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Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta
IJG-08797; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
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CLINICAL ARTICLE
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Zhenyu Chen, Ju Li ⁎, Jian Shen, Jiaxi Jin, Wei Zhang, Wan Zhong
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Article history: Received 26 January 2016 Received in revised form 26 May 2016 Accepted 15 August 2016
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Department of Obstetrics and Gynaecology, No. 202 People’s Liberation Army Hospital, Shenyang, China
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Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta
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Objective: To evaluate direct puncture embolization of the internal iliac artery with hemostatic gelatin sponge particles to treat pernicious placenta previa coexisting with placenta accreta during cesarean delivery. Methods: A retrospective study was conducted of data from women with pernicious placenta previa and placenta accreta who underwent direct puncture embolization of the internal iliac artery during cesarean delivery at a center in China between September 1, 2013, and February 28, 2015. Information regarding surgical procedures, operative data, and outcomes during hospitalization were obtained from medical records. Results: The procedure was successful in all 16 cases included. Mean operative time was 78 minutes (range 65–90) and mean estimated blood loss was 1550 mL (range 1000–2500). Complications such as fever, buttock pain, or acute limb ischemia were not observed. The procedure was performed after partial cystectomy for two patients with bladder invasion. Postoperative Doppler imaging indicated uterine recovery and normalized uterine blood flow in all patients. Conclusion: Direct puncture embolization of the internal iliac artery during cesarean delivery was a safe, effective, simple, and rapid method to control hemorrhage among women with pernicious placenta previa and placenta accreta. © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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Keywords: Artery embolization Hemorrhage Pernicious placenta previa Placenta accreta
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1. Introduction
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Pernicious placenta previa (defined as placenta previa attached to previous cesarean delivery scars [1]) is often associated with placenta accreta: in a retrospective study [2], Sumigama et al. showed that 37% of cases of placenta previa among women who had previously delivered by cesarean were associated with placenta increta/percreta. In the past 10 years, the incidence of pernicious placenta previa coexisting with placenta accreta has gradually risen in China as a result of the increased use of cesarean delivery, as well as implementation of a two-child policy [3]. Pernicious placenta previa and placenta accreta can lead to lifethreatening maternal hemorrhage and appreciable challenges for clinical management. Postpartum hemorrhage caused by pernicious placenta previa coexisting with placenta accreta is more severe than that caused by uterine atony, with a mean blood loss of 3000–5000 mL [3]. In the study by Sumigama et al. [2], mean intraoperative blood loss was 3630 ± 2216 g among the patients with pernicious placenta previa and placenta increta and 12 140 ± 8343 g among those with placenta percreta; 4.35% of the affected women died due to hemorrhage.
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⁎ Corresponding author at: Department of Obstetrics and Gynaecology, No. 202 People’s Liberation Army Hospital, No 5 Guangrong Street, Heping District, Shenyang, China, 110003. Tel./fax: +86 2428853560. E-mail address: [email protected] (J. Li).
Furthermore, clinical treatment of this condition is complex. Inappropriate management could result in severe bleeding and instantaneous shock. Several techniques are currently available to treat pernicious placenta previa coexisting with placenta accreta during cesarean delivery. These methods include internal iliac artery ligation, hysterectomy, interventional arterial radioembolization, and balloon occlusion of the artery [4–8]. However, all these methods have limitations and their clinical efficacy is far from ideal owing to technical difficulties, increased duration, and the requirement for complex equipment [9]. The risk of hysterectomy among women with pernicious placenta previa and placenta accreta increases with the number of previous cesarean deliveries [4,10,11]. Internal iliac artery ligation was initially used to control intraoperative bleeding associated with cervical cancer, but later became an option for the treatment of postpartum hemorrhage [12,13]. The uterus can be preserved for some patients with severe postpartum hemorrhage treated by internal iliac artery ligation, and maternal outcome can be improved [5]. However, the procedure is usually performed by experienced surgeons or by obstetricians with a lot of surgical experience. The internal iliac artery must be freed in this operation, which can lead to the injury of ureter and iliac vein, severe pelvic-floor bleeding, prolonged operation time, and postoperative ureteral fistula [13]. Additionally, the effective hemostasis time of this procedure can be short because of the plentiful blood flow from collateral circulation. Pernicious placenta previa coexisting with placenta accreta has traditionally been treated by hysterectomy during cesarean delivery to
http://dx.doi.org/10.1016/j.ijgo.2016.05.018 0020-7292/© 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Chen Z, et al, Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.05.018
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A retrospective study was conducted among patients with pernicious placenta previa coexisting with placenta accreta who attended the Department of Obstetrics and Gynaecology, No. 202 People’s Liberation Army Hospital, Shenyang, China, for cesarean delivery between September 1, 2013, and February 28, 2015. Eligible patients met the inclusion criteria: placenta previa with at least one previous cesarean delivery and the major placenta attached to the uterine scar; placenta accreta suspected by ultrasonography or magnetic resonance imaging, and confirmed by histologic examination; and direct puncture embolization of the internal iliac artery performed during cesarean delivery. Patients for whom there was insufficient data and those who had no desire to preserve fertility were excluded. The protocol was approved by the ethics committee of the present study center. All included patients had provided written informed consent at the time of treatment for the use of their data in future studies. Before cesarean delivery, each patient and her family were informed about the risks of pernicious placenta previa coexisting with placenta accreta, the procedure details, and the potential complications of internal iliac artery embolization during cesarean delivery. Preoperative preparation procedures included careful assessment by Doppler ultrasonography and magnetic resonance imaging of the site to establish invaded depth, scope of placenta accreta, and extrauterine organs affected. The administrative department of hospital was informed and effective coordination set up among a multidisciplinary team, which comprised staff from the departments of obstetrics, urology, anesthesia, and neonatology, as well as the blood bank. Sufficient supplies of the blood products, coagulation factors, and instruments required for surgery were made available. Large-bore venous access and central venous pressure access were inserted before surgery. All operations were performed under epidural anesthesia. Scar tissue was removed from the abdominal wall before entering the intraperitoneal cavity. A