Triple P procedure to prevent peripartum hysterectomy in

patients with morbidly adherent placenta: a cohort study

Poster No.:

C-2445

Congress:

ECR 2013

Type:

Scientific Exhibit

Authors:

M. Teixidor Vias, A.-M. Belli, E. Chandraharan; London/UK

Keywords:

Interventional vascular, Digital radiography, Balloon occlusion,

Arterial access, Hemorrhage, Obstetrics

DOI:

10.1594/ecr2013/C-2445

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org

Page 1 of 18

Purpose
Morbidly adherent placenta (MAP) is a condition which causes significant maternal
morbidity and mortality from post partum haemorrhage. It occurs when there is invasion
[1]

of the chorionic villi into the myometrium and its incidence is increasing , in line with the
increase in caesarian delivery. There are three types of MAP: Placenta percreta, increta
and acreta. Placenta percreta is the most severebut less common.
This is a potentially life threatening condition. It requires a radical treatment such as
peripartum hysterectomy with or without bowel or bladder resection depending on the
degree of infiltration of these organs

[2]

. Alternative therapies have included compression

sutures and balloon tamponade with the placenta remaining in situ

[3]

MAP can be diagnosed before delivery by ultrasound (US) and magnetic resonance
[4]

imaging (MRI) .
This led us to commence a programme in 2007 of prophylactic occlusion balloon insertion
into both internal iliac arteries before caesarian delivery in women with the most severe
forms of morbidly adherent placenta increta and percreta.
The purpose of the occlusion balloons is to reduce blood flow in the uterine arteries
after caesarian delivery and so reduce blood loss, transfusion requirements and need for
caesarian hysterectomy.
Following the success of this programme, in July 2010 our institution developed a
[5]

multidisciplinary procedure, called the Triple-P procedure on page

The Triple-P procedure is a three step conservative treatment involving obstetricians,

anesthetists and interventional radiologists to prevent significant haemorrhage and peripartum hysterectomy. The three steps are:
1.
2.
3.

Perioperative location of the placenta and delivery of the fetus by an incision

above the upper border of the placenta.
Pelvic devascularisation by inflating radiologically pre-placed occlusion
balloons in both internal iliac arteries.
Placental non-separation with myometrial excision and reconstruction of the
uterine wall.

Page 2 of 18

The purpose is to describe a tertiary referral centre's experience with prophylactic

balloon occlusion in women at high risk of obstetric haemorrhage from morbidly adherent
placenta.

Methods and Materials

Between December 2007 and September 2012, pregnant women identified as having
MAP by US or MRI at our institution, were defined as high risk of postpartum
haemorrhage.
Indications for placement of prophylactic occlusion balloons included women with the
diagnosis of placenta percreta and increta.
A date for caesarian delivery was planned electively.
On the morning of delivery, an epidural catheter was inserted by the anesthetists before
the patient was transferred to the Interventional Radiology suite for insertion of the internal
iliac artery occlusion balloons. With informed consent, bilateral common femoral arterial
punctures were performed under local anesthesia and occlusion balloons (7 Fr Standard
Occlusion Balloons Catheters, Boston Scientific) positioned contralaterally with their
tips in the anterior divisions of each internal iliac artery under pulsed low dose fluoroscopic
[6]

guidance to minimize radiation exposure to the mother and fetus on page

Page 3 of 18

Fig. 1: Contrast injected through the catheters confirms their correct position.
References: radiology, Saint George's Hospital - London/UK
Test occlusion was performed to ensure reduction/stasis in uterine artery blood flow and
the volume of half strength contrast medium and normal saline solution required was
recorded in the patient's notes and luer lock syringes with the required volume were
attached to the catheters.

Page 4 of 18

Fig. 2: Contralateral placement of occlusion balloon catheters into both internal iliac
areries. Only fluoroscopic images are obtained.
References: radiology, Saint George's Hospital - London/UK
The balloons were then deflated, and the catheter and the sheath flushed, stitched and
dressed to minimize the possibility of movement during the patient's transfer.
In the obstetric theatre a mobile image intensifier was in position so that the interventional
radiologist could check the final position of the balloon catheter and change it if necessary
before caesarian section commenced.
After the baby was delivered and the umbilical cord clamped, the interventional radiologist
was responsible for inflating each balloon to reduce blood flow whilst the obstetrician
closed the uterus.
If there was no evidence of haemorrhage, the balloon catheters were deflated after four
hours and the patient observed for bleeding overnight. If the patient remained stable, the
sheaths and occlusion balloon catheters were removed by the interventional radiologists
the next morning.

