The Clinical Evaluation of IIA Balloon Occlusion for Pernicious Placenta Previa Patients with Placenta Accreta: A Retrospective Study

The Clinical Evaluation of IIA Balloon Occlusion for Pernicious Placenta Previa Patients with Placenta Accreta: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Clinical Evaluation of IIA Balloon Occlusion for Pernicious Placenta Previa Patients with Placenta Accreta: A Retrospective Study Ling Hong, Aner Chen, Jinliang Chen, Xiuxiu Li, Wenming Zhuang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-900376/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Objective: This study aimed to evaluate the clinical efficacy of internal iliac artery(IIA) balloon occlusion in patients with pernicious placenta previa coexisting with placenta accreta. Background: Pernicious placenta previa is frequently reported to be complicated with placenta accreta, which contributes to serious consequences such as severe obstetric postpartum hemorrhage or even maternal mortality. Methods: Fifty-eight pernicious placenta previa patients complicated with placenta accreta were retrospectively reviewed. The ballon group consisted of 23 patients, who underwent a caesarean delivery with internal iliac artery occlusion. 35 patients were in the control group, who had a standard caesarean delivery. The primary outcomes were estimated blood loss (EBL), cesarean hysterectomy, and blood transferring volume. The secondary outcomes were operating time, intraoperative hemostatic approaches, surgical complications, balloon catheter–related complications, length of maternal stay, cost of hospitalization, and neonatal outcomes. Results: No difference was observed in estimated blood loss (EBL), blood transferring percentages and volume, additional measures to secure hemostasis , surgical complications, hospital stay postoperatively and newborn outcomes. More than 40% of the balloon group underwent hysterectomy because of uncontrollable postpartum bleeding (10[43.48%] vs. 11[31.43%],P=0.350).Complications related to occlusion of IIA did not occur.The duration of the surgery of the balloon group was significantly longer than that of the control group(123.52 min±74.76 versus 89.17±48.68,P=0.038), and the total hospitalization cost was also significantly higher than that of the control group(45116.67±9358.67 yuan versus 30615.41±11587.44yuan,P=0.000). Conclusion: IIA balloon occlusion in patients with pernicious placenta previa coexisting with placenta accreta did not reduce the hysterectomy rate during cesarean section, nor did it reduce blood loss and blood transfusion, but it prolonged the duration of the surgery and increased the total cost. Maternal & Fetal Medicine Sexual & Reproductive Medicine Pernicious placenta previa Placenta accrete IIA balloon occlusion Figures Figure 1 Figure 2 Background Pernicious placenta previa(PPP), the attachment of placental previa to the previous cesarean delivery scars, was first proposed by Chattopadhyay et al [1] ,and it is often related to placenta accreta. In past decades, women increasingly preferred to deliver by cesarean section, leading to the increasing incidence of pernicious placenta previa [2] . It is reported with an incidence of 1 per 533 pregnancies [3] . One of the main and deadliest complications of pernicious placenta previa with placenta accreta is massive bleeding. The average blood loss in these cases has been estimated to range between 2 and 3 liters [4] . Therefore, strategies to prevent and treat bleeding are paramount to manage this pathology. Various approaches have been employed in controlling intraoperative blood loss in cases of abnormal placentation. These include inserting uterine tamponade balloons, applying uterine gauze packing, placing uterine brace or isthmic compression sutures, and performing a hysterectomy. The arterial occlusion balloon was introduced and used in pernicious placenta previa, recently, and the role of intraoperative internal iliac artery(IIA) balloon occlusion to improve hemorrhagic outcomes in women with placenta accreta has been evaluated in many studies, most of which showed some benefit [5–9] , but others failed to demonstrate any [10–12] . In this retrospective study, we aimed to evaluate the clinical efficacy of IIA balloon occlusion in patients with pernicious placenta previa coexisting with placenta accreta. Methods Fifty-eight pernicious placenta previa patients who were complicated with placenta accreta underwent balloon occlusion of IIA between January 2015 and June 2018 at Ningbo Women and Children’s Hospital were retrospectively reviewed in this study. The Institutional Review Board of Ningbo Women and Children’s approved this study, and the need for informed consent was waived because of retrospective nature of this study. Cases were identified using the electronic medical record system. The inclusion criteria were a diagnosis of pernicious placenta previa with placenta accreta and having caesarean sections performed by the same experienced surgeon. The following patients were excluded: those who had a history of gynecological cancers or other solid cancers, hematological malignancies, gynecological surgeries (such as myomectomy, cervicoplasty and uterine rupture repair); those severe platelet disorders; twin pregnancy, those who underwent emergent delivery and cases with missing data. For all women included in this study, a diagnosis of placenta accreta had been made on prenatal imaging with either ultrasound and/or magnetic resonance imaging(Figure 1 ) and abnormal placental status was confirmed clinically, or histopathologically, after delivery. Each clinical case was discussed in multidisciplinary meetings with interventional radiologists, obstetricians, neonatologists, and urologist. Finally, whether to accept IIA balloon occlusion is determined according to patients’ willingness, which were subsequently divided into the balloon group and the control group. There were 23 patients in the balloon group and 35 patients in the control group. Occlusion balloon placement was performed by one of two senior interventional radiologists, who each had more than five years of experience with the similar procedure of uterine artery embolisation for caesarean scar ectopic pregnancy. Procedure for the management of IIA balloon catheters was as follows. Arteriopuncture of bilateral femoral arteries via the Seldinger technique was performed after local anesthesia; 6- French sheaths were then put in place. Next, selective contralateral IIA catheterization was performed with fluoroscopy guidance, and a PTA catheter (Abbott, USA) was inserted into the IIA. The balloon (Abbott, USA), which was approximately 8-10 mm in diameter, was exchanged by using a 0.035- inch super- hard exchange guide wire and then positioned in the IIA with the head pointing to the branch of the anterior IIA, as confirmed by angiography (Figure 2 ). After the insertion, The balloon was briefly inflated, and contrast injected to verify occlusion of the artery. Once positioning was satisfactory, the balloon catheter and its sheath were fixed on the skin. Patients were then transferred to the operating room for cesarean delivery. After the baby was delivered, the occlusion balloons were inflated immediately. The placenta was then delivered and cesarean delivery was continued in the usual manner. Balloons were deflated before skin closure. Balloon catheters and wires were removed after surgery, and 1 sheath was left in place to allow for resuscitation and emergency embolization if needed. Perioperative management was similar in the two groups except for catheter placement and balloon occlusion of bilateral internal iliac arteries. Perioperative management was similar in the two groups except for catheter placement and balloon occlusion of bilateral internal iliac arteries. The primary outcomes were estimated blood loss (EBL), cesarean hysterectomy, and blood transferring volume. The secondary outcomes were as follows: operating time, intraoperative hemostatic approaches ( such as intrauterine tamponade, compression