transverse incision (approximately 3 cm in length) was made in the seromuscular layer of the uterine segment, which avoided the placenta. The amniotic sac was ruptured with forceps and the amniotic fluid promptly aspirated. Neonates were delivered rapidly after making a bilateral tear of 10–12 cm to the incision. A 20-IU dose of oxytocin was administered intravenously immediately after delivery. Thereafter, a dose of 10–20 IU oxytocin (dissolved in 500 mL of a 0.9% solution of saline) was administered by continuous intravenous infusion, and repeated as necessary. Prostaglandin F2α (250 μg) was injected into the uterine muscle to control hemorrhage. The incision edges were held by oval forceps and the uterine cavity was packed using a gauze pad to stop bleeding from the uterine incision and placental tissue. Direct embolization of the internal iliac artery was performed after temporary hemostasis had been established. The uterus was removed from the pelvis and then retracted upwards and laterally to expose the common iliac artery and its branches. An incision was made in the peritoneum over the blood vessel (3–5 cm in length), along the internal iliac artery, and the ureter was pushed medially. The bifurcation of the common iliac artery was fully exposed and the internal iliac artery was carefully identified. A 100-mg aliquot of hemostatic gelatin sponge particles (diameter 1000–1400 μm) was dissolved in 20 mL 0.9% saline and then carefully transferred into a 20-mL syringe. The dissolved particles were injected into the internal iliac artery using a 14-gauge needle from a position approximately 2.5 cm below the bifurcation of the common iliac artery. The needle of the syringe was held at a 45° angle from the horizon, with the slope of the tip pointing downward. To stop any bleeding, the injection site was pressed with a
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clinical benefits. The aim of the present study was to evaluate a novel operative strategy involving direct puncture embolization of the internal iliac artery to control bleeding during cesarean delivery among Chinese women.
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prevent life-threatening bleeding [14,15]. Hysterectomy can achieve the goal of controlling bleeding; however, the sudden loss of fertility after this operation can result in substantial negative consequences for physical and mental health [16]. Additionally, cesarean hysterectomy requires more time and experience than does simple hysterectomy, and is associated with severe intraoperative hemorrhage [17]. This procedure should, therefore, be performed only when conservative treatment is ineffective. For cultural reasons, it is our experience that women in China tend not to accept hysterectomy because it will lead to the loss of fertility. Interventional arterial radioembolization therapy requires a plastic catheter to be inserted into either the bleeding uterine artery or internal iliac artery, with gelatin sponge particles injected into the target blood vessel under radiographic guidance [18]. Uterine artery or internal iliac artery radioembolization can effectively prevent bleeding and decrease the incidence of hysterectomy. However, this technique must be performed in well-equipped hospitals with close coordination among skilled radiologists and obstetricians. Primary hospitals in China are often inadequately equipped and lack suitable resources to perform radioembolization. In most cases, patients are transferred to the radiology department for postoperative radioembolization when surgical hemostasis fails during cesarean delivery. However, owing to continuous bleeding and hemodynamic instability, it is unsafe to transfer women with placenta accreta who are undergoing cesarean delivery from the operating room to the radiology department. The transfer of patients will delay the rescue time, increase the amount of bleeding, and raise the need for hysterectomy. Cesarean delivery could be performed in the radiology department of well-equipped hospitals, which would allow the radiologist to undertake preoperative prophylactic internal iliac artery catheterization using radiographic guidance while the patient is anesthetized, followed by cesarean delivery by the obstetric team. Immediate emergency radioembolization might be performed when hemorrhage after delivery is uncontrollable. Preoperative prophylactic placement of an occlusion balloon in the bilateral internal iliac artery or abdominal aortic can reduce uterine artery pressure and blood loss among patients with placenta accreta when the balloon is inflated to temporarily occlude the primary blood supply to the uterus [6,7]. Although such occlusion of the internal iliac arteries was considered safe, substantial intraoperative blood loss and the need for transfusion were reported in one study; consequently, the common iliac arteries, rather than the internal iliac arteries, were proposed as the optimum location for the occlusion balloon [8]. Thon et al. [19] reported that balloon occlusion of the internal iliac artery was useful for only some patients; furthermore, the risks of blood loss and hysterectomy remained high. These researchers also showed that balloon catheters were associated with adverse outcomes, including groin hematoma, air in pressurized lines, symptomatic hypotension, leg ischemia, and catheter migration [19]. Balloon occlusion might also damage the arterial wall, resulting in the formation of iliac artery thrombosis, iliac artery pseudoaneurysm, and deep-vein thrombosis [20]. Both interventional radioembolization and balloon occlusion of the artery under radiation have limitations for widespread clinical application. These techniques must be performed in hospital with adequate resources and experienced doctors. Both methods also expose the mother and fetus to ionizing radiation. The safety of such maternal– fetal exposure requires further research. Additionally, it can be a threat to mother and fetus if the internal iliac artery catheters are inserted before cesarean delivery after anesthesia: in one study [19], pregnant women had supine hypotension during insertion, and the fetus was in a state of intrauterine hypoxia. The combination of cesarean delivery and interventional treatment requires close coordination of the multidisciplinary team. Any breakdown in the procedure will delay time to treatment and increase the risk of bleeding. Establishing a new method to promote hemostasis that is simple, fast, and effective would bring substantial
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Please cite this article as: Chen Z, et al, Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.05.018
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bladder invasion; treatment was by partial cystectomy. One (6%) patient displayed disseminated intravascular coagulopathy, which was corrected during the operation. Bleeding was markedly reduced in the operation field after bilateral internal iliac artery embolization. The B-lynch compression sutures were used among 9 (56%) patients. The combination of internal iliac artery embolization and B-lynch compression suturing led to complete cessation of the uterine cavity bleeding. No hysterectomies were performed and all the neonates (n=16) were healthy. The mean estimated blood loss was 1550 mL (range 1000–2500). Transfusion comprised red blood cells (mean 6.4 units, range 2–10) and fresh frozen plasma (mean 750 mL, range 200–1000). Postoperative vaginal bleeding was minimal and no complications (e.g. fever, buttock pain, or acute limb ischemia) were recorded. The mean hospital stay after cesarean delivery was 8 days (range 5–15). Histological examination confirmed the diagnosis of placenta accreta for all 16 patients. No abnormalities in resistance index, pulsatility index, or ratio of peak systolic to end diastolic blood flow velocities of uterine blood flow were found by ultrasonography and color Doppler imaging 42 days after surgery.
