doi: 10.1111/j.1399-6576.2011.02611.x
Case Report
1
Department of Radiology, St. Olavs University Hospital, Trondheim, Norway, 2Department of Radiology, Stavanger University Hospital,
Stavanger, Norway, 3Department of Anesthesiology, St. Olavs University Hospital, Trondheim, Norway and 4Department of Gynecology and
Obstetrics, St. Olavs University Hospital, Trondheim, Norway
Case report
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However, this procedure can also be performed by anaesthesiologists or surgeons who are trained in vascular access
techniques.
Accepted for publication 4 November 2011
2012 The Authors
Acta Anaesthesiologica Scandinavica
2012 The Acta Anaesthesiologica Scandinavica Foundation
Cases
Patient 1
Labour was induced during week 37 of gestation in
a 26-year-old primigravida woman due to severe
Patient 2
A 38-year-old woman was admitted at term for her
second childbirth. Soon after delivery, increasing
vaginal bleeding was observed, and post-partum
atony was suspected. Due to uncontrollable bleeding, she was admitted to the operation theatre with
an Hb level of 4.7 g/dl. Gynaecological inspection
revealed several vaginal tears and an atonic uterus.
Carboprost was given intramyometrically.
An IABO catheter was inserted without the use
of US. An initial increase in systolic BP from
40 mmHg to 80 mmHg was achieved after treatment with intravenous volume expanders. The
systolic BP increased further from 80 mmHg to
130 mmHg as the balloon was inflated, and partial
haemostasis simplified the suturing of the vaginal
tears. After 30 min, the balloon was deflated, which
was accompanied by a fall in systolic BP to
60 mmHg. Subsequently bleeding was attributed to
be mainly caused by atony of the uterus. Afterwards, a hysterectomy was performed; however,
vaginal bleeding was observed. Therefore, the
patient was taken to the angiography laboratory for
embolization, with the balloon still inflated. After
deflation of the balloon, no bleeding was observed
and embolization was not performed. The balloon
was then removed, and the arterial introducer was
left in place until the next day. The total estimated
blood loss was 10 l.
Patient 3
After delivery of a healthy baby, a 30-year-old
primigravida woman developed a profound vaginal
bleeding. The patient presented with pre-shock
symptoms and was taken to the operating theatre.
Under general anaesthesia, an IABO catheter was
rapidly inserted under US guidance into the
abdominal aorta. An immediate increase in BP from
below 70 mmHg to over 90 mmHg was noted. The
balloon was partly deflated after 1 min and retracted
to the aortic bifurcation where it was reinflated and
left for 10 min before the second deflation. No
vaginal bleeding or cervical tears were seen, but placental material was evacuated by curettage. The
balloon was inflated for a third time for 13 min
before deflation. Meanwhile, carboprost was given
intramyometrically. After these procedures, the
uterus was well contracted, and the bleeding gradually stopped. The total blood loss was estimated to
be 2300 ml. (Fig. 1)
The femoral introducer was left in place until the
next day. (Fig. 2)
Patient 4
Planned labour was induced with misoprostol due
to gestational impaired glucose tolerance in a
44-year-old woman at term.
After delivery, PPH was observed, with blood
loss increasing after 1 h to 1700 ml as the patient
developed atony of the uterus. Curettage was performed, and minimal residual placenta was
removed. An intrauterine balloon and B-Lynch
sutures were used without effect. A hysterectomy
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E. Svik et al.
Patient 6
Patient 5
A 30-year-old woman was admitted for her third
childbirth. The patient had gestational diabetes
during this third pregnancy. After delivery, the
patient had a retained placenta, and manual extraction and revision were performed. The patient had
ongoing bleeding due to atony despite intravenous
medication and intramyometrial prostaglandin
administration. She was given 21 units of RBC, 6
units of human plasma solution and 8 IU of platelets. An intrauterine balloon was unsuccessful, and
Hg fell to 3.5 g/dl. An aortic balloon was inserted
under US guidance, which caused the bleeding to
stop immediately, with a rise in the systolic BP from
85 mmHg to 115 mmHg. A hysterectomy was performed without further complications. The introducer was removed the following day, and the
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Methodology
In 2008, we assembled an aortic occlusion kit that
consisted of two NuMED PTX-S [NuMED Canada
Inc., Cornwall, ON, Canada (25 30 mm)] paediatric
Discussion
Fig. 3. X-ray picture from an embolization procedure of the
uterine arteries after a Caesarean section. This patient is not
referred to in this article; however, this image illustrates the position of an aortic occlusion balloon inflated in the distal abdominal
aorta.
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E. Svik et al.
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smaller syringe, which makes it easier for the interventionalist to feel the resistance as the balloon hits
the aortic wall during inflation. Successful use of this
smaller balloon has been performed recently but is
not referred to in this article.
With the method described in this article, six IRs
were able to place an aortic occlusion catheter into
the abdominal aorta without the use of fluoroscopy
in six patients with life-threatening PPH. In hospitals without IRs on-call, we believe that anaesthesiologists can also perform this procedure if they are
trained in US-guided access to the common femoral
artery.
Conclusion
This article describes the use of IABO without
the use of fluoroscopy to halt potentially lifethreatening PPH in six patients. The procedures
resulted in reduced bleeding and acted as a bridge
intervention that allowed for the eventual delivery
of definitive treatment. We believe this method will
contribute to a reduced mortality among patients
with severe PPH.
Conflict of interest: There is no known conflict of
interest.
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Address:
Edmund Svik
Department of Radiology
St. Olavs University Hospital
7006 Trondheim
Norway
e-mail: edmund.sovik@stolav.no
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