|Year : 2014 | Volume
| Issue : 4 | Page : 146-150
Prophylactic bilateral internal iliac artery ligation for management of low-lying placenta accreta: a prospective study
Waleed Refaie, Muhammad Fawzy, Ahmed Shabana
Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
|Date of Submission||03-Jul-2014|
|Date of Acceptance||26-Sep-2014|
|Date of Web Publication||21-Nov-2014|
Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, 35514 Mansoura
Morbidly adherent placenta is one of the most feared complications causing high morbidity and mortality in obstetrics. Cesarean hysterectomy is still the main procedure in the current management of patients diagnosed with morbidly adherent placenta.
To evaluate the efficacy of prophylactic bilateral hypogastric arteries ligation on maternal outcome in diagnosed cases of morbidly adherent placenta.
Obstetrics and Gynecology Department, Mansoura University Hospital, Egypt.
This was a prospective cohort study of 51 pregnant women with a history of previous cesarean sections and diagnosed with low-lying abnormally adherent placenta. All patients underwent prophylactic internal iliac artery ligation after fetal delivery and before extraction of the placenta, the placenta was removed manually in a piecemeal manner and any remaining bleeding points from the placental site were then controlled by hemostatic sutures.
Bilateral internal iliac artery ligation was performed in patients with invasive placenta (accreta and increta) (46/51 = 90.1%) and satisfactory hemostasis was achieved in 38 patients (38/46 = 82.6%). In five patients with placenta previa increta (5/17 = 29.4%), there was uncontrolled blood loss; thus, we proceeded to cesarean hysterectomy. The mean intraoperative blood loss was 1255 ± 589 ml. Blood transfusion was necessary in 35 patients (35/46 = 76%) during the operations. The mean hemoglobin and hematocrit 1 day after the operation were 9.8 ± 1.3 and 31.4 ± 2.3, respectively.
Prophylactic bilateral internal iliac artery ligation before extraction of placenta accrete seemed to be an effective technique to decrease cesarean complications and avoid emergent peripartum hysterectomy.
Keywords: bilateral hypogastric ligations, morbidly adherent placenta, placenta accreta
|How to cite this article:|
Refaie W, Fawzy M, Shabana A. Prophylactic bilateral internal iliac artery ligation for management of low-lying placenta accreta: a prospective study. Tanta Med J 2014;42:146-50
|How to cite this URL:|
Refaie W, Fawzy M, Shabana A. Prophylactic bilateral internal iliac artery ligation for management of low-lying placenta accreta: a prospective study. Tanta Med J [serial online] 2014 [cited 2017 Jun 22];42:146-50. Available from: http://www.tdj.eg.net/text.asp?2014/42/4/146/145278
| Introduction|| |
Pathological adherent placenta with its variants is one of the most common causes of high morbidity and mortality in obstetrics. Its incidence is 1/200-2500 deliveries in USA and one in 800 deliveries in UK because of the increase in the rate of delivery by Cesarean section (CS) . Postpartum hemorrhage is the most common complication, responsible for a quarter of the maternal mortality in the UK and worldwide [2,3].
Pathological adherent placenta occurs when the chorionic villi penetrate the decidua basalis deep into the uterine wall with the absence of the normal intervening Nitabuch's layer. Short-term morbidity (intensive care unit admission, massive blood transfusion, coagulopathy, urological injury, relaparotomy) associated with an attempt at removing the placenta first and repairing the lower uterine segment is less likely to occur if a planned cesarean hysterectomy is performed. Another management option for patients who seek preservation of fertility is leaving the placenta in place as attempting placental separation may increase the risk for hysterectomy in up to 100% of cases .
Many of the techniques that have been developed to minimize intraoperative blood loss have focused on reducing pelvic circulation, primarily of the internal iliac arteries or their branches. Preoperative catheterization with intraoperative balloon occlusion of the hypogastric arteries and embolization are current methods used to control intraoperative bleeding [5,6].