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4. Discussion
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3. Results
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Sixteen patients were included (Table 1). Age at hospitalization ranged from 25 to 35 years, and cesarean delivery was performed between 32 and 38 weeks of pregnancy. All cesarean deliveries were elective. Five (31%) of the 16 women had undergone two previous cesarean deliveries. The mean operative time was 78 minutes (range 65–90). Several engorged blood vessels were apparent on the former cesarean delivery scar of the uterus during surgery. The myometrium was lost under the serous membrane of the former uterus scar among all 16 patients. For 2 (13%) patients, the placenta penetrated the uterine serosa with
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Table 1 Clinical profile of the patients who underwent direct puncture embolization of the internal iliac artery (n=16).
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The present study found that direct puncture embolization of the internal iliac artery with hemostatic gelatin sponge particles was a safe and effective option for controlling hemorrhage among women with pernicious placenta previa coexisting with placenta accreta during cesarean delivery. The novel technique of combining cesarean delivery with direct puncture embolization that was evaluated in the present study took advantage of the clinical strengths of these procedures, while minimizing their respective weaknesses. Either internal iliac artery ligation or internal iliac artery embolization can decrease vascular pressure distal to the site of occlusion, reduce blood loss, slow the rate of blood flow, and control bleeding effectively. One hemodynamic study [21] showed that internal iliac artery ligation reduced local pulse pressure by 25%–75% and local blood flow by 50%. Collateral blood circulation developed
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small piece of gauze for approximately 5 minutes after the needle was removed. The contralateral internal iliac artery underwent embolization by the same method. The uterine scar and placental tissue adhering to the uterus were excised together. The remainder of the unimplanted placenta was also removed. The B-lynch compression suture was used to reduce hemorrhage that resulted from removal of the placental tissues. The cesarean delivery incision was closed after cessation of bleeding. The uterus was returned to the abdominal cavity and a drain was placed in the pelvic cavity before closure. Particular attention was paid to ensuring that no gelatin sponge particles could enter the external iliac artery. The surgical assistant was responsible for checking the pulse of the dorsal artery of the foot, measuring the skin temperature, and closely observing any color changes in the limb skin. Damage to the internal iliac vein located under the internal iliac artery was avoided to prevent serious pelvic-floor hemorrhage. The amount of bleeding was estimated from the total volume present in the suction containers, the change in weight of the gauze pads, and a visual estimation of vaginal blood loss. At 42 days after surgery, patients underwent uterine ultrasonography examination to observe blood flow. The relevant data were obtained by reviewing each patient's medical records for the period of hospitalization for cesarean delivery. The data were analyzed using SPSS version 16.0 (SPSS Inc, Chicago, IL, USA). Descriptive statistics were presented as the mean and range.
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Case Age, y Gravidity No. of previous Duration of Estimated Red blood cell Fresh frozen plasma Length of Surgical procedure and parity cesarean deliveries pregnancy, wk+d blood loss, mL transfusion, units transfusion, mL surgery, min
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1500
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700
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1800
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1650 2500
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1000 1000
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2500
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G4P1
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G3P1
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35 33
G2P1 G4P2
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5
30
G3P2
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6 7
32 35
G6P2 G2P1
2 1
36 38+1
1000 1600
4.0 7.5
650 850
65 65
t1:11
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G5P2
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37+0
1550
6.5
800
90
t1:12 t1:13
9 10
35 35
G3P1 G4P1
1 1
38+4 36+4
1000 1700
4.0 6.5
450 800
65 90
t1:14 t1:15
11 12
33 25
G4P1 G2P1
1 1
36+0 35+6
1000 2100
2.0 10.0
200 1000
65 90
t1:16
13
35
G3P2
2
37+3
1400
6.5
800
90
1 1 1
+3
1200 1150 1150
4.5 4.0 4.0
650 550 550
80 90 75
t1:17 t1:18 t1:19 t1:20
14 15 16
35 35 33
G3P1 G4P1 G4P1
37 32+0 38+0
Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization Direct puncture embolization; B-lynch compressing sutures; cystectomy Direct puncture embolization; B-lynch compressing sutures; cystectomy Direct puncture embolization Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization Direct puncture embolization Direct puncture embolization
Abbreviations: G, gravidity; P, parity.
Please cite this article as: Chen Z, et al, Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.05.018
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The authors have no conflicts of interest.
