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Where is the Balloon? Misadventures in Interventional Radiology For A Patient with Placenta Accreta
Abstract Number: F-70
Abstract Type: Case Report/Case Series
Background: Postpartum hemorrhage is one of the leading causes of morbidity and mortality
worldwide. Abnormal placentation is a leading cause of massive obstetric hemorrhage and peripartum hysterectomy1. In order to minimize postpartum bleeding, perioperative endovascular internal iliac or uterine artery balloon occlusion catheters may be placed. The efficacies of such minimally invasive balloons are controversial but generally accepted as safe3. We report a case of a potentially dangerous team miscommunication in the interventional radiology suite while placing prophylactic balloon occlusion catheters.
Case: The patient, a 29 year old G2P1at 34weeks gestation, with a history of one prior cesarean delivery presented for a planned repeat cesarean delivery. Antenatal ultrasound revealed placenta previa with concern for placenta accreta. A subsequent MRI was consistent with placenta increta. A plan was devised between Maternal-Fetal Medicine, Anesthesiology, and Interventional Radiology to facilitate delivery via cesarean delivery and possible hysterectomy following internal iliac artery balloon placement in the interventional radiology suite. A lumbar epidural was placed by the anesthesia service in the interventional radiology suite. The interventional radiology team then placed balloon occlusion catheters into the uterine arteries. After catheter placement, the fetal heart tones were noted to be below 100 BPM despite intrauterine resuscitation maneuvers to optimize uterine blood flow. The interventional radiology team offered to withdraw the catheters (which were in the uterine arteries) and the obstetric and anesthesia providers declined this maneuver, believing the catheters to be in the internal iliac arteries. The obstetric and anesthesiology teams decided to take the patient emergently to the operating room where a cesarean delivery was performed under epidural anesthesia with delivery of a healthy infant. The placenta separated easily and fertility was preserved.
Discussion: Complications of internal iliac and uterine artery occlusion catheters is imperative during management of obstetric hemorrhage. An occlusion catheter intended for the internal iliac artery may completely obliterate the lumen of the uterine artery, which can be 50% smaller in size. Additionally uterine artery vasospasm, precipitated by manipulation, can manifest as fetal distress2-3. Withdrawing the balloon catheters, suggested by the IR physician but not well understood by the Anesthesia and MFM team, may have prevented an emergent delivery of a patient at high risk for hemorrhage. Although there was no additional morbidity to mother or fetus, thorough knowledge and communication regarding arterial occlusion techniques may have avoided emergent cesarean delivery and minimized risk.
1) Kuczkowski. Curr Opin Obstet Gynecol. 2011 Dec;23(6):401-7
2) Masamoto et al. Gynecol Obstet Invest. 2009;67(2):92-5
3) Sadashivaiah J et al. Int J Obstet Anesth. 2011 Oct;20(4)