balloon occlusion of internal iliac arteries in

ORIGINAL ARTICLE

BALLOON OCCLUSION OF INTERNAL ILIAC ARTERIES IN MANAGEMENT OF MORBIDLY ADHERENT PLACENTA: INITIAL EXPERIENCE AT OUR CENTER Fazia Raza,1 Aman Nawaz Khan,2 Ummara Siddique Umer,2 Syed Ghulam Ghaus,2 Seema Gul,2 Shahjehan Alam,2 Sara Gul,1 Hadia Abid,2 Abdullah Safi,2 Kalsoom Nawab2 1Gynae 2De

col ogy De partm e nt, Re h m an M e dicalIns titute , Pe s h aw ar, Pak is tan. partm e ntofRadiol ogy, Re h m an M e dicalIns titute , Pe s h aw ar, Pak is tan.

PJR April - June 2018; 28(2): 109-114

ABSTRACT PURPO SE: To e val uate th e initialre s ul ts of pe r ope rative intra-arte rialoccl uding bal l oons w h e n us e d as an adjunct to s urge ry to re duce patie nt m orbidity in patie nts w ith m orbidl y adh e re nt pl ace nta. PATIENTS AND M ETH ODS: Th is is a re tros pe ctive s tudy conducte d atradiol ogy and gyne col ogy de partm e nts ofRe h m an M e dical Ins titute Pe s h aw ar. W e re tros pe ctive l y s tudie d e l e ve n cas e s ove r a pe riod of tw o ye ars from M ay 2015 to M ay 2017 and patie nts w e re diagnos e d of h aving m orbidl y adh e re nt pl ace nta during ante natalpe riod e ith e r by ul tras ound or m agne tic re s onance im aging (M RI). Th e m e an ge s tationalage atpre s e ntation w as 36 w e e k s . Al l patie nts w e re in age group of 30-36 yrs w ith m e an age of ± 33.37 yrs . Al lw e re m ul tiparous w ith a m e an parity of± 4-5. Pre vious Ce s are an Se ction de l ive ry w as th e m ajor inde pe nde nt ris k factor in m os tofth e cas e s . About 60% cas e s w e re diagnos e d during ante natalch e ck up and in m os tofth e cas e s th e pl ace nta w e re type IVPl ace nta pre via. Patie nts w e re divide d into tw o groups . 5 patie nts w e re m anage d by conve ntionaltre atm e nt(conve ntional group). In 6 cas e s , inte rve ntionalradiol ogis t w as invol ve d for trans -cath e te r arte rialbal l oon occl us ion bal l oon occl us ion (s tudy group). Th e inte rnalil iac bal l oons w e re ins e rte d pre -ope rative l y and arte rialoccl us ion w as done jus t afte r th e de l ive ry and in one cas e additionalute rine arte ry e m bol iz ation w as done pos t-ope rative l y. In conve ntionaltre atm e nt, no proph yl actic te m porary bal l oon occl us ion w as done and patie nts w e re tre ate d by e ith e r re m ovalofpl ace nta and ove rs e w ing ofth e pl ace ntalbe d or cae s are an h ys te re ctom y. One patie ntpre s e nte d pos tope rative l y w ith pl ace nta in s itu and s e ptice m ia. RESULTS: Th e re s ul ts of th e tw o groups w e re com pare d tak ing diffe re ntvariabl e s into account. In com paring th e ope rating tim e th e m e an ope rating tim e in conve ntional group w as + 2.37 h r and th atin inte rve ntionalgroup w as ± 1.25 h r w ith a totalincre as e ofapprox.1.12 h r, w h ich is q uie t s ignificant. Th e ave rage bl ood l os s w as 9 62 m lm ore in conve ntionalgroup (m e an 2037 m lvs 1075 m l ) and cons e q ue ntl y incre as e d trans fus ion ofbl ood (m e an ± 6.5 pack s vs . 2.25 pack s i.e 4.25 pack s m ore ). In our com parative s tudy pl ate l e ts and fre s h froz e n pl as m a (FFP) w as e xcl us ive l y ne e de d in conve ntionalgroup. M e an s tay in inte ns ive care unit(ICU) w as m ore in conve ntionalgroup w ith a m e an of2.7 days as com pare d to 1 day in inte rve ntionalgroup. In 2 cas e s th e re w as pe r-ope rative injury to s urrounding s tructure s attribute d to difficul t obs te tric e m e rge ncy and e xce s s ive bl ood l os s . In one cas e th e patie nth ad ure te ric injury and in oth e r cas e th e re w as bl adde r injury. In inte rve ntionalgroup, note ve n a s ingl e cas e ofdam age to s urrounding s tructure w as note d, w h ich can be partl y attribute d to l e s s s tre s s of th e s urge on due to com parative l y be tte r h e m odynam ic s tabil ity of patie nt and partl y due to cl e ar fie l d of th e s urge on. CO NCLUSIO N: W e concl ude th at us e of pe r-ope rative arte rialoccl us ive bal l oons for m anaging m orbidl y adh e re nt pl ace nta at our ce nte r s h ow e d good initialre s ul ts w ith de cre as e d patie ntm orbidity. K e y w ords : Pl ace nta pe rcre ta;M orbidl y adh e re nt pl ace nta;Pl ace nta accre ta;Pl ace nta incre ta;Intra-arte rial occl us ive bal l oons .

