This column summarizes patient cases posted to SIR Connect (SIR’s popular online member community), the responses from other SIR members and how that feedback helped the original poster. To see how SIR’s online community can help you, visit SIR Connect at connect.sirweb.org.
Original Post, lightly edited for flow:
The patient is a 32-year-old woman (G1P1) post C-section. The obstetrician was unable to remove all of her placenta and she had persistent mild spotting for weeks. An MRI shows placenta accreta with RPOC. I would think I should embolize this to encourage involution. Agree? Should I use Gelfoam or Embospheres?
What is your preferred embolization approach in treating placenta accreta?
Gelfoam.
Is there a role for collaboration between OB/GYN and IR for treating placenta accreta?
The OB/GYN service is always involved from the beginning. We have a uterine hemorrhage protocol at our institution so that IR is promptly notified of a patient who is in the OR or Labor and Delivery who might need embolization.
What specifically prompted you to reach out regarding this case?
The patient was unusual for me in that she did not have an immediate or delayed postpartum hemorrhage like my previous patients but, rather, persistent mild symptoms. I didn't know whether embolization for this would be too aggressive.
What post(s) were most valuable to you and why?
There was consensus on embolization, which was helpful, but not on what type of agent (I would use Gelfoam slurry). The advice to look out for AV shunting was a most useful reminder to avoid complications.
Will you or have you changed your practice patterns based off of responses on SIR Connect? Please describe any changes you are considering.
This patient ended up not needing embolization. However, in the future I will keep all the helpful advice in mind. Since I work in a community hospital setting, it is always helpful to ask for expert advice on the SIR Connect Open Forum, which I have received many times over the years. Many thanks to my kind colleagues who respond so promptly and appropriately.
Additional commentary:
Uterine artery embolization (UAE) has recently been studied in the context of management of placenta accreta (PA).1–6 This technique has historically been considered a safe and effective option for fibroid management in patients wishing to retain their uterus in the appropriate setting.2,3 When applied to PA, the goal of UAE is to aid in encouraging placental involution while also retaining the uterus for future childbearing in milder cases of PA.6–7 The other main potential applications for UAE to PA are as conservative primary management and as a method of bleeding prophylaxis in the time between cesarean delivery and hysterectomy.5–8 In a systematic review that highlighted various forms of conservative management of PA, 45 patients treated with UAE demonstrated a secondary hysterectomy rate of 18%, menstruation rate of 62%, and subsequent pregnancy rate of 15% with full survival rate in all patients.5,6 An additional study indicated that prophylactic UAE following cesarean delivery but before hysterectomy in the management of PA is a safe and feasible technique with results that include mitigating blood loss during hysterectomy, decreasing transfusion requirements and potential ICU length of stay for patients.1,4 While studies such as these provide us with valuable insight on UAE outcomes for PA, there is still insufficient literature at this time that compares hysterectomy to UAE overall as primary management of PA.9
Furthermore, in evaluating a patient for UAE treatment, it is also worth mentioning that, while a plethora of data exists in the domain of UAE for UFE, publications caution against extrapolating UFE techniques to UAE in the setting of PA.4 This is mainly due to the timing of delivery, higher thrombotic state of pregnancy and the frequent additional targets of PA embolization.4 For example, in a study of prophylactic embolization of the uterine arteries in the peri-operative management of PA, 31 of 83 patients (37%) who underwent embolization required embolization of additional arteries other than the uterine vessels. These may include the vesical or vaginal arteries if these vessels provide significant uterine vascular supply pre-operatively.4 In UFE, there is occasionally ovarian arterial supply to the uterus and fibroids; however, this occurs in roughly 5% of patients.2
Embolic agent choice in UAE arises as a central question in this particular case and for UAE in general. When analyzing UAE for fibroids, two of the typical embolic agents are polyvinyl alcohol (PVA) and microspheres.2 Absorbable gelatin powder particles dissolve 3–4 weeks after use and have been utilized as an embolic agent in the setting of uterine arterial hemorrhage.9,10 This agent is ideal in its ability to temporarily interface with the uterine vascular bed with minimal complications while also maintaining uterine function,10 however there are no overt studies directly comparing the effects of embolics on reproductive outcomes.12 Postprocedure embolization complications may include fever, infection, transient foot or buttock ischemia, iliac thrombosis and uterine necrosis.11 Arteriovenous shunting, which may be present as a result of previous gynecological procedures, should also be assessed as this can also contribute to postpartum hemorrhage and has been shown to safely respond to absorbable gelatin powder.12
In summary, while the use of UAE has proven effective in treatment of fibroids, AV uterine shunting and peri- and postpartum hemorrhage, its role in encouraging involution and preserving uterine reproduction remains an area of ongoing investigations.9,4,10,11
References
- Wang M, Ballah D, Wade A, Taylor AG, Rizzuto G, Li B, Lucero J, Chen LM, Kohi MP. Uterine artery embolization following cesarean delivery but prior to hysterectomy in the management of patients with invasive placenta. J Vasc Interv Radiol. 2019;30(5):687–691.
- Spies J. Uterine Fibroid Embolization. Handbook of Interventional Radiologic Procedures, by Krishna Kandarpa et al., Lippincott Williams & Wilkins, 2016:475–
- ACOG Practice Bulletin No. 96: Alternatives to hysterectomy in the management of leiomyomas. Obstetrics & Gynecology. 2008;112(2):387–400.
- Izbizky G. Feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta. J Vasc Interv Radiol. 2015;26(2):162–69.
- Cheung CS, Chan BC. The sonographic appearance and obstetric management of placenta accreta. Int J Womens Health. 2012;4:587–
- Steins Bisschop CN, Schaap TP, Vogelvang TE, Scholten PC. Invasive placentation and uterus preserving treatment modalities: A systematic review. Arch Gynecol Obstet. 2011;284(2):491–502
- Cahill, AG. Placenta accreta spectrum. Am J Obstet Gynec. 2018;219(6)B2–16.
- Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.
- Noufaily A. Uterine artery embolization for management of placenta accreta, a single-center experience and literature review. The Arab J Interv Radiol. 2017;1(1):37.
- Corr P. Arterial embolization for haemorrhage in the obstetric patient. Best Pract Res Clin Obstet Gynaecol. 2001;15(4):557–61.
- Huang KL, Tsai CC, Fu HC, Cheng HH, Lai YJ, Hung HN, Tsang LLC, Hsu TY. Prophylactic transcatheter arterial embolization helps intraoperative hemorrhagic control for REMOVING invasive placenta. Journ Clin Med. 2018; 7(11):460.
- Camacho A, Ahn EH, Appel E, et al. Uterine artery embolization with Gelfoam for acquired symptomatic uterine arteriovenous shunting. J Vasc Interv Radiol. 2019;30(11):1750–
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