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[1] He Y, Chen D. New understanding of the diagnosis and management of pernicious placenta previa [in Chinese]. Chin J Perinat Med 2015;18(7):494–6. [2] Sumigama S, Itakura A, Ota T, Okada M, Kotani T, Hayakawa H, et al. Placenta previa increta/percreta in Japan: a retrospective study of ultrasound findings, management and clinical course. J Obstet Gynaecol Res 2007;33(5):606–11. [3] Liu Y, Lin Y, Zhou H, Liu X, Wang L. Clinical analysis of bilateral internal iliac arteries balloon occlusion in controlling hemorrhage during caesarean section of patients with pernicious placenta previa. J Pract Obstet Gynecol 2014;30(7):552–4. [4] Sivan E, Spira M, Achiron R, Rimon U, Golan G, Mazaki-Tovi S, et al. Prophylactic pelvic artery catheterization and embolization in women with placenta accreta: can it prevent cesarean hysterectomy? Am J Perinatol 2010;27(6):455–61. [5] Joshi VM, Otiv SR, Majumder R, Nikam YA, Shrivastava M. Internal iliac artery ligation for arresting postpartum haemorrhage. BJOG 2007;114(3):356–61. [6] Paull JD, Smith J, Williams L, Davison G, Devine T, Holt M. Balloon occlusion of the abdominal aorta during caesarean hysterectomy for placenta percreta. Anaesth Intensive Care 1995;23(6):731–4. [7] Tan CH, Tay KH, Sheah K, Kwek K, Wong K, Tan HK, et al. Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta. AJR Am J Roentgenol 2007;189(5):1158–63. [8] Clausen C, Stensballe J, Albrechtsen CK, Hansen MA, Lönn L, Langhoff-Roos J. Balloon occlusion of the internal iliac arteries in the multidisciplinary management of placenta percreta. Acta Obstet Gynecol Scand 2013;92(4):386–91. [9] Angstmann T, Gard G, Harrington T, Ward E, Thomson A, Giles W. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet Gynecol 2010;202(1):38.e1–9. [10] Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005;192(5):1458–61. [11] Armstrong CA, Harding S, Matthews T, Dickinson JE. Is placenta accreta catching up with us? Aust N Z J Obstet Gynaecol 2004;44(3):210–3. [12] Lang WR. Ligation of the hypogastric (internal iliac) arteries in the control of hemorrhage from carcinoma of the cervix. Surg Gynecol Obstet 1963;117:94–6. [13] Camuzcuoglu H, Toy H, Vural M, Yildiz F, Aydin H. Internal iliac artery ligation for severe postpartum hemorrhage and severe hemorrhage after postpartum hysterectomy. J Obstet Gynaecol Res 2010;36(3):538–43. [14] Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 2006;107(4):927–41. [15] Committee on Obstetric Practice. ACOG committee opinion. Placenta accreta. Number 266, January 2002. American College of Obstetricians and Gynecologists. Int J Gynecol Obstet 2002;77(1):77–8. [16] Marcovici I, Rosenzweig BA, Brill AI, Khan M, Scommegna A. Cervical pregnancy: case reports and a current literature review. Obstet Gynecol Surv 1994;49(1): 49–55. [17] Xu H, Li X. Surgical treatment of intractable postpartum hemorrhage. Chin J Pract Gynecol Obstet 2014;30(4):272–4. [18] Chauleur C, Fanget C, Tourne G, Levy R, Larchez C, Seffert P. Serious primary postpartum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases. Hum Reprod 2008;23(7):1553–9. [19] Thon S, McLintic A, Wagner Y. Prophylactic endovascular placement of internal iliac occlusion balloon catheters in parturients with placenta accreta: a retrospective case series. Int J Obstet Anesth 2011;20(1):64–70. [20] Bishop S, Butler K, Monaghan S, Chan K, Murphy G, Edozien L. Multiple complications following the use of prophylactic internal iliac artery balloon catheterisation in a patient with placenta percreta. Int J Obstet Anesth 2011;20(1):70–3. [21] Burchell RC. Internal iliac artery ligation: hemodynamics. Obstet Gynecol 1964;24: 737–9.
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pernicious placenta previa coexisting with placenta accreta. This technique can also be used to treat uterine hemorrhage resulting from other obstetric causes. Consequently, direct puncture embolization potentially offers a novel and flexible approach for clinical practice.
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approximately 1 hour after internal iliac artery ligation; therefore, the other pelvic organs (ovaries, fallopian tube, ureter, bladder, and rectum) retained sufficient blood supplies and did not become necrotic [21]. The new technique assessed in the present study is simple, fast, and effective. It also reduces the probability of damage to the surrounding organs. The new technique eliminates the need to fully free the iliac artery, which substantially reduces the complexity of the procedure, shortens operative time, and avoids injury to the ureter and iliac vein. Severe and potentially life-threatening pelvic-floor bleeding will occur if the internal iliac vein is damaged. Additionally, the gelatin sponge particles used in this procedure are cheap and easily absorbed. Recanalization can be performed 2–3 weeks after embolization, with complete recanalization within approximately 3 months, which will not affect the recovery of menstruation and fertility. By contrast, after ligation of the internal iliac artery, the occluded vessel could fail to recanalize, which would mean that the organ blood supply could be maintained only by collateral circulation and that function might be negatively affected. The new technique is easy to master, without the need for any sophisticated techniques and expensive equipment. This procedure can be performed by an obstetrician–gynecologist without the involvement of radiologists and the associated interdepartmental transfer steps. Therefore, this new method potentially reduces the need for manpower, materials, and financial resources; it also substantially decreases the complexity and time required for surgery. As a result, the bleeding caused by pernicious placenta previa coexisting with placenta accreta can be effectively controlled. Additionally, there is no exposure to ionizing radiation during the operation, which greatly relieves the concerns of the patient and her family. Owing to their large diameter, the diluted gelatin sponge particles used in the new technique were injected into the internal iliac artery using a 20-mL syringe. Bleeding from the needle puncture site was not a concern because the arterial wall is thick, elastic, and rich in both smooth muscle tissue and elastic fibers. After the needle was pulled out, any bleeding was minimal and could be stopped quickly using gauze compression. Potential complications of the new technique might include hip pain (as a result of superior gluteal artery embolization), recurrence of bleeding (owing to collateral circulation), or failure to control bleeding (as a result of anastomoses between the ovarian artery and uterine artery). However, no such complications were found in the present study cohort, which strongly suggested that the procedure was safe. Nevertheless, some limitations of the present study should be highlighted. Despite the increasing incidence of pernicious placenta previa coexisting with placenta accreta, the total number of cases remains low and the present study included only 16 affected individuals. Furthermore, a prospective randomized controlled trial could not be conducted owing to the increased risk of mortality experienced by such patients during cesarean delivery. Data from future well-designed studies involving multiple centers and large numbers of patients will be required to provide vigorous assessment and validation of the efficacy of this novel technique. In conclusion, the present study found that direct puncture embolization of the internal iliac artery during cesarean delivery offered many potential advantages over the other methods currently available to treat
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Please cite this article as: Chen Z, et al, Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.05.018
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
