Albaro José Nieto-Calvache1, José Miguel Palacios-Jaraquemada2, Rozi Aditya Aryananda3, Fernando Rodriguez4, Carlos A Ordoñez4, Adriana Messa Bryon5, Juan Pablo Benavides Calvache5, Jaime Lopez5, Clara Ivette Campos6, Mauricio Mejia7, Martin Rengifo7, Lina Maria Vergara Galliadi8, Juliana Maya9, Maria Andrea Zambrano10, Isabella Prado Aguayo9, Isabella Gutierrez Carabalí9, Juan Manuel Burgos5. 1. Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos). Electronic address: albaro.nieto@fvl.org.co. 2. Hospital Universitario de CEMIC, Buenos Aires, Argentina (Dr Palacios-Jaraquemada). 3. Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Aryananda). 4. Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez). 5. Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos). 6. Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Patología y Laboratorio Clínico, Fundación Valle del Lili, Cali, Colombia (Dr Campos). 7. Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo). 8. Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Dr Galliadi). 9. Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí). 10. Programa de Ginecología y Obstetricia, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Dr Zambrano).
Abstract
BACKGROUND: The placenta accreta spectrum disorder may lead to severe complications. Helpful interventions to prevent placenta accreta spectrum bleeding include vascular control procedures in the aorta or pelvic vessels. Although these procedures are related to lower intraoperative bleeding, they are associated with complications, so the possibility of selecting patients at highest risk of bleeding while avoiding vascular procedures for all cases is attractive. OBJECTIVE: We describe an intraoperative staging protocol whose objective is to identify the need to use vascular control procedures in patients with placenta accreta spectrum. We also describe the results of its application in a placenta accreta spectrum referral hospital. STUDY DESIGN: This descriptive, retrospective study included patients with suspected prenatal placenta accreta spectrum treated at a referral center for placenta accreta spectrum between April 2016 and June 2020. The use of the resuscitative endovascular balloon occlusion of the aorta allowed the prevention and treatment of excessive bleeding; its application was performed according to 3 approaches: (1) presurgical use in all placenta accreta spectrum patients (Group 1), (2) according to the prenatal placenta accreta spectrum topography (Group 2), and (3) according to the "intraoperative staging" (Group 3). In addition, the frequency of use of resuscitative endovascular balloon occlusion of the aorta and the clinical results in the management of placenta accreta spectrum were described in the 3 groups. RESULTS: Seventy patients underwent surgery for a prenatal suspicion of placenta accreta spectrum. Of these, 16 underwent intraoperative staging (Group 3); in 20 cases, resuscitative endovascular balloon occlusion of the aorta was used based on the prenatal imaging topographic classification (Group 2), and in the remaining 34 patients (Group 1), it was always used before the laparotomy. The frequency of use of resuscitative endovascular balloon occlusion of the aorta was progressively lower in Groups 1 (32 patients, 94.1% of cases), 2 (11 patients, 75% of cases), and 3 (4 patients, 25% of cases). Similarly, resuscitative endovascular balloon occlusion of the aorta went from being applied predominantly before the laparotomy (all cases in Group 1) to being applied after intraoperative staging (all cases in Group 3). The percentage of endovascular devices applied but not used, decreased from 23.5% in Group 1 to 0% in Group 3. Complications related to the resuscitative endovascular balloon occlusion of the aorta were seen in 4 patients (2 women in Group 1, and 1 woman each in Groups 2 and 3). CONCLUSION: The "intraoperative staging" of placenta accreta spectrum allows the optimization of the use of resuscitative endovascular balloon occlusion of the aorta, which decreases the frequency of its use without increasing the volume of blood loss.
BACKGROUND: The placenta accreta spectrum disorder may lead to severe complications. Helpful interventions to prevent placenta accreta spectrum bleeding include vascular control procedures in the aorta or pelvic vessels. Although these procedures are related to lower intraoperative bleeding, they are associated with complications, so the possibility of selecting patients at highest risk of bleeding while avoiding vascular procedures for all cases is attractive. OBJECTIVE: We describe an intraoperative staging protocol whose objective is to identify the need to use vascular control procedures in patients with placenta accreta spectrum. We also describe the results of its application in a placenta accreta spectrum referral hospital. STUDY DESIGN: This descriptive, retrospective study included patients with suspected prenatal placenta accreta spectrum treated at a referral center for placenta accreta spectrum between April 2016 and June 2020. The use of the resuscitative endovascular balloon occlusion of the aorta allowed the prevention and treatment of excessive bleeding; its application was performed according to 3 approaches: (1) presurgical use in all placenta accreta spectrum patients (Group 1), (2) according to the prenatal placenta accreta spectrum topography (Group 2), and (3) according to the "intraoperative staging" (Group 3). In addition, the frequency of use of resuscitative endovascular balloon occlusion of the aorta and the clinical results in the management of placenta accreta spectrum were described in the 3 groups. RESULTS: Seventy patients underwent surgery for a prenatal suspicion of placenta accreta spectrum. Of these, 16 underwent intraoperative staging (Group 3); in 20 cases, resuscitative endovascular balloon occlusion of the aorta was used based on the prenatal imaging topographic classification (Group 2), and in the remaining 34 patients (Group 1), it was always used before the laparotomy. The frequency of use of resuscitative endovascular balloon occlusion of the aorta was progressively lower in Groups 1 (32 patients, 94.1% of cases), 2 (11 patients, 75% of cases), and 3 (4 patients, 25% of cases). Similarly, resuscitative endovascular balloon occlusion of the aorta went from being applied predominantly before the laparotomy (all cases in Group 1) to being applied after intraoperative staging (all cases in Group 3). The percentage of endovascular devices applied but not used, decreased from 23.5% in Group 1 to 0% in Group 3. Complications related to the resuscitative endovascular balloon occlusion of the aorta were seen in 4 patients (2 women in Group 1, and 1 woman each in Groups 2 and 3). CONCLUSION: The "intraoperative staging" of placenta accreta spectrum allows the optimization of the use of resuscitative endovascular balloon occlusion of the aorta, which decreases the frequency of its use without increasing the volume of blood loss.