Editorial| Volume 20, ISSUE 4, P279-281, October 2011

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Interventional radiology in the treatment of morbidly adherent placenta: are we asking the right questions?

Published:September 12, 2011DOI:
      Morbidly adherent placenta or abnormal placentation comprises placenta accreta where placental villi adhere directly to the myometrium; placenta increta with invasion into the myometrium; and placenta percreta with invasion through the myometrium into the peritoneal cavity and possibly into other pelvic organs. Common to these conditions is failure of the placenta to separate normally after birth with accompanying uterine atony and ensuing major haemorrhage. There has been a 10-fold rise in the incidence of morbidly adherent placenta over the last four decades. Independent risk factors are the presence of a placenta praevia, previous caesarean section and advanced maternal age and as such it comes as no surprise that the incidence should be rising. Morbidly adherent placenta is associated with severe morbidity and mortality with intrapartum and postpartum haemorrhage the most common complications
      • Silver R.M.
      • Landon M.B.
      • Rouse D.J.
      • et al.
      Maternal morbidity associated with multiple repeat cesarean deliveries.
      , responsible for 39% of peripartum hysterectomies in the UK.
      • Knight M.
      Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage.
      Other complications include damage to bladder or ureters, requirement for intensive care and ventilation and repeat laparotomy.
      • Silver R.M.
      • Landon M.B.
      • Rouse D.J.
      • et al.
      Maternal morbidity associated with multiple repeat cesarean deliveries.
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        • Silver R.M.
        • Landon M.B.
        • Rouse D.J.
        • et al.
        Maternal morbidity associated with multiple repeat cesarean deliveries.
        Obstet Gynecol. 2006; 107: 1226-1232
        • Knight M.
        Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage.
        BJOG. 2007; 114: 1380-1387
        • Shih J.C.
        • Palacios Jaraquemada J.M.P.
        • Su Y.N.
        • et al.
        Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques.
        Ultrasound Obstet Gynecol. 2009; 33: 193-203
        • Lilker S.J.
        • Meyer R.A.
        • Downey K.N.
        • Macarthur A.J.
        Anesthetic considerations for placenta accreta.
        Int J Obstet Anesth. 2011; 20
        • Sadashivaiah J.
        • Wilson R.
        • Thein A.
        • McLure H.
        • Hammond C.J.
        • Lyons G.
        Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta.
        Int J Obstet Anesth. 2011; 20
        • Wholey M.H.
        • Stockdale R.
        • Hung T.K.
        A percutaneous balloon catheter for the immediate control of hemorrhage.
        Radiology. 1970; 95: 65-71
        • Brown B.J.
        • Heaston D.K.
        • Poulson A.M.
        • Gabert H.A.
        • Mineau D.E.
        • Miller F.J.J.
        Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization.
        Obstet Gynecol. 1979; 54: 361-365
        • Cooper G.M.
        • McClure J.H.
        Anaesthesia chapter from Saving mothers’ lives; reviewing maternal deaths to make pregnancy safer.
        Br J Anaesth. 2008; 100: 17-22
      1. Royal College of Obstetricians and Gynaecologists. The role of emergency and elective interventional radiology in postpartum haemorrhage. Royal College of Obstetricians and Gynaecologists Good Practice Guideline No. 6; 2007.

      2. Royal College of Obstetricians and Gynaecologists. Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management. Green Top Guideline No. 27; January 2011.

