Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China.
Int J Gynaecol Obstet. 2024 Oct;167(1):109-127. doi: 10.1002/ijgo.15704. Epub 2024 Jun 20.
Placenta accreta spectrum (PAS) disorder is a critical and severe obstetric condition associated with high risk of intraoperative massive hemorrhage and cesarean hysterectomy. Severe obstetric hemorrhage is currently one of the leading causes of maternal death worldwide. Prophylactic balloon occlusions, including prophylactic balloon occlusion of the abdominal aorta (PBOAA) and prophylactic balloon occlusion of the internal iliac arteries (PBOIIA), are the most common means of controlling hemorrhage in patients with PAS disorder, but their effectiveness is still debated.
A systematic review and meta-analysis were conducted to evaluate the clinical effectiveness of prophylactic balloon occlusion during cesarean section (CS) in improving maternal outcomes for PAS patients.
MEDLINE, EMBASE, OVID, PubMed and the Cochrane Library were systematically searched from the inception dates to June 2022, using the keywords "placenta accreta spectrum disorder/morbidly adherent placenta (placenta previa, placenta accreta, placenta increta, placenta percreta), balloon occlusion, internal iliac arteries, abdominal aorta, hemorrhage, hysterectomy, estimated blood loss (EBL), packed red blood cells (PRBCs)" to identify the systematic reviews or meta-analyses.
All articles regarding PAS disorders and including the application of balloon occlusion were included in the screening.
Two independent researchers performed the data extraction and assessed study quality. EBL volume and PRBC transfusion volume was regarded as the primary endpoints. Random and fixed effects models were used for the meta-analysis (RRs and 95% CIs), and the Newcastle-Ottawa Scale was used for quality assessments.
Of 429 studies identified, a total of 35 trials involving the application of balloon occlusion for patients with PAS disorder during CS were included. A total of 19 studies involving 935 patients who underwent PBOIIA were included in the PBOIIA group, and 851 patients were included in control 1 group. Ten studies including 428 patients with PAS who underwent PBOAA were allocated to the PBOAA group, and 324 patients without PBOAA were included in control 2 group. Simultaneously, we compared the effect on PBOAA and PBOIIA including seven studies, which referred to 267 cases in the PBOAA group and 313 cases in the PBOIIA group. The results showed that the PBOIIA group had a reduced EBL volume (MD: 342.06 mL, 95% CI: -509.90 to -174.23 mL, I = 77%, P < 0.0001) and PRBC volume (MD: -1.57 U, 95% CI: -2.49 to -0.66 U, I = 91%, P = 0.0008) than that in control 1 group. With regard to the EBL volume (MD: -926.42 mL, 95% CI: -1437.07 to -415.77 mL, I = 96%, P = 0.0004) and PRBC transfusion volume (MD: -2.42 U, 95% CI: -4.25 to -0.59 U, I = 99%, P = 0.009) we found significant differences between the PBOAA group and control 2 group. Prophylactic balloon occlusion (PBOAA and PBOIIA) had a significant effect on reducing intraoperative blood loss and blood transfusion volume in patients with PAS. Moreover, PBOAA was more effective than PBOIIA in reducing intraoperative blood loss (MD: -406.63 mL, 95% CI: -754.12 to -59.13 mL, I = 92%, P = 0.020), but no significant difference in controlling PRBCs (MD: -3.48 U, 95% CI: -8.90 to 1.95 U, I = 99%, P = 0.210) between the PBOIIA group and the PBOAA group. Hierarchical analysis was conducted by differentiating gestational weeks and maternal age to reduce the high heterogeneity of meta-analysis. Hierarchical analysis results demonstrated the heterogeneities of the study were reduced to some extent, and gestational weeks and maternal age might be the cause of increased heterogeneity.
