ENDOVASCULAR BALLOON OCCLUSION TECHNIQUE IN CAESAREAN HYSTERECTOMY OF PLACENTA

ACCRETA SPECTRUM

A Successful Management to Prevent Massive Bleeding

Gagah Baskara Adi Nugraha1, Dympna Prameilita Prisasanti1, Eric Edwin Yuliantara2, Sri Sulistyowati3, M.
Adrianes Bachnas2, Nutria Widya Purna Anggraini2, Robert Ridwan2, Darmawan Ismail4, Subandrio4, Arif
Prasetyo Utomo4, Rakadian Wijaya4, Prima Kharisma Hayuningrat4, Rth. Supraptomo5

1
Resident of Obstetrics and Gynecology Sebelas Maret University, Dr. Moewardi Surakarta Hospital, Indonesia
2
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology Dr. Moewardi Surakarta
Hospital, Indonesia
3
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology UNS Hospital Surakarta,
Indonesia
4
Division of Thoracic, Cardiac and Vascular Surgeon, Department of Surgery Dr. Moewardi Surakarta Hospital,
Indonesia
5
Division of Obstetrics Anesthesia, Department of Anesthesiologist and Intensive Therapy Dr. Moewardi
Surakarta Hospital, Indonesia

Abstract
Introduction: Placenta accreta is a life-threatening condition, with high levels of maternal and fetal
morbidity and mortality. Due to invasion of the placenta into the myometrium, the risk of severe
bleeding is increased, necessitating blood transfusions and often caesarean hysterectomy to control
significant blood loss. In order to treat and prevent maternal death due to massive hemorrhage,
nowadays the Endovascular Balloon Occlusion technique is known which is effective in reducing
intraoperative bleeding during CS.
Case Report: We present a 36-year-old woman who was 39 weeks of gestational age (Gravid 5,
Parity 3, Abortus 1) and had placenta previa total with high risk of morbidly adherent placenta.
Caesarean hysterectomy was chosen for this patient with accompanied by endovascular balloon
occlusion technique in order to prevent massive bleeding during the surgery. Blood production
during the surgery was total 500 mL with good outcome of the patient and baby.
Conclusion: Intraoperative aortic balloon occlusion is a relatively safe method and may be useful for
prevent massive bleeding and maintaining fertility. Infrarenal aortic balloon occlusion produces
better clinical outcomes than internal iliac artery balloon occlusion.
Keyword: Balloon occlusion, Hysterectomy, Placenta Accreta

Abstrak
Pendahuluan: Plasenta akreta merupakan kondisi yang mengancam jiwa, dengan tingkat morbiditas
dan mortalitas ibu maupun janin yang cukup tinggi. Akibat invasi plasenta ke dalam miometrium,
risiko terjadinya perdarahan hebat semakin meningkat, sehingga diperlukan transfusi darah dan
seringkali histerektomi caesar untuk mengontrol kehilangan darah yang signifikan. Untuk mengatasi
dan mencegah kematian ibu akibat perdarahan masif, saat ini telah dikenal teknik Endovascular
Balloon Occlusion yang efektif mengurangi perdarahan intraoperatif selama CS.
Laporan Kasus: Dilaporkan wanita 36 tahun dengan usia kehamilan 39 minggu G5P3A1 datang ke
Poliklinik Kandungan. Pasien didiagnosis plasenta previa total dengan risiko tinggi plasenta akreta.
Operasi caesar dipilih untuk pasien ini dengan disertai teknik oklusi balon endovaskular untuk
mencegah perdarahan masif selama operasi. Produksi darah selama operasi adalah total 500 mL
dengan luaran pasien dan bayi yang baik.
Simpulan: Oklusi balon aorta intraoperatif adalah metode yang relatif aman dan mungkin berguna
untuk mencegah perdarahan masif dan mempertahankan uterus. Oklusi balon aorta infrarenal
menghasilkan hasil klinis yang lebih baik daripada oklusi balon arteri iliaka interna.
Kata kunci: Oklusi balon, Histerektomi, Plasenta Akreta
INTRODUCTION