Corre s ponde nce : Dr. Um m ara Siddiq ue Um e r De partm e ntofRadiol ogy, Re h m an M e dicalIns titute , Pe s h aw ar, Pak is tan. Em ail : um m ara_ 81@ h otm ail .com Subm itte d 6 January 2018, Acce pte d 16 Fe bruary 2018

PA K I S TA N J O U R N A L O F R A D I O LO G Y

PJR April - June 2018; 28(2)

109

Introduction Abnorm alpl ace ntation is a pote ntialcaus e ofm ate rnal m orbidity and m ortal ity from m as s ive pos tpartum 1 bl e e ding. Th e re porte d com pl ications as s ociate d w ith it are pos tpartum h e m orrh age (PPH ), m as s ive bl ood trans fus ion, ne e d for bl ood products , dis s e m inate d intravas cul ar coagul ation (DIC), Pe ripartum H ys te re ctom y, ne e d for adm is s ion in inte ns ive care unit(ICU), s urgicalcom pl ications , e ndom e tritis , e ndovas cul ar e ve nts and m ortal ity. Tim e l y diagnos is during ante natalpe riod w ith prope r e val uation ofris k factors and pre h and patie ntcouns e l l ing re garding ne e d for abdom inalde l ive ry, arrange m e nts ofbl ood and bl ood products & cons e nt for Ce s are an h ys te re ctom y is im portant. Th e incide nce ofm orbidl y adh e re ntpl ace nta is ris ing and is dire ctl y proportionalto th e rate ofris e ofcae s are an de l ive rie s . M anage m e ntofpre gnancie s w ith a m orbidl y adh e re nt pl ace nta is e xtre m e l y ch al l e nging and is be com ing an incre as ingl y com m on probl e m for m ate rnity units gl obal l y. De s pite im prove m e ntin ante nataldiagnos is by accuracy of ul tras ound and M RI te ch niq ue s , itis s til las s ociate d w ith a h igh m ate rnalm orbidity rate . Th e m ain ch al l e nge s incl ude control l ing h e m orrh age and dis s e ction ofth e invade d tis s ue s . Inte rve ntionalradiol ogy h as im pre s s ive rol e in m anage m e nt of various obs te tricale m e rge ncie s . Pe l vic arte rialoccl us ion and e m bol iz ation h as adde d a ne w dim e ns ion in th e m anage m e nt of obs te tric h e m orrh age .2 Traditional l y, th e s e cas e s w e re m anage d by cae s are an h ys te re ctom y. Th e re h as now be e n a s h ift tow ards cons e rvative m anage m e nt of m orbidl y adh e re nt pl ace nta, invol ving ute rine and pl ace ntalcons e rvation, w ith th e aid of inte rve ntionalradiol ogy by m e ans of ins e rtion ofoccl uding bal l oons into appropriate ve s s e l s .3 Th is te ch niq ue h as now adays gaine d acce ptance as a firs tl ine tre atm e ntoption for control l ing pos t-partum h e m orrh age w h e n th e cons e rvative m e as ure s fail . It is m ore com m onl y done to controlbl e e ding in cas e s ofute rine atony, th ough pe l vic arte riale m bol i-z ation is al s o indicate d in bl e e ding due to l ace rations of fe m al e ge nitaltract, abnorm alpl ace ntation, arte riove nous m al form ations and pos ts urgicalcom pl ications and ute rine te ars atth e tim e ofC-s e ctons .4 Th is s tudy de s cribe s m orbidl y adh e re nt pl ace ntas


