triple p procedure cohort study

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Triple P procedure to prevent peripartum hysterectomy inpatients with morbidly adherent placenta: a cohort study

Poster No.: C-2445

Congress: ECR 2013

Type: Scientific Exhibit

Authors: M. Teixidor Viñas, A.-M. Belli, E. Chandraharan; London/UK

Keywords: Interventional vascular, Digital radiography, Balloon occlusion,

Arterial access, Hemorrhage, Obstetrics

DOI: 10.1594/ecr2013/C-2445

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Purpose

Morbidly adherent placenta (MAP) is a condition which causes significant maternal

morbidity and mortality from post partum haemorrhage. It occurs when there is invasion

of the chorionic villi into the myometrium and its incidence is increasing[1]

, in line with the

increase in caesarian delivery. There are three types of MAP: Placenta percreta, increta

and acreta. Placenta percreta is the most severebut less common.

This is a potentially life threatening condition. It requires a radical treatment such as

peripartum hysterectomy with or without bowel or bladder resection depending on the

degree of infiltration of these organs[2]

. Alternative therapies have included compression

sutures and balloon tamponade with the placenta remaining in situ[3]

.

MAP can be diagnosed before delivery by ultrasound (US) and magnetic resonance

imaging (MRI)[4]

.

This led us to commence a programme in 2007 of prophylactic occlusion balloon insertion

into both internal iliac arteries before caesarian delivery in women with the most severe

forms of morbidly adherent placenta increta and percreta.

The purpose of the occlusion balloons is to reduce blood flow in the uterine arteries

after caesarian delivery and so reduce blood loss, transfusion requirements and need for

caesarian hysterectomy.

Following the success of this programme, in July 2010 our institution developed a

multidisciplinary procedure, called the Triple-P procedure[5]

on page .

The Triple-P procedure is a three step conservative treatment involving obstetricians,

anesthetists and interventional radiologists to prevent significant haemorrhage and peri-

partum hysterectomy. The three steps are:

1. Perioperative location of the placenta and delivery of the fetus by an incisionabove the upper border of the placenta.

2. Pelvic devascularisation by inflating radiologically pre-placed occlusionballoons in both internal iliac arteries.

3. Placental non-separation with myometrial excision and reconstruction of theuterine wall.


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The purpose is to describe a tertiary referral centre's experience with prophylactic

balloon occlusion in women at high risk of obstetric haemorrhage from morbidly adherent

placenta.

Methods and Materials

Between December 2007 and September 2012, pregnant women identified as having

MAP by US or MRI at our institution, were defined as high risk of postpartum

haemorrhage.

Indications for placement of prophylactic occlusion balloons included women with the

diagnosis of placenta percreta and increta.

A date for caesarian delivery was planned electively.

On the morning of delivery, an epidural catheter was inserted by the anesthetists beforethe patient was transferred to the Interventional Radiology suite for insertion of the internal

iliac artery occlusion balloons. With informed consent, bilateral common femoral arterial

punctures were performed under local anesthesia and occlusion balloons (7 Fr Standard

Occlusion Balloons Catheters, Boston Scientific®) positioned contralaterally with their

tips in the anterior divisions of each internal iliac artery under pulsed low dose fluoroscopic

guidance to minimize radiation exposure to the mother and fetus[6]

on page .


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Fig. 1: Contrast injected through the catheters confirms their correct position.References: radiology, Saint George's Hospital - London/UK

Test occlusion was performed to ensure reduction/stasis in uterine artery blood flow and

the volume of half strength contrast medium and normal saline solution required was

recorded in the patient's notes and luer lock syringes with the required volume were

attached to the catheters.


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Fig. 2: Contralateral placement of occlusion balloon catheters into both internal iliacareries. Only fluoroscopic images are obtained.References: radiology, Saint George's Hospital - London/UK

The balloons were then deflated, and the catheter and the sheath flushed, stitched and

dressed to minimize the possibility of movement during the patient's transfer.

In the obstetric theatre a mobile image intensifier was in position so that the interventional

radiologist could check the final position of the balloon catheter and change it if necessary

before caesarian section commenced.

After the baby was delivered and the umbilical cord clamped, the interventional radiologist

was responsible for inflating each balloon to reduce blood flow whilst the obstetrician

closed the uterus.

If there was no evidence of haemorrhage, the balloon catheters were deflated after four

hours and the patient observed for bleeding overnight. If the patient remained stable, the

sheaths and occlusion balloon catheters were removed by the interventional radiologists

the next morning.


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If bleeding commenced, then the occlusion balloons could be rapidly re-inflated and the

patient transferred for embolization. If significant hemorrhage occurred immediately in

theatre, either the patient could be transferred to the IR suite or if deemed too unstable for

transfer, the IR could proceed immediately to embolization with gelatin sponge through

the occlusion balloon catheters.

