Comparative analysis of the effectiveness of different methods of surgical hemostasis in patients with placenta accreta spectrum disorders

Introduction

Placenta previa and placenta accreta cause significant maternal and perinatal morbidity and mortality. Therefore, with an increase in the frequency of both cesarean sections and pregnancies achieved using assisted reproductive technologies, these conditions associated with pathological invasive placentation are becoming more and more common [1–3]. The frequency of abnormal placental invasion increased worldwide from 1 in 2,500 pregnancies in 1980 to 1 in 500 pregnancies in 2011 [4].

Currently, at the initiative of the International Federation of Gynecology and Obstetrics (FIGO), a completely new and more precise terminology of placenta accreta spectrum (PAS) disorder covering both abnormally adhesive and invasive placentas has been introduced [5]. PAS carries a large burden of adverse outcomes for the mother, primarily such as loss of the reproductive organ and significant blood loss, which can be life-threatening. The depth and area of placental ingrowth are the main factors determining surgical tactics and outcomes for patients [5][6].

As the frequency of PAS increases and the accuracy of prenatal diagnosis of this complication increases, the development of a number of skills and practices based on interdisciplinary team actions significantly improved clinical results [7][8]. In recent years, various strategies have been proposed for the management and surgical treatment of pregnant women with PAS, but the problem of minimizing blood loss during cesarean section remains unresolved [8].

The undoubted successes in the theory and practice of PAS achieved over the past decade are now included in the guidelines at the national level in the United Kingdom, Canada, the United States [9-11], and the Russian Federation [12][13]. Undoubtedly, all these national algorithms and protocols complement the recent series of guidelines issued by the International Federation of Gynecology and Obstetrics (FIGO) and the International Society for Placenta Accreta Spectrum (IS-PAS) [14][15].

In 2010, specialists from the UK (St. George's University Hospital, London) proposed the Triple-P surgical method, which should be considered a conservative, less risky alternative to intraoperative hysterectomy (IH) in patients with placenta accreta [16]. This procedure includes three main stages – perioperative localization of the upper edge of the placenta, devascularization of the pelvic organs (by means of temporary balloon occlusion of the internal iliac artery), and separation of the placenta with excision of the myometrium and subsequent elimination of the myometrial defect.

In a retrospective study by Pinas-Carrillo et al., based on the results of 50 patients with placenta accreta who underwent the Triple-P procedure from September 2010 to May 2017 in the maternity ward of St. George's Clinic, the average intraoperative blood loss was 2318 ml (range – 400–7300 ml), and the average length of hospital stay – 4 days (range – 2–8 days). Three women (6.0%) developed arterial thrombosis without any long-term complications, and none of the patients required a hysterectomy [17][18].

In recent decades, endovascular technologies associated with embolization or balloon occlusion of arterial vessels have been widely used in surgical and obstetric practice in order to reduce intraoperative blood loss.

Temporary balloon occlusion of the internal iliac artery (TBOIIA)

Until recently, the question of whether balloon occlusion of the internal iliac artery (BOIIA) during cesarean section with placenta previa can reduce postpartum hemorrhage and other complications in the mother remained unresolved. The effectiveness of preventive BOIIA in patients with placenta accreta remains controversial. Therefore, a large number of studies have been devoted to solving this issue [19–33].

In 2018, specialists from the American College of Obstetricians and Gynecologists recommended a multidisciplinary clinical approach to the treatment of patients with placenta accreta. As potential members of an interdisciplinary team, interventional radiologists can perform preventive BOIIA before cesarean section surgery as an additional procedure to reduce potentially life-threatening postpartum hemorrhage [23].

According to Zhou et al., the main indicators compared, such as the volume of blood loss during cesarean section, the frequency of blood transfusions, and the volume of transfused blood in the main group (with TBOIIA), were significantly lower than in the control group (without TBOIIA). At the same time, the frequency of disseminated intravascular coagulation and hysterectomy had no significant differences. In addition, in the main group, one of the patients had thrombosis of the left popliteal artery, and four patients had a fever. The authors believe that preventive BOIIA is an alternative method of controlling postpartum hemorrhage in women with placenta previa and accreta. However, the use of this procedure cannot reduce the frequency of hysterectomies [24].

