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Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis

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Abstract

Purpose

To evaluate the effectiveness and safety of prophylactic intraoperative uterine artery embolization (UAE) performed immediately after fetal delivery during planned cesarean section or cesarean hysterectomy in patients with placenta accreta spectrum disorder or placenta previa.

Methods

A systematic search was conducted on Ovid MEDLINE and Embase, PubMed, Web of Science, and Cochrane databases. Studies were selected using the Population/Intervention/Comparison/Outcomes (PICO) strategy. The intraoperative blood loss and the rate of emergent peripartum hysterectomy (EPH) were the primary outcomes, whereas the length of hospital stay and volume of blood transfused were the secondary outcomes. A random-effects model was employed to pool each effect size. The cumulative values of the primary outcomes were calculated using the generic inverse variance method.

Results

Eleven retrospective cohort studies and five case series were included, recruiting 421 women who underwent prophylactic intraoperative UAE (UAE group) and 374 women who did not (control group). Compared with the control group, the UAE group had significantly reduced intraoperative blood loss (p = 0.020) during cesarean section or cesarean hysterectomy. Furthermore, the EPH rate was also significantly decreased (p = 0.020; cumulative rate: 19.65%), but not the length of hospital stay (p = 0.850) and volume of pRBC transfused (p = 0.140), after cesarean section in the UAE group. The incidence of major complications was low (3.33%), despite two patients with uterine necrosis.

Conclusion

The currently available data provides encouraging evidence that prophylactic intraoperative UAE may contribute to hemorrhage control and fertility preservation in women with abnormal placentation.

Registration

PROSPERO registration code: CRD42021230581. https://clinicaltrials.gov/ct2/show/CRD42021230581

Level of Evidence

Level 2a, systematic review of retrospective cohort studies.

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References

  1. Silver RM, Branch DW. Placenta accreta spectrum. N Engl J Med. 2018;378:1529–36.

    PubMed  Google Scholar 

  2. Cahill AG, Beigi R, Heine RP, Silver RM, Wax JR. Placenta accreta spectrum. Am J Obstet Gynecol. 2018;219:B2–16.

    PubMed  Google Scholar 

  3. Jauniaux E, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, et al. Placenta praevia and placenta accrete diagnosis and management: Green-top guideline No. 27a. BJOG Int J Obstet Gy. 2019;126:e1–48.

    Google Scholar 

  4. Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol. 2018;218:75–87.

    PubMed  Google Scholar 

  5. Jauniaux E, Gronbeck L, Bunce C, Langhoff-Roos J, Collins SL. Epidemiology of placenta previa accreta: a systematic review and meta-analysis. BMJ Open. 2019;9:e031193.

    PubMed  PubMed Central  Google Scholar 

  6. Jauniaux E, Bunce C, Gronbeck L, Langhoff-Roos J. Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol. 2019;221:208–18.

    PubMed  Google Scholar 

  7. Kingdom JC, Hobson SR, Murji A, Allen L, Windrim RC, Lockhart E, et al. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020. Am J Obstet Gynecol. 2020;223:322–9.

    PubMed  PubMed Central  Google Scholar 

  8. Kil KC, Lim SY, Ko HS, Kim SJ, Kwon DJ, Shin JC, et al. The risk factors of emergency cesarean hysterectomy for placenta previa. Korean J Obstet Gynecol. 2007;50:423–8.

    Google Scholar 

  9. Crane JM, Van den Hof MC, Dodds L, Armson BA, Liston R. Maternal complications with placenta previa. Am J Perinatol. 2000;17:101–5.

    CAS  PubMed  Google Scholar 

  10. Sentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J, Jauniaux E, Diagnosis FPA, et al. FIGO consensus guidelines on placenta accreta spectrum disorders: Conservative management. Int J Gynaecol Obstet. 2018;140:291–8.

