UOG Journal Club: Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure

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Information about UOG Journal Club: Prevention of postpartum hemorrhage and hysterectomy...

Published on September 4, 2015

Author: isuog

Source: slideshare.net

1. UOG Journal Club: September 2015 Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure M. Teixidor Vinas, A. M. Belli, S. Arulkumaran and E. Chandraharan Volume 46, Issue 3, Date: September, pages 350–355 Journal Club slides prepared by Dr Joel Naftalin (UOG Editor for Trainees)

2. Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015 Background • Morbidly adherent placenta (MAP) is the second highest cause of hemorrhage leading to peripartum hysterectomy in the UK • Traditional management has been Cesarean hysterectomy • In the absence of an antenatal diagnosis, this Caesarean hysterectomy is associated with a mean expected blood loss of 7800mL and significant maternal and fetal morbidity and mortality • MAP can now be diagnosed prenatally by ultrasound or MRI, allowing a specific management plan to be instituted, however the optimal management of these women is yet to be determined

3. Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015 To evaluate patient outcomes and need for further interventions in women with MAP, before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall Objective

4. Patients and Methods • Cohort study including 30 pregnant women with MAP treated at the study center between December 2007 and February 2014 • In 2007, a policy of placing bilateral prophylactic occlusion balloon catheters in both internal iliac arteries before Cesarean delivery, with non-placental separation and preservation of the uterus, was instituted • In 2010, the surgical technique was modified and the Triple-P procedure was introduced • 19 women received the Triple-P procedure (study group) and 11 did not (control group) Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015

5. The Triple-P procedure • Step 1 – Preoperative location of the placenta and delivery of the fetus by an incision above the upper border of the placenta • Step 2 – Pelvic devascularization by inflating pre-placed occlusion balloons in both internal iliac arteries under imaging guidance • Step 3 – Placental non-separation with myometrial excision and reconstruction of the uterine wall Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015

6. Patients and Methods • Estimated blood loss (EBL), uterine artery embolization, hysterectomy and quantity of blood products given were compared between the two groups • When affected myometrium was removed or hysterectomy was performed, histological confirmation of the degree of placental invasion was recorded • When histological confirmation was not possible (control group, as the placenta was left in part or entirely within the uterus), surgical assessment of the type of MAP was recorded • Statistical analysis comparing the two groups was performed using chi-square test (Fisher’s exact test) for categorical variables and the Wilcoxon and Mann– Whitney U-tests for continuous variables Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015

7. Results Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015 Demographics of the two groups Mode of treatment and result in the two groups

8. Results Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015

9. Results Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015 • EBL was lower in the study group than in the control group but the difference was not statistically significant (1.7L vs 2.2L, p = 0.445) • The risks of postpartum haemorrhage (16% vs 55%) and emergency peripartum hysterectomy (0% vs 27%) were statistically significantly lower (p < 0.05) in the study group receiving the Triple-P procedure than in the control group • There was also a significant difference (p = 0.044) in mean duration of inpatient stay, with a significantly lower duration among women treated in the study group (4.8 vs 7.7 days)

10. Results Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015

11. Results Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015 Maternal complications Control group • One patient suffered bilateral occlusion balloon rupture after Cesarean delivery, contributing to a massive obstetric hemorrhage (12L) and immediate hysterectomy • For two patients, PPH was controlled inadequately by uterine artery embolization and hysterectomy was required • One patient required a second uterine artery embolization 4 months postpartum for secondary PPH Study group • One patient developed a right common iliac and external iliac artery thrombosis after removal of the occlusion balloon catheters and sheaths

12. Conclusion Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015 • Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP

13. Strengths Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015 • This is the largest reported study in the literature of women with MAP being treated conservatively • It is a novel study with a standardized management protocol • The same team were used for both groups therefore minimizing the possibility that reported differences are due to variables other than the change in the management protocol

14. • The number of cases were small (n = 30)  • Case-historical cohort design rather than a randomised trial • The study only evaluated short-term outcomes Limitations Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015

15. • Might the results be explained by the temporal nature of the study, i.e. perhaps the results improved over time as the team accrued greater experience of using prophylactic occlusion balloon catheters, rather than due to the introduction of a new surgical technique in 2010? • Is it possible to fully evaluate conservative measures in the management of MAP, without knowing the pregnancy outcomes for women who subsequently conceived? • Should all women diagnosed antenatally with MAP be referred to tertiary referral centers with access to uterine artery embolization? Discussion points Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure Teixidor Vinas et al., UOG 2015

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