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CLINICAL ARTICLE
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Zhenyu Chen, Ju Li ⁎, Jian Shen, Jiaxi Jin, Wei Zhang, Wan Zhong
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Article history: Received 26 January 2016 Received in revised form 26 May 2016 Accepted 15 August 2016
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Department of Obstetrics and Gynaecology, No. 202 People’s Liberation Army Hospital, Shenyang, China
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Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta
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Objective: To evaluate direct puncture embolization of the internal iliac artery with hemostatic gelatin sponge particles to treat pernicious placenta previa coexisting with placenta accreta during cesarean delivery. Methods: A retrospective study was conducted of data from women with pernicious placenta previa and placenta accreta who underwent direct puncture embolization of the internal iliac artery during cesarean delivery at a center in China between September 1, 2013, and February 28, 2015. Information regarding surgical procedures, operative data, and outcomes during hospitalization were obtained from medical records. Results: The procedure was successful in all 16 cases included. Mean operative time was 78 minutes (range 65–90) and mean estimated blood loss was 1550 mL (range 1000–2500). Complications such as fever, buttock pain, or acute limb ischemia were not observed. The procedure was performed after partial cystectomy for two patients with bladder invasion. Postoperative Doppler imaging indicated uterine recovery and normalized uterine blood flow in all patients. Conclusion: Direct puncture embolization of the internal iliac artery during cesarean delivery was a safe, effective, simple, and rapid method to control hemorrhage among women with pernicious placenta previa and placenta accreta. © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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Keywords: Artery embolization Hemorrhage Pernicious placenta previa Placenta accreta
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1. Introduction
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Pernicious placenta previa (defined as placenta previa attached to previous cesarean delivery scars [1]) is often associated with placenta accreta: in a retrospective study [2], Sumigama et al. showed that 37% of cases of placenta previa among women who had previously delivered by cesarean were associated with placenta increta/percreta. In the past 10 years, the incidence of pernicious placenta previa coexisting with placenta accreta has gradually risen in China as a result of the increased use of cesarean delivery, as well as implementation of a two-child policy [3]. Pernicious placenta previa and placenta accreta can lead to lifethreatening maternal hemorrhage and appreciable challenges for clinical management. Postpartum hemorrhage caused by pernicious placenta previa coexisting with placenta accreta is more severe than that caused by uterine atony, with a mean blood loss of 3000–5000 mL [3]. In the study by Sumigama et al. [2], mean intraoperative blood loss was 3630 ± 2216 g among the patients with pernicious placenta previa and placenta increta and 12 140 ± 8343 g among those with placenta percreta; 4.35% of the affected women died due to hemorrhage.
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⁎ Corresponding author at: Department of Obstetrics and Gynaecology, No. 202 People’s Liberation Army Hospital, No 5 Guangrong Street, Heping District, Shenyang, China, 110003. Tel./fax: +86 2428853560. E-mail address: [email protected] (J. Li).
Furthermore, clinical treatment of this condition is complex. Inappropriate management could result in severe bleeding and instantaneous shock. Several techniques are currently available to treat pernicious placenta previa coexisting with placenta accreta during cesarean delivery. These methods include internal iliac artery ligation, hysterectomy, interventional arterial radioembolization, and balloon occlusion of the artery [4–8]. However, all these methods have limitations and their clinical efficacy is far from ideal owing to technical difficulties, increased duration, and the requirement for complex equipment [9]. The risk of hysterectomy among women with pernicious placenta previa and placenta accreta increases with the number of previous cesarean deliveries [4,10,11]. Internal iliac artery ligation was initially used to control intraoperative bleeding associated with cervical cancer, but later became an option for the treatment of postpartum hemorrhage [12,13]. The uterus can be preserved for some patients with severe postpartum hemorrhage treated by internal iliac artery ligation, and maternal outcome can be improved [5]. However, the procedure is usually performed by experienced surgeons or by obstetricians with a lot of surgical experience. The internal iliac artery must be freed in this operation, which can lead to the injury of ureter and iliac vein, severe pelvic-floor bleeding, prolonged operation time, and postoperative ureteral fistula [13]. Additionally, the effective hemostasis time of this procedure can be short because of the plentiful blood flow from collateral circulation. Pernicious placenta previa coexisting with placenta accreta has traditionally been treated by hysterectomy during cesarean delivery to
http://dx.doi.org/10.1016/j.ijgo.2016.05.018 0020-7292/© 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Chen Z, et al, Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.05.018
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A retrospective study was conducted among patients with pernicious placenta previa coexisting with placenta accreta who attended the Department of Obstetrics and Gynaecology, No. 202 People’s Liberation Army Hospital, Shenyang, China, for cesarean delivery between September 1, 2013, and February 28, 2015. Eligible patients met the inclusion criteria: placenta previa with at least one previous cesarean delivery and the major placenta attached to the uterine scar; placenta accreta suspected by ultrasonography or magnetic resonance imaging, and confirmed by histologic examination; and direct puncture embolization of the internal iliac artery performed during cesarean delivery. Patients for whom there was insufficient data and those who had no desire to preserve fertility were excluded. The protocol was approved by the ethics committee of the present study center. All included patients had provided written informed consent at the time of treatment for the use of their data in future studies. Before cesarean delivery, each patient and her family were informed about the risks of pernicious placenta previa coexisting with placenta accreta, the procedure details, and the potential complications of internal iliac artery embolization during cesarean delivery. Preoperative preparation procedures included careful assessment by Doppler ultrasonography and magnetic resonance imaging of the site to establish invaded depth, scope of placenta accreta, and extrauterine organs affected. The administrative department of hospital was informed and effective coordination set up among a multidisciplinary team, which comprised staff from the departments of obstetrics, urology, anesthesia, and neonatology, as well as the blood bank. Sufficient supplies of the blood products, coagulation factors, and instruments required for surgery were made available. Large-bore venous access and central venous pressure access were inserted before surgery. All operations were performed under epidural anesthesia. Scar tissue was removed from the abdominal wall before entering the intraperitoneal cavity. A transverse incision (approximately 3 cm in length) was made in the seromuscular layer of the uterine segment, which avoided the placenta. The