Application Of Temporary Infrarenal Intra-aortic Balloon Occlusion In Cesarean Section Of Pernicious Placenta Previa

Purpose:Pernicious placenta previa(PPP)can cause catastrophic or fatal hemorrhage during cesarean section(CS).In order to reduce the massive hemorrhage in CS and decrease the rate of hysterectomy,a series of improvement measures have been applied in CS of PPP;such as intravenous injection of oxytocin,injection of ergoxine,gauze and Bakri balloon filling uterine cavity,local uterine pressure suture,B-Lynch suture and uterine artery or branch ligation,eta.However,these methods are still not to avoid the adverse pregnancy outcome caused by massive hemorrhage during CS,and hysterectomy is often needed to save the life of women with PPP.With the devolopment of interventional radiology past two decades,endovascular interventional radiology has been widely used in CS of PPP.These techniques include prophylactic/temporary intra-aortic balloon occlusion,bilateral intra iliac/common iliac artery balloon occlusion,and uterine artery embolization.Among thses techniques,temporary infrarenal intra-aortic balloon occlusion(TIABO)is considered to be the most effective rescue measure to decrease bleeding in CS of women with PPP.And it is more advantageous than other methods or measures in decrease cesarean hysterectomy for women with PPP.However,due to the lack of evidence of randomized controlled trials(RCTs),and its complication such as thrombosis,there is still no complete consensus about its safety and effectiveness.Whether the application of TIABO in CS of women with PPP is beneficial,whether there are methods and measures to reduce or avoid complications,and when is the best time to inflate balloon remain to be further studied.Therefore,the main purposes of our studies are as following:(1)To further evaluate the efficacy of TIABO during CS for women complicated with PPP using a propensity score matching(PSM)analysis.(2)To retrospectively analyze the efficacy and safety of continuous low-flow perfusion of diluted heparin saline in prevention of TIABO related thrombosis,so as to provide further practical basis for the application of TIABO during CS for women with PPP.(3)To investigate the role and value of the timing of TIABO during CS in women with PPP and compare the effect of different occlusion timing on maternal and infant.Materials and methods:Ⅰ.Application of temporary infrarenal intra-aortic balloon occlusion in cesarean section of women with pernicious placenta previa--A propensity score matching analysisBy searching the electronic medical records(EMRs)of the First Affiliated Hospital of Nanchang University,we collected the data of all women who underwent CS in our hospital due to PPP from January 2012 to December 2019.They were divided into two groups according to TIABO used or not.Women with TIABO performed were assigned to the study group and others were in the control group.We collected maternal base data(ages,pregnancy length,number of gravidity,number of parity,number of previous CS),and covariates or confounders(periuterine adhesions,absence of the myometrium,abnormal vascularization or dilated vessels on uterine wall,placenta previa types,the location of the main body of the placenta,morbidly adherent placenta types)that may influence pregnancy outcomes.The PSM module in SPSS25.0 software was used to estimate the propensity score value by Logistic regression.Then a 1:1 match between the two groups was applied through the nearest available neighbor matching with a caliper width of 0.01 standard deviation of the logit of the propensity scores.Intraoperative blood loss,transfusion volume,transfusion rate,hysterectomy rate,operative time,postoperative hospitalization days,and neonatal status included 1-minute Apgar score and neonatal weight were compared between the study and control group.The test level was set as~a=0.05.Ⅱ.Study on the prevention of temporary infrarenal intra-aortic balloon occlusion related thrombosis by continuous low-flow perfusion of diluted heparin salineWe collected data of women who were diagnosed PPP and performed TIABO in order to reduce intraoperative bleeding during CS in the First Affiliated Hospital of Nanchang University from March 2016 to December 2019.All women were divided into the study group and the control group according to using continuous low-flow perfusion of diluted heparin saline for preventing TIABO related thrombosis or not.The incidence of thrombosis,and some other outcomes such as intraoperative blood loss were compared between the two groups.We also discussed the effective managements of thrombus.The test level was set as~a=0.05.