Solved on SIR Connect
By William Korn, MD, Jackson Bennett, MD, Mithil B. Pandi, DO, and Sudhen B. Desai, MD, FSIR
Feedback on uterine artery embolization for placenta accreta
Original post, lightly edited for flow:
bit.ly/3qCsgcb
The patient is a 32-year- old woman (G1P1) post C-section. The obstetrician was unable to remove all of her placenta and she had persistent mild spotting for weeks. An MRI shows placenta accreta with RPOC. I would think I should embolize this to encourage involution. Agree? Should I use Gelfoam or Embospheres?
Is there a role for collaboration between OB/GYN and IR for treating placenta accreta? The OB/GYN service is always involved from the beginning. We have a uterine hemorrhage protocol at our institution so that IR is promptly notified of a patient who is in the OR or Labor and Delivery who might need embolization.
What specifically prompted you to reach out regarding this case? The patient was unusual for me in that she did not have an immediate or delayed postpartum hemorrhage like my previous patients but, rather, persistent mild symptoms. I didn't know whether embolization for this would be too aggressive.
What post(s) were most valuable to you and why? There was consensus on embolization, which was helpful, but not on what type of agent (I would use Gelfoam slurry). The advice to look out for AV shunting was a most useful reminder to avoid complications.
Will you or have you changed your practice patterns based off of responses on SIR Connect? Please describe any changes you are considering. This patient ended up not needing embolization. However, in the future I will keep all the helpful advice in mind. Since I work in a community hospital setting, it is always helpful to ask for expert advice on the SIR Connect Open Forum, which I have received many times over the years. Many thanks to my kind colleagues who respond so promptly and appropriately.
Author name and contact information William Korn, MD., Winchester Hospital
Author background and current practice preferences for UAE in the setting of placenta accreta? I have worked in hospital IR/DR practice for 28 years.
What is your preferred embolization approach in treating placenta accreta? Gelfoam.
Additional commentary: Uterine artery embolization (UAE) has recently been studied in the context of management of placenta accreta (PA).1–6
This technique has historically
been considered a safe and effective option for fibroid management in patients wishing to retain their uterus in the appropriate setting.2,3
When
applied to PA, the goal of UAE is to aid in encouraging placental involution while also retaining the uterus for future childbearing in milder cases of PA.6–7
The other main potential
applications for UAE to PA are as conservative primary management and as a method of bleeding prophylaxis in the time between cesarean delivery and hysterectomy.5–8
In a systematic
review that highlighted various forms of conservative management of PA, 45 patients treated with UAE demonstrated a secondary hysterectomy rate of 18%, menstruation rate of 62%, and subsequent pregnancy rate of 15% with full survival rate in all patients.5,6 An additional study indicated that prophylactic UAE following cesarean delivery but before hysterectomy in
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