Interventional Options in Management of Placenta Abnormalities

Caroline Clausen and Lars Lönn

Department of Cardiovascular Radiology Faculty of Health Sciences Copenhagen UniversityRigshospitalet, Denmark.

1

On the behalf of the multidisciplinary team: Obstetrics, Gynecology, Anesthesiology, Section for Transfusion Medicine, Foetal Medicine, Neonatology, Cardiovascular Radiology Copenhagen DK

Learning Objectives

• There are various management options - including the uterus preserving treatment modalities local resection and leaving placenta in situ

• The emphasis is on the role of interventional radiology in a multidisciplinary team, both for the elective and acute setting

• An overview of complications associated with the different management modalities

2Management options for placenta percreta© Caroline Clausen

Background

• Placenta percreta is a rare life-threatening obstetrical condition associated with severe hemorrhage

• The placenta invades the entire depth

of the uterine wall in placenta percreta

• Placenta accreta and increta represents

less severe variants of the same condition

– Risk factors are placenta previa and previous cesarean section

3Management options for placenta percreta© Caroline Clausen

Background

• Personalized approach• Multidisciplinary intervention

– in case of excessive bleeding during pregnancy

• Multidisciplinary activity – at elective cesarean section at 34 weeks gestation

The object of interventional radiological adjunctive support isto reduce hemorrhage and allow appropriate surgery

which imply a low maternal and fetal morbidity and maintained fertility

4Management options for placenta percreta© Caroline Clausen

Early diagnosis by US Doppler and MRI in high risk pregnancies to identify cases for follow-up and advance multidisciplinary planning of cesarean section.

Outline• Hysterectomy is often necessary

– increasing request for maintained fertility

• The main surgical approaches are- Cesarean hysterectomy

- Local extirpative surgical technique

- Leaving placenta or part of placenta in situ combined with embolization

• IR approaches are - Balloon occlusion

- Embolization after delivery.

- Embolization if bleeding persists or reoccurs postop

5

Management options for placenta percreta© Caroline Clausen

Balloon occlusion• Prophylactic temporary occlusion balloon catheters can be placed

bilaterally in the internal or the common iliac arteries to assist establishment of hemodynamic control during local resection of the percreta area or hysterectomy. Alternatively a balloon can be placed in the abdominal aorta. (requiring a 6 or 7 F sheath respectively)

• The catheters are placed under fluoroscopic guidance prior to delivery. • However, in an emergency situation, the aortic occlusion balloon can be

placed without X-ray guidance (REBOA)

• Both balloon occlusion of the common iliac arteries and the abdominal aorta , compared to occlusion of the internal iliac arteries, will in addition block the supply to the placenta percreta from the external iliac arteries.

• Occlusion of the abdominal aorta furthermore arrests blood flow from the median sacral, low lumbar and in some cases the inferior mesenteric artery. However, blood flow from the ovarian and higher lumbar arteries will not be controlled in either of the balloon occlusion techniques.

6

Management options for placenta percreta© Caroline Clausen

Occlusion balloons• To establish temporary hemodynamic control

• Placed under fluoroscopic guidance prior to delivery – Balloon volume tested under fluoroscopic guidance

• Balloons kept deflated while transferred back to the OR

• Balloons can be inflated in the OR without fluoroscopic guidance after the delivery

7

Simple technique

8

Removed postoperatively followed by 10 minutes of manual compression.

Occlusion balloons

• Not any controlled studies regarding the use of interventional radiology in management of placenta percreta

• Initially we placed occlusion balloons in the internal iliac arteries– To limit the extent of ischemia– At the time the most frequently described

9

Balloons in internal iliac arteries

• 17 women with placenta percreta– No complications associated with the use of balloons– Local resection feasible in 9 of the 11 women who requested

preservation of their uterus

• However:– Blood loss was still significant

• Median: 2500 mL (range 450-16.000 mL). Mean: 4050 mL

– 15 of 17 women received blood transfusions

Clausen C et al: Acta Obstet Gynecol Scand. 2013 Apr;92(4):386-91

10

Collateral circulation

• Extensive collateral circulation limits the effect of internal iliac balloon occlusion and embolization

– External iliac arteries– Ovarian arteries– Lumbar arteries– Inferior mesenteric artery– Median sacral artery

11

Chait A, Moltz A, Nelson JH, Jr. 1968.Palacios Jaraquemada JM, Garcia MR, Barbosa NE, Ferle L, Iriarte H, Conesa HA. 2007.

Occlusion balloons• Decision: a more proximal

balloon position

Common iliac arteries?

• Aorta?

• Both will block the supply from the external iliac arteries and iliolumbars

12

Whycommon iliac arteries?

• Most of our cases are anterior percreta.

• Possible to test the balloon volume one site at a time under fluoroscopic guidance prior to delivery– Avoid arresting blood flow to fetus

• Smaller size sheaths at the puncture sites– Lower risk of puncture site complications.

– Easier hemostasis when the balloons are removed

13

Aortic balloon

• Arrests blood flow from the

– median sacral

– low lumbar

– inferior mesenteric artery

• Flow from the ovarian arteries will often not be controlled

14

Aortic balloon REBOA

• In emergency situations

– Can be placed in the OR without fluoroscopic guidance.

• However, ideally in a “hybrid suite”

15

Common iliac arteries

• Four women with placenta percreta until now

– The surgical field seemed considerably ”drier”

– Mean blood loss 1500 mL (range 600-2500 mL).

– One required blood transfusion

16

Common iliac arteries

17

Easy to place as compared to in the internal iliac arteries.

Transarterial embolization

• Selective catheterization of the bleeding vessels or region

• Gel foam or more permanent inert particles are injected under fluoroscopic guidance after the delivery

18

Transarterial embolization

• Transfer to an “angio suite” is necessary– unless a “hybrid suite” is available.

• Some centers describe using internal iliac balloons during transfer

19

Transarterial embolization

• Embolization in placenta percreta has proved to be less effective than in other cases of post-partum hemorrhage (Poujade O, Zappa M, Letendre I, Ceccaldi PF, Vilgrain V, Luton D. 2012)

• Not immediately reversible

• The exposure to ionizing radiation higher than for placement of occlusion balloons

20

Complications

• All transarterial procedures carries a <2% risk of:– access site hematoma

– pseudo aneurysm

– dissection

• Thromboembolism is far less frequent, approx 1‰.– the risk increases if a sheath is left in situ postoperatively.

• In transarterial embolization there is an additional risk of non-target embolization and necrosis

21

Embolization combined with leaving placenta in situ

• Associated with severe complications such as:

– late post-partum hemorrhage up to nine months after the cesarean section

– acute secondary hysterectomy up to nine months after the cesarean section

– Increased risk of infections

22

Clausen C et al: Acta Obstet Gynecol Scand. 2014Review of of 119 placenta percreta cases

Dinkel HP, Durig P, Schnatterbeck P, Triller J. 2003.Luo G, Perni SC, Jean-Pierre C, Baergen RN, Predanic M. 2005.Teo SB, Kanagalingam D, Tan HK, Tan LK. 2008.Yu PC, Ou HY, Tsang LL, Kung FT, Hsu TY, Cheng YF. 2009.

Conclusions• Based on different balloon positions and the review published:

In cases of suspected placenta percreta we recommend:- Balloon occlusion of the common iliac arteries in elective cesarean section.- Balloon occlusion of the abdominal aorta in emergency situations.- Consider embolization only if severe bleeding persists or reoccurs postoperatively.

Whereas:- Embolization combined with leaving placenta in situ associated with severe complications.

23