Intra-aortic balloon occlusion without fluoroscopy for life-threating post-partum hemorrhage

Case report

A 34-year-old primipara pregnant woman was referred to our university hospital by her primary care physician at 30 weeks of gestation for the evaluation of a giant myoma of the uterus that was discovered during her pregnancy. Transabdominal ultrasonography showed a giant interstitial myoma (19×21 cm) located in the upper anterior wall of the uterus, without necrosis or calcification. The medical history of the patient was unremarkable, and she was followed up as an outpatient until 37 weeks of gestation. Elective cesarean section (CS) was performed at 37 weeks of gestation due to transverse presentation, during which time a midline vertical skin incision was made between the symphysis pubis and the umbilicus. A transverse incision was then made on the anterior wall of the upper uterine segment, from the fundus to upper anterior wall of the uterus, avoiding the locations of the myoma and the placenta.

A healthy 2663 g female infant was delivered from the left sacrum transverse position with Apgar scores of 8 and 9 at 1 min and 5 min after delivery, respectively. The complete removal of the membranes and placenta was achieved manually and the uterus was well contracted. The blood loss during the operation was 2130 mL.

An hour after the CS, the patient’s vaginal bleeding increased. Despite the provision of conservative treatment, including fundal massage, cooling and the administration of uterotonic agents (oxytocin, prostaglandin F2α, methylergometrine), there was no decrease in the patient’s atonic bleeding. The amount of bleeding was estimated to be 3300 g, her blood pressure (BP) was 78/35 mm Hg, and her pulse was 140 beats per minutes (bpm). She was diagnosed with hemorrhagic shock due to postpartum hemorrhage. Based on this diagnosis, we alerted an emergency team and secured a sufficient number of staff members and space at 75 min after the CS. Her blood test results were as follows: hemoglobin, 9.8 g/dL; hematocrit, 29.7%; platelet, 26.6×10⁴/μL; fibrinogen, 175 mg/dL; FDP, 1687 μg/mL; and D-dimer, 774 μg/mL. She had slight consciousness impairment and decreasing SpO₂ (86%). After intubation she was transferred to the emergency room. A blood gas analysis showed the following results: pH, 7.417; PCO₂, 23.7 mm Hg; PO₂, 158 mm Hg; HCO₃, 14.9 mm Hg; BE, –9.1; and hemoglobin, 3.8 g/dL. In the emergency room, 18 units of red blood cells (RBCs), and 20 units of fresh frozen plasma were used. Since her blood pressure remained unstable and her atonic vaginal bleeding continued, we decided to perform a hysterectomy. A temporary aortic occlusion was made using an intra-aortic occlusion catheter to achieve hemostasis (this was also inserted to reduce hemorrhaging before the operation). An intra-aortic balloon occlusion (IABO) procedure was immediately performed, without fluoroscopy, by an emergency physician as a sterile procedure using Seldinger technique. Before needle insertion the physician disinfected the puncture site with povidone iodine. Soon after the insertion of the IABO catheter, the position of the tip of the balloon was confirmed by chest X-ray (Figure 1). The balloon was then inflated with 10 mL saline, and estimated balloon diameter was 20 mm. Consequently, since the massive vaginal hemorrhage was controlled and the patient’s BP had immediately increased to 142/82 mm Hg, the patient was transferred to the operation room. At this time a blood gas analysis showed the following: pH, 6.928; PCO₂, 72.9 mm Hg; PO₂, 359.8 mm Hg; HCO₃, 14.9 mm Hg; BE, –16.4; and hemoglobin, 6.7 g/dL. The balloon was deflated after 30 min, which was accompanied by a fall in BP to 78/38 mm Hg and increased vaginal bleeding. After 11 min of deflation, the balloon reinflated for 22 min. After the second inflation of the IABO, the balloon was deflated for 6 min and subsequently reinflated for 5 min. Five minutes later, the uterine arteries were clamped and the balloon was deflated. The bleeding from the uterus was controlled and the patient’s vital signs improved without the reinflation of the IABO. A hysterectomy was performed without further complications. The total blood loss was estimated to be 7000 mL, and 34 units of RBCs and 38 units of FFP 40 units of platelets were transfused. Sheath was left in the place until the next day (about 24 h after insertion of the catheter) when it was removed. After removing the catheter, we performed compression hemostasis on the puncture site manually for 20 min and then we use a tampon for compression on the puncture site and make a carefully observation with the patient on the bed.

Figure 1:

A chest X-ray image.

The arrow shows the position of the balloon, which is located in zone I.

Tracheal tube was also removed one day after the hysterectomy. The patient had progressed without any vascular complication in the extremity. She was discharged without complications on post-operative day 8.

Discussion

The use of the IABO procedure without fluoroscopy for the control of bleeding is established in the treatment of traumatic shock and is commonly used in emergency departments [1]. In the present case, the patient had massive continuous bleeding which was refractory to various conservative treatments and massive blood transfusion was required, which resulted in progressive DIC soon after the CS. The patient’s laboratory data also showed severe acidosis and coagulopathy. We then inflated an IABO catheter to reduce bleeding. This step is termed resuscitative endovascular aortic balloon occlusion of the aorta (REBOA) [1]. Soon after the inflation of the balloon, the patient’s massive bleeding was controlled and it was possible to safely perform a hysterectomy as radical treatment.

