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Internal iliac artery balloon catheterization prior to non-elective cesarean delivery in a patient with placenta accreta
Abstract Number: 167
Abstract Type: Case Report/Case Series
Uterine artery embolization or internal iliac artery balloon catheters (IAC) can reduce perioperative bleeding and maternal morbidity in patients with placenta accreta (PA) requiring elective cesarean delivery (CS) (1). There are risks of major hemorrhage in patients with PA associated with labor, and there is no consensus regarding the use of these techniques prior to non-elective CS. We describe a patient with PA, placenta previa, and vasa previa requiring non-elective CS who received preoperative IAC.
A healthy 27 yr-old (G3P2) at 32 weeks gestation, with a history of 2 prior CS, was admitted for preterm contractions. MRI of the uterus at 32 weeks confirmed a bi-lobed placenta accreta, joined by a membranous portion over the cervical os (placenta previa). Additional findings included umbilical cord insertion into the membrane over the os (vasa previa).
Tocolysis was initially achieved using magnesium sulfate, and elective CS was planned for 35-36 weeks. The patient was type and crossed for 4 units RBCs (admission Hct=36.9), and wide-bore IV access was attained. Preterm contractions re-occurred at 33 weeks, and after obstetric review, an urgent CS with possible hysterectomy was arranged. As the patient was hemodynamically stable without vaginal bleeding, she was transferred to IR for placement of bilateral IAC. Epidural anesthesia was performed at L3-L4 using 15 ml 2% lidocaine with epinephrine 1:200K.
After IAC placement, the patient was transferred to the OR. A T4 block was achieved with an additional 20 ml 2% lidocaine, and an arterial line was inserted. The patient underwent uncomplicated CS and hysterectomy, with inflation of the IAC after delivery (Apgars= 8,9). During the hysterectomy, general anesthesia was induced due to patient discomfort. Total EBL=1500 ml; total IV fluids=5.5 L; intraoperative Hct=28. No RBCs or blood products were administered intraoperatively. The patient was extubated and IAC were removed postoperatively.
The initial postoperative labs were: Hct=25.7, Plt=113, PTT/INR=32.2/1.4, and the patient was transfused 2 units RBCs. She was discharged on POD #4 (Hct= 22.9) without complication. Pathology reported a bi-lobed placenta, complete previa, placenta percreta and vasa previa.
Patients with PA with preterm contractions require urgent or emergent CS due to the risk of severe obstetric hemorrhage. In our case, the patient received constant surveillance and remained hemodynamically stable without evidence of bleeding during IAC prior to CS. IAC can assist in reducing perioperative bleeding during emergency CS for PA (2), however patients with PA undergoing urgent IAC require continuous, active monitoring. Further investigation is needed to determine whether the risk of massive intraoperative bleeding without IAC outweighs the risk of delaying delivery for IAC in this setting.
1)Obstet Gynecol Clin N Am 2007;34:599-616.
2)Int J Obstet Anesth 2008;17:255-61.