m anage d atour unitw h e re m e ticul ous pre ope rative pl anning, m ul tidis cipl inary approach and th e k e y rol e ofinte rve ntionalradiol ogy l e d to a s afe outcom e for both th e m oth e r and th e baby. Th e aim ofth is articl e is to dis cus s th e val uabl e rol e th atradiol ogis ts pl ay w ith obs te tricians and ane s th e s iol ogis ts in th e m anage m e ntofth e s e obs te tric e m e rge ncie s .

Patie nts and M e th ods Th is is a re tros pe ctive s tudy conducte d atradiol ogy and gyne col ogy de partm e nts of Re h m an M e dical Ins titute Pe s h aw ar. W e s tudie d e l e ve n cas e s ove r a pe riod oftw o ye ars from M ay 2015 to M ay 2017 and patie nts w h o w e re diagnos e d of h aving m orbidl y adh e re nt pl ace nta during ante natalpe riod and got ope rate d atour ce nte r. Th e m e an ge s tationalage at pre s e ntation w as 36 w e e k s . Patie nt’s de tail e d re cord incl uding num be r of ce s are an s e ctions , pl ace ntal l ocation, pre s e nce ofpl ace nta pre via, e s tim ate d bl ood l os s during th e ope ration, am ounts of trans fus ion, inte ns ive care unit(ICU) adm is s ion, s tay in h os pital and pe ripartum h ys te re ctom y w e re obtaine d from gyne col ogy unit. Es tim ate d bl ood l os s w as q uantifie d. M orbidl y adh e re nt pl ace nta w as diagnos e d on ul tras ound (US). O n US, pl ace ntaladh e s ion s h ow e d an irre gul ar, th in ute rine w al l , prom ine nt pl ace ntal ve s s e l s and in s om e cas e s dis ruption ofth e bl adde r to th e m yom e trialinte rface . Magne tic re s onance im aging (M RI) w as done in 6 patie nts (Fig. 1), w h ich s h ow e d ute rine bul ging, h e te roge ne ous s ignalinte ns ity w ith in th e pl ace nta, dark intrapl ace ntalbands , focal inte rrup-tion in th e m yom e trialw al land invas ion of pe l vic s tructure s by pl ace ntaltis s ue . Th e patie nts w e re divide d into tw o groups : one group h ad unde rgone a conve ntionalce s are an s e ction (controlgroup, n=5) and in th e oth e r group inte rve ntionalradiol ogis tw as invol ve d for pe r ope rative trans cath e te r arte rialinte rnalil iac bal l oon ins e rtion pre ope rative l y w ith arte rialoccl us ion jus tafte r th e de l ive ry (s tudy group, n=6). O f6 patie nts in th e s tudy group, 1 patie nt h ad ute rine arte ry e m bol iz ation afte r th e s urge ry. In controlgroup, no proph yl actic te m porary bal l oon occl us ion w as done and patie nts w e re tre ate d by e ith e r re m ovalofpl ace nta and ove rs e w ing ofth e pl ace ntalbe d or cae s are an h ys te re ctom y. One patie nt pre s e nte d pos tope rative l y w ith pl ace nta in s itu and


110

Ifth e patie nt's condition w as uns tabl e , th e doctor of de partm e nt of ane s th e s iol ogy k e pt m onitoring th e patie nt's condition during th e proce dure . H ys te re ctom y w as pe rform e d afte r fail ure to controlbl e e ding w ith both occl uding bal l oons and UAE.

