Prophylactic radiologic interventions to reduce postpartum hemorrhage in women with risk factors for placenta accreta spectrum disorder: a nationwide cohort study

Abstract

Objective

To quantify the association between prophylactic radiologic interventions and perioperative blood loss in women with risk factors for placenta accreta spectrum disorder (PAS)

Methods

We conducted a retrospective nationwide cohort study of women with risk factors for placenta accreta spectrum disorder who underwent planned cesarean section in 69 Dutch hospitals between 2008 and 2013. All women had two risk factors for PAS: placenta previa/anterior low-lying placenta and a history of cesarean section(s). Women with and without ultrasonographic signs of PAS were studied as two separate groups. We compared the total blood loss of women with prophylactic radiologic interventions, defined as preoperative placement of balloon catheters or sheaths in the internal iliac or uterine arteries, with that of a control group consisting of women without prophylactic radiologic interventions using multivariable regression. We evaluated maternal morbidity by the number of red blood cell (RBC) units transfused within 24 h following childbirth (categories: 0, 1–3, >4), duration of hospital admission, and need for intensive care unit (ICU) admission.

Results

A total of 350 women with placenta previa/anterior low-lying placenta and history of cesarean section(s) were included: 289 with normal ultrasonography, of whom 21 received prophylactic radiologic intervention, and 61 had abnormal ultrasonography, of whom 22 received prophylactic intervention. Among women with normal ultrasonography without prophylactic intervention (n = 268), the median blood loss was 725 mL (interquartile range (IQR) 500–1500) vs. 1000 mL (IQR 550–1750) in women with intervention (n = 21); the adjusted difference in blood loss was 9 mL (95% confidence interval (CI) −315–513), p = .97). Among women with abnormal ultrasonography, those without prophylactic intervention (n = 39) had a median blood loss of 2500 mL (IQR 1200–5000) vs. 1750 mL (IQR 775–4000) in women with intervention (n = 22); the adjusted difference in blood loss was −1141 mL (95% CI −1694– −219, p = .02). Results of outcomes on maternal morbidity were comparable among women with and without prophylactic intervention.

Conclusion

These findings suggest that prophylactic radiologic interventions prior to planned cesarean section may help to limit perioperative blood loss in women with clear signs of placenta accreta spectrum disorder on ultrasonography, but there was no evidence of a difference within the subgroup without such ultrasonographic signs. The use of these interventions should be discussed in a multidisciplinary shared decision-making process, including discussions of potential benefits and possible complications.

Trial registration

Netherlands Trial Registry, https://onderzoekmetmensen.nl/en/trial/28238, identifier NL4210 (NTR4363)

Keywords:

• Placenta accreta spectrum
• postpartum hemorrhage
• radiologic interventions
• maternal morbidity

Acknowledgments

We would like to thank all 69 participating hospitals for their contribution to the TeMpOH-3 study. See the supplementary material for the list of the TeMpOH-3 study group (Appendix C). This study was part of a pilot of The Journal of Maternal-Fetal and Neonatal Medicine, using Paperpal as a text correction tool.

Author contributions

Concept, design, and obtained funding: VH, DH, JvdB, KB, JD, JvR, and JZ. Statistical analysis: LB, SF, AP, DH, JvdB, TvdA. Drafting of manuscript: LB, SF, JvdB, and DH. Interpretation of data and critical review of the manuscript: All authors.

Ethical approval

Institutional ethics committee approval (reference number: P13.264) was obtained on January 21^st 2014, by the Medical Ethics Research Committee of Leiden University Medical Center and from the institutional review board of each study center.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The data that support the findings of this study are available from the corresponding author, JvdB, upon reasonable request.

Additional information

Funding

This work was supported by an internal grant from the Sanquin Blood Supply Foundation (PPOC No 13-RvB-03).