    PubMed  Google Scholar 

  11. Pinas-Carrillo A, Bhide A, Moore J, Hartopp R, Belli AM, Arulkumaran S, et al. Outcomes of the first 50 patients with abnormally invasive placenta managed using the “Triple P Procedure” conservative surgical approach. Int J Gynaecol Obstet. 2020;148:65–71.

    PubMed  Google Scholar 

  12. Teixidor Vinas M, Belli AM, Arulkumaran S, Chandraharan E. Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure. Ultrasound Obstet Gynecol. 2015;46:350–5.

    CAS  PubMed  Google Scholar 

  13. Shahin Y, Pang CL. Endovascular interventional modalities for haemorrhage control in abnormal placental implantation deliveries: a systematic review and meta-analysis. Eur Radiol. 2018;28:2713–26.

    PubMed  Google Scholar 

  14. Chen C, Lee SM, Kim JW, Shin JH. Recent update of embolization of postpartum hemorrhage. Korean J Radiol. 2018;19:585–96.

    PubMed  PubMed Central  Google Scholar 

  15. Chandraharan E, Rao S, Belli AM, Arulkumaran S. The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta. Int J Gynaecol Obstet. 2012;117:191–4.

    PubMed  Google Scholar 

  16. Palacios-Jaraquemada JM, Fiorillo A, Hamer J, Martinez M, Bruno C. Placenta accreta spectrum: a hysterectomy can be prevented in almost 80% of cases using a resective-reconstructive technique. J Matern Fetal Neonatal Med. 2020. https://doi.org/10.1080/14767058.2020.1716715.

    Article  PubMed  Google Scholar 

  17. Teixidor Vinas M, Chandraharan E, Moneta MV, Belli AM. The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta. Clin Radiol. 2014;69:e345–51.

    CAS  PubMed  Google Scholar 

  18. Picel AC, Wolford B, Cochran RL, Ramos GA, Roberts AC. Prophylactic internal iliac artery occlusion balloon placement to reduce operative blood loss in patients with invasive placenta. J Vasc Interv Radiol. 2018;29:219–24.

    PubMed  Google Scholar 

  19. Salim R, Chulski A, Romano S, Garmi G, Rudin M, Shalev E. Precesarean prophylactic balloon catheters for suspected placenta accreta: a randomized controlled trial. Obstet Gynecol. 2015;126:1022–8.

    CAS  PubMed  Google Scholar 

  20. Chen M, Liu X, You Y, Wang X, Li T, Luo H, et al. Internal iliac artery balloon occlusion for placenta previa and suspected placenta accreta: a randomized controlled trial. Obstet Gynecol. 2020;135:1112–9.

    PubMed  Google Scholar 

  21. Wei X, Zhang J, Chu Q, Du Y, Xing N, Xu X, et al. Prophylactic abdominal aorta balloon occlusion during caesarean section: a retrospective case series. Int J Obstet Anesth. 2016;27:3–8.

    PubMed  Google Scholar 

  22. Collins SL, Alemdar B, van Beekhuizen HJ, Bertholdt C, Braun T, Calda P, et al. Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta. Am J Obstet Gynecol. 2019;220:511–26.

    PubMed  Google Scholar 

  23. Makary M, Chowdary P, Westgate JA. Vascular balloon occlusion and planned caesarean hysterectomy for morbidly adherent placenta: a systematic review. Aust N Z J Obstet Gynaecol. 2019;59:608–15.

    PubMed  Google Scholar 

  24. Pan Y, Zhou X, Yang Z, Cui S, De W, Sun L. Retrospective cohort study of prophylactic intraoperative uterine artery embolization for abnormally invasive placenta. Int J Gynaecol Obstet. 2017;137:45–50.

    PubMed  Google Scholar 

  25. Huang KL, Tsai CC, Fu HC, Cheng HH, Lai YJ, Hung HN, et al. Prophylactic transcatheter arterial embolization helps intraoperative hemorrhagic control for removing invasive placenta. J Clin Med. 2018;7:460.