Re s ul ts Th e re s ul ts ofth e tw o groups w e re com pare d tak ing diffe re nt variabl e s into account (Tab.1 & 2). In com paring th e ope rating tim e th e m e an ope rating tim e in conve ntionalgroup w as ± 2.37 h r and th atin S.No Age Gravida Parity POG

Figure 1: M RI ofpl ace nta pe rcre ta: SagittalT2W I s h ow s h e te roge nous pl ace nta pre via h aving inte rnall ow bands , ante rior l ow e r bul ging com pone ntw ith th inning ofm yom e trium and l os s ofm yom e trial -pl ace ntalinte rface .

s e ptice m ia. Th e inte rnalil iac arte rie s w e re cath e te riz e d bil ate ral l y and a guide w ire s ins e rte d w ith th e dis tal e nd pl ace d in th e re ar branch of th e inte rnalil iac arte rie s . O ccl us ion bal l oon cath e te rs ins e rte d in both inte rnalil iac arte rie s . Fol l ow ing ins e rtion of th e angiograph ic guide w ire , a bal l oon cath e te r w as introduce d into th e arte ry us ing pul sed l ow -dos e fl uoros copic guidance to m inim iz e radiation e xpos ure . Th e tim e of PTABO and ope ration w as s ch e dul ed afte r ful ldis cus s ion w ith inte rve ntionalradiol ogy and ane s th e s iol ogy th e day be fore th e ce s are an s e ction. Fol l ow ing de l ive ry of baby during ce s are an s e ction, te m porary arte rialbal l oon occl us ion w as pe rform e d prior to pl ace ntaldis s e ction. Fol l ow ing re m ovalofth e pl ace nta, th e bl ood ve s s e l s on th e ute rine w al lw e re l igate d during infl ation ofth e bal l oon. Ifope ration w as prol onge d, th e bal l oons w e re de fl ate d for a w h il e and th e n infl ate d to avoid cl otting. Bl e e ding continue d afte r occl uding bal l oons in one patie nt, s o patie nt w as m ove d to th e inte rve ntionalradiol ogy s uite from ope rating room im m e diate l y afte r th e cae s arian s e ction and ute rine arte ry e m bol iz ation (UAE) w as pe rform e d.


Previous C-section / placenta previa

1

32

4

P2+1

37

Previous 2 C- Section

2

30

3

P2

36+4


3

32

5

P2+2 36+5 Previous 2 C- Section with type 4 previa

4

32

3

P1+1

5

35

6

P5

6

35

5

P3+1

36

Previous 3 C- Section with type 4 previa

7

36

4

P2+1

36

Previous 2 C- Section with type 4 previa

8

35

6

P5

9

36


36+4 Previous 2 C- Section with type 4 previa

36+4 Previous 3 C- Section with type 4previa

33

4

3

35

Previous 3 C- Section with type 4previa

10 30

3

2

35


11 34

3

2

36


Tabl e 1: Sh ow ing ris k s for m orbidl y adh e re ntpl ace nta incl uding m ul tparity, pl ace nta pre via and pre vious Ce s arian s e ction (C-s e ction).

Control Group

Study Group

S.No

Per-op complication

Days in ICU

Total hospital stay

Endovascular events

1

Ureteric ligation

5days

8

---

2

---

1day

5

---

3

Bladder injury

2days

5

---

3

---

4

---

5

Reopening

2 days

7

1

---

1day

3

---

2

---

1day

3

----

3

---

1day

4

----

4

---

1day

3

----

5

---

1

3

6

---

2

5

Acute limb ischemia

Tabl e 2: Com paris on ofpatie ntm orbidity in tw o groups .


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inte rve ntionalgroup w as ± 1.25 h r w ith a totalincre as e of approx.1.12 h r, w h ich is q uie t s ignificant. Th e ave rage bl ood l os s w as 9 62 m lm ore in conve ntional group (m e an 2037 m lvs 1075 m l ) and cons e q ue ntl y incre as e d trans fus ion ofbl ood (m e an ± 6.5 pack s vs . 2.25 pack s i.e 4.25 pack s m ore ). In our com parative s tudy pl ate l e ts and fre s h froz e n pl as m a (FFP) w as e xcl us ive l y ne e de d in conve ntionalgroup. M e an s tay in inte ns ive care unit(ICU) w as m ore in conve ntional group w ith a m e an of2.7 days as com pare d to 1 day in inte rve ntionalgroup. In 2 cas e s th e re w as pe rope rative injury to s urrounding s tructure s attribute d to difficul tobs te tric e m e rge ncy and e xce s s ive bl ood l os s . In one cas e th e patie nt h ad ure te ric injury and in oth e r cas e th e re w as bl adde r injury. In inte rve ntional group, note ve n a s ingl e cas e ofdam age to s urrounding s tructure w as note d, w h ich can be partl y attribute d to l e s s s tre s s of th e s urge on due to com parative l y be tte r h e m odynam ic s tabil ity of patie nt and partl y due to cl e ar fie l d ofth e s urge on.