According to the results of a prospective randomized study, the use of prophylactic BOIIA in patients with placental presentation who underwent cesarean section did not reduce the magnitude of postpartum hemorrhage and did not have any effect on maternal or neonatal morbidity [20]. There were no significant differences between the two groups of patients (with BOIIA and without this procedure) with respect to the average intraoperative blood loss – 1451 (1024–2388) ml versus 1454 (888–2300) ml, p = 0.945; the average duration of surgery – 49 (30–62) min. against 37 (30–5) min., p = 0.204 or the need for blood transfusion during surgery – 57.9% vs. 50.0%.

In a retrospective case-control study presented by Peng et al. In 2020, the clinical efficacy of the preventive use of BOIIA was also studied. In the main group (48 cases), preliminary BOIIA was performed, while the control group (56 cases) was not subjected to this procedure. There were no significant differences between the groups in the amount of blood loss, the volume of blood transfusion, and the frequency of damage to the organs of the urinary system. The frequency of hysterectomies in the main group was even significantly higher than in the control group. In addition, during hysterectomy among patients with invasive placenta (placenta increta et percreta), the values of blood loss also did not differ significantly between the groups [19].

Similar results indicating the absence of a BOIIA association with improved outcomes during cesarean section in women with placenta previa and accreta were obtained during a retrospective cohort study conducted at the third-level Chinese center during the period from January 1, 2012 to December 31, 2017 [21].

At the same time, the results of a large-scale study published by Nankali et al. in 2021, it was shown that the use of prophylactic TBOIIA in patients with placenta previa or RAS had such advantages as a reduction in intraoperative blood loss and a decrease in the frequency of hysterectomies [25].

Soyer et al. believe that due to the high frequency of adverse events, prophylactic TBOIIA should be used with caution and used mainly when the endpoint is a hysterectomy [34]. 

Temporary balloon occlusion of the common iliac artery (TBOCIA)

In 2005, Shih et al. reported that intraoperative bleeding in patients with invasive placenta previa may be reduced by placing a balloon catheter in the common iliac artery for temporary occlusion of blood flow in the uterus during cesarean section [35].

Kurtzer was the first in Russia to introduce the technology of temporary balloon occlusion of the common iliac arteries (TBOCIA) during operative delivery in women with PAS [36].

Savelyeva et al. in 2019 published the results of a comparative analysis of methods for preventing/stopping bleeding during surgical delivery of patients with placenta accreta (TBOCIA, ligation of internal iliac arteries, embolization of uterine arteries). The analysis showed that the ligation of the internal iliac arteries in such situations was ineffective. The TBOCIA method demonstrated the greatest effect of the presented methods of temporary “devascularization” of the uterus [37].

The data presented in this particular review (Table 2) indicate that TBOCIA appears to be more effective and safe than TBOIIA [37–39]. At the same time, clinicians should be aware of potential risks and take measures to prevent them.

Even if the blood flow in the internal iliac arteries is blocked, blood flow to the uterus is maintained by collateral circulation from the external iliac artery, so the bleeding is not sufficiently controlled by blocking only the internal iliac arteries. Collateral blood circulation is possible due to such arteries as the gluteal artery, the occlusal artery, and the ilio-lumbar artery [40][41]. It is believed that bleeding in PAS is more effectively controlled by blocking blood circulation in the common iliac artery in order to simultaneously block blood circulation in both the external and internal iliac arteries [19].

In a study by Chou et al., a statistically significant decrease in surgical blood loss was observed after the use of temporary TBOCIA compared with the control group in which this procedure was not performed. In the main group, the average blood loss was 1902.3 ± 578.8 ml (in the range of 500–8000 ml), and in the control group – 4445.7 ± 996.48 ml (in the range of 1040–15,000 ml). In addition, arterial thrombosis was noted in two patients [42]. Despite the fact that these data were based on a small number of patients (n=13), the frequency of thrombotic complications leaves some doubts about the safety of the method of TBOCIA.

