Prophylactic balloon occlusion of internal iliac arteries in women with placenta accreta: Literature review and analysis

Aim

To review the literature on the use of prophylactic balloon occlusion alone and in conjunction with arterial embolization of the internal iliac arteries in women with placenta accreta.

Materials and methods

The PubMed, MEDLINE, CINAHL, EMBASE, and Cochrane Library databases were searched for keywords related to this technique and its use in the avoidance of caesarean hysterectomy. The relevant published articles were selected and then searched for further references.

Results

The literature search found 15 case reports and five studies for a total of 20 articles. The use of balloon catheters to prevent post-partum haemorrhage in women with placenta accreta is controversial with some investigators reporting reduced blood loss and transfusion requirements while others reporting no benefit. This procedure does not appear to reduce operative time or hospital stay. Some groups have described catheter-related complications, such as maternal thromboembolic events and the need for stent placement and/or arterial bypass. Thus far, there is no reported maternal or foetal mortality related to this procedure.

Conclusion

Current evidence is based upon case reports and small retrospective studies. Larger studies or randomized controlled trials are essential in order to demonstrate the safety and efficacy of bilateral iliac balloon occlusion. The creation of a data registry would also facilitate the reporting of this technique.

Introduction

Placenta accreta is an abnormal adherence of all or part of the placenta to the uterine wall. The degree of invasion of the placenta into the myometrium is classified as placenta accreta, percreta, and increta. Placenta accreta denotes a superficial myometrial invasion, percreta a deep invasion, and increta invasion through the myometrium with possible adjacent structure involvement.¹

Placenta accreta has an overall incidence of about 1 in 500 with strongest risk factors including previous caesarean delivery, placenta previa, and advanced maternal age.² Placenta accreta is an important cause of life-threatening post-partum haemorrhage with a maternal mortality rate of 7%, and 40% chance of requiring transfusion of >10 units of packed red cells.3, 4

Prenatal diagnosis of placenta accreta is based primarily upon the presence of characteristic findings on ultrasound examination, the primary screening tool for this condition. Ultrasound is reported to have a sensitivity of 93% and specificity of 71% for the diagnosis of placenta accreta.⁵ The use of magnetic resonance imaging (MRI) in detecting placenta accreta has varying results but may complement ultrasound in assessing depth of invasion and adjacent organ involvement for surgical planning and prognosis.⁶

Management for prenatally diagnosed placenta accreta usually consists of a scheduled caesarean hysterectomy.² The internal iliac arteries may be catheterized preoperatively for prophylactic intraoperative balloon occlusion. Prophylactic balloon occlusion of the internal iliac arteries was first reported in 1997 by Dubois et al.⁷ Although there have been scattered reports in the literature concerning the use of this technique since then, there has not yet been any attempt to synthesize the efficacy and complications of this technique. This synthesis is the purpose of the present literature review.