Dis cus s ion Morbidl y adh e re ntpl ace nta, incl uding accre ta , incre ta and pe rcre ta is pote ntial l yl ife th re ate ning condition. It is in oth e r w ords cal l e d as obs te tric nigh tm are as m os tl y itis undiagnos e d e m e rge ncy. Th e curre ntrate y be caus e is 1 pe r 2500.5 Its incide nce is on ris e m os tl ofris ing rate ofce s are an s e ction de l ive ry, advance d m ate rnalage and pl ace nta pre via. Tak ing into account th e is s uing incide nce of pl ace nta prae via ,accre ta, pe rccre ta, inccre ta ante nataldiagnos is s h oul d be e m ph as iz e d for w h ich prope r ante natalbook ing and fol l ow up of al lth e h igh ris k cas e s on s tandard protocol s is ne ce s s ary. In our s tudy, in-tim e ante nataldiagnos is ofpl ace ntal adh e s ion re duce d h e m orrh age and th e ne e d for bl ood trans fus ion. Th is m ay be th e re s ul t ofdiffe re nce s in th e m anage m e ntofante natal l y diagnos e d and undiagnos e d w om e n. Im aging s tudy is im portantfor diagnos is ante natal l y, w h ich re ve al e d pl ace ntall acunae , l os s of cl e ar s pace , dis ruption of bl adde r-m yom e trial inte rface , incre as e d vas cul arity by ul tras onograph y and ute rine bul ging, h e te roge ne ous s ignalinte ns ity w ith in pl ace nta, dark intrapl ace ntalbands , focal inte rruptions in m yom e trialw al land invas ion ofpe l vic s tructure s by pl ace ntaltis s ue by M RI. Al th ough diag-

PA K I S TA N J O U R N A L O F R AD I OL O GY

nos is is m ade by Doppl e r US in m os t of th e cas e s butnow MRIis incre as ingl y be ing us e d for as s e s s m e nt of de pth of invas ion into th e bl adde r and pos te rior pl ace nta. M RI is gol d s tandard inve s tigation to s e e th e de pth of pl ace nta w h e n s us picion is rais e d by Doppl e r US. Re ce ntl y, radiol ogicalinte rve ntionalproce dure s s uch as trans cath e te r occl uding bal l oons and ute rine arte ry e m bol iz ation are be ing pe rform e d for pos tpartum h e m orrh age . Th e re are pote ntialbe ne fits to de cre as ing th e ris k of pos tpartum h e m orrh age and h ys te re ctom y by adm inis te ring proph yl actic inte rve ntion e s pe cial l y occl uding bal l oons . In its cl inical appl ication, th e m os t difficul t probl e m is m oving patie nts w ith th e bal l oon cath e te r from th e inte rve ntion room ofradiol ogy to th e ope ration room for ce s are an l oon cath e te r s e ction. Vinas 6 re porte d 2 cas e s ofbal m igration during patie nttrans fe r to de l ive ry s ite from th e IR s uite . In our s tudy group, fortunate l y, no w om e n unde rw e nt dis pl ace m e nt of th e bal l oon cath e te r or h ad fail ure of bl e e ding controldue to dis l ocation of th e bal l oon cath e te r. Afte r th e bal l oons w e re ins e rte d, ops ite adh e s ive drape s w e re us e d to s e cure th e cath e te rs and patie nts trans fe r to O pe ration Th e ate r w as unde r s upe rvis ion of inte rve ntionalradiol ogy s taff, re q uiring gre atcare . Inte rve ntionalradiol ogy is now incre as ingl y invol ve d for cath e te riz ation of inte rnalil iac arte ry to control bl ood l os s by bal l oon occl us ion pe r-ope rative l y. In our s tudy, th e ave rage bl ood l os s w as 9 62 m lm ore in controlgroup (m e an 2037 m lfor controlvs 1075 m l for s tudy) and cons e q ue ntl yl arge num be r of bl ood trans fus ion pack s w e re us e d (m e an ± 6.5 pack s for controlvs . 2.25 pack s for s tudy group i.e . ± 4.25 pack s m ore ). In our com parative s tudy, pl ate l e ts and FFPs w e re e xcl us ive l y ne e de d in controlgroup. In com paring th e ope rating tim e , th e m e an ope rating tim e in controlgroup w as ± 2.37 h r and th atin s tudy group w as ± 1.25 h r, w ith a totalincre as e ofapprox. 1.12 h r w h ich is q uie t s ignificant. M e an s tay in ICU w as again m ore in controlgroup w ith a m e an of2.7 days as com pare d to 1 day in inte rve ntionalgroup. Th e s e re s ul ts indicate th at intra-arte rialoccl uding bal l oons h ad s om e e ffe ct in re ducing m ate rnal m orbidity during ce s are an s e ction in cas e s ofpl ace ntal adh e s ion. Com paris on m ade w ith re s ul ts of pre vious s tudie s . 7 Cal i e talobs e rve d no im prove m e ntin th e outcom e s ofw om e n tre ate d w ith occl uding bal l oons , com pare d