Prophylactic balloon occlusion is a safe and effective method to control hemorrhage and reduce PRBC transfusion volume for patients with PAS, and PBOAA could reduce more intraoperative blood loss than PBOIIA. However, we found no statistical difference in lessening packed red blood cell transfusion volume for PAS patients. Hence, preoperative prophylactic balloon occlusion is the recommended application for PAS patients in obstetric CSs. Furthermore, PBOAA is preferred for controlling intraoperative bleeding in patients with corresponding medical conditions.
胎盘植入谱系（PAS）疾病是一种严重的产科疾病，与术中大量出血和剖宫产子宫切除术的风险较高相关。严重的产科出血是目前全球产妇死亡的主要原因之一。预防性球囊闭塞术，包括腹主动脉预防性球囊闭塞术（PBOAA）和髂内动脉预防性球囊闭塞术（PBOIIA），是 PAS 疾病患者控制出血的最常见方法，但它们的效果仍存在争议。
系统评价和荟萃分析评估了剖宫产术中预防性球囊闭塞术改善 PAS 患者产妇结局的临床效果。
从建库日期到 2022 年 6 月，系统检索 MEDLINE、EMBASE、OVID、PubMed 和 Cochrane 图书馆，使用关键词“胎盘植入谱系障碍/黏附性胎盘前置（胎盘前置、胎盘植入、胎盘植入、胎盘穿透）、球囊闭塞、髂内动脉、腹主动脉、出血、子宫切除术、估计失血量（EBL）、浓缩红细胞（PRBC）”来识别系统评价或荟萃分析。
所有关于 PAS 疾病并包括球囊闭塞应用的文章均被纳入筛选。
两名独立研究人员进行了数据提取和研究质量评估。EBL 量和 PRBC 输血量被视为主要终点。使用随机和固定效应模型进行荟萃分析（RR 和 95%CI），并使用纽卡斯尔-渥太华量表进行质量评估。
在 429 项研究中，共有 35 项试验纳入了 PAS 疾病患者剖宫产中应用球囊闭塞术的研究。共有 19 项研究纳入了 935 例接受 PBOIIA 的患者，纳入对照组 1 的患者为 851 例。10 项研究纳入了 428 例接受 PBOAA 的 PAS 患者，分为 PBOAA 组，纳入对照组 2 的患者为 324 例。同时，我们比较了包括 7 项研究在内的 PBOAA 和 PBOIIA 的效果，涉及 267 例 PBOAA 组和 313 例 PBOIIA 组。结果显示，PBOIIA 组的 EBL 量（MD：-509.90 至-174.23 ml，I=77%，P<0.0001）和 PRBC 量（MD：-2.49 至-0.66 U，I=91%，P=0.0008）均低于对照组 1 组。EBL 量（MD：-1437.07 至-415.77 ml，I=96%，P=0.0004）和 PRBC 输血（MD：-4.25 至-0.59 U，I=99%，P=0.009）的差异也有统计学意义。PBOAA 组和对照组 2 组之间。预防性球囊闭塞术（PBOAA 和 PBOIIA）在降低 PAS 患者术中出血量和输血方面具有显著效果。此外，PBOAA 在降低术中出血量方面比 PBOIIA 更有效（MD：-754.12 至-59.13 ml，I=92%，P=0.020），但在控制 PRBC 方面差异无统计学意义（MD：-8.90 至 1.95 U，I=99%，P=0.210）。通过区分孕龄和产妇年龄进行分层分析，以降低荟萃分析的高异质性。分层分析结果表明，研究的异质性在一定程度上有所降低，孕龄和产妇年龄可能是增加异质性的原因。
预防性球囊闭塞术是一种安全有效的控制 PAS 患者出血和减少 PRBC 输血的方法，PBOAA 可减少术中出血量多于 PBOIIA。然而，我们没有发现 PBOAA 对减少 PAS 患者的浓缩红细胞输血量有统计学差异。因此，对于 PAS 患者在产科 CS 中，术前预防性球囊闭塞术是推荐的应用。此外，对于具有相应医疗条件的患者，PBOAA 更适合控制术中出血。
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