**Author details**

**Figure 2** shows an algorithm used in the Kobe University Hospital for the management of pregnant women with placenta previa. All pregnant women with placenta previa receive workup for placenta accreta in inpatient or outpatient care. If women have bleeding, they are hospitalized immediately and receive intravenous administration of tocolytic agents such as magnesium sulfate or β-stimulant. Even if they do not have bleeding, they are hospitalized at 32–34GW. Women have a PPAP score ≥ 8, who are suspected of having placenta accreta, receive both preoperative internal iliac artery occlusion balloon catheters placement and elec-

**Figure 3** shows a flow algorithm used in the Kobe University Hospital for the preoperative preparation and operative procedures for women with suspicion of placenta accreta. Women with placenta previa had a PPAP score ≥ 8, who were suspected of having placenta accreta, received preoperative internal iliac artery occlusion balloon catheters placement. After fetal delivery by a CS using transverse uterine fundal incision method, the internal iliac artery occlusion balloon catheters were inflated. After occlusion of the artery, local injection of oxytocin into the myometrium and uterine massage were performed to induce spontaneous placental separation. If placental separation did not occur at all and women did not have a desire for future fertility, cesarean hysterectomy was performed. When the placenta was not partially separated, partial resection of uterine wall or removal of placenta using advanced bipolar was performed.

**Figure 2.** An algorithm for the management of pregnant women with placenta previa. MRI, magnetic resonance imaging;

GW, weeks of gestation; NRFS, non-reassuring fetal status; and CS, cesarean section.

tive CS at 35–37GW.

90 Placenta

Kenji Tanimura and Hideto Yamada\*

\*Address all correspondence to: yhideto@med.kobe-u.ac.jp

Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan

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**Chapter 7**

**Provisional chapter**

**Management of High-Risk Obstetrical Patients with**

**Resuscitative Endovascular Balloon Occlusion of the** 

**Management of High-Risk Obstetrical Patients** 

**with Morbidly Adherent Placenta in the Age of** 

**Endovascular Balloon Occlusion of the Aorta**

Rachel M. Russo, Eugenia Girda, Hui Chen,

Rachel M. Russo, Eugenia Girda, Hui Chen,

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

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

Vanessa Kennedy

Vanessa Kennedy

**Abstract**

**1. Introduction**

**Aorta**

Nina Schloemerkemper, Misty D. Humphries and

Nina Schloemerkemper, Misty D. Humphries and

**Morbidly Adherent Placenta in the Age of Resuscitative**

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality worldwide. At highest risk of massive obstetric hemorrhage, are women with morbidly adherent placenta (MAP). The complications associated with MAP are even more devastating in very high-risk obstetrical patients, where blood transfusion is not an option, either due to lack of resources or patient refusal, such as for Jehovah's Witnesses. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally-invasive technique used in trauma surgery to control non-compressible hemorrhage. REBOA is emerging as useful tool for managing high-risk obstetric surgery for MAP. This review aims to provide a framework for use of REBOA in obstetric care in challenging circumstances.

**Keywords:** accreta, aortic balloon, balloon occlusion, Jehovah's Witness, morbidly

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality worldwide [1]. At highest risk of massive obstetric hemorrhage are women with a morbidly adherent placenta (MAP). MAP describes the penetration of placental chorionic villi into the uterus to varying degrees classified as—placenta accreta, increta, and percreta. The incidence of MAP is increasing.

adherent placenta, obstetric hemorrhage, percreta, REBOA

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.78753

[31] Royal College of Obstetricians and Gynecologists. Placenta praevia, placenta praevia accreta and vasa previa: diagnosis and management. Green-Top Guideline No. 27. 2011. pp. e1-e26

#### **Management of High-Risk Obstetrical Patients with Morbidly Adherent Placenta in the Age of Resuscitative Endovascular Balloon Occlusion of the Aorta Management of High-Risk Obstetrical Patients with Morbidly Adherent Placenta in the Age of Resuscitative Endovascular Balloon Occlusion of the Aorta**

DOI: 10.5772/intechopen.78753

Rachel M. Russo, Eugenia Girda, Hui Chen, Nina Schloemerkemper, Misty D. Humphries and Vanessa Kennedy Rachel M. Russo, Eugenia Girda, Hui Chen, Nina Schloemerkemper, Misty D. Humphries and Vanessa Kennedy

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

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

#### **Abstract**

[30] Butt K, Gagnon A, Delisle MF. Failure of methotrexate and internal iliac balloon catheterization to manage placenta percreta. Obstetrics and Gynecology. 2002;**99**:981-982 [31] Royal College of Obstetricians and Gynecologists. Placenta praevia, placenta praevia accreta and vasa previa: diagnosis and management. Green-Top Guideline No. 27. 2011.

pp. e1-e26

94 Placenta

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality worldwide. At highest risk of massive obstetric hemorrhage, are women with morbidly adherent placenta (MAP). The complications associated with MAP are even more devastating in very high-risk obstetrical patients, where blood transfusion is not an option, either due to lack of resources or patient refusal, such as for Jehovah's Witnesses. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally-invasive technique used in trauma surgery to control non-compressible hemorrhage. REBOA is emerging as useful tool for managing high-risk obstetric surgery for MAP. This review aims to provide a framework for use of REBOA in obstetric care in challenging circumstances.

**Keywords:** accreta, aortic balloon, balloon occlusion, Jehovah's Witness, morbidly adherent placenta, obstetric hemorrhage, percreta, REBOA