Placenta accreta is a life-threatening condition, with high levels of maternal and fetal
morbidity and mortality. The incidence of placenta accreta is increasing, reporting from 1 in 30,000
deliveries in 1950 to 1 in 2500 deliveries (a ten-fold increase) in 1997. 1,2 A study in Dr Moewardi
Hospital has recorded an increase of placenta accreta spectrum cases until 54% from 2016 to August
2020. Based on the study data, there were 77.8% of women experiencing antepartum hemorrhage,
and 88.9% of women requiring preoperative transfusion because of hemoglobin anemia levels. Most
women with placenta accreta at Dr Moewardi Hospital required a hysterectomy instead resection of
the uterus to resolve bleeding complications during labor. The mean intraoperative hemorrhage was
3655 ± 2248 cc of blood, while the mean postoperative transfusion was 2788 ± 2493cc. 1
The increase of placenta accreta’s incidences has been associated with an increase of
cesarean section (CS) worldwide. A previous study estimated that a continuous increase rate of
cesarean section (CS) may lead an increase of placenta previa-accreta and maternal mortality. 2,3
Most women with placenta accreta have identifiable risk factors. 3 Placenta previa and previous
cesarean delivery are major risk factors. The risk increases with the number of previous cesarean
sections. 4,5 Trauma or damage to the myometrial wall and scar tissue due to repeated dilatation and
curettage, are also risk factors for developing placenta accreta. Other risk factors include maternal
age, multiparity, previous history of other uterine surgery, Asherman syndrome, leiomyoma, uterine
anomalies, hypertension in pregnancy, and smoking. 4,5
Management of women with placenta accreta is usually by cesarean section (CS). Due to
invasion of the placenta into the myometrium, the risk of severe bleeding is increased, necessitating
blood transfusions and often caesarean hysterectomy to control significant blood loss. 7 Because of
the high morbidity associated with this condition, better management is needed to manage massive
bleeding during cesarean section (CS). 5,6
To treat and prevent maternal death due to massive hemorrhage, nowadays the endovascular
balloon occlusion technique is known which is effective in reducing intraoperative bleeding during
CS. There are several techniques of endovascular balloon occlusion according to the position of the
balloon, there are infrarenal abdominal aortic artery, the common iliac arteries and the internal iliac
arteries' balloon. 7,8 This technique not only can control bleeding during hysterectomy but can also
reduce the likelihood of hysterectomy in women who wish to maintain their fertility. 7,8 In this case
report, we present successful management of an endovascular balloon occlusion technique during
cesarean section (CS) in women with high risk placenta accreta.

