Balloon Occlusion of Internal Iliac Arteries in Management of Morbidly Adherent Placenta: Initial Experience at Our Centre

Background: Abnormal placentation is a potential cause of maternal morbidity and mortality from massive postpartum bleeding. Interventional radiology has impressive role in management of various obstetrical emergencies. Pelvic arterial embolization has added a new dimension in the management of obstetric hemorrhage. Method(s): This is a retrospective study conducted at radiology and gynecology departments of Rehman Medical Institute Peshawar. We retrospectively studied eleven cases over a period of two years from May 2015 to May 2017 and patients were diagnosed of having morbidly adherent placenta during antenatal period either by ultrasound or magnetic resonance imaging (MRI). The mean gestational age at presentation was 36 weeks. All patients were in age group of 30-36 yrs with mean age of +33.37 yrs. All were multiparous with a mean parity of +4-5. Previous Cesarean Section delivery was the major independent risk factor in most of the cases. About 60% cases were diagnosed during antenatal checkup and in most of the cases the placenta were type IV Placenta previa. Patients were divided into two groups. 5 patients were managed by conventional treatment (conventional group). In 6 cases, interventional radiologist was involved for trans-catheter arterial balloon occlusion balloon occlusion (study group). The internal iliac balloons were inserted pre-operatively and arterial occlusion was done just after the delivery and in one case additional uterine artery embolization was done post-operatively. In Conventional treatment, no prophylactic temporary balloon occlusion was done and patients were treated by either removal of placenta and oversewing of the placental bed or caesarean hysterectomy. One patient presented postoperatively with placenta in situ and septicemia. Result(s): The results of the two groups were compared taking different variables into account. In comparing the operating time the mean operating time in conventional group was +2.37 hr and that in interventional group was +1.25 hr with a total increase of approx.1.12 hr, which is quiet significant. The average blood loss was 962 ml more in conventional group (mean 2037 ml vs 1075 ml) and consequently increased transfusion of blood (mean+6.5 packs vs. 2.25 packs i.e 4.25 packs more). In our comparative study platelets and fresh frozen plasma (FFP) was exclusively needed in conventional group. Mean stay in intensive care unit (ICU) was more in conventional group with a mean of 2.7 days as compared to 1 day in interventional group. In 2 cases there was per-operative injury to surrounding structures attributed to difficult obstetric emergency and excessive blood loss. In one case the patient had ureteric injury and in other case there was bladder injury. In interventional group, not even a single case of damage to surrounding structure was noted, which can be partly attributed to less stress of the surgeon due to comparatively better hemodynamic stability of patient and partly due to clear field of the surgeon. Conclusion(s): We conclude that use of per-operative arterial occlusive balloons for managing morbidly adherent placenta at our center showed good initial results with decreased patient morbidity.

Keywords: Intra-arterial occlusive balloons, morbidly adherent placenta, placenta accreta, placenta increta, placenta percreta

 

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Publication History

Article published online:
11 May 2021