Interventional Radiology: Making Childbirth Safer

1. Interventional Radiology:Making Childbirth Safer Dr Rob Beecroft, MD Interventional Radiologist University Health Network – Mount Sinai Hospital Toronto, Canada

2. Interventional Radiology is making childbirth safer for women with uncommon condition called “invasive” placenta. Accomplished through minimally invasive non-surgical procedure – described as “prophylactic uterine artery occlusion balloons and embolization.” Compared to surgery alone for invasive placenta, this advanced interventional radiology option makes delivery safer with less bleeding and much less risk of requiring hysterectomy (removal of uterus).

3. Interventional radiology • Interventional radiology is an advanced branch of medicine that uses minimally invasive procedures to treat a variety of conditions • One of the best known applications of interventional radiology is to control or stop excessive bleeding through procedure called embolization – blocking arteries from inside. • This technique can be used to reduce bleeding during childbirth

4. How do we do it? • Through a small nick in the skin, interventional radiologists can place catheters inside the arteries in the body, direct them under x-ray guidance to control bleeding from within • No surgical incision • No need for general anesthesia

5. Interventional radiology and invasive placenta • Invasive placenta is an unusual abnormality of the placenta in pregnant women • 1/1000 to 1/2500 deliveries • Incidence increasing with number of C-sections • Women with invasive placenta require cesarean section • Occurs abnormal growth of placenta into or through uterine wall

6. Normal placenta Uterine wall Placenta • The placenta normally lies against the inside wall of the uterus, and comes away easily after delivery of the baby.

7. Severe invasive placenta Placenta may invade right through the uterine wall • With invasive placenta, the placenta is abnormally attached to and “invades” into the wall of the uterus

8. Classification • Placenta accreta 84% mildest • Placenta increta 13% • Placenta percreta 3% most severe

9. Classification • Placenta accreta 84% mildest • Placenta increta 13% • Placenta percreta 3% most severe

10. Why is invasive placenta potentially dangerous? • Women are at high risk of excessive bleeding during delivery. With surgery alone - 90% of women require blood transfusion - surgery can become difficult and risky due to excessive bleeding

11. Why is invasive placenta potentially dangerous? 2. Placenta often can’t be delivered because it is so firmly attached, and must be left inside the uterus. This can potentially lead to: - delayed bleeding (post-partum hemorrhage) - infection

12. Why is invasive placenta potentially dangerous? • For these reasons, with traditional surgical treatment alone: - 80% of women with invasive placenta require a hysterectomy - 7% risk of maternal death

13. How can Interventional Radiology help? • Interventional radiologists can direct special catheters into the arteries that supply blood to the uterus before delivery, and these: • can be used control bleeding during surgery • making delivery safer • avoid the need for hysterectomy

14. University of Toronto study “Combined prophylactic internal iliac artery balloon occlusion and uterine artery embolization in the management of invasive placenta” DL D’Souza, JR Kachura, JR Beecroft, RC Windrim, JC Kingdom

15. Our study group: • 14 women with severe forms of invasive placenta • 6 placenta increta • 8 placenta percreta • All had cesarean section, as well as interventional radiology procedures before and after delivery to control blood loss

16. Our technique: 1) Prior to cesarean section, in interventional radiology: - Small nick made in both groins - Inserted catheters with balloons on ends which can be inflated (“Occlusion balloon catheters”) into arteries supplying the uterus

18. 2) During cesarean section: - Balloons inflated after baby removed from uterus. Purpose: to temporarily block blood flow through the arteries supplying the uterus in order to decrease blood loss and make surgery easier and safer.

