**1. Introduction**

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.

© 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.

In the United States alone, the rate doubled from 5.4 in 10,000 deliveries to 11.9 in 10,000 over a period of 6 years [2]. The most severe form, placenta percreta, in which chorionic villi penetrate through the uterine wall and into adjacent organs, has increased 50-fold in the last 50 years [3].

The morbidity and mortality associated with MAP is even more devastating when blood transfusion is not an option, either from lack of resources or patient refusal. Patients decline blood transfusions for a variety of reasons, most commonly due to religious grounds, such as for Jehovah's Witnesses. For these patients, the risk of mortality due to obstetric hemorrhage

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

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During the first prenatal visit, willingness to accept blood products should be addressed and alternatives to transfusion discussed. For patients who indicate that they would not accept blood transfusion, providers should investigate which, if any, blood products or alternatives may be acceptable in the case of an emergency. In addition to establishing patient capacity, a thorough discussion of the potential risks and benefits of transfusion is necessary. This discussion with patients should be performed privately and confidentially. It must be free of coercion and judgment from outside parties [14, 15]. In circumstances of a religious basis for blood refusal, patients frequently consult with religious leaders, family and friends prior to making a decision, but the final decision must rest in the hands of the patient herself. These

Preoperative optimization of hemoglobin by treating underlying anemia is ideal. Many patients who do not accept blood will accept other methods to improve hemoglobin levels. Iron, vitamin B12, folate and recombinant erythropoietin can be used preoperatively [14, 15]. Intravenous iron is preferred over oral preparations because of faster and more reliable increases in hemoglobin. Recombinant erythropoietin can optimize hemoglobin both preoperatively and postoperatively. However, there are no clear guidelines on optimal dosing. While studies suggest erythropoietin is safe to use in pregnancy, it can increase the risk of venous thromboembolism (VTE), which may exacerbate an already hypercoagulable state [16]. Consultation and coordination with a

As the pregnancy advances, careful monitoring of the placenta is imperative to understanding the extent of MAP. A plan for delivery in an appropriately-resourced setting is crucial. Advanced directives should be established, with legal counsel as necessary. A multidisciplinary effort should be assembled to discuss the optimal approach to planned and unplanned delivery. Ideally, this team should include members of the surgical obstetric team (which may include gynecologic oncology), maternal fetal medicine, neonatology, anesthesia, and in-house emergency surgery providers (such as trauma or vascular surgery) as indicated. Working with risk management, social services, and the ethics board may be necessary to

Minimization of intraoperative blood loss and optimization of anemia tolerance improves outcomes. While the surgical team focuses on hemostatic techniques to decrease blood loss,

is 130 times greater than in the normal population [5].

**3.1. Preoperative optimization**

hematologist should be considered.

**3.2. Intraoperative adjuncts**

**3. Traditional hemorrhage mitigation strategies**

discussions must be clearly documented in the medical record.

optimize outcomes in these complex, high-risk situations.

Women with multiple prior cesarean deliveries are at greatest risk for MAP. The risk of MAP in patients after one, two, or three prior cesarean deliveries increases 2.9, 4.6 and 12.6-fold, respectively [4]. Additional risk factors include prior surgical injury to the myometrium, including dilation and curettage, and advanced maternal age.

The potential consequences of obstetric hemorrhage are most dire in women who refuse, or cannot receive, blood products. For example, the maternal mortality ratio (MMR) due to major obstetric hemorrhage in Jehovah's Witnesses was 68 per 100,000 live births in one study; 130 times that of the general population [5]. Furthermore, in low resource settings, where blood products are not readily available, the MMR can be up to 645 per 100,000 live births [6]. Obstetric hemorrhage accounts for up to 42% of maternal deaths in low resource settings [7]. With this in mind, new strategies for obstetric hemorrhage control are essential for improving transfusion-free survival.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging, minimallyinvasive technique to control non-compressible hemorrhage. Although initially developed for the management of traumatic hemorrhage, REBOA has been gaining popularity for the control of non-traumatic hemorrhage. Early reports of REBOA use in obstetric hemorrhage indicate that the approach reduces blood loss, improves maternal outcomes, and decreases rates of hysterectomy compared to traditional techniques, such as uterine balloon tamponade, and hypogastric or uterine artery occlusion [8–10]. This review describes the potential applications of REBOA for control of obstetric hemorrhage in high-risk obstetric surgery for MAP.

High-quality evidence to inform management of obstetric hemorrhage when transfusion is not an option is generally lacking. Small numbers of patients, clinical heterogeneity, and ethical principles preclude against randomized studies, so most data are drawn from case series and case reports, as well as from physiological principles and expert opinions. REBOA is a growing modality with novel applications, as well as technical and technological improvements that are continually evolving. The application of REBOA to obstetric hemorrhage is in its infancy, thus comparative data and long-term follow-up are lacking. While this may limit the strength of any generalizations that can be drawn from the literature, this review aims to provide a framework for use of REBOA in obstetric care in this challenging circumstance.
