Delayed bleeding after prophylactic bilateral internal iliac artery balloon occlusion in elective caesarean hysterectomy for the management of placenta accreta

Abdul Karim Othman, Noraslawati Razak, Mohd Hanif Che Mat


Morbidly adherent placenta (MAP) can be divided into placenta accrete, placenta increta and placenta percreta. It is associated with high parity, multifetal gestation, advanced maternal age, assisted reproductive technologies, placenta previa, and more importantly a history of caesarean section or uterine surgery. Globally, the incidence of placenta accrete has increased and seems to be in parallel with the increasing rate of caesarean section delivery.

Despite rapidly evolving diagnostic imaging, and growing of surgical expertise, morbidly adherent placenta (MAP) remains an important cause of maternal morbidity and mortality, especially related with life-threatening postpartum haemorrhage. Although the choice of treatment for placenta accrete is puerperal hysterectomy, this procedure itself involves a greater risk of intra-operative haemorrhage.

Elective caesarean hysterectomy using prophylactic bilateral internal iliac artery balloon occlusion offer an interesting approach which can minimize the risk of intra-operative haemorrhage. However, our case report describes the case of a 28-year old Gravida 3 Para 2 morbidly obese parturient diagnosed to have placenta previa type 3 posterior with accrete who experienced a complication of life threatening massive bleeding post-operatively after an elective caesarean hysterectomy using a prophylactic bilateral internal iliac artery balloon occlusion intra-operatively.


Morbidly adherent placenta, Maternal morbidity, Mortality, Placenta accrete

Full Text:



Committee on Obstetric Practice. Committee Opinion No. 529: Placenta accrete. Obstet Gynecol. 2012;120:207.

Badner LJ, Nosher JL, Gribbin C, Siegel RL, Beala S, Scotza W. Balloon-assisted occlusion of the internal iliac arteries in patients with placenta accrete/percreta. Cardiovase Intervent Radiol. 2006;29:354-61

Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192:1458-61.

Read JA, Cotton DB, Miller FC. Placenta accrete: changing clinical aspects and outcome. Obstet Gynecol. 1980;56:31-4.

Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997;177(1):210-4.

Mehrabadi A, Hutcheon JA, Liu S, Bartholomew S, Kramer MS, Liston RM. Contribution of placenta accrete to the incidence of post-partum haemorrhage. Obstet Gynecol. 2015;125:814-21.

Silver RM, Landon MB, Rouse Dj, Leveno KJ, Seong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat caesarean deliveries. Obstet Gynecol. 2006;107:1226-32.

Dubois J, Garel L, Grignon A, Lemay M, Leduc L. Placenta-percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses. Am J Obstet Gynecol. 1997;176:723-6.

Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric haemorrhage. Surg Gynecol Obstet. 1985;160:250-3.

Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric haemorrhage. Obstet Gynecol. 1985;66:353-6.

Paull JD, Smith J, Williams L, Davison G, Devine T, Holt M. Balloon occlusion of the abdominal aorta during caesarean hysterectomy for placenta percreta. Anaesth Intensive Care.1995;23(6):731-4.

Dilauro MD, Dason S, Wagner Y. Prophylactic balloon occlusion of internal iliac arteries in women with placenta accreta: literature review and analysis. Clin. Rad. 2012;67:515-20.

Shrivavastava V, Nageotte M, Major C, Haydon M, Wing D. Case-control comparison of caesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol. 2007;197(4):401-5.

Chou MM, Kung HF, Hwang JI, Chen WC, Tseng JJ. Temporary prophylactic intravascular balloon occlusion of the common iliac arteries before caesarean hysterectomy for controlling operative blood loss in abnormal placentation. Taiwan J. Obstet Gynecol. 2015;54(5):493-8.

Jessica PS, Sukhbir SS, Cleve Z. Internal iliac artery rupture caused by endovascular balloons in a woman with placenta percreta. J. Obstet Gynecol Can. 2016;38(11):1024-7.

Gagnon J, Boucher L, Kaufman I, Brown R, Moure A. Iliac artery rupture related to balloon insertion for placenta accreta causing maternal haemorrhage and neonatal compromise. Can J. Anaesth. 2013;60:1212-7.

Teixidor VM, Chandraharan E, Moneta MV, Belli AM. The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta. Clin Radiol. 2014;69(8):345-51.