        • Paterson-Brown S.
        • Singh C.
        Developing a care bundle for the management of suspected placenta accreta.
        Obstetr Gynaecol. 2010; 12: 21-27
        • Webster V.J.
        • Stewart R.
        • Stewart P.
        A survey of interventional radiology for the management of obstetric haemorrhage in the United Kingdom.
        Int J Obstet Anesth. 2010; 19: 278-281
        • Alvarez M.
        • Lockwood C.J.
        • Ghidini A.
        • Dottino P.
        • Mitty H.A.
        • Berkowitz R.L.
        Prophylactic and emergent arterial catheterization for selective embolization in obstetric hemorrhage.
        Am J Perinatol. 1992; 9: 441-444
        • Dubois J.
        • Garel L.
        • Grignon A.
        • Lemay M.
        • Leduc L.
        Placenta percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses.
        Am J Obstet Gynecol. 1997; 176: 723-726
        • Tan C.H.
        • Tay K.H.
        • Sheah K.
        • et al.
        Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta.
        AJR Am J Roentgenol. 2007; 189: 1158-1163
        • Sivan E.
        • Spira M.
        • Achiron R.
        • et al.
        Prophylactic pelvic artery catheterization and embolization in women with placenta accreta: can it prevent cesarean hysterectomy?.
        Am J Perinatol. 2010; 27: 455-461
        • Mok M.
        • Heidemann B.
        • Dundas K.
        • Gillespie I.
        • Clark V.
        Interventional radiology in women with suspected placenta accreta undergoing caesarean section.
        Int J Obstet Anesth. 2008; 17: 255-261
        • Fuller A.J.
        • Carvalho B.
        • Brummel C.
        • Riley E.T.
        Epidural anesthesia for elective cesarean delivery with intraoperative arterial occlusion balloon catheter placement.
        Anesth Analg. 2006; 102: 585-587
        • Mitty H.A.
        • Sterling K.M.
        • Alvarez M.
        • Gendler R.
        Obstetric hemorrhage: prophylactic and emergency arterial catheterization and embolotherapy.
        Radiology. 1993; 188: 183-187
        • Hansch E.
        • Chitkara U.
        • McAlpine J.
        • El-Sayed Y.
        • Dake M.D.
        • Razavi M.K.
        Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience.
        Am J Obstet Gynecol. 1999; 180: 1454-1460
        • Ojala K.
        • Perälä J.
        • Kariniemi J.
        • Ranta P.
        • Raudaskoski T.
        • Tekay A.
        Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage∗.
        Acta Obstet Gynecol Scand. 2005; 84: 1075-1080
        • Thon S.
        • McLintic A.
        • Wagner Y.
        Prophylactic endovascular placement of internal iliac occlusion balloon catheters in parturients with placenta accreta: a retrospective case series.
        Int J Obstet Anesth. 2011; 20: 64-70
        • Levine A.B.
        • Kuhlman K.
        • Bonn J.
        Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters.
        J Matern Fetal Med. 1999; 8: 173-176
        • Bodner L.J.
        • Nosher J.L.
        • Gribbin C.
        • Siegel R.L.
        • Beale S.
        • Scorza W.
        Balloon-assisted occlusion of the internal iliac arteries in patients with placenta accreta/percreta.
        Cardiovasc Intervent Radiol. 2006; 29: 354-361
        • Shrivastava V.
        • Nageotte M.
        • Major C.
        • Haydon M.
        • Wing D.
        Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta.
        Am J Obstet Gynecol. 2007; 197: 402.e1-402.e5
        • Gonsalves M.
        • Belli A.
        The role of interventional radiology in obstetric hemorrhage.
        Cardiovasc Intervent Radiol. 2010; 33: 887-895
        • 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: 70-73
        • Jeffrey A.
        • Clark V.
        The anaesthetic management of caesarean section in the interventional radiology suite.
        Curr Opin Anaesthesiol. 2011; 24: 439-444
        • Kodali B.S.
        Bloodless trilogy? Anesthesia, obstetrics and interventional radiology for cesarean delivery.
        Int J Obstet Anesth. 2010; 19: 131-132
        • Parekh N.
        • Husaini S.W.
        • Russell I.F.
        Caesarean section for placenta praevia: a retrospective study of anaesthetic management.
        Br J Anaesth. 2000; 84: 725-730
        • Welsh A.W.
        • Ellwood D.
        • Carter J.
        • Peduto A.J.
        • Vedelago J.
        • Bennett M.
        Opinion: integration of diagnostic and management perspectives for placenta accreta.
        Aust N Z J Obstet Gynaecol. 2009; 49: 578-587
        • Angstmann T.
        • Gard G.
        • Harrington T.
        • Ward E.
        • Thomson A.
        • Giles W.
        Surgical management of placenta accreta: a cohort series and suggested approach.
        Am J Obstet Gynecol. 2010; 202: 38.e1-38.e9