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Common Iliac Ballooning for Placenta Percreta
Abstract Number: F-70
Abstract Type: Case Report/Case Series
Introduction: The incidence of abnormal placentation is rising, likely due to increasing cesarean delivery rate and maternal age. Pelvic arterial occlusion is gaining popularity as a method to decrease blood loss and possibly morbidity in these cases.
Case: A 42 YO G6P5 at 33.1wks transferred to our institution for management of placenta
precreta (PP). She had a history of 4 uncomplicated NSVDs and primary LTCS for arrest of dilation.
A polypectomy at 13 weeks showed fragments of immature chorionic villi suggestive of abnormal
placentation. At 29 weeks, an ultrasound showed complete anterior previa, along with placental
invasion of the bladder, rectus abdominus and abdominal wall.
Multidisciplinary team meetings including MFM, anesthesia, nursing, gyne-onc, interventional radiology (IR), blood bank, vascular surgery, neonatology and urology resulted in the final delivery plan.
On the day of delivery, the patient presented to the IR suite for prophylactic placement of common iliac artery (CIA) balloon catheters. She was transferred to the OR where standard ASA monitors and pre- induction arterial line was placed prior to rapid sequence intubation. A 9-Fr central line was placed. CIA balloons were deployed immediately after delivery of a healthy fetus. A trial balloon deflation was completed 62 minutes later without notification of the anesthesia team. The patient had severe hypotension and bradycardia, requiring epinephrine, bicarbonate, and calcium. Hemodynamic stability was then recovered. After discussion with the IR team, subsequent inflation of the balloons for 25 min followed by slow sequential deflation resulted in minimal hemodynamic changes. Final estimated blood loss was 6L. In the OR, she received of 8units PRBCs, 250mL cell saver, 5 units FFP, 2 units of platelets, and 1 unit of cryoprecipitate. She was transferred to the ICU and was extubated on POD2. Her postpartum course was uneventful.
Discussion: Various strategies have been described to mitigate blood loss in patients with abnormal placentation, including uterine artery ligation or embolization, internal iliac artery occlusion, and infrarenal aortic cross clamping (1). Data supporting outcome benefits after these interventions is weak, and these procedures involve significant risk (2). The use of common iliac occlusion has also been reported (3). Advantages include ease of placement with minimal fluoroscopy and control of collateral pelvic blood flow. Theoretical risks include thrombosis and reperfusion injury. In our case, the use of CIA balloons likely prevented catastrophic blood loss. However, the sudden deflation of both balloons with notification of the anesthesia team likely contributed to severe hemodynamic instability in the setting of massive blood loss.
1. Chou MM et al. Taiwan J Obstet Gynecol [2010, 49(1):72-6] 2. Shrivastava V et al. Am J Obstet Gynecol 2007;197:402.e1-402.e5. 3. Shih JC et al. Am J Obstet Gynecol 2005;193:1756–8