**6. Recommendations**

During balloon inflation, the anesthesia team should work to off-set unwanted blood pressure augmentation and maintain normal physiologic pressures. The surgical teams should aim to achieve hemorrhage control rapidly to keep the duration of Zone 1 occlusion to a minimum. Other methods used to reduce ischemia include intermittent or partial balloon deflation and relocating the REBOA balloon to Zone 3 when able [55]. These techniques will allow some distal blood flow to perfuse ischemic tissues and prolong the overall duration of REBOA use. Providers should be aware that balloon deflation is associated with the rapid redistribution of circulating blood volume and the washout of ischemic metabolites, including a bolus of potassium, which can result in rebound hypotension and cardiac instability [55]. The combination of partial occlusion and relocation from Zone 1 to Zone 3, along with close communication with the anesthesia providers to time fluid and drug administration with inflation and

There is a dearth of published information about management of intra-arterial balloons during high-risk obstetric procedures. Of all reported cases, there has been only one documented aortic rupture due to a smaller than expected aortic diameter [45]. Few cases describe flushing the sheath or catheters, although doing so is a well-established principle of vascular surgery. Whether the flush solution should contain heparin is additionally controversial when these catheters are used for hemorrhage control in patients that cannot receive blood. The authors' practice is to use 30 ml 2% heparin (2 units of heparin per 100 ml of crystalloid) through the sheath and another 30 ml through the central lumen of the REBOA catheter every 10 minutes, while monitoring thromboelastography to ensure the absence of systemic coagulopathy. Frequent monitoring of distal pulses in the ipsilateral extremity should be maintained throughout the case and for 24 hours after sheath removal. Continuous Doppler may be a

The risks and benefits of anticoagulation deserve special consideration in this patient population. Pregnancy itself confers a hypercoagulable state. These patients may be at even higher risk of clot formation due to the administration of TXA, erythropoietin, cryoprecipitate or other coagulation factors. Postoperatively, VTE risk remains high in the setting of immobility and/or symptomatic anemia. In the immediate postoperative period, the risk of death from hemorrhage may outweigh the risks from VTE. Within several days of surgery however, the probability of hemorrhage decreases, justifying prophylactic heparin administration to

REBOA is a novel, minimally-invasive method to control non-compressible hemorrhage. Much of the literature regarding techniques for placement and risks of use are derived male trauma patients. More research is needed to investigate the use of REBOA in a peripartum setting. Reports of prophylactic use of REBOA to minimize blood loss during high-risk obstetric operations, claim to reduce blood loss and improve rates of uterine salvage compared to other types of arterial occlusion techniques, such as hypogastric and uterine artery occlusion. Most of this evidence comes from retrospective case series out of Asia. Comparative data is needed to

deflation, can aid in maintaining hemodynamic stability throughout surgery.

helpful adjunct to aid in early detection of arterial access complications.

reduce the risk of VTE.

104 Placenta

**5. Future directions**

For high-risk patients with MAP, thorough planning throughout the prenatal period is critical to successful management. Prenatal optimization of hemoglobin and preoperative involvement of a multidisciplinary team can improve maternal outcomes. If blood products are not readily available or are declined by the patient, alternative options should be discussed. Clearly eliciting if blood fractions, clotting factors, and TXA will be accepted by the patient can assist in surgical planning. Meticulous surgical techniques and clear communication with the anesthesia team can minimize intraoperative hemorrhage. Additional adjuncts such as ANH and cell salvage may ease the effects of blood loss. Consideration of REBOA use may decrease the volume of blood lost and the need for transfusion. Planning for REBOA use in a proactive and prophylactic setting may limit the risks of the procedure and improve morbidity and mortality.

Implementing REBOA in the obstetric patient requires careful multidisciplinary management and clear communication throughout the perioperative period. General principles of vascular access should be respected. Minimizing the risk of limb ischemia requires selecting the smallest sheath possible to accommodate the selected balloon catheter, frequent vascular checks of both lower extremities, consideration of post-procedural angiography, and prompt sheath removal. The duration of balloon inflation should be minimized, and intermittent or partial balloon deflation should be used as adjuncts to reduce ischemia when necessary. Anticipating


**Acronyms and abbreviations**

MMR maternal mortality ratio

rFVIIa recombinant factor VIIa

VTE venous thromboembolism

, Eugenia Girda2

\*Address all correspondence to: hachen@ucdavis.edu

of California Davis, Sacramento, CA, USA

vWF Von Willebrand factor

TXA tranexamic acid

**Author details**

Rachel M. Russo1

Misty D. Humphries5

Sacramento, CA, USA

2016;**388**:1775-1812

2000;**164**:1270-1274

accreta. BJOG. 2009;**115**:648-654

**References**

MAP morbidly adherent placenta

FVIII Factor VIII

ANH acute normovolemic hemodilution

REBOA resuscitative endovascular balloon occlusion of the aorta

, Hui Chen3

1 Department of Surgery, University of California Davis, Sacramento, CA, USA

3 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University

[1] Collaborators GMM. Global, regional, and national levels of maternal mortality, 1990-2015: A systematic analysis for the global burden of disease study 2015. Lancet.

[2] Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta

[3] Abbas F, Talati J, Wasti S, Akram S, Ghaffar S, Qureshi R. Placenta percreta with bladder invasion as a cause for life threatening hemorrhage. The Journal of Urology.

4 Department of Anesthesiology, University of California Davis, Sacramento, CA, USA 5 Division of Vascular Surgery, Department of Surgery, University of California Davis,

and Vanessa Kennedy3

2 Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA

\*, Nina Schloemerkemper4

Management of High-Risk Obstetrical Patients with Morbidly Adherent Placenta in the Age…

,

http://dx.doi.org/10.5772/intechopen.78753

107


**Table 5.** Summary recommendations.

hemodynamic and metabolic changes associated with balloon inflation and deflation is paramount and requires frequent communication between the operating and anesthesia teams to time the administration of medications and fluids.

Finally, providing supportive care for profound anemia and limiting unnecessary lab draws can improve postoperative outcomes. Careful consideration must be given to the use and timing of anticoagulation in setting where further hemorrhage could be detrimental to patients. A summary of the recommendations can be found in **Table 5**.
