Prophylactic Internal Iliac Artery Ligation in cases of Placenta Previa Accreta; Randomized Controlled Trial

Abstract

Obstetric hemorrhage andabnormal placentation are leadingcauses of maternal morbidity and mortality worldwide (Perez-Delboy, 2013). Placenta accreta is a life-threatening conditioncharacterized byabnormal adherence of the placental villi to underlying myometrium as a result of the defectiveor absence of the normal decidua basalis and the fibrinousNitabuch’s layer (Sentihles et al., 2013). Placenta accreta is associated with considerable maternalmorbidity and potential mortality, the morbidity includes massive blood transfusion, peripartumhysterectomy and loss of fertility, cystotomy and other vesicus injury, intensive care unit (ICU)admission, infection, prolonged hospitalization and psychological trauma (Eller et al., 2009). Outcomes are improved when delivery of women withplacenta accreta is accomplished in centers with multidisciplinaryexpertise and experience in the care of thispathology. Such expertise may include: maternal and fetalmedicine; gynecological surgery; gynecological oncology;vascular, trauma and urological surgery; transfusion medicine;intensive care, neonatologists, interventional radiologistsand anesthesiologists; specialized nursing staff; andancillary personnel(Selman et al., 2015). Cesarean hysterectomy is considered the reference standard treatment for placentaaccreta. In young women who want the option of future pregnancy andagree to close follow-up monitoring, conservative treatment is a valid option.Several key points of both cesarean hysterectomy and conservative treatmentremain debatable, such as timing of delivery, attempted removal of the placenta,use of temporal internal iliac occlusion balloon catheters, ureteral stents, prophylactic embolization, and methotrexate. In cases of placenta percreta withbladder involvement, conservative treatment may be the optimal management(Sentihles et al., 2013). As regardinternal iliac artery ligation; The recommendations from American Colleague of obstetrician and gynecology: the current evidence is not sufficient to make firm recommendations regarding occlusion of the internal iliac artery in cases of abnormal presentation to reduce blood loss or to improve the surgical outcomes, according to ACOG the data still insufficient, some reports no benefit and others even report significant complication especially with embolization (ACOG, 2012).