    PubMed Central  Google Scholar 

  26. Mohan B, Wander G, Bansal R, Mutti J, Tandon P, Juneja S, et al. Intra-operative uterine artery embolization with caesarean delivery in an adjoining operating theatre and catheter lab (OT/CL) complex vs. conventional management in patients with abnormally invasive placenta: a retrospective case control study. J Obstet Gynaecol. 2020;40:324–9.

    PubMed  Google Scholar 

  27. Wang J, Shi X, Li Y, Li Z, Chen Y, Zhou J. Prophylactic intraoperative uterine or internal iliac artery embolization in planned cesarean for pernicious placenta previa in the third trimester of pregnancy: an observational study (STROBE compliant). Medicine (Baltimore). 2019;98:e17767.

    Google Scholar 

  28. Wang M, Ballah D, Wade A, Taylor AG, Rizzuto G, Li B, et al. Uterine artery embolization following cesarean delivery but prior to hysterectomy in the management of patients with invasive placenta. J Vasc Interv Radiol. 2019;30:687–91.

    PubMed  Google Scholar 

  29. Yuan Q, Jin Y, Chen L, Ling L, Bai XM. Prophylactic uterine artery embolization during cesarean delivery for placenta previa complicated by placenta accreta. Int J Gynaecol Obstet. 2020;149:43–7.

    PubMed  Google Scholar 

  30. Radaelli T, Ferrari MM, Duiella SF, Gazzola FG, Campoleoni M, Merlini C, et al. Prophylactic intraoperative uterine artery embolization for the management of major placenta previa. J Matern Fetal Neonatal Med. 2020. https://doi.org/10.1080/14767058.2020.1818218.

    Article  PubMed  Google Scholar 

  31. Niola R, Giurazza F, Nazzaro G, Silvestre M, Nasti G, Di Pasquale MA, et al. Uterine artery embolization before delivery to prevent postpartum hemorrhage. J Vasc Interv Radiol. 2016;27:376–82.

    PubMed  Google Scholar 

  32. Lo TK, Yung WK, Lau WL, Law B, Lau S, Leung WC. Planned conservative management of placenta accreta - experience of a regional general hospital. J Matern Fetal Neonatal Med. 2014;27:291–6.

    PubMed  Google Scholar 

  33. Li Q, Yang ZQ, Mohammed W, Feng YL, Shi HB, Zhou X. Prophylactic uterine artery embolization assisted cesarean section for the prevention of intrapartum hemorrhage in high-risk patients. Cardiovasc Intervent Radiol. 2014;37:1458–63.

    PubMed  PubMed Central  Google Scholar 

  34. Giurazza F, Albano G, Valentino L, Schena E, Capussela T, Di Pasquale MA, et al. Predelivery uterine arteries embolization in patients affected by placental implant anomalies. Radiol Med. 2018;123:71–8.

    PubMed  Google Scholar 

  35. Sun XW, Bai XM, Chen Q, Shen JF, Yang L, Zhang JY, et al. Preset catheter sheaths for uterine arterial embolization in the cesarean section of pernicious preplacental placenta: its application. Clin Exp Obstet Gynecol. 2019;46:108–12.

    Google Scholar 

  36. Mori K, Obata-Yasuoka M, Saida T, Nishida K, Takahashi H, Hosokawa Y, et al. Pelvic arterial embolisation with cyanoacrylate during caesarean hysterectomy for placenta accreta. Minim Invasive Ther Allied Technol. 2020. https://doi.org/10.1080/13645706.2020.1811730.

    Article  PubMed  Google Scholar 

  37. Bouvier A, Sentilhes L, Thouveny F, Bouet PE, Gillard P, Willoteaux S, et al. Planned caesarean in the interventional radiology cath lab to enable immediate uterine artery embolization for the conservative treatment of placenta accreta. Clin Radiol. 2012;67:1089–94.

