Fetal and neonatal outcomes following maternal aortic balloon occlusion for hemorrhage in pregnancy: A review of the literature

Abstract

BACKGROUND: Hemorrhage is a leading cause of maternal death worldwide, with increased risk in women with abnormal placentation. Aortic balloon occlusion (ABO), including resuscitative endovascular balloon occlusion, has been used for obstetrical hemorrhage for 20 years, and is associated with decreased operative blood loss, fewer transfusions, and lower rates of hysterectomy. However, the effect of aortic occlusion on fetal/neonatal outcomes is not well known. METHODS:A literature review on ABO for obstetrical or traumatic hemorrhage was performed. Cases were included if fetal/neonatal outcomes were reported. Data were collected on timing of balloon inflation (predelivery or postdelivery), fetal/neonatal mortality, and Apgar scores. Secondary maternal outcomes included blood loss, need for hysterectomy, ABO-related complications, and mortality. RESULTS:Twenty-one reports of ABO in 825 cases of obstetrical hemorrhage were reviewed (nine case reports/series and twelve comparative studies). 13.5% (111/825) had aortic occlusion prior to delivery of the fetus. Comparative cohorts included 448 patients who underwent iliac artery balloon occlusion (n = 219) or no vascular balloon occlusion (n = 229). The most common neonatal outcome reported was Apgar scores, with no difference in fetal/neonatal outcomes between ABO and non-ABO patients in any study. One neonatal mortality occurred in the sole reported case of ABO use in a pregnant trauma patient at 24 weeks gestation. One maternal mortality occurred because of aortic dissection. Five comparative studies reported significantly decreased blood loss in ABO patients compared to non-ABO patients, and four studies reported significantly lower rates of hysterectomy in ABO patients. ABO-related complications were reported in 1.6% of patients (13/825). CONCLUSION: Obstetrical hemorrhage is a devastating complication, and ABO may potentially decrease blood loss and reduce the hysterectomy rate without compromising fetal and neonatal outcomes. Further research is needed to determine the safety of predelivery aortic occlusion as this occurred in 14% of the cases.

Aortic balloon occlusion in distal zone 3 reduces blood loss from obstetric hemorrhage in placenta accreta spectrum

“…3 Several groups have reported superior outcomes with resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to hemorrhage control during cesarean hysterectomy for PAS. [4][5][6][7][8][9][10][11][12] A meta-analysis of 731 PAS patients who underwent cesarean deliveries in which a REBOA catheter was used to occlude the infrarenal aorta, termed zone 3, found that these women experienced significantly less blood loss, received fewer transfusions, and achieved a higher rate of uterine preservation compared with other hemorrhage control strategies. 9 However, in the 11 studies pooled to generate this metaanalysis, there was no specific standard location of occlusion within zone 3 of the aorta.…”

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

“…The first report on the use of REBOA in the field of obstetrics was in 1995, in a case of PAS 19) . Since then, over 1,000 cases of aortic balloon occlusion have been reported in obstetrics, mainly for cases with PAS to control obstetric hemorrhage during cesarean hysterectomy 20) .…”

A team approach to peripartum hemorrhage control incorporating resuscitative endovascular balloon occlusion of the aorta

“…Inflation may begin just after delivery of the infant when the risk of hemorrhage is high, upon vascular pedicle ligation, or may be delayed until hemorrhage is encountered depending on the clinical features of the case. Although there has been as many as 150 published cases of REBOA inflation prior to delivery with reportedly good fetal outcomes in Asia, 10 our practice emphasizes avoiding predelivery aortic occlusion when the fetus is viable.…”