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w ith th e outcom e s ofw om e n tre ate d w ith outoccl uding bal l oons . Re ce ntl y, a s tudy publ is h e d in Kore a by uding bal l oons h ad Ch o and fe l l ow s 8 s h ow e d th atoccl s om e e ffe ct in re ducing m ate rnalm orbidity during ce s are an s e ction in cas e s of pl ace ntaladh e s ion. Th e s e re s ul ts are com parabl e w ith our s tudy. H ow e ve r, in our s tudy th e num be r ofICU and totalh os pitals tay w as al so l e s s for s tudy group, w h ich is a good indicator. Re garding th e proce dure re l ate d com pl ications , in one patie nt th e re w as an e ndovas cul ar e ve nt w ith patie ntcom pl aining ofrigh tl e g pain pos tope rative l y. Th e inte rve ntionalradiol ogis t w as inform e d and e m bol e ctom y w as pe rform e d im m e diate l y and th e patie nt w as s tarte d on intrave nous h e parin. Th e patie ntw as dis ch arge d h om e s tabl e on fifth day. No oth e r proce dure re l ate d com pl ications obs e rve d in th e group. Surge ry re l ate d com pl ications w e re in 2 cas e s of controlgroup w ith injury to s urrounding s tructure s attribute d to difficul tobs te tric e m e rge ncy and e xce s s ive bl ood l os s . In one cas e th e patie nth ad ure te ric injury and in oth e r cas e th e re w as bl adde r injury. In s tudy group, not e ve n a s ingl e cas e of dam age to s urrounding s tructure s w as note d, w h ich can be partl y attribute d to l e s s s tre s s of th e s urge on due to com parative l y be tte r h e m odynam ic s tabil ity ofth e patie nt and partl y due to cl e ar fie l d ofth e s urge on. In controlgrou p, th e re w as 100% pe ripartu m h ys te re ctom y rate , w h il e in s tudy group itw as re duce d to about50% . In one cas e , th e re w as te ch nicaldifficul ty due to intra-abdom inaladh e s ions and intractabl e h e m orrh age w ith a ch ance ofiatroge nic injury to th e s urrounding s tructure s . Ute rine pack ing w as done and inte rve ntionalradiol ogis tw as invol ve d for ute rine arte ry e m bol iz ation (UAE), w h ich prove d to be l ife s aving as th e bl e e ding got control l e d and ute rus s ave d. Al lth e ne ce s s ary pre -ope rative pre parations s h oul d be m ade be fore h and during l as ttrim e s te r w ith prope r couns e l l ing ofth e patie nt. In de ve l oping country l ik e ours , th e m ain is s ue is un- book e d, undiagnos e d obs te tric e m e rge ncie s w h e re th e diagnos is is ofte n m ade w h e n difficul ty is e ncounte re d in e s tabl is h ing th e cl e avage pl ane w h il e re m oving pl ace nta or w h e n com pl e te pl ace ntalre m ovaldoe s not occur during vaginalde l ive ry. Conve ntional l y in PPH , h ys te re ctom y h as be e n traditional l y advis e d. Cons e rvative m anage -