The results of the study by Ono et al. (2018) have demonstrated that hemorrhage during delivery in patients with PAS can be successfully reduced with the help of temporary TBOCIA. The average blood loss in the group of patients who underwent BOCIA (2027 ± 1638 ml) was significantly lower than in the other two groups. The average blood loss in the group of patients without occlusion was 3787 ± 2936 mm, and in the group of patients who underwent ligation of the internal iliac artery – 4175 ± 1921 ml. This study also confirmed the safety of TBOCIA in relation to ischemia of the lower extremities of the mother and fetal irradiation during balloon placement [43].

Completely different results were obtained by Australian specialists (John Hunter Hospital, Newcastle, Australia) as a result of an analysis of the outcomes of 52 cases of placenta accreta. The authors failed to find statistically significant differences between the compared groups in the volume of blood loss, the frequency of postoperative hemoglobin reduction, the need for blood transfusion and blood substitutes. In addition, acute thromboembolic complications were observed in two cases in the main group [44]. 

Temporary balloon occlusion of the abdominal aorta (TBOAA)

In the last few decades, surgeons have begun to successfully use preventive TBOAA before performing a cesarean section in order to prevent intra- and postoperative bleeding [45–47]. It is likely that due to the insufficiency of occlusion of the internal iliac artery and the common iliac artery, due to the developed collateral circulation, TBOAA can give better clinical results [45].

It has been reported in numerous publications that TBOAA can be a safe and effective method for surgical delivery of patients with placental increment, helps to reduce the volume of blood loss during cesarean section, and reduces the risks associated with hysterectomy [46–55]. At the same time, the clinical efficacy of preventive BOIA has been described by various authors with different results (Table 3). 

In the vast majority of studies, the attention is drawn to the low volume of blood loss during cesarean section in patients with PAS while using prophylactic TBOAA: 413.8 ± 105.9 ml, according to Zhu et al. [56], 620 ±570 ml, according to Wang et al. [53], 598.7 ml, according to Ryazanova [54], 1000 ml, according to Lu et al. [50], 1600 ml, according to Li et al. [51].

Zhu et al. showed that prophylactic TBOIA in combination with a cross-section was more effective (main group, n=42) than the TBOAA performed after childbirth (control group, n=37). The average blood loss in the main and control groups was 413.8 ± 105.9 ml and 810.3 ± 180.3 ml, the frequency of use of blood products was 30.23% and 89.2%, and the frequency of hysterectomies was 0% and 2.53%, respectively [56].

One of the largest studies included 623 patients with placenta previa and accreta, who underwent TBOAA [53]. In addition, 78 patients additionally underwent sequential bilateral embolization of the uterine arteries. The average intraoperative blood loss was only 620 ±570 ml, the frequency of blood transfusion was 15.4%, and the average amount of transfused blood was 750 ± 400 ml. The uterus was successfully preserved in all the patients.

The data on the effective use of the TBOAA method presented by Russian specialists (D. O. Ott Research Institute of Obstetrics and Gynecology, St. Petersburg) in 2021 [54] are also very interesting. There was a retrospective comparative study in women with PAS who underwent TBOCIA (from October 2017 to October 2018 or TBOAA (from November 2018 to November 2019) in order to prevent pathological postpartum hemorrhage during a planned cesarean section. All the TBOAA catheters were successfully placed in the third zone of the aorta under ultrasound control. The average amount of blood loss was significantly lower in the group of TBOAA (541 ml [CI 300–750]) compared with the group of TBOCIA (3331 ml [CI 1150–4750]). As a result, the total volume of substitution therapy with blood preparations and blood substitutes was significantly lower in the group of TBOAA compared to the group of TBOCIA. None of the women with TBOAA required a hysterectomy, while in the comparison group – in 50% of cases. The only complication associated with TBOAA was non-occlusive thrombosis of the femoral artery, while surgical treatment was not required.

In addition to endovascular methods of uterine devascularization, so-called compression methods are currently used in obstetric practice, which have proven themselves well during organ-preserving operations in pregnant women with PAS [57][58].

