Grand Rounds

Suspected Accreta: Does Internal Iliac Balloon Occlusion Reduce Blood Loss

BACKGROUND AND PURPOSE:

Evidence of benefit for the use of intraoperative internal iliac balloon occlusion in the setting of placenta previa with suspected accreta is generally derived from retrospective studies
Chen et al. (Obstetrics & Gynecology, 2020) prospectively assessed the effect of intraoperative internal iliac artery balloon occlusion in women with placenta previa and suspected placenta accreta

Single-center, randomized controlled trial (RCT)
Participants
- Placenta previa and suspected placenta accreta
- Diagnosis based on strict ultrasound criteria (all patients) and MRI at discretion of managing ObGyn
Interventions
- Balloon occlusion group
  - Catheter placed preoperatively, followed by intraoperative occlusion of bilateral internal iliac arteries
- Control group: No balloon occlusion
Statistical analysis
- Perioperative management similar for both groups
- 80% and two-sided α of 0.05: A sample size of 48 women per group was required to identify mean reduction of 2 units packed RBCs
Primary outcome
- Number of packed red blood cell (RBC) units transfused
Secondary outcomes
- Transfusion of other blood products | EBL | Cesarean hysterectomy | Other maternal and newborn outcomes and adverse events

100 women participated were randomized
- Balloon group: 50 women
- Control group: 50 women
- Demographic, obstetric, and placental imaging characteristics were similar between groups
- Confirmation of accreta diagnosis
  - Surgical: 98% had surgical diagnosis
  - 70% had a histologic confirmation of accreta or percreta
There was no significant difference in the number of packed RBC units transfused between the groups (p=0.54)
- Balloon group: 5.3±5.3 units
- Control group: 4.7±5.4 units
There were no differences in secondary outcomes including
- Other transfusion outcomes | Intraoperative EBL | Cesarean hysterectomy | Surgical injuries | Maternal ICU admission | Neonatal outcomes
Post hoc analysis analyzing only women who underwent cesarean hysterectomy also demonstrated no difference in primary outcome or EBL
The balloon group experienced significantly higher
- Hospitalization costs: $7456 vs $4803 (P<.01)
- Incidence of postoperative fever: 18% vs 2%; relative risk (RR) 10.8 (95% CI, 1.3 to 88.5, P=.02)

Authors recognize limitations
- Single center
- Study not blinded and could introduce bias as surgeons determine need for transfusion
For women with placenta previa and suspected placenta accreta, intraoperative balloon occlusion of the internal iliac arteries did not result in a decrease in the number of packed RBC units transfused and may be associated with increased incidence of post-op fever

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