suturing, uterine artery ligation), surgical complications, balloon catheter–related complications (including puncture site hematoma, thrombosis, embolic events, and vascular rupture), length of maternal stay, cost of hospitalization, and neonatal outcomes. Statistics Statistical analysis was performed using SPSS 20.0 software. Data were presented as mean ± SD, median (range) or count (percentage). Comparison between 2 groups was determined by t test, Wilcoxon rank sum test or chi-square test. p < 0.05 was considered significant. Result Fifty-eight women were included. Twenty- three women were in the balloon group and thirty-five women were in the control group. Baseline characteristics are summarized in Table 1 . There was no significant difference between the two groups with respect to patient age at delivery, gestational age, gravidity, parity, type of pregnancy, number of previous uterine surgeries and abdominal surgeries, number of previous cesarean deliveries, types of placenta accretion and hemoglobin before cesarean section. Table 1 Demographic characteristics and incidence of different forms of placenta accretion in the two study groups. Characteristic/Outcome Balloon Group(n=23) Control group(n=35) p- value Mean age, years 33.00±3.77 33.37±4.44 0.742 gestational age, weeks 34.86±1.05 35.47±1.20 0.113 Gravidity 3.70±1.11 3.91±1.29 0.508 Parity 2.13±0.55 2.14±0.43 0.924 number of previous uterine surgeries 1.52±1.47 1.74±1.17 0.528 number of previous cesarean deliveries 1.09±0.29 1.14±0.36 0.531 Hemoglobin before cesarean section, g/dl 11.23±1.33 11.19±1.25 0.914 Deepth of Placenta percreta accreta 4 11 0.232 Increta 9(56.52%) 16(77.14%) 0.620 Percreta 10(43.48%) 8(22.86%) 0.097 The intraoperative and postoperative outcomes for the two groups are summarized in Table 2 , 3 . The median EBL was 2500ml (range,1750-5750ml) in the balloon group versus 2000ml (range, 1500-3350ml) in the control group ( p =0.171). There was no statistically significant difference observed between the groups with intraoperative hemorrhage volumes of 2500 mL and above ( p =0.421). More than 40% of the balloon group underwent hysterectomy because of uncontrollable postpartum bleeding (10[43.48%] vs. 11[31.43%], p =0.350). The need for additional measures to secure hemostasis similarly showed no difference between the groups (Table 3 ). Table 2 Blood loss and transfusion requirements between the two study groups. Parameters Balloon Group(n=23) Control group(n=35) p -value Estimated blood loss, ml # 2500(1750-5750) 2000(1500-3350) 0.226 Blood loss≥2500ml, n(%) 13(56.52%) 16(45.71%) 0.421 Transfusion, n(%) 21(91.30%) 35(100%) 0.076 Autologous blood transfusion, n(%) 20(86.96%) 34(97.14%) 0.134 Autologous blood transfusion, ml # 600(335-1050) 500(278.5-745.5) 0.347 RBC transfusion, n(%) 12(52.17%) 17(48.57%) 0.788 RBC, units # 3(0-6) 0(0-4.5) 0.486 FFP transfusion, n(%) 18(78.26%) 20(57.14%) 0.098 FFP, units # 1080(555-1200) 500(0-1160) 1.000 Cryoprecipitate transfusion, n(%) 12(52.17%) 10(28.57%) 0.070 Cryoprecipitate, units # 5(0-10) 0(0-9.75) 0.343 Decrease in Hb after surgery # 1.3(-1.5-1.7) 1.35(0.1-2.45) 0.266 RBC, red blood cells; FFP, fresh frozen plasma; Hb, haemoglobin concentration. #Data were presented as median (range). Comparison between 2 groups was determined by Wilcoxon rank sum test. Table 3 Surgical details and postoperative outcomes between the two study groups. Parameters Balloon Group(n=23) Control group(n=35) p -value Cesarean hysterectomy, n(%) 10(43.48%) 11(31.43%) 0.350 Additional measures to secure hemostasis, n(%) 15(65.22%) 27(77.14%) 0.320 Iodoform gauze packing of the uterine cavity, n(%) 14(60.87%) 26(74.29%) 0.280 Balloon tamponade, n(%) 8(34.78%) 20(57.14%) 0.096 Uterine artery ligation, n(%) 2(8.70%) 2(5.71%) 0.661 uterine artery embolization, n(%) 6(26.09%) 12(34.29%) 0.509 Partial excision of the invaded uterine wall, n(%) 3 2 0.303 Duration of the surgery, min * 123.52±74.76 89.17±48.68 0.038 Hospital stay postoperatively, days 7.96±2.14 7.74±1.90 0.692 Hospitalization cost, yuan * 45116.67±9358.67 30615.41±11587.44 0.000 Surgical complications, n(%) 14(60.87%) 22(62.86%) 0.879 Fever, n(%) 11(47.83%) 20(57.14%) 0.487 DIC, n(%) 2(8.70%) 4(11.43%) 0.738 Pneumonedema, n(%) 0 1(2.86%) 0.414 Bladder injury, n(%) 3(13.04%) 1(2.86%) 0.134 Relaparotomy, n(%) 2(8.70%) 3(8.57%) 0.987 Maternal death 0 0 - Balloon related complications Hematoma puncture 0 0 - Vein thrombosis 0 0 - Neonatal outcome Neonatal birth weight, g 2540±480 2740±360 0.074 Apgar score of 1min 8.70±0.56 8.46±1.12 0.349 Apgar score of 5min 9.78±0.42 9.69±0.93 0.642 Neonatal mortality 0 0 - DIC disseminated intravascular coagulation * P <0.05 Twenty-one women in the balloon group and all women in the control group received blood transfusions. No significant differences were noted both in the percentages and volumes of autologous blood transfusion, red blood cell transfusion, fresh frozen plasma transfusion and cryoprecipitate transfusion between the two groups. There was no significant difference in the Hb decrease between the two groups (1.3 (range, -1.5-1.7) vs 1.35 (range, 0.1-2.45), p =0.266). The duration of the surgery of the balloon group was significantly longer than that of the control group(123.52 min±74.76 versus 89.17±48.68, p =0.038), and the total hospitalization cost was also significantly higher than that of the control group(45116.67±9358.67 yuan versus 30615.41±11587.44yuan, p =0.000). There was no significant difference in surgical complications, postoperative hospital stay, newborn weight, Apgar scores at 1 and 5 minute between the two groups. No still births or maternal death were observed in either group. No balloon related complication occurred in the balloon group. Discussion This study showed that balloon occlusion of IIA in patients with pernicious placenta previa coexisting with placenta accreta did not reduce the hysterectomy rate during cesarean section, nor did it reduce blood loss and blood transfusion, but it prolonged the duration of the surgery and increased the total cost. Although advances in obstetric care have led to a substantial improvement in pregnancy outcomes, the death rate from placenta accreta remains as high as 7%, largely due to massive haemorrhage [13, 14] ,which may then lead to disseminated intravascular coagulation, fluid overload, acute respiratory distress syndrome and infection. It seems logical that occlusion of the internal iliac arteries with prophylactically- placed balloon catheters would be a more effective treatment option, but reported results are controversial. Some retrospective studies [6–9] reported that intraoperative IIA balloon occlusion had benefits in reducing blood loss and the amount of blood transfusion. Some previous systematic reviews also reported that intraoperative IIA balloon occlusion had benefits in reducing blood loss, the volumes of blood transfusion and even the percentages of cesarean hysterectomy in women with accrete [5,15] . Nicholson et al. also reported that patients with IIA balloon occlusion had a decreased rate of hysterectomy compared to those without it [16] . Recently, Yao FAN and Soo BuemCho 's two randomized controlled studies also agree with this view [15,17] . However, randomized controlled studies [10,18] and several case control studies [11,12,19] did not find any benefit. Our findings accord with the previous randomized controlled trial conducted by Meng Chen et al [18] . In our study, we selected the most serious type of disease in the placenta previa spectrum--pernicious placenta previa with placenta accreta, and tried to exclude the heterogeneity caused by the study subjects; In addition, In addition, in our study, all patients are operated by the same surgeon, who has more than 20 years of experience and performs nearly 1,000 cesarean sections a year. They also received the same standard peripartum care apart from the insertion of iliac artery balloons which also eliminate the surgical procedural heterogeneity between surgeons and teams. This is the most significant advantage of our research, which