Prophylactic internal iliac balloon placement prior to C-section preserves uterus in patients with placenta accreta

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The results of a new study presented at the annual meeting of the Radiological Society of North America (30 November–5 December, Chicago, USA) show that placement of internal iliac balloons is technically feasible, well-tolerated and leads to satisfactory maternal and foetal outcomes with minimal complications.

Placenta accreta, in which the placenta abnormally implants in the uterus, can lead to additional complications, including massive obstetric haemorrhage at delivery. Hysterectomy is commonly required to control such bleeding.

“Massive obstetric haemorrhage is the number one cause of maternal mortality worldwide and abnormal placental implantation is a major risk factor for this,” said Patrick Nicholson, Cork University Hospital, Cork, Ireland.

At Cork University Hospital, patients with abnormal placental implantation are treated by a multidisciplinary team that plans both an elective Caesarean (C-)section and prophylactic internal iliac balloon placement under fluoroscopic guidance. Immediately prior to the patient’s C-section, an interventional radiologist inserts balloons into the two internal iliac arteries in the pelvis that supply the uterus with blood flow.

“Following the delivery of the baby, these balloons can be inflated to slow blood flow to the uterus, which allows the obstetrician time to gain control of the haemorrhage,” Nicholson said.

Nicholson and team retrospectively reviewed the charts of all patients with abnormal placental implantation who received prophylactic internal iliac balloon placement since 2009. Over a 44-month period, the hospital treated 21 patients (mean age 35) who underwent balloon placement immediately followed by C-section.

In 13 of the 21 deliveries, the arterial balloons were inflated and when no longer needed, deflated and removed from the patient. The interventional radiology procedure was a technical success in 100% of the cases. However, despite use of the balloons, two of the patients required a hysterectomy.

“Without the balloons, many more of the patients would likely have required a hysterectomy,” Nicholson said. There were no maternal or foetal complications resulting from the interventional procedure.

“We are the first group to report on the foetal outcomes associated with prophylactic internal iliac artery balloon placement,” Nicholson said. “There were no adverse outcomes for the babies as a result of this procedure.”

According to Nicholson, the incidence of abnormal placental implantation has been increasing steadily over recent years.

“The risks for placenta accreta and its variations increase with a woman’s age, previous C-sections and in vitro fertilisation, all of which we expect to see more of in the coming decades,” he said. “There is clearly a need for more research in this field.”

Nicholson noted that results of the study add to a growing body of evidence that high-risk placental implantation pregnancies are best managed in a multidisciplinary setting. “This research highlights the value of interventional radiology in managing this very serious, high-risk condition to control bleeding and maternal and foetal complications,” Nicholson said.