Intra-arterial Balloon Occlusion to Reduce Operative Bleeding for Placenta Previa Accreta Spectrum.

Cesarean section for placenta previa accreta spectrum carries a significant risk of massive hemorrhage. Hence, it is necessary to understand the various hemostatic procedures, damage control surgery and resuscitation for massive hemorrhage, and systemic management against hypovolemic shock and coagulopathy. In cases of placenta previa with previous cesarean section, the operation should be performed in a tertiary medical facility with well-trained staff and blood availability for transfusion. Preoperative placement of an intra-arterial balloon occlusion catheter in the common iliac artery or aorta is useful for preventing massive hemorrhage.

Placenta Previa Accreta Spectrum: Cesarean Hysterectomy.

When cesarean hysterectomy is scheduled in cases of placenta previa accreta/increta/percreta, it is necessary that the departments of obstetrics, anesthesiology, blood transfusion, urology, and radiology hold a preoperative conference to assure full preparation for the surgery. A ureteral stent inserted just before cesarean section serves as a marker. A uterine incision should be made at a site free of placental contact. The presence/absence of bladder invasion by villi, adhesions, and the degree of vascularization greatly influence the amount of bleeding, and bleeding control is a key point. For prevention of massive hemorrhage, methods of blood flow blockage, such as balloon occlusion catheterization of the aorta or common iliac artery, should be considered. Stored autologous blood and Cell Saver should be prepared. When hysterectomy is performed with the placenta left in situ, handling of the elongated cardinal ligament, ureteric injury, and bladder injury are important issues because the lower uterine segment is enlarged with the placenta. If blood flow is not blocked, separation of the bladder at the area of placenta percreta should be performed as the last step, to reduce bleeding (Pelosi's method). At this time, after handling of the cardinal ligament, bladder separation can be performed more safely if the posterior vaginal wall is incised and exposed first. In cases of placenta accreta or partial placenta accreta/increta/percreta, a diagnosis of morbidly adherent placenta may not be obtained until separation of the placenta is performed. If bleeding from the placental separation surface cannot be controlled, total hysterectomy should be performed without hesitation.

Study of the utility and problems of common iliac artery balloon occlusion for placenta previa with accreta.

AIMS: We investigated whether common iliac artery balloon occlusion (CIABO) was effective for decreasing blood loss during cesarean hysterectomy (CH) in patients with placenta previa with accreta and was safe for mothers and fetuses. METHODS: Of the 67 patients who underwent CH for placenta previa with accreta at our facility from 1985 to 2014, 57 patients were eligible for the study. The amount of intraoperative bleeding during CH was compared between three groups: surgery without blood flow occlusion (13 patients), internal iliac artery ligation (15 patients) and CIABO (29 patients). Additionally, multivariate analysis was performed to assess risk factors for massive bleeding during CH. RESULTS: The mean blood loss in the CIABO group (2027 ± 1638 mL) was significantly lower than in the other two groups (3787 ± 2936 mL in the no occlusion, 4175 ± 1921 mL in the internal iliac artery ligation group; P < 0.05). Multivariate analysis showed that spontaneous placental detachment during surgery (odds ratio [OR] 49.174, 95% confidence interval [CI] 4.98-1763.67), a history of ≥ 2 cesarean sections (OR 9.226, 95% CI 1.07-231.15) and no use of CIABO (OR 26.403, 95% CI 3.20-645.17) were significantly related to massive bleeding during surgery. There was no case of necrosis resulting from ischemia. The mean radiation dose during balloon placement never exceeded the threshold value for fetal exposure. CONCLUSION: Bleeding during CH for placenta previa with accreta can be decreased by CIABO. This study also confirmed the safety of CIABO in regard to maternal lower limb ischemia and fetal radiation exposure during balloon placement.

Usefulness of shock indicators for determining the need for blood transfusion after massive obstetric hemorrhage.

AIM: Massive obstetric hemorrhage (MOH) requires prompt transfusion of red blood cells and coagulation factors. Because MOH has a diverse pathogenesis, the shock index (SI) alone may be insufficient for determining blood transfusion. Here, we retrospectively analyzed patients with MOH to determine usefulness of the indicators of shock including the SI in evaluating the need for blood transfusion. METHODS: We reviewed records of 80 emergency referral patients who had received blood transfusions at our department between 1 January 2009 and 31 July 2011. The shock indicators for blood transfusion are estimated blood loss, fibrinogen level, hemoglobin concentration, the Japan Society of Obstetrics and Gynecology disseminated intravascular coagulation (JSOG DIC) score and the SI. The strength of the correlation of each shock indicator with the transfusion volume was ranked using Spearman's rank correlation coefficient-ρ and multivariate analysis. RESULTS: Although the SI showed significant positive correlation with blood transfusion volume for red blood cell concentrate (RCC) and fresh frozen plasma (FFP) in patients with dilutional coagulopathy, a stronger correlation was seen with the fibrinogen level and JSOG DIC score. In patients with consumptive coagulopathy, the strongest correlation was seen between RCC transfusion volume and fibrinogen level, and between FFP transfusion volume and JSOG DIC score followed by fibrinogen level. In multivariate analysis, only fibrinogen level was significantly associated with both RCC and FFP massive transfusion. CONCLUSION: Because MOH has a diverse pathogenesis, various indicators should be evaluated. Among shock indicators, fibrinogen level was the best indicator of the need for blood transfusion following MOH.

A retrospective analysis of transfusion management for obstetric hemorrhage in a Japanese obstetric center.

Background. Since cryoprecipitate, fibrinogen concentrate, or recombinant activated factor VII is not approved by public medical insurance in Japan, we retrospectively assessed blood product usage in patients with obstetric hemorrhage at our tertiary obstetric center. Material and Methods. 220 patients with obstetric hemorrhagic disorders who underwent blood product transfusion in our institution during a 5-year period were reviewed for the types and volumes of blood products transfused. Results. There was a significant positive correlation (P< 0.001) between the volume of RCC (red blood cell concentrate) transfused and that of FFP (fresh frozen plasma), irrespective of underlying obstetric disorders. The median of FFP to RCC ratio in each patient was 1.3-1.4, when 6 or more units of RCC were transfused. Conclusions. In transfusion for massive obstetric hemorrhage in terms of appropriate supplementation of coagulation factors, the transfusion of RCC : FFP = 1 : 1.3-1.4 may be desirable.

Limitations of internal iliac artery ligation for the reduction of intraoperative hemorrhage during cesarean hysterectomy in cases of placenta previa accreta.

AIM: Our purpose was to evaluate the effect of internal iliac ligation as a bleeding control during cesarean hysterectomy for placenta accreta. METHODS: We retrospectively reviewed the cases of placenta accreta receiving cesarean hysterectomy during the period of 1987-2006 in the Saitama Medical Center. The clinical outcomes of these patients either receiving or not receiving internal iliac artery ligation were compared in terms of bleeding amount, and length of hospitalization. The bleeding amounts in the variants of placenta accreta managed with internal iliac artery ligation were also analyzed to determine whether the different pathological findings would affect blood loss during cesarean hysterectomy. RESULTS: Among 23 cases, the mean blood loss during the operation and the length of hospitalization after the operation, with or without internal iliac artery ligation (IIAL) were not significantly different. There was no significant difference between the mean blood loss and the pathological findings of cases managed with IIAL. CONCLUSION: In cases of placenta previa accreta, ligation of the internal iliac artery did not significantly contribute to hemostasis during cesarean hysterectomy.