In this prospective study, we evaluated the efficacy of prophylactic intraoperative bilateral internal iliac artery ligation before the removal of the placenta after extraction of the fetus to avoid the risks of hemorrhage and hysterectomy, aiming finally for preservation of fertility in such high-risk patients.
| Patients and methods|| |
This prospective study was carried out in a high-risk pregnancy unit, Obstetrics and Gynecology Department, Mansoura University Hospital, a tertiary care teaching hospital, from January 2011 to October 2013. The study was approved by the Institutional Research Ethical Committee. A written consent was obtained from the patients after informing them about the risk of intrapartum and postpartum hemorrhage, the need for blood transfusion, and the possibility of hysterectomy if needed to stop massive blood loss. Pregnant women with low-lying anterior placenta underlying the CS scar were evaluated. Placental localization was performed by an ultrasound scan and abnormal adhesion of the placenta was verified by color flow Doppler in the third trimester of pregnancy. Routine evaluation of all patients and fetuses was carried out according to the unit's policy by assessment of history, clinical examination, and investigations including 3D ultrasound scan and color flow Doppler. Fifty-one pregnant women with findings confirmed by these imaging modalities were admitted to the high-risk pregnancy unit at 34 weeks of gestation or earlier if vaginal bleeding occurred. All CS were planned at 37 weeks of gestation unless the clinical situations necessitated earlier termination of pregnancy.
A multidisciplinary team including a senior obstetrician and assistant, a urologist, an anesthesiologist, and a pediatrician was involved in the operation. Four units of cross-matched blood were prepared for each patient. After extraction of the fetus, the uterus with the placenta inside was exteriorized outside the incision and the anterior division of the internal iliac artery was ligated 4 cm below the bifurcation of the common iliac on both sides. Then, the placenta was removed manually in a piecemeal manner; any remaining bleeding points from the placental site were then controlled by hemostatic sutures, followed by repair of the uterus and the abdominal wall.
Outcome measures included intraoperative blood loss, total number of blood transfusion units, postoperative hemoglobin and hematocrit, cesarean hysterectomy, maternal morbidity, and mortality. Data obtained were analyzed using SPSS for Windows, version 17.0 (SPSS, Chicago, Illinois, USA). Data were expressed as percentages and mean ± SD.
| Results|| |
A total of 51 patients diagnosed by color Doppler with an abnormally adherent low-lying placenta were studied; 41(41/51 = 80.3%) of these patients presented with antepartum hemorrhage and 10 were discovered accidentally during regular ultrasound scanning ([Table 1]). Forty-nine (96%) patients had undergone previous single or multiple CS. Eight patients had a history of first-trimester miscarriage (8/51 = 15.6%) and all were terminated surgically. There was a history of previous placenta previa in one patient. Pregnancy was terminated in five patients because of antepartum hemorrhage before 36 weeks, whereas 46 patients (90.2%) completed their pregnancy beyond 36 weeks.
Bilateral internal iliac artery ligation was performed in all patients with morbid invasive placenta (46/51 = 90.1%), whereas uterine artery ligation was performed in five patients (5/51 = 9.8%) in whom the low-lying placenta was not pathologically adherent. Satisfactory hemostasis was achieved in 38 patients (38/46 = 82.6%), whereas additional uterine compression suture was performed in one patient (1/17 = 5.8%). Supracervical hysterectomy was performed in five patients with placenta previa increta (5/17 = 29.4%) complicated by intraoperative uncontrollable hemorrhage ([Table 2]).
The mean intraoperative blood loss was 1255 ± 589 mm 3 . Blood transfusion was recordered in 35 patients (35/46 = 76%) during the operation and in two patients (2/46 = 4.3%) on the first day after the operation. The mean hemoglobin and hematocrit 1 day after the operation were 9.8 ± 1.3 and 31.4 ± 2.3, respectively. No febrile complications or infection were encountered during the postoperative period. Out of five patients who underwent hysterectomy, one patient had accidental bladder and unilateral ureteric injury. Intraoperative consultation with a urologist was advised. Ureteric reimplantation and urinary bladder repair were performed, with uneventful outcomes.
| Discussion|| |
The incidence of placental invasion is increasing because of the increased rate of CS. It has increased up to 10-fold in the past 50 years . Forty-nine (96%) patients with reported placenta accreta had undergone previous one or more CS. Up to 88% of these patients had concomitant placenta previa .
In this study, the incidence of placenta accreta in women without a history of CS was 2/51 (3.9%), whereas it increased up to 8/51 (15.7%) in women with a history of delivery by one CS, 33/51 (64.7%) in women with a history of previous two or three CS, and 10/51 (19.6%) in women with a history of previous four CS. Clark et al.  reported that placenta previa in women without a history of delivery by CS was 0.26%, whereas it increased up to 0.65% in women with a history of delivery by one CS, reaching 10% after four or more CS, whereas the ACOG committee on obstetric practice 2002 reported that the incidence of adherent placenta increased up to 39% for those who had undergone previous two CS [8,9].
Obstetric hemorrhage remains a leading cause of pregnancy-related mortality in the USA. Approximately 29% of maternal deaths are because of bleeding . Placenta accreta is an important cause of obstetric hemorrhage and a leading cause of peripartum hysterectomy .
