背景:胎盘植入谱(PAS)障碍是一种危重的产科疾病,与术中大出血和剖宫产子宫切除术的高风险相关。严重的产科出血是目前全球孕产妇死亡的主要原因之一。预防性球囊闭塞,包括腹主动脉预防性球囊闭塞(PBOAA)和髂内动脉预防性球囊闭塞(PBOIIA),是控制PAS障碍患者出血的最常见手段,但它们的有效性仍在争论中。
目的:进行系统评价和荟萃分析,以评估剖宫产(CS)期间预防性球囊闭塞改善PAS患者产妇结局的临床有效性。
方法:MEDLINE,EMBASE,OVID,PubMed和Cochrane图书馆从开始日期到2022年6月进行了系统搜索,使用关键字\“胎盘植入谱系障碍/病态粘附胎盘(前置胎盘,胎盘植入,胎盘植入,胎盘穿孔),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)“以确定系统评价或荟萃分析。
方法:所有关于PAS疾病和包括球囊闭塞的应用的文章都包括在筛查中。
方法:两名独立研究人员进行数据提取并评估研究质量。EBL体积和PRBC输血体积被视为主要终点。随机和固定效应模型用于荟萃分析(RR和95%CI),纽卡斯尔-渥太华量表用于质量评估。
结果:在确定的429项研究中,共纳入了35项涉及在CS期间对PAS障碍患者应用球囊闭塞的试验.共有19项研究包括935名接受PBOIIA的患者,851例患者被纳入对照1组。10项研究包括428名接受PBOAA的PAS患者被分配到PBOAA组。对照2组纳入324例无PBOAA患者。同时,我们比较了对PBOAA和PBOIIA的影响,包括七项研究,其中PBOAA组267例,PBOIIA组313例。结果表明,PBOIIA组的EBL体积减少(MD:342.06mL,95%CI:-509.90至-174.23毫升,I2=77%,P<0.0001)和PRBC体积(MD:-1.57U,95%CI:-2.49至-0.66U,I2=91%,P=0.0008)比对照1组。关于EBL体积(MD:-926.42mL,95%CI:-1437.07至-415.77毫升,I2=96%,P=0.0004)和PRBC输血量(MD:-2.42U,95%CI:-4.25至-0.59U,I2=99%,P=0.009)我们发现PBOAA组与对照组2之间存在显着差异。预防性球囊封堵术(PBOAA和PBOIIA)对减少PAS患者术中失血量和输血量有显著作用。此外,PBOAA在减少术中失血方面比PBOIIA更有效(MD:-406.63mL,95%CI:-754.12至-59.13mL,I2=92%,P=0.020),但在控制PRBC方面没有显着差异(MD:-3.48U,95%CI:-8.90至1.95U,I2=99%,PBOIIA组和PBOAA组之间的P=0.210)。通过区分孕周和母亲年龄进行层次分析,以减少meta分析的高度异质性。层次分析结果表明,研究的异质性在一定程度上降低,孕周和母亲年龄可能是异质性增加的原因。
结论:预防性球囊封堵术是一种安全有效的方法,可控制PAS患者出血,减少PRBC输血量。与PBOIIA相比,PBOAA可以减少更多的术中失血量。然而,我们发现PAS患者在减少充血红细胞输注量方面没有统计学差异.因此,术前预防性球囊闭塞是产科CSs中PAS患者的推荐应用.此外,PBOAA优选用于控制具有相应医疗条件的患者的术中出血。
BACKGROUND: 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.
OBJECTIVE: 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.
METHODS: 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.
METHODS: All articles regarding PAS disorders and including the application of balloon occlusion were included in the screening.
METHODS: 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.
RESULTS: 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, I2 = 77%, P < 0.0001) and PRBC volume (MD: -1.57 U, 95% CI: -2.49 to -0.66 U, I2 = 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, I2 = 96%, P = 0.0004) and PRBC transfusion volume (MD: -2.42 U, 95% CI: -4.25 to -0.59 U, I2 = 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, I2 = 92%, P = 0.020), but no significant difference in controlling PRBCs (MD: -3.48 U, 95% CI: -8.90 to 1.95 U, I2 = 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.
CONCLUSIONS: 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.