has not been reported in other studies. It is unclear why occlusion of the internal iliac arteries failed to reduce haemorrhage in our study. The uterine arteries account for most of the blood supply to the uterus, but the extensive collateral supply from the ovarian arteries will not be affected [20] .It may also be possible that IIA balloon occlusion does not provide enough arterial flow attenuation in cases of severe abnormal placentation. In a recent case report, escalating from IIA balloon occlusion to common iliac artery balloon occlusion was found to be more effective in reducing operative blood loss during cesarean hysterectomy for morbidly adherent placenta [21] probably because common iliac artery balloon occlusion occluded more collateral arteries than IIA balloon occlusion. In addition, there may be a risk of balloon displacement. As the women were transferred from the interventional unit to the operating theatre after balloon insertion, and we were unable to perform real-time balloon imaging during the caesarean section, the possibility of balloon migration cannot be excluded. Teixidor has confirmed this in his research [22] . In order to avoid catheter displacement as much as possible, we used general anesthesia in the balloon group. In our study, the transfusion rate was 91.3% in the balloon group and 100% in the control group, which was much higher than the 50% or so reported in the literature [23] . In our hospital, autologous blood transfusion is one of the necessary means to reduce the bleeding during the operation of pregnant women with placenta accreta spectrum. Therefore, nearly every pregnant woman in our study underwent autologous blood transfusion during cesarean section, which may be the reason for the increased transfusion rate in our study. Our results show that the duration of surgery in the balloon group is significantly longer than in the control group, which should be interpreted with caution. Pregnant women in the balloon group needed an interventional surgeon to remove the balloon after surgery, whereas women in the control group did not. This study has several limitations, including the retrospective, single-center nature of the investigation. The lack of randomization in the outcome could lead to more complex cases being selected for balloon lacement while the less severe cases may have tended to undergo standard caesarean delivery. Blood loss was estimated, and transfusion was performed based on surgeon preference, which may have varied based on practice. Conclusion IIA balloon occlusion in patients with pernicious placenta previa coexisting with placenta accreta did not reduce the hysterectomy rate during cesarean section, nor did it reduce blood loss and blood transfusion, but it prolonged the duration of the surgery and increased the total cost. Abbreviations PPP: Pernicious placenta previa; IIA: internal iliac artery; EBL: estimated blood loss; RBC: red blood cells; FFP: fresh frozen plasma; Hb: haemoglobin concentration; DIC: disseminated intravascular coagulation. Declarations Ethics approval and consent to participate The Institutional Review Board of Ningbo Women and Children’s approved this study , and the need for informed consent was waived because of retrospective nature of this study. (EC2019–043). All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable for this publication. Availability of data and materials The research data used to support the findings of this study were supplied by Ms.Zhang under license and so cannot be made freely available. Requests for access to these data should be made to Ms.Zhang (Email: [email protected] ). Competing interests We declare that we don’t have competing interests with publication of this article. Funding The study was supported by the grant from Health Commission of Zhejiang Province 2020PY024 and Ningbo Science and Technology Bureau 2019C50090. Author contributions LH: data collection and analysis; primary author of manuscript. AC: evaluation design; Surgeon of cesarean section; JC: Imaging technical guidance, image collection. XL, ,YS,QD: data analysis and interpretation; manuscript preparation and review. WZ: obtaining funding and ethics approval. LZ: leads all aspects of this study including study concept and design; obtaining funding and ethics approval; supervision of data collection and implementation; and manuscript supervision and revision for critical intellectual input. All authors have read and approved the manuscript. Acknowledgements Not applicable. Author details 1 Department of obstetrics and gynecology, Ningbo women and children's hospital, Ningbo, China 2 Radiology department, Ningbo women and children's hospital, Ningbo, China 3 Department of science and education, Ningbo women and children's hospital, Ningbo, China References Chattopadhyay SK, Khariff H, Sherbeeni MM. Placenta previa and accreta after previous cesarean section[J]. Eur J Obstet Gynecol Reprod Biol, 1993, 52(3): 151-156. Karla N Solheim, Tania F Esakoff, Sarah E Little, Yvonne W Cheng, Teresa N Sparks, Aaron B Caughey; The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2011 Nov;24(11):1341-6. 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Albaro José Nieto-Calvache, Lina María Vergara-Galliadi, Fernando Rodríguez, Carlos A Ordoñez, Alberto Federico García, María Camila López, Ramiro Manzano, Jorge Velásquez, Juan Pablo Carbonell, Adriana Messa Bryon, Maria Paula Echavarría, Maria Fernanda Escobar, Javier Carvajal, Juan Pablo Benavides-Calvache, Juan Manuel Burgos; A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum.The journal of trauma and acute care surgery 2021 05 01;90(5):807-816. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 10 Nov, 2021 Reviews received at journal 01 Nov, 2021 Reviewers agreed at journal 01 Nov, 2021 Reviewers invited by journal 30 Oct, 2021 Editor assigned by journal 30 Oct, 2021 Editor invited by journal 07 Oct, 2021 Submission checks completed at journal 07 Oct, 2021 First submitted to journal 13 Sep, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-900376","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":55821540,"identity":"0bc4aab6-cb54-447d-937c-f923550a909a","order_by":0,"name":"Ling Hong","email":"","orcid":"","institution":"Ningbo women and children's hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ling","middleName":"","lastName":"Hong","suffix":""},{"id":55821541,"identity":"adee8e81-47c7-4c03-80d4-cac41e31b736","order_by":1,"name":"Aner Chen","email":"","orcid":"","institution":"Ningbo women and children's hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aner","middleName":"","lastName":"Chen","suffix":""},{"id":55821542,"identity":"b1ee7a9f-7360-48ea-8379-9354fae66777","order_by":2,"name":"Jinliang Chen","email":"","orcid":"","institution":"Ningbo women and children's hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jinliang","middleName":"","lastName":"Chen","suffix":""},{"id":55821544,"identity":"b103c7ab-b5d3-41e3-8044-38016fda037f","order_by":3,"name":"Xiuxiu Li","email":"","orcid":"","institution":"Ningbo women and children's hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiuxiu","middleName":"","lastName":"Li","suffix":""},{"id":55821545,"identity":"de47c46b-da0e-4b9a-825a-47576c4de366","order_by":4,"name":"Wenming Zhuang","email":"","orcid":"","institution":"Ningbo women and children's hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wenming","middleName":"","lastName":"Zhuang","suffix":""},{"id":55821547,"identity":"45e7921f-03e5-4170-b173-15045420e7a8","order_by":5,"name":"Yijing Shen","email":"","orcid":"","institution":"Ningbo women and children's hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yijing","middleName":"","lastName":"Shen","suffix":""},{"id":55821549,"identity":"2f030f7c-bce7-4c1d-93bd-06ffe0cf227a","order_by":6,"name":"Qiaohong Dai","email":"","orcid":"","institution":"Ningbo women and children's hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qiaohong","middleName":"","lastName":"Dai","suffix":""},{"id":55821552,"identity":"103e3364-7afb-48c0-975d-dae92994d102","order_by":7,"name":"Li