The following parameters were recorded for each procedure: radiographic exposure,

volume of blood loss, transfusion requirements, uterine artery embolization, peri-partumhysterectomy, APGAR scores and any maternal complications including length of stay

on ITU.

Study design and participants:

Twenty two patients were diagnosed with morbidly adherent placenta between December

2007 and September 2012.

• Between December 2007 and February 2010 eleven patients hadprophylactic occlusion balloon catheters placed in both anterior trunks of theIIA and an elective caesarean delivery (Group 1).

• Between March 2010 and September 2012, eleven patients were treatedusing the Triple P procedure (Group 2).


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Fig. 3: Distribution of study population by mode of treatment, and result.References: radiology, Saint George's Hospital - London/UK

All caesarean deliveries apart from one were performed electively. In all cases occlusion

balloons were successfully placed prior to caesarian delivery.

Statistical methods:

Descriptive characteristics were calculated for the variables of interest. Statistic analysis

comparing both groups has been done using the Chi-square test (Fisher's Exact Test)

for categorical variables; and the Wilcoxon-Mann & Whitney for numerical variables.

on page

Images for this section:


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Fig. 1: Contrast injected through the catheters confirms their correct position.


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Fig. 2: Contralateral placement of occlusion balloon catheters into both internal iliac

areries. Only fluoroscopic images are obtained.


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Fig. 3: Distribution of study population by mode of treatment, and result.


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Results

Twenty two patients were diagnosed with morbidly adherent placenta between December

2007 and September 2012.

• Between December 2007 and February 2010 eleven patients had

prophylactic occlusion balloon catheters placed in both anterior trunks of theIIA and an elective caesarean delivery (Group 1).

• Between March 2010 and September 2012, eleven patients were treatedusing the Triple P procedure (Group 2).

All caesarean deliveries apart from one were performed electively. In all cases occlusion

balloons were successfully placed prior to caesarian delivery.

The clinical characteristics of the patients of both groups are summarized in Table 1.

Table 1: The clinical characteristics of all the patients included in the study and forboth groups are summarized in the table.


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References: radiology, Saint George's Hospital - London/UK

There were no significant differences between the groups for age, parity, previous

gynaecological surgery or degree of morbidly adherent placenta.

Fig. 4: Patients with previous gynaecological surgery distribution.References: radiology, Saint George's Hospital - London/UK

The mean age at study entry was 34 years old and the weeks of gestation were 34.3

(+/-5.44). Only one woman was nulliparous in our study, and she was part of Group 1.

A reduction in mean radiation dose between the two groups (168, 91 +/- 122,64 mGy

in Group 1 vs 81,01 +/- 51,4 mGy in Group 2) was observed . There was no change in

radiographic equipment.

Mean blood loss during the surgery was 2,17 +/- 2,47 liters in Group 1 vs 1,44 +/-

0,54 liters in Group 2, p= 0.847. Although reduced blood loss was observed in Group 2

compared with Group 1, this was not statistically significant between the two groups.


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Fig. 5: BLOOD LOST DURING THE PROCEDURE: The boxplots represents thesmallest and largest observation, lower and upper quartile and median of blood lostduring the procedure. Group 1 had patients outliers and the group is less uniform in

blood lost. The graphic 1 showed than more than 50% of patients treated in Group 2bled less than the median of blood lost in Group 1.References: radiology, Saint George's Hospital - London/UK

There was no significant difference between the number of women requiring a transfusion

in both groups (45.5% in Group 1 vs 54.5% in Group 2, p=0,67) although there was a

trend to increased volume of transfused products in Group 1.

There were 8 patients in total who required emergency embolisation for postpartum

haemorrhage (36,4%):

- five of them in Group 1 (45,5%)

- 3 in Group 2 (27,3%),

but this was not statistically significant between both groups (p=0.659).


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Three women in Group 1 required an emergency hysterectomy (27.3%) whilst nobody in

group 2 required hysterectomy. However the total numbers in this report are too small to

detect a statistically significant difference.

There were no minor or major maternal or infant complications.

All patients were transferred to intensive care unit immediately after the delivery as perprotocol, with a mean stay of 2,82 days (+/- 2,64 days) in Group 1 and 3,44 days (+/- 1,51

days) in Group 2. Also, there were no significant differences between the whole inpatient

stay in both groups (p=0,603).

COMPLICATIONS

In one case in Group 1, rupture of the occlusion balloons occurred after caesarian section.