Specialists of the Federal State Budgetary Institution “The National Medical Research Center of Obstetrics, Gynecology and Perinatology named after V. I. Kulakov” (Moscow, Russia) have developed an innovative technology of complex compression hemostasis while performing organ-preserving operative delivery in patients with placenta previa and accreta [58]. The essence of the method lies in the fact that at the level of the isthmus along the rib of the uterus on the left and right, tourniquets made of elastic rubber tubes are applied and tightened. Additionally, the third turnstile is carried out around the cervix, which is also tightened at the level of the cervix, thereby carrying out the devascularization of the uterus. In some cases, balloon tamponade of the uterus is performed during the surgery.

In 2020, Shmakov et al. published data on the effectiveness of this method based on the outcomes in 64 pregnant women with suspected placenta accreta. At the same time, the diagnosis of placenta accreta was confirmed in 18, increta – in 42, and percreta – in 4 patients. The volume of total blood loss increased depending on the degree of placenta invasion: the average was 975 ml with placenta accreta, 1300 ml – with placenta increta, and 2200 ml – with placenta percreta [6].

Barinov et al. recommended performing organ-preserving operations with placenta previa and postpartum hemorrhage caused by placenta accreta by means of using combined methods of operative obstetrics, such as bilateral ligation of the descending branch of the uterine artery, external uterine supra-placental assembly suture, controlled balloon tamponade with uterine and vaginal balloon catheters of Zhukovsky. This technique allowed the authors not only to reduce the volume of blood loss but also to significantly reduce the frequency of hysterectomies [59][60].

In 2020, Fu et al. presented their own method of applying compression sutures with a parallel loop in the lower parts of the uterus (compression anterior posterior parallel tightening sutures) with placenta previa complicated by its increment. Therefore, 124 patients were enumerated in the study, including 38 who underwent compression suture surgery with a parallel loop (the main group), and 86 patients of the control group. In the main group of patients, the volume of lost blood was lower than in the control group (2152.6 ± 1169.4 and 2960.5 ± 1963.6 ml), which, respectively, contributed to a decrease in the doses of hemotransfusion (7.2 ± 3.5 and 10.3 ± 8.7 units) and plasma transfusion (552.6 ± 350.3 and 968.0 ± 799.8 ml). The authors believe that this procedure is an effective, fast, practical, and safe method of reducing postpartum hemorrhage in women with placenta previa and accreta [61].

In 2019, Peng et al. presented a new surgical technology of two parallel transverse incisions and two parallel compression turnstiles during cesarean section in patients with PAS. This new procedure consists of two parallel incisions: the first transverse incision is made near the bottom of the uterus and above the upper border of the placenta, and the second transverse incision of the uterus is made in the lower segment of the uterus, which allows delaying the removal of the placenta after uterine devascularization. A modified technique of the Ruby tourniquet was performed: first, the lower segment of the uterus was tightly bandaged with a narrow rubber tube in order to restrict blood flow in the uterine arteries. Another rubber tube was tightly bandaged around the uterus to limit the flow of blood in the uterus's own ligaments. The average blood loss in the patients of the main group was 2150 (800–6500) ml, in the control group – 2800 (800–15,000) ml, the frequency of hysterectomy was 3.3% and 21.9%, respectively. Thus, the use of this method was associated with a noticeable decrease in blood loss and the need for blood transfusion [62].

Conclusion

The main goals of surgery in obstetrics are safe delivery for the mother and fetus, as well as reliable measures that may ensure surgical hemostasis. For many women with PAS, surgical hemostasis can be safely achieved by means of using various methods of uterine devascularization without the use of hysterectomy. According to the results of the analysis of randomized clinical trials, systematic reviews, and meta-analyses, the most effective methods of hemostasis in patients with PAS are TBOAA and the domestic method of distal hemostasis. The advantage of the distal compression hemostasis method is that it is effective in patients with PAS, also it does not require endovascular intervention and does not have risks of thromboembolic complications. At the same time, there is still no ideal method of uterine devascularization in PAS, and clinical studies in this direction should be continued.