Hysterectomy has traditionally been the management of choice in placenta accreta, but this represents a problem for patients who desire to preserve the uterus for future fertility thus, other alternative interventions include leaving the placenta after cesarean delivery with surgical uterine devascularization, embolization of the uterine vessels, uterine compression sutures, and/or oversewing of the placental vascular bed .
Many of the procedures that have been developed to minimize intraoperative blood loss depend on reducing pelvic circulation, primarily of the internal iliac arteries for disruption of the arterial supply to the uterus while preserving the blood supply of the pelvic organs and lower limbs. This has been accomplished with varying success either by temporary balloon occlusion or by irreversible surgical internal iliac ligation and embolization by an interventional radiologist. Isolated cases reporting the efficacy of devascularization of the uterine arteries have been published, but the techniques have not become popular so far .
Surgical internal iliac artery ligation is often used to attempt to control otherwise intractable obstetric hemorrhage. Therefore, a huge amount of blood loss has already occurred before hemorrhage can be controlled by arterial ligation. In this study, early prophylactic intraoperative bilateral internal iliac artery ligation was performed before any attempt to remove the abnormally adherent placenta, which is the main source of severe blood loss that might occur in such a situation, a technique to reduce the pulse pressure distal to the site of ligation, thus minimizing blood loss during cesarean delivery in placenta accreta. It seemed to be successful in patients with placenta accreta as none of these patients (n = 29) required hysterectomy or suffered morbidity; however, five patients with placenta increta (5/17, 29.4%) required hysterectomy, with more blood loss, and in one of them, maternal morbidities in the form of bladder and ureteric injury occurred.
The mean estimated blood loss was 1255 ± 589 ml, requiring an average of 1.8 ± 1.3 blood units. Aggarwal et al. reported massive blood loss as the prominent feature in all women with morbidly adherent placenta, with a mean blood loss of 2710 ml, and an average of 6 U of whole blood were transfused. Thus, internal iliac artery ligation may not only limit blood loss but may also minimize the risk of transfusion reactions and blood-borne infections. In contrast, Berg et al.  reported that ligation of the internal iliac arteries appears to be effective for bleeding because of uterine atony; it is less effective for placenta accreta. The efficacy of ligation is limited by rapid recruitment of an extensive collateral system in the pelvis .
The sole use of occlusion balloons in controlling hemorrhage in patients with placenta accreta is even less common. Tan et al. and Carnevale et al. found that balloon occlusion of the main trunk of the internal iliac arteries reduced intraoperative blood loss and transfusion requirements when comparing the patients retrospectively with a control group [16,17]. Occlusion balloons have the advantage of being completely reversible immediately after the procedure in comparison with surgical ligation of internal iliac arteries. Surgical internal iliac artery ligation requires only an expert obstetrician and just a few minutes for bilateral ligation, but preoperative balloon occlusion procedures require a team approach to patient care, and timely actions by the interventional radiologist are essential. Balloon access to the internal iliac arteries through a bilateral common femoral artery approach was gained within 30 min .
Preoperative prophylactic internal iliac artery embolization apparently reduces intraoperative blood loss and transfusion requirements in patients with placenta accreta compared with historical controls . A review of the literature by Alanis and colleagues showed arterial embolization to be effective in treating placenta increta in women who sought to preserve fertility. In 72 women, a 76.9% success rate and an 11% complication rate were found . A major advantage of surgical internal iliac artery ligation over intraoperative balloon occlusion and embolization is prevention of exposure of both the patient and the fetus to ionizing radiation, save time and team works as interventional radiologist. Also, complications of balloon occlusion with embolization occur in about 7% of patients. These include complications of angiography, pelvic infection (i.e. pelvic abscess), and ischemic phenomena such as bladder gangrene and a postembolization syndrome, a self-limited condition of fever, elevated white blood cells, and pain from tissue necrosis or vascular thrombosis .
Our results must be interpreted with caution because the long-term effects of internal iliac ligation were not assessed in this series. This is one of the shortcomings of this study. Moreover, the number of patients was small and the study was a prospective case series rather than a comparative study.
| Conclusion|| |
Abnormal placentation such as placenta accreta or increta is a potentially life-threatening hemorrhagic condition that carries a high rate of maternal morbidity and mortality. Prophylactic bilateral internal iliac artery ligations before extraction of placenta accrete seemed to be an effective and safe technique to decrease intrapartum and postpartum complications, and to avoid emergent peripartum hysterectomy.
| Acknowledgements|| |
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[Table 1], [Table 2]