amniotic sac was ruptured with forceps and the amniotic fluid promptly aspirated. Neonates were delivered rapidly after making a bilateral tear of 10–12 cm to the incision. A 20-IU dose of oxytocin was administered intravenously immediately after delivery. Thereafter, a dose of 10–20 IU oxytocin (dissolved in 500 mL of a 0.9% solution of saline) was administered by continuous intravenous infusion, and repeated as necessary. Prostaglandin F2α (250 μg) was injected into the uterine muscle to control hemorrhage. The incision edges were held by oval forceps and the uterine cavity was packed using a gauze pad to stop bleeding from the uterine incision and placental tissue. Direct embolization of the internal iliac artery was performed after temporary hemostasis had been established. The uterus was removed from the pelvis and then retracted upwards and laterally to expose the common iliac artery and its branches. An incision was made in the peritoneum over the blood vessel (3–5 cm in length), along the internal iliac artery, and the ureter was pushed medially. The bifurcation of the common iliac artery was fully exposed and the internal iliac artery was carefully identified. A 100-mg aliquot of hemostatic gelatin sponge particles (diameter 1000–1400 μm) was dissolved in 20 mL 0.9% saline and then carefully transferred into a 20-mL syringe. The dissolved particles were injected into the internal iliac artery using a 14-gauge needle from a position approximately 2.5 cm below the bifurcation of the common iliac artery. The needle of the syringe was held at a 45° angle from the horizon, with the slope of the tip pointing downward. To stop any bleeding, the injection site was pressed with a
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2. Materials and methods
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clinical benefits. The aim of the present study was to evaluate a novel operative strategy involving direct puncture embolization of the internal iliac artery to control bleeding during cesarean delivery among Chinese women.
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prevent life-threatening bleeding [14,15]. Hysterectomy can achieve the goal of controlling bleeding; however, the sudden loss of fertility after this operation can result in substantial negative consequences for physical and mental health [16]. Additionally, cesarean hysterectomy requires more time and experience than does simple hysterectomy, and is associated with severe intraoperative hemorrhage [17]. This procedure should, therefore, be performed only when conservative treatment is ineffective. For cultural reasons, it is our experience that women in China tend not to accept hysterectomy because it will lead to the loss of fertility. Interventional arterial radioembolization therapy requires a plastic catheter to be inserted into either the bleeding uterine artery or internal iliac artery, with gelatin sponge particles injected into the target blood vessel under radiographic guidance [18]. Uterine artery or internal iliac artery radioembolization can effectively prevent bleeding and decrease the incidence of hysterectomy. However, this technique must be performed in well-equipped hospitals with close coordination among skilled radiologists and obstetricians. Primary hospitals in China are often inadequately equipped and lack suitable resources to perform radioembolization. In most cases, patients are transferred to the radiology department for postoperative radioembolization when surgical hemostasis fails during cesarean delivery. However, owing to continuous bleeding and hemodynamic instability, it is unsafe to transfer women with placenta accreta who are undergoing cesarean delivery from the operating room to the radiology department. The transfer of patients will delay the rescue time, increase the amount of bleeding, and raise the need for hysterectomy. Cesarean delivery could be performed in the radiology department of well-equipped hospitals, which would allow the radiologist to undertake preoperative prophylactic internal iliac artery catheterization using radiographic guidance while the patient is anesthetized, followed by cesarean delivery by the obstetric team. Immediate emergency radioembolization might be performed when hemorrhage after delivery is uncontrollable. Preoperative prophylactic placement of an occlusion balloon in the bilateral internal iliac artery or abdominal aortic can reduce uterine artery pressure and blood loss among patients with placenta accreta when the balloon is inflated to temporarily occlude the primary blood supply to the uterus [6,7]. Although such occlusion of the internal iliac arteries was considered safe, substantial intraoperative blood loss and the need for transfusion were reported in one study; consequently, the common iliac arteries, rather than the internal iliac arteries, were proposed as the optimum location for the occlusion balloon [8]. Thon et al. [19] reported that balloon occlusion of the internal iliac artery was useful for only some patients; furthermore, the risks of blood loss and hysterectomy remained high. These researchers also showed that balloon catheters were associated with adverse outcomes, including groin hematoma, air in pressurized lines, symptomatic hypotension, leg ischemia, and catheter migration [19]. Balloon occlusion might also damage the arterial wall, resulting in the formation of iliac artery thrombosis, iliac artery pseudoaneurysm, and deep-vein thrombosis [20]. Both interventional radioembolization and balloon occlusion of the artery under radiation have limitations for widespread clinical application. These techniques must be performed in hospital with adequate resources and experienced doctors. Both methods also expose the mother and fetus to ionizing radiation. The safety of such maternal– fetal exposure requires further research. Additionally, it can be a threat to mother and fetus if the internal iliac artery catheters are inserted before cesarean delivery after anesthesia: in one study [19], pregnant women had supine hypotension during insertion, and the fetus was in a state of intrauterine hypoxia. The combination of cesarean delivery and interventional treatment requires close coordination of the multidisciplinary team. Any breakdown in the procedure will delay time to treatment and increase the risk of bleeding. Establishing a new method to promote hemostasis that is simple, fast, and effective would bring substantial
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Please cite this article as: Chen Z, et al, Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.05.018
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bladder invasion; treatment was by partial cystectomy. One (6%) patient displayed disseminated intravascular coagulopathy, which was corrected during the operation. Bleeding was markedly reduced in the operation field after bilateral internal iliac artery embolization. The B-lynch compression sutures were used among 9 (56%) patients. The combination of internal iliac artery embolization and B-lynch compression suturing led to complete cessation of the uterine cavity bleeding. No hysterectomies were performed and all the neonates (n=16) were healthy. The mean estimated blood loss was 1550 mL (range 1000–2500). Transfusion comprised red blood cells (mean 6.4 units, range 2–10) and fresh frozen plasma (mean 750 mL, range 200–1000). Postoperative vaginal bleeding was minimal and no complications (e.g. fever, buttock pain, or acute limb ischemia) were recorded. The mean hospital stay after cesarean delivery was 8 days (range 5–15). Histological examination confirmed the diagnosis of placenta accreta for all 16 patients. No abnormalities in resistance index, pulsatility index, or ratio of peak systolic to end diastolic blood flow velocities of uterine blood flow were found by ultrasonography and color Doppler imaging 42 days after surgery.
