This retrospective cohort study showed that the use of prophylactic internal iliac artery balloon occlusion does not lead to a statistically significant reduction in the EBL or rate of hysterectomy in women with PPP and PA during PTUI CS. Cell salvage was associated with a reduction in the rate of donor blood transfusion during PTUI CS, and no cases of amniotic fluid embolism were observed because of the use of leukocyte depletion filters.
PPP and PA are the main cause of severe obstetric postpartum hemorrhage [13-15] and hysterectomy [16-17] and often require allogeneic blood transfusion . Efficient hemostatic techniques should be performed to prevent PPH and preserve the uterus before, during and after CS. At present, there are many obstetric hemostatic techniques, such as abdominal aorta  or pelvic artery balloon occlusion [20-21], cell salvage , and modified surgical procedure [5,23]. BO (abdominal aorta or IIA) is the only technique that can be employed before CS in patients who need to keep the uterus and reserve fertility. The use of endovascular interventional procedures with BO has been described in the management of obstetric hemorrhage of various causes [24-25], but the effect of intraoperative IIA BO in women with PPP and PA is still controversial. Some authors advocate the use of IIA BO for treatment of PA, and they found preoperative prophylactic BO was associated with reduced EBL and fewer massive donor transfusions . However, other studies have found the opposite . These studies have focused on the use of BO in traditional CS, and there are no reports on the preoperative application of BO during PTUI CS. In the study by Yong You
et al, a novel technique using PTUI during CS is presented that could effectively control bleeding and preserve the uterus in patients with placenta previa and placenta accreta . Prophylactic internal IIA BO and cell salvage are increasingly being performed during PTUI CS when there is a high risk of hemorrhage in our hospital. To our knowledge, this is first report about efficacy of IIA BO on reducing EBL during PTUI CS.
In our report, 34 patients with PPP and PA underwent prophylactic IIA BO during PTUI CS, and 30 did not. The EBL was significantly higher in the IIA group compared to the control group (2883.5 ML in IIA group versus 1868.7 ML in control group, P=0.001). In patients without IIA OB, the average bleeding during PTUI CS surgery was only 1868.7 ml. This amount of bleeding is not a life-threating event for high-risk patients with PPP and PA if treated correctly. This result is consistent with published results regarding the reduction of intraoperative EBL in PTUI CS . Although the difference in the rate of hysterectomy between the two groups was not statistically significant, 8.8% (3/34) patients in the IIA group and 3.3% (1/30) of patients in the control group received final hysterectomy. Histopathological examination confirmed the diagnosis of severe PA in those 4 patients. These results suggest that when PTUI CS is performed without IIA BO, the rate of hysterectomy is very low. Hysterectomy cannot be completely avoided when PTUI CS is combined with IIA BO. In addition to the mode of PTUI CS, the occurrence of hysterectomy is closely related to the severity of placental implantation. Our findings suggest that PTUI CS may be an effective method to reduce the intraoperative EBL in patients with PPP and PA but does not completely eliminate the risk of hysterectomy.
Our findings concerning the effectiveness of IIA BO show that prophylactic IIA BO during PTUI CS did not lead to a statistically significant reduction in the EBL. There are three possible reasons for these findings. First, the obstetricians in the IIA group and those in the control group included for analysis were not the same surgical team. All PTUI CS were not performed by the same surgical team. In the IIA group, 17 of 34 PTUI CS were performed by the same surgical team, while in the control group, 22 of 30 PTUI CS were performed by the same surgical team. Technical differences may be one reason for the difference in EBL. Second, by the analysis of the clinical data of cases of EBL more than 4000 ml, we found that there were 8 cases of EBL more than 4000 ml in the IIA group, while there was none in the control group. In 5 of those eight cases, the PTUI procedure was slightly different. The placenta was delivered directly from the first transverse incision at the uterine fundus after the delivery of the fetus. During the delivery of the placenta, increased bleeding was found. Then, a second incision was made in the lower uterine segment to control the bleeding under direct vision. In the remaining cases, the standard PTUI CS, which comprised two incisions and two temporary ligations of the uterus, was used. The newborn was delivered safely and smoothly through the first incision, which was then sutured rapidly. A rubber tourniquet was passed below the cervix and uterine body under the first fundus incision and ligated tightly. A second, transverse uterine incision was then made in the lower segment of the uterus, followed by manual removal of the placenta under direct observation. This slight difference in the procedure may be one reason for the difference in the outcome. Third, 5 of those eight patients with the EBL more than 4000 ml were diagnosed with severe PA in the lower uterine segment. Severity of PA may have contributed to the difference in the outcome.
