Introduction and utility of resuscitative endovascular balloon occlusion of the aorta for cases with a potential high risk of postpartum hemorrhage: A single tertiary care center experience of two cases

Abstract

Postpartum hemorrhage is an important obstetric complication and the leading cause of maternal mortality worldwide. Occasionally, we encounter unexpected massive postpartum hemorrhage diagnosed for the first time after delivery. Therefore, it is essential to pay attention to patients with a high risk of postpartum hemorrhage. The authors report two cases of patients at high risk of postpartum hemorrhage that were successfully managed by resuscitative endovascular balloon occlusion of the aorta before cesarean section. Case 1: A 32-year-old woman with a history of cesarean section and who conceived using assisted reproductive technology was diagnosed with partial placenta previa at 25 weeks of gestation. Because of tocolysis failure, emergent cesarean section with resuscitative endovascular balloon occlusion of the aorta was performed at 36 weeks of gestation. Natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage. Case 2: A 41-year-old woman with suspected placenta accreta spectrum due to a cesarean scar pregnancy was referred to our hospital at 33 weeks of gestation. A planned cesarean section with resuscitative endovascular balloon occlusion of the aorta was conducted at 37 weeks of gestation. There was no visual evidence of abnormal placental invasion of the myometrium, and natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage.

Keywords: Intra-aortic balloon occlusion; postpartum hemorrhage; pregnancy; preventive medicine; resuscitative endovascular balloon occlusion of the aorta.

Fig. 1.

MRI of the pelvis at 30 weeks of gestation showed evidence of partial placenta previa in which the intra-os was covered completely. It was mainly located on the posterior wall side of the myometrium (arrow).

Fig. 2.

MRI of the pelvis at 30 weeks of gestation showed no evidence of placenta previa; arrow (1) indicates that the placenta is located on the myometrium anterior wall. Arrow (2) shows that the enlarged thin uterine myometrium seems covered by the placental margin, suggesting that the placenta is located on the cesarean scar.

Fig. 3a.

After spinal anesthesia, a 7 Fr sheath was placed via right femoral artery under the guide of surface ultrasound (arrow indicates right femoral artery).

Fig. 3b.

REBOA was then placed above the celiac artery under the guidance of x-ray. After the x-ray, a balloon was moved toward a more distal zone and set just upper the celiac artery.