Resuscitative aortic balloon occlusion was first reported in the 1950s [2]; however, it did not gain immediate popularity because the procedure was associated with critical complications and because the balloon took a great deal of time to insert and did not improve the patient’s prognosis. Recent advances in endovascular technology and the clear benefits of resuscitative aortic balloon occlusion in the management of vascular disease suggests that this technology should be reappraised [1]. Many recent reports have mentioned the usefulness of the IABO procedure in the patients with ruptured abdominal aortic aneurysms, gastrointestinal bleeding, multiple trauma and severe pelvic fractures [2–4]. In obstetrics, there are some reports on the use of IABO in reducing the amount of bleeding due to placental previa percreta [3, 5]. However, there are few reports which mention the successful application of IABO in patients with postpartum hemorrhage [6].

In principle to control excessive bleeding for postpartum hemorrhage, it is necessary to insert the balloon in the central side of the aorta where the vessel responsible for the massive bleeding branches off. The section of the aorta related to REBOA is divided into three zones: zone I is the descending thoratic aorta between the origin of the left subclavian and celiac arteries; zone II extends from the celiac artery to the lowest renal artery; and zone III extends from the lowest renal artery to the aortic bifurcation [1]. The inflation of the balloon within the aorta may result in damage to the aorta and its branch vessels or to the end organs, such as the viscera or brain, due to embolization or dissection.

In the present case we used a 7Fr IABO catheter [RESCUE BALLOON^®Tokai Medical Products, Inc., Aichi, Japan (http://www.tokaimedpro.co.jp/)] which consists of 7Fr IABO catheter which balloon is high compliant Type 7 French short sheath, 11 cm 7 French sheath dilator, three guidewires (0.035 inch 80 cm, 0.025 inch 145 cm, 0.025 inch 240 cm) and 19 gauge femoral insertion needle. We inserted the IABO catheter by the following procedure. The first step was to gain percutaneous access to the femoral artery. The femoral artery was identified by palpation, without the use of ultrasonography, and the artery was entered at a 45-degree angle with a hollow 19-gauge needle through which a 0.035-inch wire could be passed. After the guide wire was inserted into the artery, the needle was removed and a dilater was inserted. A sheath was placed over the guide wire into the artery. The second step was to position the balloon. We placed the IABO catheter in aortic zone I without fluoroscopy. It took approximately 5 min to perform this procedure. We checked the location of the catheter by X-ray soon after the insertion of the balloon (Figure 1). Zone II or III might have been sufficient for the purpose of controlling bleeding in this case; however, the patient’s vital signs were terribly unstable and she was in a life threatening condition. We judged that inflating balloon in aortic zone I was necessary to preserve circulation to the most important organs (such as the brain and heart), while at the same time controlling her massive vaginal bleeding. The third step was the inflation and deflation of the balloon. The volume of saline instilled into the balloon depends on the case. The emergency physician determine the volume of the saline with three points. One is the site of the occlusion, second is the volume for which the physician feels resistance and the last is if the volume was enough to control the bleeding and to stabilize the circulation or not. For using IABO controlling the bleeding of the PPH, in most of cases it is enough to block off the blood stream under the lowest renal artery (Zone III). The average of the diameter of the site is 16 mm. In order to attain obstruction of Zone III, we use 8 mL of saline first and adjust the volume individually.

We counted the time from the start of inflation and restricted the inflating time to under 30 min in order to prevent complications caused by hemostasis. The IABO was inflated for a total of 58 min. A shorter inflation time would have been better, however, this was an extremely threatening situation. A recent study, which used a swine model of hemorrhagic shock, suggested that a REBOA time of 60 min was tolerated and recoverable [7]. Ideally it would be best to use fluoroscopy to check the position of the intra-aortic balloon. Ferguson et al. have stated that major intra-aortic balloon complications occur in 2.6% of patients [8]. On the other hand, it is impossible to transport a patient to the IVR department if the patient has ongoing massive bleeding and unstable vital signs. The patient’s massive, ongoing, life-threatening bleeding and the need to stop bleeding as soon as possible, meant that the possibility of complications were regarded as a minor problem and that the IABO technique without fluoroscopy was a very good tool. This procedure has the ability to reduce the volume of bleeding and the amount of blood products that must be administered to achieve hemostasis.

The use of IABO is associated with a limitation in that it is impossible to transfer the patient due to massive bleeding, there are no other means of instantly controlling vaginal bleeding in critical patients and proceeding to radical treatment. We have to recognize that this procedure is not radical in nature, but temporal. The REBOA procedure simply saves some time in recovering the patient’s general condition (vital signs and coagulopathy). At the same time, radical treatment should be attempted as soon as possible.

On the other hand, the convenience of this IABO procedure without fluoroscopy will expand the possibility of using this technique as a prevenient way of reducing the amount of bleeding not only for patients of placenta previa percreta or ongoing massive bleeding but also high risk patients for PPH. In this case we use RESCUE BALLOON®, and recently another REBOA device [Pryor’s ER-REBOA Catheter® Pryor Medical, Arvada, Colorado (http://www.pryormedical.com)] has been reported and is being developed. Such new catheters are guidewire-free, fluoroscopy free and include the flexible tip which help the physician place the device. Less invasive catheter and improvement of endovascular technology will make it possible to expand the indication of this procedure and contribute reducing the amount of bleeding of high risk patient, saving more PPH patients.

Conclusion

IABO without fluoroscopy is an effective treatment for patients in end-stage shock due to massive postpartum hemorrhage. Recent advances in endovascular technology and improvements of catheters have made it possible to safely perform this procedure. The procedure allows the caregiver to cope with massive bleeding in an emergency setting without fluoroscope facilities. This method will be helpful and enable a greater number of medical facilities to respond to massive postpartum hemorrhage and possibly increase the number of lives that are saved.