Page 5 of 18

If bleeding commenced, then the occlusion balloons could be rapidly re-inflated and the
patient transferred for embolization. If significant hemorrhage occurred immediately in
theatre, either the patient could be transferred to the IR suite or if deemed too unstable for
transfer, the IR could proceed immediately to embolization with gelatin sponge through
the occlusion balloon catheters.
The following parameters were recorded for each procedure: radiographic exposure,
volume of blood loss, transfusion requirements, uterine artery embolization, peri-partum
hysterectomy, APGAR scores and any maternal complications including length of stay
on ITU.

Study design and participants:

Twenty two patients were diagnosed with morbidly adherent placenta between December
2007 and September 2012.

Between December 2007 and February 2010 eleven patients had

prophylactic occlusion balloon catheters placed in both anterior trunks of the
IIA and an elective caesarean delivery (Group 1).
Between March 2010 and September 2012, eleven patients were treated
using the Triple P procedure (Group 2).

Page 6 of 18

Fig. 3: Distribution of study population by mode of treatment, and result.

References: radiology, Saint George's Hospital - London/UK
All caesarean deliveries apart from one were performed electively. In all cases occlusion
balloons were successfully placed prior to caesarian delivery.
Statistical methods:
Descriptive characteristics were calculated for the variables of interest. Statistic analysis
comparing both groups has been done using the Chi-square test (Fisher's Exact Test)
for categorical variables; and the Wilcoxon-Mann & Whitney for numerical variables.
on page
Images for this section:

Page 7 of 18

Fig. 1: Contrast injected through the catheters confirms their correct position.

Page 8 of 18

Fig. 2: Contralateral placement of occlusion balloon catheters into both internal iliac
areries. Only fluoroscopic images are obtained.

Page 9 of 18

Fig. 3: Distribution of study population by mode of treatment, and result.

Page 10 of 18

Results
Twenty two patients were diagnosed with morbidly adherent placenta between December
2007 and September 2012.

Between December 2007 and February 2010 eleven patients had

prophylactic occlusion balloon catheters placed in both anterior trunks of the
IIA and an elective caesarean delivery (Group 1).
Between March 2010 and September 2012, eleven patients were treated
using the Triple P procedure (Group 2).

All caesarean deliveries apart from one were performed electively. In all cases occlusion
balloons were successfully placed prior to caesarian delivery.
The clinical characteristics of the patients of both groups are summarized in Table 1.

Table 1: The clinical characteristics of all the patients included in the study and for
both groups are summarized in the table.

Page 11 of 18

References: radiology, Saint George's Hospital - London/UK

There were no significant differences between the groups for age, parity, previous
gynaecological surgery or degree of morbidly adherent placenta.

Fig. 4: Patients with previous gynaecological surgery distribution.

References: radiology, Saint George's Hospital - London/UK
The mean age at study entry was 34 years old and the weeks of gestation were 34.3
(+/-5.44). Only one woman was nulliparous in our study, and she was part of Group 1.
A reduction in mean radiation dose between the two groups (168, 91 +/- 122,64 mGy
in Group 1 vs 81,01 +/- 51,4 mGy in Group 2) was observed . There was no change in
radiographic equipment.
Mean blood loss during the surgery was 2,17 +/- 2,47 liters in Group 1 vs 1,44 +/0,54 liters in Group 2, p= 0.847. Although reduced blood loss was observed in Group 2
compared with Group 1, this was not statistically significant between the two groups.

Page 12 of 18

Fig. 5: BLOOD LOST DURING THE PROCEDURE: The boxplots represents the
smallest and largest observation, lower and upper quartile and median of blood lost
during the procedure. Group 1 had patients outliers and the group is less uniform in
blood lost. The graphic 1 showed than more than 50% of patients treated in Group 2
bled less than the median of blood lost in Group 1.
References: radiology, Saint George's Hospital - London/UK
There was no significant difference between the number of women requiring a transfusion
in both groups (45.5% in Group 1 vs 54.5% in Group 2, p=0,67) although there was a
trend to increased volume of transfused products in Group 1.
There were 8 patients in total who required emergency embolisation for postpartum
haemorrhage (36,4%):
- five of them in Group 1 (45,5%)
- 3 in Group 2 (27,3%),
but this was not statistically significant between both groups (p=0.659).