    CAS  PubMed  Google Scholar 

  38. Mohr-Sasson A, Hochman R, Anteby M, Spira M, Castel E, Hendler I, et al. Cesarean delivery with and without uterine artery embolization for the management of placenta accreta spectrum disorder - a comparative study. Acta Obstet Gynecol Scand. 2020;99:1374–80.

    PubMed  Google Scholar 

  39. Diop AN, Chabrot P, Bertrand A, Constantin JM, Cassagnes L, Storme B, et al. Placenta accreta: management with uterine artery embolization in 17 cases. J Vasc Interv Radiol. 2010;21:644–8.

    PubMed  Google Scholar 

  40. Moher D, Liberati A, Tetzlaff J, Altman DG. Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

    PubMed  PubMed Central  Google Scholar 

  41. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonradomised studies in meta-analysis. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.

  42. Meller CH, Garcia-Monaco RD, Izbizky G, Lamm M, Jaunarena J, Peralta O, et al. Non-conservative management of placenta accreta spectrum in the hybrid pperating room: a retrospective cohort study. Cardiovasc Intervent Radiol. 2019;42:365–70.

    PubMed  Google Scholar 

  43. Gabay M, Boucher BA. An essential primer for understanding the role of topical hemostats, surgical sealants, and adhesives for maintaining hemostasis. Pharmacotherapy. 2013;33:935–55.

    PubMed  Google Scholar 

  44. Saiga A, Yokota H, Higashide T, Takishima H, Omoto A, Kubota Y, et al. The relationship between gelatin sponge preparation methods and the incidence of intrauterine synechia following uterine artery embolization for postpartum hemorrhage. Cardiovasc Intervent Radiol. 2019;42:195–204.

    PubMed  Google Scholar 

  45. Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study. BJOG. 2014;121:62–70.

    CAS  PubMed  Google Scholar 

  46. Khalilzadeh O, Baerlocher MO, Shyn PB, Connolly BL, Devane AM, Morris CS, et al. Proposal of a new adverse event classification by the Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol. 2017;28:1432–7.

    PubMed  Google Scholar 

  47. Machado LS. Emergency peripartum hysterectomy: Incidence, indications, risk factors and outcome. N Am J Med Sci. 2011;3:358–61.

    PubMed  PubMed Central  Google Scholar 

  48. Chawla J, Arora D, Paul M, Ajmani SN. Emergency obstetric hysterectomy: a retrospective study from a teaching hospital in north India over eight years. Oman Med J. 2015;30:181–6.

    PubMed  PubMed Central  Google Scholar 

  49. Huque S, Roberts I, Fawole B, Chaudhri R, Arulkumaran S, Shakur-Still H. Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial. BMC Pregnancy Childbirth. 2018;18:186.

    PubMed  PubMed Central  Google Scholar 

  50. Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MA, Diagnosis FPA, et al. FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management. Int J Gynaecol Obstet. 2018;140:281–90.

    PubMed  Google Scholar 

  51. D’Antonio F, Iacovelli A, Liberati M, Leombroni M, Murgano D, Cali G, et al. Role of interventional radiology in pregnancy complicated by placenta accreta spectrum disorder: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2019;53:743–51.

    CAS  PubMed  Google Scholar 

  52. Nankali A, Salari N, Kazeminia M, Mohammadi M, Rasoulinya S, Hosseinian-Far M. The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis. Reprod Biol Endocrinol. 2021;19:40.

    PubMed  PubMed Central  Google Scholar 

  53. Rand T, Patel R, Magerle W, Uberoi R. CIRSE standards of practice on gynaecological and obstetric haemorrhage. CVIR Endovasc. 2020;3:85.

    PubMed  PubMed Central  Google Scholar 

  54. Soyer P, Barat M, Loffroy R, Barral M, Dautry R, Vidal V, et al. The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences. Quant Imaging Med Surg. 2020;10:1370–91.

    PubMed  PubMed Central  Google Scholar 

  55. Dumousset E, Chabrot P, Rabischong B, Mazet N, Nasser S, Darcha C, et al. Preoperative uterine artery embolization (PUAE) before uterine fibroid myomectomy. Cardiovasc Intervent Radiol. 2008;31:514–20.