CASE REPORT
A 36-year-old woman who was 39 weeks of gestational age (Gravid 5, Parity 3, Abortus 1)
came to Maternal-Fetal medicine clinic at Dr. Moewardi Surakarta Hospital to carried out Ante Natal
Care (ANC). Patient had routine ANC and discovered abnormality implantation of the placenta in her
33 weeks of pregnancy. This was her first experience to had abnormality implantation of the
placenta. She felt good fetal movement and denied any complaints of uterine contraction, vaginal
bleeding or vaginal discharge during her pregnancy. She confessed to had history of curettage at her
first pregnancy because of miscarriage and also prior twice of cesarean section at her third and
fourth pregnancies. Patient had no history of hypertension, blood glucose disturbance or heart
disease. Patient also denied any history of in vitro fertilization for her pregnancies.
At physical examination, all vital sign was observed in normal range. Fetal heart rate was 145
beat per minute, with good variability, no sign of deceleration and no proved of any uterine
contraction during cardiotocography monitoring. Fundal height was observed 30 centimeters.
Biophysical profile of the fetus within normal range with estimated fetal weight was 2977 grams.
Examination of suspected placental abnormality implantation used ultrasound integrated to
Morbidly Adherent Placenta scoring system (MAP Score). From the examination were found amount
of the lacuna more than 2, and each diameter had more than 2 centimeters, there was obliteration
of uteroplacental demarcation, and also hypervascularity of the placenta-bladder. The implantation
of the placenta was found covering the internal ostium of uterine. The total score obtained was 12
accordant to Morbidly Adherent Placenta High Risk. At laboratory findings were in normal limits and
no abnormal description.
Patient were diagnosed placenta previa total with high risk of morbidly adherent placenta in
multigravida full term pregnancy with twice history of cesarean section. The patient was well
prepared for distinctive major surgery. Discussion to Thoracic, Cardiac and Vascular Surgeon Division
and Obstetrics Anesthesia Division was built in order to determine the best technique of surgery for
this case. Caesarean hysterectomy was chosen for this patient with accompanied by endovascular
balloon occlusion technique in order to prevent massive bleeding during the surgery. The Surgery
was held two days after discussion and lasts for four hours. The surgery was used general anesthesia
with endotracheal tube intubation to control respiratory rates. Blood production during the surgery
was total 500 mL with good outcome of the patient and baby. After the procedure, the patient was
admitted in Intensive Care Unit for two days and moved to ward after hemodynamically stable.

DISCUSSION
Prior twice of CS and curettage in this partient were the biggest risk factors for placenta
accreta.2,3 It was reported that CS increase the risk of developing placenta accreta from 2% to 39%. 3
Prior of CS once can increase the risk of 0.3%, whereas with a history of CS more than 5 times, it can
increase to 6.74% incidence of placenta accreta. The presence of trauma to the uterus due to
curettage was also a risk factor for placenta accreta in this case. 1,2,3

A B

Figure 1. A. Pre operation USG examination, B. Obliteration of Blood Vessel in The Uterus

Another risk factor for this patient is the maternal age of 36 years, which in women aged> 35
years can increase the risk of placenta accreta. Transabdominal ultrasound are complementary
diagnostic techniques and should be used as needed. 2,3 Ultrasound has a specificity of 70-94% and a
sensitivity of 53-74% in diagnosing placenta accreta. 5.7 The screening examination in these patients
can be done with MAP (Morbidly Adherent Placenta) scoring. Table 1 describes the MAP scoring. 7
 Table 1. MAP scoring 7
Parameter Score
Number of previous cesarean deliveries
1 1
≥2 2
Lacuna maximum dimension
≤2 1
>2 2
Number of lacunae
≤2 1
>2 2
Obliteration of uteroplacental demarcation 2
Location of placenta
Anterior 1
Placenta previa 2
Doppler assessment
Blood flow in placental lacunae 1
Hypervascularity of placenta bladder and / or uteroplacental interface 2
MAP score 12 in this case, indicating that the patient had a high risk of MAP. The MAP score
has a sensitivity of 92.3% and specificity of 94.1% in diagnosing placenta accreta. 6,7 The hysterectomy
performed on a patient with a pregnancy of 36 weeks aims to prevent the risk of vaginal bleeding
after 36 weeks because of oxytocin activity. Give birth to a baby who is 36 weeks had a good chance
of life even though preterm, and prevents dangerous complications to the mother (maternal
hemorrhage), reducing the likelihood of fetal death due to antepartum hemorrhage. 5,6,7
Caesarean hysterectomy is the definitive treatment for life-threatening postpartum
hemorrhage caused by placenta accreta. However, the risk of massive bleeding during this
procedure cannot be avoided. Increasing expectations about quality of life have changed
management approaches to this condition. Recent management is needed in order to maintain
maternal fertility and avoid removal of the uterus. 7,8,9
Previous studies have evaluated the technique of endovascular balloon occlusion of the pelvic
arteries to reduce intraoperative blood loss during cesarean hysterectomy for placenta accreta.
Endovascular balloon occlusion technique is placing a balloon through fluoroscopy in the abdominal
aorta or pelvic artery to allow temporary blockage of the perfusion artery to the pelvis during
surgery. Placement is performed in an interventional radiology room (cath lab) or operating room
prior to a scheduled cesarean hysterectomy. 8,9,10 The results of a recently published study suggest
that endovascular balloon occlusion with or without uterine arterial embolization (UAE) during CS for
placenta previa major and / or placenta accreta to preserve the uterus and reduce bleeding. 8,10
The most common endovascular occlusion technique mentioned in several studies are
infrarenal aorta balloon occlusion (IABO) and internal iliac artery balloon (IIA). Various studies are
reported regarding the comparison of the number of estimated blood loss (EBL) and the rate of
hysterectomy in both techniques. 9,10
In this patient, an Infrarenal aorta balloon occlusion technique (IABO) was performed. Prior to
balloon occlusion, abdominal aortic angiography was performed. Catheter and glidewire are utilized
to select femoral access. The sheath is inserted from the right femoral artery by means of the
Seldinger technique under local anesthesia. The balloon then inserted following glidewire and
deflated until the balloon is noted and marked on the angiography. The occlusion balloon catheter is
placed with its tip under the renal artery. Accurate balloon placement was confirmed
angiographically (Figure 2). The balloon is inflated after delivered of the baby. It because blood
circulation must be maintained in order to prevent risk of fetal hypoxia. Balloon must be inflated
until the patient's pulse and oxygen saturation in the big toe are not detected. The total balloon
inflating time is less than 10 second. The glidewires are secured to the balloon catheter using a
FloSwitch and left in place. The sheath is secured and a bandage is applied over the sheath. The
balloon will deflated before closing the peritoneal cavity to confirm hemostasis. 8.9