19. 3) After cesarean section, patient returned to interventional radiology for embolization: - Inject spongy particles (Gelfoam) into uterine arteries to block them Purpose: to block blood flow to the uterus and stop bleeding

20. Our results – compared to cesarean-section alone, patients who had interventional radiology treatment had: • Significantly less blood loss during cesarean section • Average only 1.25L compared to typical average 3.0 - 5.0L for surgery only • Needed blood transfusions less often • Only 28% of patients compared to 90% of patients for surgery only

21. Significantly lower hysterectomy rate • Only 33% of women had hysterectomy compared to typical average 80%

22. Conclusion • Interventional radiologists can use minimally invasive techniques that are safe and effective to control blood loss, make delivery safer, and avoid hysterectomy in women with invasive placenta • We work closely with obstetricians to enhance the care of women and make childbirth safer.

23. Thank you.

24. References • Oyelese Y & Smulian JC. Placenta previa, placenta accreta, and vasa previa, Obstet Gynecol 2006 Apr;107(4):927-41 • Timmermans S, van Hof AC, Duvekot JJ. Conservative management of abnormally invasive placentation, Obstet Gynecol Surv 2007 Aug;62(8):529-39 • Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta, Am J Obstet Gynecol 1997 Jul;177(1):210-4 • O'Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies, Am J Obstet Gynecol 1996 Dec;175(6):1632-8 • Hudon L, Belfort MA, Broome DR. Diagnosis and management of placenta percreta: a review, Obstet Gynecol Surv 1998 Aug;53(8):509-17 • Levine AB, Kuhlman K, Bonn J. Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters, J Matern Fetal Med 1999 Jul-Aug;8(4):173-6 • Kidney DD, Nguyen AM, Ahdoot D, Bickmore D, Deutsch LS, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation, Am J Roentgenol 2001 Jun;176(6):1521-4 • Tan CH, Tay KH, Sheah K, Kwek K, Wong K, Tan HK, Tan BS. Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta, Am J Roentgenol 2007 Nov;189(5):1158-63 • Bodner LJ, Nosher JL, Gribbin C, Siegel RL, Beale S, Scorza W. Balloon-assisted occlusion of the internal iliac arteries in patients with placenta accreta/percreta, Cardiovasc Intervent Radiol 2006 May-Jun;29(3):354-61 • Shrivastava V, Nageotte M, Major C, Haydon M, Wing D. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta, Am J Obstet Gynecol 2007 Oct;197(4):402.e1-5 • Ojala K, Perälä J, Kariniemi J, Ranta P, Raudaskoski T, Tekay A. Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage, Acta Obstet Gynecol Scand 2005 Nov;84(11):1075-80 • Chou MM, Hwang JI, Tseng JJ, Ho ES. Internal iliac artery embolization before hysterectomy for placenta accreta, J Vasc Interv Radiol 2003 Sep;14(9 Pt 1):1195-9 • Mok M, Heidemann B, Dundas K, Gillespie I, Clark V. Interventional radiology in women with suspected placenta accreta undergoing caesarean section, Int J Obstet Anesth 2008 Jul;17(3):255-61 • Descargues G, Douvrin F, Degré S, Lemoine JP, Marpeau L, Clavier E. Abnormal placentation and selective embolization of the uterine arteries, Eur J Obstet Gynecol Reprod Biol 2001 Nov;99(1):47-52

25. Background • Excessive blood loss occurs during childbirth in 4 - 7% of deliveries • Severe bleeding can have catastrophic effects on the mother: - circulatory collapse (shock) - organ failure - death • Surgery and hysterectomy possibly required to treat

26. Our results: Compared to c-section alone, patients who had interventional radiology treatment had: • Significantly lower blood loss during cesarean section: Average only 1.25L compared to typical average 3.0 - 5.0L average for surgery only • Significantly lower requirement for blood transfusion: Only28% of patients compared to typical average 90% of patients for surgery only

27. Significantly lower hysterectomy rate: Only 33% of women required hysterectomy compared to typical average 80% • No complications specific to the interventional radiology procedures performed • No surgical complications • No deaths

28. No complications specific to the interventional radiology procedures performed • No surgical complications • No deaths