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Sixteen patients were included (Table 1). Age at hospitalization ranged from 25 to 35 years, and cesarean delivery was performed between 32 and 38 weeks of pregnancy. All cesarean deliveries were elective. Five (31%) of the 16 women had undergone two previous cesarean deliveries. The mean operative time was 78 minutes (range 65–90). Several engorged blood vessels were apparent on the former cesarean delivery scar of the uterus during surgery. The myometrium was lost under the serous membrane of the former uterus scar among all 16 patients. For 2 (13%) patients, the placenta penetrated the uterine serosa with
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Table 1 Clinical profile of the patients who underwent direct puncture embolization of the internal iliac artery (n=16).
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The present study found that direct puncture embolization of the internal iliac artery with hemostatic gelatin sponge particles was a safe and effective option for controlling hemorrhage among women with pernicious placenta previa coexisting with placenta accreta during cesarean delivery. The novel technique of combining cesarean delivery with direct puncture embolization that was evaluated in the present study took advantage of the clinical strengths of these procedures, while minimizing their respective weaknesses. Either internal iliac artery ligation or internal iliac artery embolization can decrease vascular pressure distal to the site of occlusion, reduce blood loss, slow the rate of blood flow, and control bleeding effectively. One hemodynamic study [21] showed that internal iliac artery ligation reduced local pulse pressure by 25%–75% and local blood flow by 50%. Collateral blood circulation developed
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small piece of gauze for approximately 5 minutes after the needle was removed. The contralateral internal iliac artery underwent embolization by the same method. The uterine scar and placental tissue adhering to the uterus were excised together. The remainder of the unimplanted placenta was also removed. The B-lynch compression suture was used to reduce hemorrhage that resulted from removal of the placental tissues. The cesarean delivery incision was closed after cessation of bleeding. The uterus was returned to the abdominal cavity and a drain was placed in the pelvic cavity before closure. Particular attention was paid to ensuring that no gelatin sponge particles could enter the external iliac artery. The surgical assistant was responsible for checking the pulse of the dorsal artery of the foot, measuring the skin temperature, and closely observing any color changes in the limb skin. Damage to the internal iliac vein located under the internal iliac artery was avoided to prevent serious pelvic-floor hemorrhage. The amount of bleeding was estimated from the total volume present in the suction containers, the change in weight of the gauze pads, and a visual estimation of vaginal blood loss. At 42 days after surgery, patients underwent uterine ultrasonography examination to observe blood flow. The relevant data were obtained by reviewing each patient's medical records for the period of hospitalization for cesarean delivery. The data were analyzed using SPSS version 16.0 (SPSS Inc, Chicago, IL, USA). Descriptive statistics were presented as the mean and range.
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Case Age, y Gravidity No. of previous Duration of Estimated Red blood cell Fresh frozen plasma Length of Surgical procedure and parity cesarean deliveries pregnancy, wk+d blood loss, mL transfusion, units transfusion, mL surgery, min
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650 850
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G3P1 G4P1
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1000 1700
4.0 6.5
450 800
65 90
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33 25
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1 1
36+0 35+6
1000 2100
2.0 10.0
200 1000
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+3
1200 1150 1150
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650 550 550
80 90 75
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Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization Direct puncture embolization; B-lynch compressing sutures; cystectomy Direct puncture embolization; B-lynch compressing sutures; cystectomy Direct puncture embolization Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization; B-lynch compressing sutures Direct puncture embolization Direct puncture embolization Direct puncture embolization
Abbreviations: G, gravidity; P, parity.
Please cite this article as: Chen Z, et al, Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.05.018
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The authors have no conflicts of interest.
