% in Group 1 vs 54.5% in Group 2, p=0,67) although there was a
trend to increased volume of transfused products in Group 1.
There were 8 patients in total who required emergency embolisation for postpartum
haemorrhage (36,4%):
- five of them in Group 1 (45,5%)
- 3 in Group 2 (27,3%),
but this was not statistically significant between both groups (p=0.659).
Page 13 of 18
abscess on page
Page 14 of 18
Table 1: The clinical characteristics of all the patients included in the study and for both
groups are summarized in the table.
Page 15 of 18
Page 16 of 18
Fig. 5: BLOOD LOST DURING THE PROCEDURE: The boxplots represents the smallest
and largest observation, lower and upper quartile and median of blood lost during the
procedure. Group 1 had patients outliers and the group is less uniform in blood lost. The
graphic 1 showed than more than 50% of patients treated in Group 2 bled less than the
median of blood lost in Group 1.
Page 17 of 18
Conclusion
Prophylactic occlusion balloon catheter insertion in both IIA's prior to elective caesarean
delivery in patients with MAP is useful in reducing postpartum haemorrhage, and
decreases the risk of hysterectomy in young women with preservation of fertility. The
Triple P procedure leads to further improvement in outcomes and is the procedure of
choice at our institution.
References
[1]
Obstet Gynecol 2002; 99:976-80. The likelihood of placenta praevia with greater
number of caesaren deliveries and high parity. Gillam M, Rosenberg D, Davis F
[2]
Acta Obstet Gynecol Scand. Sep 2010;89 (9): 1126-33. The morbidly adherent
placenta: an overview of management options. Doumouchtsis S, Arulkumaran S.
[4]
Personal Information
Page 18 of 18