    CAS  PubMed  Google Scholar 

  56. Soyer P, Sirol M, Fargeaudou Y, Bour L, Morel O, Dohan A, et al. Placental vascularity and resorption delay after conservative management of invasive placenta: MR imaging evaluation. Eur Radiol. 2013;23:262–71.

    PubMed  Google Scholar 

  57. Ko HK, Shin JH, Ko GY, Gwon DI, Kim JH, Han K, et al. Efficacy of prophylactic uterine artery embolization before obstetrical procedures with high risk for massive bleeding. Korean J Radiol. 2017;18:355–60.

    PubMed  PubMed Central  Google Scholar 

  58. Kuhn T, Martimucci K, Al-Khan A, Bilinski R, Zamudio S, Alvarez-Perez J. Prophylactic hypogastric artery ligation during placenta percreta surgery: a retrospective cohort study. AJP Rep. 2018;8:e142–5.

    PubMed  PubMed Central  Google Scholar 

  59. Sanad AS, Mahran AE, Aboulfotouh ME, Kamel HH, Mohammed HF, Bahaa HA, et al. The effect of uterine artery ligation in patients with central placenta pevia: a randomized controlled trial. BMC Pregnancy Childbirth. 2018;18:351.

    PubMed  PubMed Central  Google Scholar 

  60. Lin J, Lin F, Zhang Y. Uterine artery ligation before placental delivery during caesarean in patients with placenta previa accreta. Medicine (Baltimore). 2019;98:e16780.

    Google Scholar 

  61. Hussein AM, Dakhly DMR, Raslan AN, Kamel A, Abdel Hafeez A, Moussa M, et al. The role of prophylactic internal iliac artery ligation in abnormally invasive placenta undergoing caesarean hysterectomy: a randomized controlled trial. J Matern Fetal Neonatal Med. 2019;32:3386–92.

    PubMed  Google Scholar 

  62. Yu SCH, Cheng YKY, Tse WT, Sahota DS, Chung MY, Wong SSM, 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(117):e1–13.

    Google Scholar 

  63. Ueshima E, Sugimoto K, Okada T, Katayama N, Koide Y, Sofue K, et al. Classification of uterine artery angiographic images: a predictive factor of failure in uterine artery embolization for postpartum hemorrhage. Jpn J Radiol. 2018;36:394–400.

    PubMed  Google Scholar 

  64. 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;20:70–3.

    CAS  PubMed  Google Scholar 

  65. Soro MP, Denys A, de Rham M, Baud D. Short & long term adverse outcomes after arterial embolisation for the treatment of postpartum haemorrhage: a systematic review. Eur Radiol. 2017;27:749–62.

    PubMed  Google Scholar 

  66. Ghanaati H, Sanaati M, Shakiba M, Bakhshandeh H, Ghavami N, Aro S, et al. Pregnancy and its outcomes in patients after uterine fibroid embolization: a systematic review and meta-analysis. Cardiovasc Intervent Radiol. 2020;43:1122–33.

    PubMed  Google Scholar 

  67. Mohr-Sasson A, Spira M, Rahav R, Manela D, Schiff E, Mazaki-Tovi S, et al. Ovarian reserve after uterine artery embolization in women with morbidly adherent placenta: a cohort study. PLoS One. 2018;13:e0208139.

    PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan

    Cheng-Chun Yang, Yi-Chen Chou, Jyun-Yan Liou, Hua-Ming Cheng & Yu-Ting Kuo

  2. Department of Obstetrics and Gynecology, Chi Mei Medical Center, Tainan, Taiwan

    Tian-Ni Kuo

  3. Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

    Yu-Ting Kuo

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  1. Cheng-Chun Yang
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Yang, CC., Chou, YC., Kuo, TN. et al. Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 45, 488–501 (2022). https://doi.org/10.1007/s00270-021-02921-2

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