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Prophylactic use of resuscitative endovascular balloon occlusion of the aorta in women with abnormal placentation

A systematic review, meta-analysis, and case series

Ordoñez, Carlos A., MD; Manzano-Nunez, Ramiro, MD; Parra, Michael W., MD; Rasmussen, Todd E., MD; Nieto, Albaro J., MD; Herrera-Escobar, Juan P., MD; Fernandez, Paula, MD; Naranjo, Maria P., MD; García, Alberto F., MD; Carvajal, Javier A., MD; Burgos, Juan M., MD; Rodriguez, Fernando, MD; Escobar-Vidarte, Maria F., MD

Journal of Trauma and Acute Care Surgery: May 2018 - Volume 84 - Issue 5 - p 809–818
doi: 10.1097/TA.0000000000001821
Systematic Reviews
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BACKGROUND We describe intraoperative and postdischarge outcomes of a case series after the prophylactic use of resuscitative endovascular balloon occlusion of the aorta (REBOA) during elective cesarean delivery in pregnant women with morbidly adherent placenta (MAP). We furthermore performed a systematic review and meta-analysis to investigate the safety and effectiveness of the use of REBOA during elective cesarean delivery in pregnant women with MAP.

METHODS Descriptive case series of REBOA (December 2015 to June 2017) used during elective cesarean delivery in pregnant women with MAP. The systematic review was conducted following PRISMA guidelines. We included studies involving pregnant women with a diagnosis of MAP who underwent an elective cesarean delivery with prophylactic REBOA placement. A meta-analysis was performed to assess the overall amount of transfusions and intraoperative hemorrhage of REBOA compared to NO-REBOA cases.

RESULTS A total of 12 patients with MAP underwent elective cesarean delivery with REBOA deployment. The median (interquartile range) of packed red blood cells transfused during the first 24 hours following surgery was two units (0–3.5). The median (interquartile range) of intraoperative blood loss was 1,500 mL (900–2,750). At 28 days, all patients were alive, and no adverse outcomes were observed. Four articles were included in the systematic review and meta-analysis. These articles included a total of 441 patients. Quantitative synthesis (meta-analysis) found that the use of REBOA as prophylaxis for the prevention of major hemorrhage was associated with a lower amount of intraoperative hemorrhage (in milliliters) (weighted mean difference, −1,384.66; 95% confidence interval, −2,141.74 to −627.58) and lower requirements of blood products transfusions (in units) (weighted mean difference, −2.42; 95% confidence interval, −3.90 to −0.94).

CONCLUSION We provide clinical data supporting the use of REBOA in the management of pregnant women with MAP undergoing elective cesarean delivery. Our findings demonstrate the feasibility of REBOA as a prophylactic intervention to improve outcomes in women at risk of catastrophic postpartum hemorrhage.

LEVEL OF EVIDENCE Therapeutic study, level V; Systematic Review, level IV.

From the Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O., R.M-N., P.F., M.P.N.), Clinical Research Center (R.M-N., A.F.G., F.R.), Fundacion Valle del Lili, Cali, Colombia; Department of Trauma Critical Care (M.W.P.), Broward General Level I Trauma Center, Fort Lauderdale, Florida; F. Edward Hebert School of Medicine, “America’s Medical School” (T.E.R.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Obstetric Critical Care Unit, Department of Gynecology and Obstetrics (A.J.N., P.F., J.A.C., J.M.B., M.F.E-V.), Fundacion Valle del Lili, Cali, Colombia; and Center for Surgery and Public Health, Department of Surgery (J.P.H-R.), Brigham & Women’s Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Submitted: November 15, 2017, Revised: December 26, 2017, Accepted: January 12, 2018, Published online: February 3, 2018.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Address for reprints: Carlos A. Ordoñez, MD, Carrera 98 18-49, Cali, Colombia; email: ordonezcarlosa@gmail.com.

© 2018 Lippincott Williams & Wilkins, Inc.