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[1] He Y, Chen D. New understanding of the diagnosis and management of pernicious placenta previa [in Chinese]. Chin J Perinat Med 2015;18(7):494–6. [2] Sumigama S, Itakura A, Ota T, Okada M, Kotani T, Hayakawa H, et al. Placenta previa increta/percreta in Japan: a retrospective study of ultrasound findings, management and clinical course. J Obstet Gynaecol Res 2007;33(5):606–11. [3] Liu Y, Lin Y, Zhou H, Liu X, Wang L. Clinical analysis of bilateral internal iliac arteries balloon occlusion in controlling hemorrhage during caesarean section of patients with pernicious placenta previa. J Pract Obstet Gynecol 2014;30(7):552–4. [4] Sivan E, Spira M, Achiron R, Rimon U, Golan G, Mazaki-Tovi S, et al. Prophylactic pelvic artery catheterization and embolization in women with placenta accreta: can it prevent cesarean hysterectomy? Am J Perinatol 2010;27(6):455–61. [5] Joshi VM, Otiv SR, Majumder R, Nikam YA, Shrivastava M. Internal iliac artery ligation for arresting postpartum haemorrhage. BJOG 2007;114(3):356–61. [6] Paull JD, Smith J, Williams L, Davison G, Devine T, Holt M. Balloon occlusion of the abdominal aorta during caesarean hysterectomy for placenta percreta. Anaesth Intensive Care 1995;23(6):731–4. [7] Tan CH, Tay KH, Sheah K, Kwek K, Wong K, Tan HK, et al. Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta. AJR Am J Roentgenol 2007;189(5):1158–63. [8] Clausen C, Stensballe J, Albrechtsen CK, Hansen MA, Lönn L, Langhoff-Roos J. Balloon occlusion of the internal iliac arteries in the multidisciplinary management of placenta percreta. Acta Obstet Gynecol Scand 2013;92(4):386–91. [9] Angstmann T, Gard G, Harrington T, Ward E, Thomson A, Giles W. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet Gynecol 2010;202(1):38.e1–9. [10] Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005;192(5):1458–61. [11] Armstrong CA, Harding S, Matthews T, Dickinson JE. Is placenta accreta catching up with us? Aust N Z J Obstet Gynaecol 2004;44(3):210–3. [12] Lang WR. Ligation of the hypogastric (internal iliac) arteries in the control of hemorrhage from carcinoma of the cervix. Surg Gynecol Obstet 1963;117:94–6. [13] Camuzcuoglu H, Toy H, Vural M, Yildiz F, Aydin H. Internal iliac artery ligation for severe postpartum hemorrhage and severe hemorrhage after postpartum hysterectomy. J Obstet Gynaecol Res 2010;36(3):538–43. [14] Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 2006;107(4):927–41. [15] Committee on Obstetric Practice. ACOG committee opinion. Placenta accreta. Number 266, January 2002. American College of Obstetricians and Gynecologists. Int J Gynecol Obstet 2002;77(1):77–8. [16] Marcovici I, Rosenzweig BA, Brill AI, Khan M, Scommegna A. Cervical pregnancy: case reports and a current literature review. Obstet Gynecol Surv 1994;49(1): 49–55. [17] Xu H, Li X. Surgical treatment of intractable postpartum hemorrhage. Chin J Pract Gynecol Obstet 2014;30(4):272–4. [18] Chauleur C, Fanget C, Tourne G, Levy R, Larchez C, Seffert P. Serious primary postpartum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases. Hum Reprod 2008;23(7):1553–9. [19] Thon S, McLintic A, Wagner Y. Prophylactic endovascular placement of internal iliac occlusion balloon catheters in parturients with placenta accreta: a retrospective case series. Int J Obstet Anesth 2011;20(1):64–70. [20] Bishop S, Butler K, Monaghan S, Chan K, Murphy G, Edozien L. Multiple complications following the use of prophylactic internal iliac artery balloon catheterisation in a patient with placenta percreta. Int J Obstet Anesth 2011;20(1):70–3. [21] Burchell RC. Internal iliac artery ligation: hemodynamics. Obstet Gynecol 1964;24: 737–9.
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pernicious placenta previa coexisting with placenta accreta. This technique can also be used to treat uterine hemorrhage resulting from other obstetric causes. Consequently, direct puncture embolization potentially offers a novel and flexible approach for clinical practice.
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approximately 1 hour after internal iliac artery ligation; therefore, the other pelvic organs (ovaries, fallopian tube, ureter, bladder, and rectum) retained sufficient blood supplies and did not become necrotic [21]. The new technique assessed in the present study is simple, fast, and effective. It also reduces the probability of damage to the surrounding organs. The new technique eliminates the need to fully free the iliac artery, which substantially reduces the complexity of the procedure, shortens operative time, and avoids injury to the ureter and iliac vein. Severe and potentially life-threatening pelvic-floor bleeding will occur if the internal iliac vein is damaged. Additionally, the gelatin sponge particles used in this procedure are cheap and easily absorbed. Recanalization can be performed 2–3 weeks after embolization, with complete recanalization within approximately 3 months, which will not affect the recovery of menstruation and fertility. By contrast, after ligation of the internal iliac artery, the occluded vessel could fail to recanalize, which would mean that the organ blood supply could be maintained only by collateral circulation and that function might be negatively affected. The new technique is easy to master, without the need for any sophisticated techniques and expensive equipment. This procedure can be performed by an obstetrician–gynecologist without the involvement of radiologists and the associated interdepartmental transfer steps. Therefore, this new method potentially reduces the need for manpower, materials, and financial resources; it also substantially decreases the complexity and time required for surgery. As a result, the bleeding caused by pernicious placenta previa coexisting with placenta accreta can be effectively controlled. Additionally, there is no exposure to ionizing radiation during the operation, which greatly relieves the concerns of the patient and her family. Owing to their large diameter, the diluted gelatin sponge particles used in the new technique were injected into the internal iliac artery using a 20-mL syringe. Bleeding from the needle puncture site was not a concern because the arterial wall is thick, elastic, and rich in both smooth muscle tissue and elastic fibers. After the needle was pulled out, any bleeding was minimal and could be stopped quickly using gauze compression. Potential complications of the new technique might include hip pain (as a result of superior gluteal artery embolization), recurrence of bleeding (owing to collateral circulation), or failure to control bleeding (as a result of anastomoses between the ovarian artery and uterine artery). However, no such complications were found in the present study cohort, which strongly suggested that the procedure was safe. Nevertheless, some limitations of the present study should be highlighted. Despite the increasing incidence of pernicious placenta previa coexisting with placenta accreta, the total number of cases remains low and the present study included only 16 affected individuals. Furthermore, a prospective randomized controlled trial could not be conducted owing to the increased risk of mortality experienced by such patients during cesarean delivery. Data from future well-designed studies involving multiple centers and large numbers of patients will be required to provide vigorous assessment and validation of the efficacy of this novel technique. In conclusion, the present study found that direct puncture embolization of the internal iliac artery during cesarean delivery offered many potential advantages over the other methods currently available to treat
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Please cite this article as: Chen Z, et al, Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.05.018