Zhang","email":"data:image/png;base64,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","orcid":"","institution":"Ningbo women and children's hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2021-09-13 09:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-900376/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-900376/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":14352178,"identity":"5f99f148-3867-4b4f-9aca-94fbdaa0bc72","added_by":"auto","created_at":"2021-10-08 16:14:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":90257,"visible":true,"origin":"","legend":"A:Color Doppler images. The arrow indicates evidence of placenta accreta (indistinct boundary of utero-placental interface); B: MRI. Placenta accreta in the lower uterine segment (indicated by an arrow). ","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-900376/v1/b3122b1ce2433a2d45f3d633.png"},{"id":14352176,"identity":"d4337893-737d-47ee-b2b9-6f0159b649c6","added_by":"auto","created_at":"2021-10-08 16:14:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":86862,"visible":true,"origin":"","legend":"Fluoroscopy showing the balloon catheters positioned in the main lumen of the internal iliac arteries bilaterally.","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-900376/v1/92dddfd6319fed3dc1306380.png"},{"id":14352204,"identity":"cf804b21-cfcd-46ef-ad71-9a7f4ab8cea1","added_by":"auto","created_at":"2021-10-08 16:14:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":451215,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-900376/v1/692c1436-cb21-43a0-b39b-b6e4eb16074a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Clinical Evaluation of IIA Balloon Occlusion for Pernicious Placenta Previa Patients with Placenta Accreta: A Retrospective Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePernicious placenta previa(PPP), the attachment of placental previa to the previous cesarean delivery scars, was first proposed by Chattopadhyay et al\u003csup\u003e[1]\u003c/sup\u003e ,and it is often related to placenta accreta. In past decades, women increasingly preferred to deliver by cesarean section, leading to the increasing incidence of pernicious placenta previa\u003csup\u003e[2]\u003c/sup\u003e. It is reported with an incidence of 1 per 533 pregnancies\u003csup\u003e[3]\u003c/sup\u003e. One of the main and deadliest complications of pernicious placenta previa with placenta accreta is massive bleeding. The average blood loss in these cases has been estimated to range between 2 and 3 liters\u003csup\u003e[4]\u003c/sup\u003e. Therefore, strategies to prevent and treat bleeding are paramount to manage this pathology. Various approaches have been employed in controlling intraoperative blood loss in cases of abnormal placentation. These include inserting uterine tamponade balloons, applying uterine gauze packing, placing uterine brace or isthmic compression sutures, and performing a hysterectomy.\u003c/p\u003e \u003cp\u003eThe arterial occlusion balloon was introduced and used in pernicious placenta previa, recently, and the role of intraoperative internal iliac artery(IIA) balloon occlusion to improve hemorrhagic outcomes in women with placenta accreta has been evaluated in many studies, most of which showed some benefit\u003csup\u003e[5\u0026ndash;9]\u003c/sup\u003e, but others failed to demonstrate any\u003csup\u003e[10\u0026ndash;12]\u003c/sup\u003e. In this retrospective study, we aimed to evaluate the clinical efficacy of IIA balloon occlusion in patients with pernicious placenta previa coexisting with placenta accreta.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFifty-eight pernicious placenta previa patients who were complicated with placenta accreta underwent balloon occlusion of IIA between January 2015 and June 2018 at Ningbo Women and Children\u0026rsquo;s Hospital were retrospectively reviewed in this study. The Institutional Review Board of Ningbo Women and Children\u0026rsquo;s approved this study, and the need for informed consent was waived because of retrospective nature of this study.\u003c/p\u003e\n\u003cp\u003eCases were identified using the electronic medical record system. The inclusion criteria were a diagnosis of pernicious placenta previa with placenta accreta and having caesarean sections performed by the same experienced surgeon. The following patients were excluded: those who had a history of gynecological cancers or other solid cancers, hematological malignancies, gynecological surgeries (such as myomectomy, cervicoplasty and uterine rupture repair); those severe platelet disorders; twin pregnancy, those who underwent emergent delivery and cases with missing data. For all women included in this study, a diagnosis of placenta accreta had been made on prenatal imaging with either ultrasound and/or magnetic resonance imaging(Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) and abnormal placental status was confirmed clinically, or histopathologically, after delivery. Each clinical case was discussed in multidisciplinary meetings with interventional radiologists, obstetricians, neonatologists, and urologist. Finally, whether to accept IIA balloon occlusion is determined according to patients\u0026rsquo; willingness, which were subsequently divided into the balloon group and the control group. There were 23 patients in the balloon group and 35 patients in the control group. Occlusion balloon placement was performed by one of two senior interventional radiologists, who each had more than five years of experience with the similar procedure of uterine artery embolisation for caesarean scar ectopic pregnancy.\u003c/p\u003e\n\u003cp\u003eProcedure for the management of IIA balloon catheters was as follows. Arteriopuncture of bilateral femoral arteries via the Seldinger technique was performed after local anesthesia; 6- French sheaths were then put in place. Next, selective contralateral IIA catheterization was performed with fluoroscopy guidance, and a PTA catheter (Abbott, USA) was inserted into the IIA. The balloon (Abbott, USA), which was approximately 8-10 mm in diameter, was exchanged by using a 0.035- inch super- hard exchange guide wire and then positioned in the IIA with the head pointing to the branch of the anterior IIA, as confirmed by angiography (Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). After the insertion, The balloon was briefly inflated, and contrast injected to verify occlusion of the artery. Once positioning was satisfactory, the balloon catheter and its sheath were fixed on the skin. Patients were then transferred to the operating room for cesarean delivery. After the baby was delivered, the occlusion balloons were inflated immediately. The placenta was then delivered and cesarean delivery was continued in the usual manner. Balloons were deflated before skin closure. Balloon catheters and wires were removed after surgery, and 1 sheath was left in place to allow for resuscitation and emergency embolization if needed. Perioperative management was similar in the two groups except for catheter placement and balloon occlusion of bilateral internal iliac arteries.\u003c/p\u003e\n\u003cp\u003ePerioperative management was similar in the two groups except for catheter placement and balloon occlusion of bilateral internal iliac arteries.\u003c/p\u003e\n\u003cp\u003eThe primary outcomes were estimated blood loss (EBL), cesarean hysterectomy, and blood transferring volume. The secondary outcomes were as follows: operating time, intraoperative hemostatic approaches ( such as intrauterine tamponade, compression suturing, uterine artery ligation), surgical complications, balloon catheter\u0026ndash;related complications (including puncture site hematoma, thrombosis, embolic events, and vascular rupture), length of maternal stay, cost of hospitalization, and neonatal outcomes. Statistics Statistical analysis was performed using SPSS 20.0 software. Data were presented as mean \u0026plusmn; SD, median (range) or count (percentage). Comparison between 2 groups was determined by t test, Wilcoxon rank sum test or chi-square test. \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05 was considered significant.