The interventional radiologist was unable to attend the delivery in this case and despite

the required volumes being written in the notes, the syringes became displaced during

transfer and a volume ten times greater than required was injected, with consequentbilateral balloon rupture. Without the reduction in blood flow in the uterine arteries, the

patient haemorrhaged during separation of the placenta and the obstetrician proceeded

immediately to hysterectomy. This highlights the importance of the IR attending the

delivery, ensuring the occlusion balloon is filled appropriately and having embolic material

and equipment available immediately in theatre.

In two other cases (Group 1), haemorrhage was treated by UAE but hysterectomy was

required as haemorrhage continued.

One patient with placenta percreta (Group 1) required a second UAE four months after

the delivery for further haemorrhage which was successful.

Migration of the balloon catheter was observed in two patients in Group 2. (fig. 5). Again,

this highlights the importance of the IR attending the delivery, ensuring the occlusion

balloon has not migrate during the patient's transfer from DSA suit to the delivery room.

None of the major surgical complications described in the literature with caesarian

hysterectomy were encountered eg vesicouterine fistula, bladder injury or postoperative

abscess[7]

on page .

Images for this section:


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Table 1: The clinical characteristics of all the patients included in the study and for both

groups are summarized in the table.


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Fig. 4: Patients with previous gynaecological surgery distribution.


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Fig. 5: BLOOD LOST DURING THE PROCEDURE: The boxplots represents the smallest

and largest observation, lower and upper quartile and median of blood lost during the

procedure. Group 1 had patients outliers and the group is less uniform in blood lost. The

graphic 1 showed than more than 50% of patients treated in Group 2 bled less than themedian of blood lost in Group 1.


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Conclusion

Prophylactic occlusion balloon catheter insertion in both IIA's prior to elective caesarean

delivery in patients with MAP is useful in reducing postpartum haemorrhage, and

decreases the risk of hysterectomy in young women with preservation of fertility. The

Triple P procedure leads to further improvement in outcomes and is the procedure of

choice at our institution.

References

[1] Obstet Gynecol 2002; 99:976-80. The likelihood of placenta praevia with greater

number of caesaren deliveries and high parity. Gillam M, Rosenberg D, Davis F

[2] BJOG 2007;114:1380-1387. Knight M on behalf of UKOSS. Peripartum hysterectomy

in the UK: management and outcomes of the associated haemorrhage.

[3] Acta Obstet Gynecol Scand. Sep 2010;89 (9): 1126-33. The morbidly adherent

placenta: an overview of management options. Doumouchtsis S, Arulkumaran S.

[4] J Obstet Gynecol 2004; 24 (7): 742-744. Imaging techniques to identify morbidly

adherent placenta praevia: a prospective study. Moodley J, Ngambu NF, Corr P

[5]

Int J Gynaecol Obstet. 2012 May;117(2):191-4. The triple- P procedure as a

conservative surgical alternative to peripartum hysterectomy for placenta percreta.Chandraharan E; Rao S; Belli A-M; Arulkumaran S.

[6]

Radiographics. 2012 Jan-Feb;32(1):255-74. Interventional Radiology in Pregnancy

Complications: Indications, Technique, and Methods for Minimizing Radiation Exposure.

Thabet A; Kelva S; Liu B; Mueller P; Lee S.

[7]

Obstet Gynecol. 2004 Sep;104(3):531-6. Conservative versus extirpative management

in cases of placenta accrete. Kayem G, Davy C, Goffinet F.

Personal Information
http://www.ncbi.nlm.nih.gov/pubmed?term=The%20triple-%20P%20procedure%20as%20a%20conservative%20surgical%20alternative%20to%20peripartum%20hysterectomy%20for%20placenta%20percreta.%20Chandraharan%20E%3B%20Rao%20S%3B%20Belli%20A-M%3B%20Arulkumaran%20S.%20International%20Journal%20of%20Gynacology%20and%20Obstetrics%20%282012%29http://www.ncbi.nlm.nih.gov/pubmed?term=Conservative%20versus%20extirpative%20management%20in%20cases%20of%20placenta%20accrete.%20Kayem%20G%2C%20Davy%20C%2C%20Goffinet%20F.%20Obstetric%20Gynecology%20%282004%29%20104%3B%20531-536.http://www.ncbi.nlm.nih.gov/pubmed?term=The%20triple-%20P%20procedure%20as%20a%20conservative%20surgical%20alternative%20to%20peripartum%20hysterectomy%20for%20placenta%20percreta.%20Chandraharan%20E%3B%20Rao%20S%3B%20Belli%20A-M%3B%20Arulkumaran%20S.%20International%20Journal%20of%20Gynacology%20and%20Obstetrics%20%282012%29http://onlinelibrary.wiley.com/doi/10.1111/aog.2010.89.issue-9/issuetoc

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