No procedure is without complications. Although rare, prophylactic IIA BO has associated complications . Placement of the IIA balloon catheter before CS might expose the fetus to some dose of radiation, although it has been reported that the dose is in the safe range. In addition, BO of IIA has been reported to cause complications, including maternal thromboembolic events, acute limb ischemia and ischemia–reperfusion injury, arterial pseudoaneurysms, and even arterial rupture. Puncture site complications, such as hematoma, false aneurysms and dissection of femoral arteries, may occur. In our opinion, during PTUI CS in the patients with PPP and PA, IIA BO should not be recommended because of its inefficiency and complications.
Our findings concerning the safety and effectiveness of cell salvage in PTUI CS shows that cell salvage may reduce the requirement for and amount of donor blood transfusion and maintains the postoperative hemoglobin concentration. PTUI CS in the IIA group was associated with higher EBL, and in these cases, cell salvage was routinely used. In the IIA group, the average estimated blood loss was up to 2883 ml. Although 33% had donor transfusion, the requirement for allogeneic blood was only 4.2 U on average, and the HB on the first day after surgery was 9.6 g. Some 41.2% (14/34) patient in IIA group had more than 1000 ml salvaged blood returned. Among them, the highest volume of salvaged blood returned was 2700 ml. These results suggest that the need for allogeneic blood may decrease because of the deployment of cell salvage. The use of cell savage during traditional CS has been reported in the management of obstetric hemorrhage of various causes. Some reported that preoperative routine use of cell salvage has not been associated with the overall reduction of donor blood transfusion during CS . One possible reason for these different findings is that patients included for analysis in our study may have been different from those included in Khan KS et al.’s study , making the aims of the two studies different. In our study, suspected diagnosis with PPP and PA were confirmed by MRI before planned PTUI CS, and planned PTUI CS was performed successfully in all cases. In contrast, Khan KS et al.  included participants with an identifiable increased risk of hemorrhage, including placentation (abnormal versus normal multiple birth, and delivery by emergency or traditional elective CS. Further multicenter randomized controlled trials are needed to investigate whether cell salvage is beneficial for reducing intraoperative use for allogeneic blood in women with PPP and PA during PTUI CS.
leukocyte depletion filter is use for all the patients who received cell salvage, and no serious adverse reactions, such as amniotic fluid embolism, were reported in the records. Our results suggest that cell salvage is a relatively simple and effective blood conservation technique and may be beneficial for patient blood management during PTUI CS. This study suggests that concerns about the risk of amniotic fluid embolism should not be contraindication to its use during PTUI CS in a patient with PPP and PA. If cell salvage is to be used, employment of leukocyte depletion filters should be considered to reduce the risk of adverse reactions. Further research on the safety and effectiveness of cell salvage during PTUI CS in high-risk patients, particularly in hospitals with a limited supply of donor blood for transfusion, will be useful in guiding decision-making.
While the PTUI CS procedure has become established in our department, we are aware that the PTUI CS is controversial, and further research in PTUI CS is necessary. Although a randomized controlled study of the management of PTUI CS procedure and IIA OB would yield the best scientific results, it is unlikely to performed a randomized controlled study because of its relative rarity and the ethical issues of such a study.
The purposes of PTUI CS are to reduce intraoperative bleeding, to ensure the safety of the mother, and to preserve the uterus. Patients included in our study had 2 incisions in the uterine body and lower uterine segment respectively. The main concern regarding PTUI CS procedure is the potential risk of uterine rupture during subsequent pregnancy. To prevent the unknown risk of uterine rupture during a subsequent pregnancy, 58.8% (20/34) patients in the IIA group and 66.6% in the control group had bilateral tubal ligation.
Our study had some limitations. First, it was a retrospective study, not a multicenter randomized controlled trial. Whether an IIA BO catheter was placed, for mostly clinical reasons, were chosen based on the obstetrician’s discretion. Potential variations existed in the PTUI CS method, and what surgical techniques of PTUI CS were performed. In a few cases, the placenta was removed and bleeding was found, and then a second incision was performed in the lower uterine segment to stop bleeding under direct vision. A potential indication bias may also have existed. However, all patients included in our research had been diagnosed with PPP and PA by MRI before PTUI CS. The diseases, PPP and PA, included in our study were consistent in different group. Most patients retrospectively reviewed were only from the West China Second University Hospital of Sichuan University. A study of different regions and different races with larger sample size is necessary. Second, all PTUI CS were not performed by the same obstetrician team. Differences in PTUI CS techniques between obstetricians might have led to bias in the study. However, the majority of the patients in both groups were treated by the same obstetrician team (17/34 in IIA group versus 22/30 in control group). PTUI CS has become established in our hospital, but we are aware that PTUI CS with or without IIA BO is controversial, and further research in PTUI CS is necessary. A multicenter randomized controlled trial is required before PTUI CS can be performed into routine clinical obstetrical practice.