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eFifty-eight women were included. Twenty- three women were in the balloon group and thirty-five women were in the control group. Baseline characteristics are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. There was no significant difference between the two groups with respect to patient age at delivery, gestational age, gravidity, parity, type of pregnancy, number of previous uterine surgeries and abdominal surgeries, number of previous cesarean deliveries, types of placenta accretion and hemoglobin before cesarean section.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic characteristics and incidence of different forms of placenta accretion in the two study groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristic/Outcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBalloon Group(n=23)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl group(n=35)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-\u003c/em\u003evalue\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean age, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.00\u0026plusmn;3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.37\u0026plusmn;4.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.742\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egestational age, weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.86\u0026plusmn;1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.47\u0026plusmn;1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.70\u0026plusmn;1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.91\u0026plusmn;1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.508\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.13\u0026plusmn;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.14\u0026plusmn;0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.924\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enumber of previous uterine surgeries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.52\u0026plusmn;1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.74\u0026plusmn;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enumber of previous cesarean deliveries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.09\u0026plusmn;0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.14\u0026plusmn;0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.531\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemoglobin before cesarean section, g/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.23\u0026plusmn;1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.19\u0026plusmn;1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.914\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeepth of Placenta percreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.232\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(56.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16(77.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.620\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePercreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(43.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(22.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe intraoperative and postoperative outcomes for the two groups are summarized in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. The median EBL was 2500ml (range,1750-5750ml) in the balloon group versus 2000ml (range, 1500-3350ml) in the control group (\u003cem\u003ep\u003c/em\u003e=0.171). There was no statistically significant difference observed between the groups with intraoperative hemorrhage volumes of 2500 mL and above (\u003cem\u003ep\u003c/em\u003e=0.421). More than 40% of the balloon group underwent hysterectomy because of uncontrollable postpartum bleeding (10[43.48%] vs. 11[31.43%], \u003cem\u003ep\u003c/em\u003e=0.350). The need for additional measures to secure hemostasis similarly showed no difference between the groups (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBlood loss and transfusion requirements between the two study groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBalloon Group(n=23)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl group(n=35)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstimated blood loss, ml\u003csup\u003e\u003cstrong\u003e#\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2500(1750-5750)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2000(1500-3350)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlood loss\u0026ge;2500ml, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(56.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16(45.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.421\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransfusion, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21(91.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAutologous blood transfusion, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20(86.96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34(97.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAutologous blood transfusion, ml\u003csup\u003e\u003cstrong\u003e#\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e600(335-1050)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e500(278.5-745.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.347\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRBC transfusion, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(52.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17(48.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.788\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRBC, units\u003csup\u003e\u003cstrong\u003e#\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(0-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0-4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.486\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFFP transfusion, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18(78.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20(57.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFFP, units\u003csup\u003e\u003cstrong\u003e#\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1080(555-1200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e500(0-1160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCryoprecipitate transfusion, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(52.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(28.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCryoprecipitate, units\u003csup\u003e\u003cstrong\u003e#\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0-9.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecrease in Hb after surgery\u003csup\u003e\u003cstrong\u003e#\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3(-1.5-1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.35(0.1-2.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eRBC, red blood cells; FFP, fresh frozen plasma; Hb, haemoglobin concentration.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e#Data were presented as median (range). Comparison between 2 groups was determined by Wilcoxon rank sum test.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSurgical details and postoperative outcomes between the two study groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBalloon Group(n=23)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl group(n=35)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCesarean hysterectomy, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(43.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(31.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdditional measures to secure hemostasis, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15(65.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27(77.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.320\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIodoform gauze packing of the uterine cavity, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14(60.87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26(74.