Interventional Radiology: Making Childbirth Safer Dr Rob Beecroft, MD Interventional Radiologist University Health Network – Mount Sinai Hospital Toronto, Canada

Interventional Radiology is making childbirth safer for women with uncommon condition called “invasive” placenta. Accomplished through minimally invasive non-surgical procedure – described as “prophylactic uterine artery occlusion balloons and embolization.” Compared to surgery alone for invasive placenta, this advanced interventional radiology option makes delivery safer with less bleeding and much less risk of requiring hysterectomy (removal of uterus).

Interventional radiology Interventional radiology is an advanced branch of medicine that uses minimally invasive procedures to treat a variety of conditions One of the best known applications of interventional radiology is to control or stop excessive bleeding through procedure called embolization – blocking arteries from inside. This technique can be used to reduce bleeding during childbirth

How do we do it? Through a small nick in the skin, interventional radiologists can place catheters inside the arteries in the body, direct them under x-ray guidance to control bleeding from within No surgical incision No need for general anesthesia

Interventional radiology and invasive placenta Invasive placenta is an unusual abnormality of the placenta in pregnant women 1/1000 to 1/2500 deliveries Incidence increasing with number of C-sections Women with invasive placenta require cesarean section Occurs abnormal growth of placenta into or through uterine wall

The placenta normally lies against the inside wall of the uterus, and comes away easily after delivery of the baby. Placenta Uterine wall Normal placenta

Severe invasive placenta With invasive placenta, the placenta is abnormally attached to and “invades” into the wall of the uterus Severe invasive placenta Placenta may invade right through the uterine wall

Classification Placenta accreta 84% mildest Placenta increta 13% Placenta percreta 3% most severe

Classification Placenta accreta 84% mildest Placenta increta 13% Placenta percreta 3% most severe

Why is invasive placenta potentially dangerous? Women are at high risk of excessive bleeding during delivery. With surgery alone - 90% of women require blood transfusion - surgery can become difficult and risky due to excessive bleeding

Why is invasive placenta potentially dangerous? 2. Placenta often can’t be delivered because it is so firmly attached, and must be left inside the uterus. This can potentially lead to: - delayed bleeding (post-partum hemorrhage) - infection

Why is invasive placenta potentially dangerous? For these reasons, with traditional surgical treatment alone: - 80% of women with invasive placenta require a hysterectomy - 7% risk of maternal death

How can Interventional Radiology help? Interventional radiologists can direct special catheters into the arteries that supply blood to the uterus before delivery, and these: can be used control bleeding during surgery making delivery safer avoid the need for hysterectomy

University of Toronto study “Combined prophylactic internal iliac artery balloon occlusion and uterine artery embolization in the management of invasive placenta” DL D’Souza, JR Kachura, JR Beecroft, RC Windrim, JC Kingdom

Our study group: 14 women with severe forms of invasive placenta 6 placenta increta 8 placenta percreta All had cesarean section, as well as interventional radiology procedures before and after delivery to control blood loss

Our technique: 1) Prior to cesarean section, in interventional radiology: - Small nick made in both groins - Inserted catheters with balloons on ends which can be inflated (“Occlusion balloon catheters”) into arteries supplying the uterus

2) During cesarean section: - Balloons inflated after baby removed from uterus. Purpose: to temporarily block blood flow through the arteries supplying the uterus in order to decrease blood loss and make surgery easier and safer.

3) After cesarean section, patient returned to interventional radiology for embolization: - Inject spongy particles (Gelfoam) into uterine arteries to block them Purpose: to block blood flow to the uterus and stop bleeding

Significantly less blood loss during cesarean section Our results – compared to cesarean-section alone, patients who had interventional radiology treatment had: Significantly less blood loss during cesarean section Average only 1.25L compared to typical average 3.0 - 5.0L for surgery only Needed blood transfusions less often Only 28% of patients compared to 90% of patients for surgery only

Significantly lower hysterectomy rate Only 33% of women had hysterectomy compared to typical average 80%

Conclusion Interventional radiologists can use minimally invasive techniques that are safe and effective to control blood loss, make delivery safer, and avoid hysterectomy in women with invasive placenta We work closely with obstetricians to enhance the care of women and make childbirth safer.

Thank you.

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Background Excessive blood loss occurs during childbirth in 4 - 7% of deliveries Severe bleeding can have catastrophic effects on the mother: - circulatory collapse (shock) - organ failure - death Surgery and hysterectomy possibly required to treat

Our results: Compared to c-section alone, patients who had interventional radiology treatment had: Significantly lower blood loss during cesarean section: Average only 1.25L compared to typical average 3.0 - 5.0L average for surgery only Significantly lower requirement for blood transfusion: Only 28% of patients compared to typical average 90% of patients for surgery only

Significantly lower hysterectomy rate: Only 33% of women required hysterectomy compared to typical average 80% No complications specific to the interventional radiology procedures performed No surgical complications No deaths

No complications specific to the interventional radiology procedures performed No surgical complications No deaths