m e nti-e l e aving pl ace nta in s tich is us ual l y opte d at cos t of h igh e r ris k of m ate rnals e ps is , w h e re th e fe rtil ity pre s e rvation is im portant. Bil ate raltrans cath e te r occl uding bal l oons in inte rnal il iac arte rie s prior to e l e ctive cae s are an de l ive ry in patie nts w ith m orbidl y adh e re nt pl ace nta, in w h om ute rine pre s e rvation is pl anne d l e ads to im prove d outcom e s . Ifm as s ive bl e e ding continue s afte r ce s are an s e ction, both UAE can be pe rform e d im m e diate l y afte r occl uding bal l oons , w h ich furth e r de cre as e s th e ris k ofm ate rnalm ortal ity and m orbidity. Th is approach s h oul d be cons ide re d w h e n re com m e nding th is practice in al lw om e n ide ntifie d as h aving pl ace nta adh e s ion. In our s tudy th e inte gration ofth is inte rve ntion s h ow e d re m ark abl e re s ul ts in re ducing al lth e re l ate d com pl ications , i.e bl ood l os s , H os pitals tay duration, bl ood trans fus ion pack s re q uire d e tc. Th e m ain l im itation ofth is s tudy is th e s m al lnum be r ofcas e s . Th e re are a l arge num be r oftrial s going on w ith invol ve m e ntofinte rve ntionalradiol ogis t for th e m anage m e ntofth is s e ve re l y m orbid condition. Pe rop inte rnalil iac arte ry bal l oon occl us ion by a radiol ogis t w ith prope r e xpe rtis e , or pre -op or pos t- op ute rine e m bol iz ation is trie d in ce nte rs w h e re facil itie s are avail abl e and th e data is s l ow l y and gradual l y book ing. Th e m ajor cons traints are ne e d of th e facil itie s in h os pital s , prope r re fe rralpath w ays , e xpe rtis e in th e fie l d ofinte rve ntionalradiol ogy and h igh cos ts ofth e proce dure .

Concl us ion W e concl ude th atus e ofpe r-ope rative intra-arte rial occl us ive bal l oons for m anaging m orbidl y adh e re nt pl ace nta at our ce nte r s h ow e d good initialre s ul ts w ith de cre as e d patie ntm orbidity.

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2. Aw an M W , Ath e r S, Ah m e d A, Ras h id N. Rol e of radiol ogy in th e diagnos is and m anage m e nt of obs te tricale m e rge ncie s . Anae s th Pain & Inte ns ive Care 2014;18(4): 436-42. 3. Rao AP, Bojah r H , Be s k i S, M acCal l um PK , Re nfre w I. Rol e ofinte rve ntionalradiol ogy in th e m anage m e nt of m orbidl y adh e re nt pl ace nta. J O bs te tGynae col . 2010;30(7): 687-9 . 4. Gons al ve s M , Be l l i A. Th e rol e of inte rve ntional radiol ogy in obs te tric h e m orrh age . Cardiovas c Inte rve ntRadiol2010;33: 887-9 5. 5. ACO G Com m itte e on O bs te tric Practice . ACO G Com m itte e opinion. Num be r 266, January 2002 : pl ace nta accre ta. O bs te t Gyne col2002; 9 9 : 169 -70. 6. Viñas M T, Ch andrah aran E, M one ta M V, Be l l i AM .Th e rol e ofinte rve ntionalradiol ogy in re ducing h ae m orrh age and h ys te re ctom y fol l ow ing cae s are an s e ction for m orbidl y adh e re ntpl ace nta. Cl in Radiol . 2014 Aug;69 (8): 345-51. 7. Cal i G, Forl ani F, Giam banco L, Am ico M L, Val l one M , Puccio G, Al io L. Proph yl actic us e of intravas cul ar bal l oon cath e te rs in w om e n w ith pl ace nta accre ta, incre ta and pe rcre ta. Eur J Obs te tGyne col Re prod Biol . Aug 2014;179 : 36-41. 8. Ch o YJ, O h YT, K im SY, e tal . Th e e fficacy ofpre de l ive ry proph yl actic trans -cath e te r arte rialbal l oon occl us ion ofbil ate ralinte rnalil iac arte ry in patie nts w ith s us pe cte d pl ace ntaladh e s ion. O bs te trics & Gyne col ogy Scie nce . 2017;60(1): 18-25.



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