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.280\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBalloon tamponade, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(34.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20(57.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUterine artery ligation, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(8.70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(5.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.661\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003euterine artery embolization, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(26.09%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(34.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.509\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartial excision of the\u003c/p\u003e\n \u003cp\u003einvaded uterine wall, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.303\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDuration of the surgery, min\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123.52\u0026plusmn;74.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89.17\u0026plusmn;48.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital stay postoperatively, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.96\u0026plusmn;2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.74\u0026plusmn;1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.692\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospitalization cost, yuan\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45116.67\u0026plusmn;9358.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30615.41\u0026plusmn;11587.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical complications, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14(60.87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22(62.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.879\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFever, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(47.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20(57.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDIC, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(8.70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(11.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.738\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePneumonedema, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(2.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBladder injury, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(13.04%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(2.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelaparotomy, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(8.70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(8.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.987\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaternal death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBalloon related complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHematoma puncture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVein thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeonatal outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeonatal birth weight, g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2540\u0026plusmn;480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2740\u0026plusmn;360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eApgar score of 1min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.70\u0026plusmn;0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.46\u0026plusmn;1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.349\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eApgar score of 5min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.78\u0026plusmn;0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.69\u0026plusmn;0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeonatal mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eDIC disseminated intravascular coagulation\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003eTwenty-one women in the balloon group and all women in the control group received blood transfusions. No significant differences were noted both in the percentages and volumes of autologous blood transfusion, red blood cell transfusion, fresh frozen plasma transfusion and cryoprecipitate transfusion between the two groups. There was no significant difference in the Hb decrease between the two groups (1.3 (range, -1.5-1.7) vs 1.35 (range, 0.1-2.45), \u003cem\u003ep\u003c/em\u003e=0.266).\u003c/p\u003e\n\u003cp\u003eThe duration of the surgery of the balloon group was significantly longer than that of the control group(123.52 min\u0026plusmn;74.76 versus 89.17\u0026plusmn;48.68, \u003cem\u003ep\u003c/em\u003e=0.038), and the total hospitalization cost was also significantly higher than that of the control group(45116.67\u0026plusmn;9358.67 yuan versus 30615.41\u0026plusmn;11587.44yuan, \u003cem\u003ep\u003c/em\u003e=0.000). There was no significant difference in surgical complications, postoperative hospital stay, newborn weight, Apgar scores at 1 and 5 minute between the two groups. No still births or maternal death were observed in either group. No balloon related complication occurred in the balloon group.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that balloon occlusion of IIA in patients with pernicious placenta previa coexisting with placenta accreta did not reduce the hysterectomy rate during cesarean section, nor did it reduce blood loss and blood transfusion, but it prolonged the duration of the surgery and increased the total cost.\u003c/p\u003e \u003cp\u003eAlthough advances in obstetric care have led to a substantial improvement in pregnancy outcomes, the death rate from placenta accreta remains as high as 7%, largely due to massive haemorrhage\u003csup\u003e[13, 14]\u003c/sup\u003e,which may then lead to disseminated intravascular coagulation, fluid overload, acute respiratory distress syndrome and infection. It seems logical that occlusion of the internal iliac arteries with prophylactically- placed balloon catheters would be a more effective treatment option, but reported results are controversial. Some retrospective studies \u003csup\u003e[6\u0026ndash;9]\u003c/sup\u003e reported that intraoperative IIA balloon occlusion had benefits in reducing blood loss and the amount of blood transfusion. Some previous systematic reviews also reported that intraoperative IIA balloon occlusion had benefits in reducing blood loss, the volumes of blood transfusion and even the percentages of cesarean hysterectomy in women with accrete\u003csup\u003e[5,15]\u003c/sup\u003e. Nicholson et al. also reported that patients with IIA balloon occlusion had a decreased rate of hysterectomy compared to those without it\u003csup\u003e[16]\u003c/sup\u003e. Recently, Yao FAN and Soo BuemCho 's two randomized controlled studies also agree with this view\u003csup\u003e[15,17]\u003c/sup\u003e. However, randomized controlled studies\u003csup\u003e[10,18]\u003c/sup\u003eand several case control studies\u003csup\u003e[11,12,19]\u003c/sup\u003edid not find any benefit. Our findings accord with the previous randomized controlled trial conducted by Meng Chen et al\u003csup\u003e[18]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, we selected the most serious type of disease in the placenta previa spectrum--pernicious placenta previa with placenta accreta, and tried to exclude the heterogeneity caused by the study subjects; In addition, In addition, in our study, all patients are operated by the same surgeon, who has more than 20 years of experience and performs nearly 1,000 cesarean sections a year. They also received the same standard peripartum care apart from the insertion of iliac artery balloons which also eliminate the surgical procedural heterogeneity between surgeons and teams. This is the most significant advantage of our research, which has not been reported in other studies.