Vasiliki Anemikos

Introduction: Placenta accreta is an acute condition that occurs during pregnancy in which the placenta attaches too firmly to the wall of the uterus, and in some cases grows into the wall of the uterus, leading to failure of the placenta to separate normally from the uterus^1,2. The most significant risk factor includes previous cesarean delivery, which can be correlated to the rising cases of placenta accreta from .8 in 1000 births to 3 in 1000 births^1,2,3,4. Placenta accreta is a major risk factor for the development of postpartum or intrapartum hemorrhage, conditions that have mortality rates as high as 7% ^4,5,6 and that are highly associated with hysterectomy ^4,7.  Multiple techniques to minimize these risks are being explored, including balloon catheter artery occlusion of the internal iliac arteries (BCA)^5,8,9. Past studies have been inconclusive regarding the efficacy if this procedure. It is assumed that the preservation of the uterus is synonymous to the preservation of fertility, more research must be done to confirm this assumption. Methods:  Patients suspected to be one the placenta accreta scale (diagnosed via ultrasound) were given cesarean sections using one of the following hemostasis methods: BCA of the iliac arteries, combined pressure hemostasis, and iliac artery ligation¹⁰. Once delivery was complete, hemostasis methods were utilized and blood loss, surgery duration, subsequent hysterectomy rate, and postoperative length of stay were measured¹⁰. Results: Without invasive placenta accreta patients who underwent BCA had significantly lower hysterectomy rates, but blood loss and other measures were similar to other methods¹⁰. With invasive placenta accreta hysterectomy rates and blood volume loss in patients who underwent BCA were similar to those treated with other methods. Regardless of invasiveness BCA patients had longer surgical times and post postoperative hospital stays were longer comparatively. Combined pressure hemostasis was shown to be the most effective method with significantly lower rates of hysterectomy and significantly less blood loss compared to other methods¹⁰. Conclusions: Studies have found that BCA is not a successful method for preventing hysterectomy and postpartum hemorrhage in women with placenta accretta^10,11. Comparatively, it is more expensive than other methods and involves unnecessary radiological intervention¹⁰. Failures in this procedure are suspected to be due to the excessive blood flow to the uterus during delivery, intrapelvic anastomoses, abnormal vascular branching, and collateral circulation¹⁰.

1.  Placenta Accreta Overview – Brigham and Women’s Hospital. Accessed March 21, 2021. https://www.brighamandwomens.org/obgyn/maternal-fetal-medicine/pregnancy-complications/placenta-accreta
2. Placenta Accreta: Types, Risks, Causes & Treatment. Accessed March 21, 2021. https://my.clevelandclinic.org/health/diseases/17846-placenta-accreta
3. Media BK-K. Publications & Guidelines | SMFM.org – The Society for Maternal-Fetal Medicine. Accessed March 22, 2021. https://www.smfm.org/publications/103-placenta-accreta
4. Garmi G, Salim R. Epidemiology, Etiology, Diagnosis, and Management of Placenta Accreta. Obstet Gynecol Int. 2012;2012. doi:1155/2012/873929
5. Barinov S, Tirskaya Y, Medyannikova I, Shamina I, Shavkun I. A new approach to fertility-preserving surgery in patients with placenta accreta. J Matern Fetal Neonatal Med. 2019;32(9):1449-1453. doi:1080/14767058.2017.1408066
6. Jauniaux ERM, Alfirevic Z, Bhide AG, et al. Placenta Praevia and Placenta Accreta: Diagnosis and Management. BJOG: An International Journal of Obstetrics & Gynaecology. 2019;126(1):e1-e48. doi:https://doi.org/10.1111/1471-0528.15306
7. Selman A. Caesarean hysterectomy for placenta praevia/accreta using an approach via the pouch of Douglas. BJOG. 2016;123(5):815-819. doi:1111/1471-0528.13762
8. Chen M, Liu X, You Y, et al. Internal Iliac Artery Balloon Occlusion for Placenta Previa and Suspected Placenta Accreta: A Randomized Controlled Trial. Obstetrics & Gynecology. 2020;135(5):1112-1119. doi:1097/AOG.0000000000003792
9. Uterine Sparing Techniques in Placenta Accreta – MedCrave online. Accessed March 21, 2021. https://medcraveonline.com/OGIJ/uterine-sparing-techniques-in-placenta-accreta.html
10. Shmakov RG, Vinitskiy AA, Chuprinin VD, Yarotskaya EL, Sukhikh GT. Alternative approaches to surgical hemostasis in patients with morbidly adherent placenta undergoing fertility-sparing surgery. The Journal of Maternal-Fetal & Neonatal Medicine. 2019;32(12):2042-2048. doi:1080/14767058.2018.1424821
11. Yu SCH, Cheng YKY, Tse WT, et al. Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial. Am J Obstet Gynecol. 2020;223(1):117.e1-117.e13. doi:1016/j.ajog.2020.01.024