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      Fluoroscopy-free Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for controlling life threatening postpartum hemorrhage

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          Abstract

          Background

          Severe postpartum hemorrhage occurs in 1/1000 women giving birth. This condition is often dramatic and may be life threatening. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has in recent years been introduced as a novel treatment for hemorrhagic shock. We present a series of fluoroscopy-free REBOA for controlling life threatening postpartum hemorrhage.

          Methods

          In 2008 an ‘aortic occlusion kit’ was assembled and used in three Norwegian university hospitals. The on-call interventional radiologist (IR) was to be contacted with a response time < 30 minutes in case of life threatening PPH. Demographics and characteristics were noted from the medical records.

          Results

          This retrospective study includes 36 patients treated with fluoroscopy-free REBOA for controlling severe postpartum hemorrhage in the years 2008–2015. The REBOA success rate was 100% and no patients died from REBOA related complications. Uterine artery embolization was performed in 17 (47%) patients and a hysterectomy in 16 (44%) patients. A short (11cm) introducer length was strongly associated with iliac artery thrombus formation ( ρ = 0.50, P = 0.002). In addition, there was a strong negative correlation between uterine artery embolization and hysterectomy ( ρ = -0.50, P = 0.002).

          Conclusions

          Our Norwegian experience indicates the clinical safety and feasibility of REBOA in life threatening PPH. Also, REBOA can be used in an emergency situation without the use of fluoroscopy with a high degree of technical success. It is important that safety implementation of REBOA is established, especially through limited aortic balloon occlusion time and a thorough balloon deflation regime.

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          Most cited references24

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          Epidemiology of postpartum haemorrhage: a systematic review.

          Edgardo Abalos, Metin A. Gülmezoglu, Cristina Cuesta … (2008)
          Postpartum haemorrhage (PPH) is an important cause of maternal mortality. We conducted a systematic review of the prevalence of PPH with the objective of evaluating its magnitude both globally and in different regions and settings: global figures, as well as regional, country and provincial variations, are likely to exist but are currently unknown. We used prespecified criteria to select databases, recorded the database characteristics and assessed their methodological quality. After establishing PPH (>or=500 mL blood loss) and severe PPH (SSPH) (>or=1000 mL blood loss) as main outcomes, we found 120 datasets (involving a total of 3,815,034 women) that reported PPH and 70 datasets (505,379 women) that reported SPPH in the primary analysis. The prevalence of PPH and SPPH is approximately 6% and 1.86% of all deliveries, respectively, with a wide variation across regions of the world. The figures we obtained give a rough estimate of the prevalence of PPH and suggest the existence of some variations. For a reliable picture of PPH worldwide - its magnitude, distribution and consequences - a global survey tackling this condition is necessary.
          Article 0 comments Cited 133 times – based on 0 reviews     Review now
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            Preventability of pregnancy-related deaths: results of a state-wide review.

            Ronella Hage, Holli Harper, D Berg … (2005)
            Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an irreducible minimum. To further reduce pregnancy-related mortality, we must understand which deaths are potentially preventable and the changes needed to prevent them. We sought to identify all pregnancy-related deaths in North Carolina and conduct a comprehensive review examining ways in which the number of these deaths could potentially be reduced. The North Carolina Pregnancy-Related Mortality Review Committee reviewed all of the 108 pregnancy-related deaths (women who died during or within 1 year of the end of pregnancy from a complication of pregnancy or its treatment) that occurred in the state in 1995-1999. For each death, the committee determined the cause of death, whether it could have been prevented, and if so, the means by which it might have been prevented. Although overall, 40% of pregnancy-related deaths were potentially preventable, this varied by the cause of death. Almost all deaths due to hemorrhage and complications of chronic diseases were believed to be potentially preventable, whereas none of the deaths due to amniotic fluid embolus, microangiopathic hemolytic syndrome, and cerebrovascular accident were considered preventable. Improved quality of medical care was considered to be the most important factor in preventing these deaths. Among African-American women, 46% of deaths were potentially preventable, compared with 33% of the deaths among white women. Despite the decline in pregnancy-related mortality rates, almost one half of these deaths could potentially be prevented, mainly through improved quality of medical care. In-depth review of pregnancy-related deaths can help determine strategies needed to continue making pregnancy safer.
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              A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation.