Page 13 of 18

Three women in Group 1 required an emergency hysterectomy (27.3%) whilst nobody in

group 2 required hysterectomy. However the total numbers in this report are too small to
detect a statistically significant difference.
There were no minor or major maternal or infant complications.
All patients were transferred to intensive care unit immediately after the delivery as per
protocol, with a mean stay of 2,82 days (+/- 2,64 days) in Group 1 and 3,44 days (+/- 1,51
days) in Group 2. Also, there were no significant differences between the whole inpatient
stay in both groups (p=0,603).
COMPLICATIONS
In one case in Group 1, rupture of the occlusion balloons occurred after caesarian section.
The interventional radiologist was unable to attend the delivery in this case and despite
the required volumes being written in the notes, the syringes became displaced during
transfer and a volume ten times greater than required was injected, with consequent
bilateral balloon rupture. Without the reduction in blood flow in the uterine arteries, the
patient haemorrhaged during separation of the placenta and the obstetrician proceeded
immediately to hysterectomy. This highlights the importance of the IR attending the
delivery, ensuring the occlusion balloon is filled appropriately and having embolic material
and equipment available immediately in theatre.
In two other cases (Group 1), haemorrhage was treated by UAE but hysterectomy was
required as haemorrhage continued.
One patient with placenta percreta (Group 1) required a second UAE four months after
the delivery for further haemorrhage which was successful.
Migration of the balloon catheter was observed in two patients in Group 2. (fig. 5). Again,
this highlights the importance of the IR attending the delivery, ensuring the occlusion
balloon has not migrate during the patient's transfer from DSA suit to the delivery room.
None of the major surgical complications described in the literature with caesarian
hysterectomy were encountered eg vesicouterine fistula, bladder injury or postoperative
[7]

abscess on page

Images for this section:

Page 14 of 18

Table 1: The clinical characteristics of all the patients included in the study and for both
groups are summarized in the table.

Page 15 of 18

Fig. 4: Patients with previous gynaecological surgery distribution.

Page 16 of 18

Fig. 5: BLOOD LOST DURING THE PROCEDURE: The boxplots represents the smallest
and largest observation, lower and upper quartile and median of blood lost during the
procedure. Group 1 had patients outliers and the group is less uniform in blood lost. The
graphic 1 showed than more than 50% of patients treated in Group 2 bled less than the
median of blood lost in Group 1.

Page 17 of 18

Conclusion
Prophylactic occlusion balloon catheter insertion in both IIA's prior to elective caesarean
delivery in patients with MAP is useful in reducing postpartum haemorrhage, and
decreases the risk of hysterectomy in young women with preservation of fertility. The
Triple P procedure leads to further improvement in outcomes and is the procedure of
choice at our institution.

References
[1]

Obstet Gynecol 2002; 99:976-80. The likelihood of placenta praevia with greater
number of caesaren deliveries and high parity. Gillam M, Rosenberg D, Davis F
[2]

BJOG 2007;114:1380-1387. Knight M on behalf of UKOSS. Peripartum hysterectomy

in the UK: management and outcomes of the associated haemorrhage.
[3]

Acta Obstet Gynecol Scand. Sep 2010;89 (9): 1126-33. The morbidly adherent
placenta: an overview of management options. Doumouchtsis S, Arulkumaran S.
[4]

J Obstet Gynecol 2004; 24 (7): 742-744. Imaging techniques to identify morbidly

adherent placenta praevia: a prospective study. Moodley J, Ngambu NF, Corr P
[5]

Int J Gynaecol Obstet. 2012 May;117(2):191-4. The triple- P procedure as a

conservative surgical alternative to peripartum hysterectomy for placenta percreta.
Chandraharan E; Rao S; Belli A-M; Arulkumaran S.
[6]

Radiographics. 2012 Jan-Feb;32(1):255-74. Interventional Radiology in Pregnancy

Complications: Indications, Technique, and Methods for Minimizing Radiation Exposure.
Thabet A; Kelva S; Liu B; Mueller P; Lee S.
[7]

Obstet Gynecol. 2004 Sep;104(3):531-6. Conservative versus extirpative management

in cases of placenta accrete. Kayem G, Davy C, Goffinet F.

Personal Information

Page 18 of 18