A B

Figure 2. A. Insertion of the balloon, B. Balloon placed in infrarenal abdominal aorta 8

Endovascular balloon occlusion technique certainly has several complications. These are lower
limb ischemia, reperfusion injury, aortic dissection / rupture, branch vessel occlusion, plaque
removal leading to distal vascular embolization, and inability to deflate or pull the balloon through
the sheath. To prevent or reduce the above complications, it is possible to minimize the occlusion
time (<60 minutes), the diameter of the balloon obstructs blood flow selected must be appropiate
size, heparin injection before inflated of the balloon and localization of the balloon under the renal
artery origin. 10.11
Several studies have shown the benefits of using the endovascular balloon occlusions
technique, there are lower estimates of blood loss, lower transfusion requirements, lower intensive
care unit admission rates, lower rates of side effects, and can prevent hysterectomy to maintain
fertility.11.12 Infrarenal aortic balloon occlusion was chosen in this case because it has more
advantages such as uterine artery embolization rate (UEA), balloon occlusion time, operative time
and fetal radiation dose were less in the infrarenal aortic balloon occlusion technique. Eventhough
estimates of blood loss (EBL), blood transfusion rate and length of stay did not differ between IABO
and IIA. 8-12
The endovascular balloon occlusion technique is a relatively safe method for treating women
with placenta previa and / or placenta accreta during either elective or emergency cesarean section
(CS), and may be useful for preventing hysterectomy and embolization in women who wish to
maintain fertility. 8

CONCLUSION
Endovascular balloon occlusion technique was successfully performed in this patient to reduce
the complications of cesarean hysterectomy due to massive bleeding. This technique is relatively
safe for treating women with placenta previa and / or placenta accreta during either elective or
emergency CS, and may be useful for preventing hysterectomy and embolization in women who
wish to maintain fertility. Intraoperative aortic balloon occlusion is a relatively safe method and may
be useful for maintaining fertility. Infrarenal aortic balloon occlusion produces better clinical
outcomes than internal iliac artery balloon occlusion.
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