Ⅲ.Effects of different timing of temporary infrarenal intra-aortic balloon occlusion during casarean section in women with pernicious placenta previaRetrospective analysis was performed on the medical records of women who were admitted to the department of obstetrics and gynecology of the First Affiliated Hospital of Nanchang University from March 2016 to December 2019 due to the PPP,and underwent TIABO during CS.All women were divided into three groups.Group A:balloon occlusion time was selected before transverse incision of the uterus was taken.Group B:after cutting open the uterus and in the process of delivery of the fetus,balloon inflating was carried out before clipping or cutting the umbilicus.Group C:after delivery of fetus and clipping or cutting the umbilicus,we inflated balloon.Intraoperative blood loss,transfusion volume,the hysterectomy rate,the duration of operation,the hospital days after CS,neonatal 1-minute Apgar score and the incidence of thrombosis,etc.were compared among women of the three groups.The test level was set as~a=0.05.Results:Ⅰ.Application of temporary infrarenal intra-aortic balloon occlusion in cesarean section of women with pernicious placenta previa--A propensity score matching analysisAfter searching the EMRs system of our hospital and reading women’s data,there were 40 women in the study group and 367 women in control group,who met the inclusion criteria.After PSM,40 women in study group were matched with 32women in the control group,and the baseline demographics and the confounders were well balanced between the two groups(P>0.05).The difference of outcome such as blood loss(Z=-3.12,P=0.002),blood transfusion(Z=-2.00,P=0.045)and transfusion rate(X~2=4.06,P=0.04)during CS was statistically significant between the two groups of women with PPP,P<0.05.And the value of the study group was lower than that of the control group.There was no statistically significant difference between the two groups in hysterectomy rate during CS(P=0.09).However,the hysterectomy rate of the study group was lower than that of the control group,which was 10%(4/40)in the study group and 25%(8/32)in the control group.There was no statistically significant difference between the two groups in duration of operation and the hospital days after CS(P>0.05).The difference of 1-min Apgar score and birth weight of newborn was no statistically significance,either(P>0.05).Ⅱ.Study on the prevention of temporary infrarenal intra-aortic balloon occlusion related thrombosis by continuous low-flow perfusion of diluted heparin salineThere were 40 women with PPP lined with inclusion criteria.There were 20women in the control group underwent CS without performing continuous low-flow perfusion of diluted heparin saline,and thrombosis occurred in 6 women(6/20,30%).While the other 20 women who were included in the study group were performed continuous low-flow perfusion of diluted heparin saline during CS for prevention of thrombosis and all of them did not occur thrombosis.The incidence of thrombus was statistically significant between the two groups(c~2=4.90,P=0.02).There was no statistically significant difference in blood loss during CS between the two groups(Z=-0.669,P=0.50).The managements of thrombus included systemic anticoagulation,catheter-directed thrombolysis(CDT),and catheter-directed anticoagulation(CDAC).One of the 6 women was lost to follow-up,and the thrombus of the other 5 women were completely dissolved.No other adverse outcomes or complications related to TIABO were observed in all women in this study.Ⅲ.Effects of different timing of temporary infrarenal intra-aortic balloon occlusion during casarean section in women with pernicious placenta previaThere were 39 eligibility women in this study.There were 17 in group A,8 in group B and 14 in group C,respectively.The baseline data including maternal age,pregnancy length,number of gravidity,number of parity,number of previous CS were not statistically significant among the three groups(P>0.05).There were no statistically significant difference in intraoperative blood loss,transfusion volume,the hysterectomy rate,the duration of operation,the hospital days after CS,neonatal1-minute Apgar score and the incidence of thrombosis among the three groups(P>0.05).Conclusion:(1)TIABO is advantageous when performing CS surgery in treating women with PPP.It helps to reduce hemorrhage and transfusion of blood products.It also has the potential to prevent women from having to undergo hysterectomy and preserve their fertility.And it does not significantly prolong the hospotal days after CS and dose not cause harm to the newborn.(2)It is a safe procedure of performing continuous low-flow infusion of diluted heparin saline when TIABO is performed during CS for women with PPP.It can effectively decrease or even avoid thrombosis without increasing intraoperative blood loss during CS for women with PPP.(3)The different timing of performing TIABO during CS would not cause different outcomes to women and their babies.