              G Tyson, Amanda DuBose, Thomas M. Scalea … (2013)
              A requirement for improved methods of hemorrhage control and resuscitation along with the translation of endovascular specialty skills has resulted in reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA) for end-stage shock. The objective of this report was to describe implementation of REBOA in civilian trauma centers. Descriptive case series of REBOA (December 2012 to March 2013) used in scenarios of end-stage hemorrhagic shock at the University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, and Herman Memorial Hospital, The Texas Trauma Institute, Houston, Texas. REBOA was performed by trauma and acute care surgeons for blunt (n = 4) and penetrating (n = 2) mechanisms. Three cases were REBOA in the descending thoracic aorta (Zone I) and three in the infrarenal aorta (Zone III). Mean (SD) systolic blood pressure at the time of REBOA was 59 (27) mm Hg, and mean (SD) base deficit was 13 (5). Arterial access was accomplished using both direct cutdown (n = 3) and percutaneous (n = 3) access to the common femoral artery. REBOA resulted in a mean (SD) increase in blood pressure of 55 (20) mm Hg, and the mean (SD) aortic occlusion time was 18 (34) minutes. There were no REBOA-related complications, and there was no hemorrhage-related mortality. REBOA is a feasible and effective means of proactive aortic control for patients in end-stage shock from blunt and penetrating mechanisms. With available technology, this method of resuscitation can be performed by trauma and acute care surgeons who have benefited from instruction on a limited endovascular skill set. Future work should be aimed at devices that allow easy, fluoroscopy-free access and studies to define patients most likely to benefit from this procedure. Therapeutic study, level V.
              Article 0 comments Cited 91 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Chiara Lazzeri: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 29 March 2017
                Publication date Collection: 2017
                Volume: 12
                Issue: 3
                Electronic Location Identifier: e0174520
                Affiliations
                [1 ]Dept of Radiology and Nuclear Medicine, St Olavs University Hospital, Trondheim, Norway
                [2 ]Institute of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
                [3 ]Dept of Radiology and Nuclear Medicine, Oslo University Hospital Ullevaal, Oslo, Norway
                [4 ]Dept of Radiology and Nuclear Medicine, Stavanger University Hospital, Stavanger, Norway
                Azienda Ospedaliero Universitaria Careggi, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: KHS E. Sovik.

                • Formal analysis: AJ.

                • Investigation: KHS AJ.

                • Methodology: KHS E. Sovik.

                • Project administration: KHS.

                • Resources: AJ YH E. Skomedal.

                • Supervision: KHS.

                • Validation: KHS.

                • Visualization: KHS E. Sovik AJ.

                • Writing – original draft: KHS.

                • Writing – review & editing: KHS E. Sovik AJ.

                Article
                Publisher ID: PONE-D-16-32954
                DOI: 10.1371/journal.pone.0174520
                PMC ID: 5371310
                PubMed ID: 28355242
                SO-VID: af304f55-916f-492b-8713-56fa971737de
                Copyright © © 2017 Stensaeth et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 17 August 2016
                Date accepted : 10 March 2017
                Page count
                Figures: 0, Tables: 2, Pages: 8
                Funding
                The authors received no specific funding for this work.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Critical Care and Emergency Medicine
                Subject: Severe Blood Loss
                Subject: Postpartum Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Diagnostic Medicine
                Subject: Signs and Symptoms
                Subject: Hemorrhage
                Subject: Severe Blood Loss
                Subject: Postpartum Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Signs and Symptoms
                Subject: Hemorrhage
                Subject: Severe Blood Loss
                Subject: Postpartum Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Hemorrhage
                Subject: Severe Blood Loss
                Subject: Postpartum Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Women's Health
                Subject: Maternal Health
                Subject: Birth
                Subject: Postpartum Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Women's Health
                Subject: Obstetrics and Gynecology
                Subject: Birth
                Subject: Postpartum Hemorrhage
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Blood Vessels
                Subject: Arteries
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Blood Vessels
                Subject: Arteries
                Subject: Medicine and Health Sciences
                Subject: Diagnostic Medicine
                Subject: Signs and Symptoms
                Subject: Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Signs and Symptoms
                Subject: Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Hemorrhage
                Subject: Biology and Life Sciences
                Subject: Biotechnology
                Subject: Medical Devices and Equipment
                Subject: Catheters
                Subject: Medicine and Health Sciences
                Subject: Medical Devices and Equipment
                Subject: Catheters
                Subject: Medicine and Health Sciences
                Subject: Surgical and Invasive Medical Procedures
                Subject: Reproductive System Procedures
                Subject: Hysterectomy
                Subject: Medicine and Health Sciences
                Subject: Surgical and Invasive Medical Procedures
                Subject: Surgical Excision
                Subject: Hysterectomy
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Blood Vessels
                Subject: Aorta
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Blood Vessels
                Subject: Aorta
                Subject: Medicine and Health Sciences
                Subject: Surgical and Invasive Medical Procedures
                Subject: Medicine and Health Sciences
                Subject: Critical Care and Emergency Medicine
                Subject: Severe Blood Loss
                Subject: Medicine and Health Sciences
                Subject: Diagnostic Medicine
                Subject: Signs and Symptoms
                Subject: Hemorrhage
                Subject: Severe Blood Loss
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Signs and Symptoms
                Subject: Hemorrhage
                Subject: Severe Blood Loss
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Hemorrhage
                Subject: Severe Blood Loss
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                Data Availability All relevant data are within the paper.

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