\u003c/p\u003e \u003cp\u003eIt is unclear why occlusion of the internal iliac arteries failed to reduce haemorrhage in our study. The uterine arteries account for most of the blood supply to the uterus, but the extensive collateral supply from the ovarian arteries will not be affected \u003csup\u003e[20]\u003c/sup\u003e.It may also be possible that IIA balloon occlusion does not provide enough arterial flow attenuation in cases of severe abnormal placentation. In a recent case report, escalating from IIA balloon occlusion to common iliac artery balloon occlusion was found to be more effective in reducing operative blood loss during cesarean hysterectomy for morbidly adherent placenta\u003csup\u003e[21]\u003c/sup\u003e probably because common iliac artery balloon occlusion occluded more collateral arteries than IIA balloon occlusion. In addition, there may be a risk of balloon displacement. As the women were transferred from the interventional unit to the operating theatre after balloon insertion, and we were unable to perform real-time balloon imaging during the caesarean section, the possibility of balloon migration cannot be excluded. Teixidor has confirmed this in his research\u003csup\u003e[22]\u003c/sup\u003e. In order to avoid catheter displacement as much as possible, we used general anesthesia in the balloon group.\u003c/p\u003e \u003cp\u003eIn our study, the transfusion rate was 91.3% in the balloon group and 100% in the control group, which was much higher than the 50% or so reported in the literature\u003csup\u003e[23]\u003c/sup\u003e. In our hospital, autologous blood transfusion is one of the necessary means to reduce the bleeding during the operation of pregnant women with placenta accreta spectrum. Therefore, nearly every pregnant woman in our study underwent autologous blood transfusion during cesarean section, which may be the reason for the increased transfusion rate in our study.\u003c/p\u003e \u003cp\u003eOur results show that the duration of surgery in the balloon group is significantly longer than in the control group, which should be interpreted with caution. Pregnant women in the balloon group needed an interventional surgeon to remove the balloon after surgery, whereas women in the control group did not.\u003c/p\u003e \u003cp\u003eThis study has several limitations, including the retrospective, single-center nature of the investigation. The lack of randomization in the outcome could lead to more complex cases being selected for balloon lacement while the less severe cases may have tended to undergo standard caesarean delivery. Blood loss was estimated, and transfusion was performed based on surgeon preference, which may have varied based on practice.\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eIIA balloon occlusion in patients with pernicious placenta previa coexisting with placenta accreta did not reduce the hysterectomy rate during cesarean section, nor did it reduce blood loss and blood transfusion, but it prolonged the duration of the surgery and increased the total cost.\u003c/p\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePPP: Pernicious placenta previa; IIA: internal iliac artery; EBL: estimated blood loss; RBC: red blood cells; FFP: fresh frozen plasma; Hb: haemoglobin concentration;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDIC: disseminated intravascular coagulation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe Institutional Review Board of Ningbo Women and Children\u0026rsquo;s approved this study , and the need for informed consent was waived because of retrospective nature of this study. (EC2019\u0026ndash;043). All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable for this publication.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe research data used to support the findings of this study were supplied by Ms.Zhang under license and so cannot be made freely available. Requests for access to these data should be made to Ms.Zhang (Email:[email protected]).\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eWe declare that we don\u0026rsquo;t have competing interests with publication of this article.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe study was supported by the grant from Health Commission of Zhejiang Province 2020PY024 and Ningbo Science and Technology Bureau 2019C50090.\u003c/p\u003e\n\u003ch2\u003eAuthor contributions\u003c/h2\u003e\n\u003cp\u003eLH: data collection and analysis; primary author of manuscript. AC: evaluation design; Surgeon of cesarean section; JC: Imaging technical guidance, image collection. XL, ,YS,QD: data analysis and interpretation; manuscript preparation and review. WZ: obtaining funding and ethics approval. LZ: leads all aspects of this study including study concept and design; obtaining funding and ethics approval; supervision of data collection and implementation; and manuscript supervision and revision for critical intellectual input. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAuthor details\u003c/h2\u003e\n\u003cp\u003e1 Department of obstetrics and gynecology, Ningbo women and children\u0026apos;s hospital, Ningbo, China\u003c/p\u003e\n\u003cp\u003e2 Radiology department, Ningbo women and children\u0026apos;s hospital, Ningbo, China\u003c/p\u003e\n\u003cp\u003e3 Department of science and education, Ningbo women and children\u0026apos;s hospital, Ningbo, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eChattopadhyay SK, Khariff H, Sherbeeni MM. Placenta previa and accreta after previous cesarean section[J]. Eur J Obstet Gynecol Reprod Biol, 1993, 52(3): 151-156.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKarla N Solheim, Tania F Esakoff, Sarah E Little, Yvonne W Cheng, Teresa N Sparks, Aaron B Caughey; The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. The journal of maternal-fetal \u0026amp; neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2011 Nov;24(11):1341-6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDazhi Fan, Song Wu, Wen Wang, Lihong Xin, Guo Tian, Li Liu, Jinping Feng, Xiaoling Guo, Zhengping Liu; Prevalence of placenta previa among deliveries in Mainland China: A PRISMA-compliant systematic review and meta-analysis.Medicine 2016 Oct;95(40):e5107\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eShamshirsaz AA, Fox KA, Salmanian B, Diaz-Arrastia CR, Lee W, Baker BW, Ballas J, Chen Q, Van Veen TR, Javadian P, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol. 2015;212(2):218.e1-218.e2189.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eShahin Y, Pang CL. Endovascular interventional modalities for haemorrhage control in abnormal placental implantation deliveries: a systematic review and meta-analysis. Eur Radiol 2018;28:2713\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDai MJ, Jin GX, Lin JH, Zhang Y, Chen YY, Zhang XB. Pre-cesarean prophylactic balloon placement in the internal iliac artery to prevent postpartum hemorrhage among women with pernicious placenta previa. Int J Gynaecol Obstet 2018;142:315\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eXin\u0026apos;e Zhou, Xiaoyan Sun, Meiling Wang, Liqiong Huang, Wen Xiong; The effectiveness of prophylactic internal iliac artery balloon occlusion in the treatment of patients with pernicious placenta previa coexisting with placenta accreta.The journal of maternal-fetal \u0026amp; neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2021 Jan;34(1):93-98.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMcGinnis JM, Simula NK, Joseph KS, Ubhi JS. Internal iliac artery balloon tamponade in placenta accreta: outcomes from the largest tertiary accreta referral centre in British Columbia.J Obstet Gynaecol Can 2019;41:466\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGulino FA, Guardo FD, Zambrotta E, Di Gregorio LM,Miranda A, Capriglione S, et al. Placenta accreta and balloon catheterization: the experience of a single center and an update of latest evidence of literature. Arch Gynecol Obstet 2018;298:83\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSalim R, Chulski A, Romano S, Garmi G, Rudin M, Shalev E.Precesarean prophylactic balloon catheters for suspected pla-centa accreta: a randomized controlled trial. Obstet Gynecol\u003c/span\u003e\u003cspan\u003e2015. ;126:1022\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChen M, Lv B, He G, Liu X. Internal iliac artery balloon occlusion during cesarean hysterectomy in women with placenta previa accreta. Int J Gynaecol Obstet 2019;145:110\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFeng S, Liao Z, Huang H. Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study. Anaesthesia 2017;72:853\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStotler B, Padmanabhan A, Devine P, Wright J, Spitalnik SL, Schwartz J. Transfusion requirements in obstetric patients with placenta accreta. Transfusion 2011; 51: 2627\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. American Journal of Obstetrics and Gynecology 1996; 175: 1632\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYao Fan, Xun Gong, Nan Wang, Ke-Tao Mu, Ling Feng, Fu-Yuan Qiao, Su-Hua Chen, Wan-Jiang Zeng, Hai-Yi Liu, Yuan-Yuan Wu, Qiong Zhou, Yuan Tian, Qiang Li, Yin Xie, Fan-Fan Li, Meng-Zhou He, Rajluxmee Beejadhursing, Dong-Rui Deng, Xiao-Yan Xu; A Participant-assigned Interventional Research of Precesarean Internal Iliac Artery Balloon Catheterization for Managing Intraoperative Hemorrhage of Placenta Previa and Placenta Accreta Spectrum Disorders After Cesarean Section.Current medical science 2021 Apr;41(2):336-341\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePatrick J Nicholson, Owen O\u0026apos;Connor, John Buckley, Liam D Spence, Richard A Greene, David J Tuite; Prophylactic Placement of Internal Iliac Balloons in Patients with Abnormal Placental Implantation: Maternal and Foetal Outcomes.Cardiovascular and interventional radiology 2018 Oct;41(10):1488-1493\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSoo Buem Cho, Seok Jin Hong, Sangmin Lee, Jung Ho Won, Ho Cheol Choi, Ji Young Ha, Jin Il Moon, Ji Kwon Park, Ji Eun Park, Sung Eun Park; Preoperative Prophylactic Balloon-Assisted Occlusion of the Internal Iliac Arteries in the Management of Placenta Increta/Percreta.Medicina (Kaunas, Lithuania) 2020 Jul 23;56(8)\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMeng Chen, Xinghui Liu, Yong You, Xiaodong Wang, Tao Li, Hong Luo, Haibo Qu, Lian Xu; Internal Iliac Artery Balloon Occlusion for Placenta Previa and Suspected Placenta Accreta: A Randomized Controlled Trial.Obstetrics and gynecology 2020 05;135(5):1112-1119\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eShrivastava 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;197:402. e1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePelage JP, Le Dref O, Soyer P, et al. Arterial anatomy of the female genital tract: variations and relevance to transcatheter embolization of the uterus. American Journal of Roentgenology 1999; 172: 989\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHishikawa K, Koshiyama M, Ueda M, Yamaguchi A, Ukita S, Yagi H, Kakui K. Exchange of intraoperative balloon occlusion of the internal iliac artery for the common iliac artery during cesarean hysterectomy in a patient with placenta percreta. Am J Case Rep. 2013 Oct 11;14:409-11.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTeixidor Vi~nas M, Chandraharan E, Moneta MV, Belli AM. The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta. Clinical Radiology 2014; 69: e345\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAlbaro Jos\u0026eacute; Nieto-Calvache, Lina Mar\u0026iacute;a Vergara-Galliadi, Fernando Rodr\u0026iacute;guez, Carlos A Ordo\u0026ntilde;ez, Alberto Federico Garc\u0026iacute;a, Mar\u0026iacute;a Camila L\u0026oacute;pez, Ramiro Manzano, Jorge Vel\u0026aacute;squez, Juan Pablo Carbonell, Adriana Messa Bryon, Maria Paula Echavarr\u0026iacute;a, Maria Fernanda Escobar, Javier Carvajal, Juan Pablo Benavides-Calvache, Juan Manuel Burgos; A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum.The journal of trauma and acute care surgery 2021 05 01;90(5):807-816.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pernicious placenta previa, Placenta accrete, IIA balloon occlusion","lastPublishedDoi":"10.21203/rs.3.rs-900376/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-900376/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This study aimed to evaluate the clinical efficacy of internal iliac artery(IIA) balloon occlusion in patients with pernicious placenta previa coexisting with placenta accreta. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePernicious placenta previa is frequently reported to be complicated with placenta accreta, which contributes to serious consequences such as severe obstetric postpartum hemorrhage or even maternal mortality. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eFifty-eight pernicious placenta previa patients complicated with placenta accreta were retrospectively reviewed. The ballon group consisted of 23 patients, who underwent a caesarean delivery with internal iliac artery occlusion. 35 patients were in the control group, who had a standard caesarean delivery. The primary outcomes were estimated blood loss (EBL), cesarean hysterectomy, and blood transferring volume. The secondary outcomes were operating time, intraoperative hemostatic approaches, surgical complications, balloon catheter–related complications, length of maternal stay, cost of hospitalization, and neonatal outcomes.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e No difference was observed in estimated blood loss (EBL), blood transferring percentages and volume, additional measures to secure hemostasis , surgical complications, hospital stay postoperatively and newborn outcomes. More than 40% of the balloon group underwent hysterectomy because of uncontrollable postpartum bleeding (10[43.48%] vs. 11[31.43%],P=0.350).Complications related to occlusion of IIA did not occur.The duration of the surgery of the balloon group was significantly longer than that of the control group(123.52 min±74.76 versus 89.17±48.68,P=0.038), and the total hospitalization cost was also significantly higher than that of the control group(45116.67±9358.67 yuan versus 30615.41±11587.44yuan,P=0.000).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e IIA balloon occlusion in patients with pernicious placenta previa coexisting with placenta accreta did not reduce the hysterectomy rate during cesarean section, nor did it reduce blood loss and blood transfusion, but it prolonged the duration of the surgery and increased the total cost.\u003c/p\u003e","manuscriptTitle":"The Clinical Evaluation of IIA Balloon Occlusion for Pernicious Placenta Previa Patients with Placenta Accreta: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-10-08 16:14:06","doi":"10.21203/rs.3.rs-900376/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-11-11T04:35:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-11-01T11:39:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cef90d89-7109-48ae-a992-ea2a37107614","date":"2021-11-01T10:57:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-10-30T17:11:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-10-30T15:03:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-10-07T11:19:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-10-07T11:15:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2021-09-13T09:09:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"34623e12-68d4-4c47-be35-11a37821a07e","owner":[],"postedDate":"October 8th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":7730761,"name":"Maternal \u0026 Fetal Medicine"},{"id":7730762,"name":"Sexual \u0026 Reproductive Medicine"}],"tags":[],"updatedAt":"2022-01-27T12:44:03+00:00","versionOfRecord":[],"versionCreatedAt":"2021-10-08 16:14:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-900376","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-900376","identity":"rs-900376","version":["v1"]},"buildId":"_rKDHFSCF-2tw6eG1fWyD","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}