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Resuscitative endovascular balloon occlusion of the aorta: the postpartum haemorrhage perspective

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become a recognised intervention in management of non-compressible traumatic haemorrhage [1] and ruptured aortic aneurisms [2] (Fig. 1). Additionally, it is used to limit blood loss in cases of post-partum haemorrhage (PPH) [3,4,5], and is lately considered a possible experimental adjunct in management of non-traumatic cardiac arrest [6] currently investigated in a prehospital randomized controlled trial [7].

Fig. 1
figure 1

Aortic zones and indications for occlusion

Application of REBOA in management of non-compressible traumatic haemorrhage is well-described. However, this aetiology for potential use may be outnumbered. Postpartum haemorrhage (PPH) remain a global health problem, responsible for 8% of maternal deaths. Rates are increasing and in the USA approximately 40/10 000 deliveries suffer from PPH [8, 9].

A recent gap-analysis assessing REBOA eligible patients with major haemorrhage in Norway used blood bank data to identify patients subject to massive transfusions [10]. The aetiology was non-traumatic in 83% of cases, dominated by PPH, followed by ruptured abdominal aortic aneurysm. This carries relevance for REBOA also in regions with low trauma burden.

Main text

Approximately, 70% of PPH is due to uterine atony, and treatment include uterine massage, B-Lynch suture and intrauterine balloon [9]. However, these interventions may be insufficient, making emergency hysterectomy a life-saving procedure. Globally, the incidence of emergency peripartum hysterectomy varies from 0.2 to 5.1 per 1000 deliveries, with increasing rates [11]. An emergent use of REBOA in management of PPH, including prophylactic strategies in placenta accreta, has been described [3,4,5]. However, a Cochrane database review on the use of mechanical interventions for treating PPH [12] and a recent review on management of PPH in the New England Journal of Medicine failed to mention REBOA as possible adjunct [9]. REBOA is a highly invasive intervention carrying a potential for serious complications and should not be applied if measures such as intrauterine balloon or uterine massage is sufficient. Nevertheless, in countries with limited access to blood products, REBOA may save lives in PPH where traditional management fails.

In high-income countries, with easy access to blood products, a difference in survival may be difficult to demonstrate. However, we suggest that survival may not represent the only relevant endpoint. REBOA in PPH may reduce hysterectomy rates, a surgical procedure considered catastrophic for any young female and potentially reduce transfusion requirements. A randomised controlled trial on REBOA in PPH with additional endpoints than survival, where hysterectomy rates, transfusion requirements and serious adverse events are investigated, is called for.

Not only in trauma centres, but also in hospitals with obstetric departments, REBOA should be considered an emergency procedure to be immediately available 24/7 by physicians trained in ultrasound-guided and fluoroscopy-free Seldinger technique. Local considerations will decide whether the REBOA is placed by an emergency physician, anaesthesiologist, obstetricians, interventional radiologist or the general surgeon.

Conclusions

REBOA carries more indications than trauma and should be increasingly considered and evaluated in management of PPH. REBOA may not only save a life, it might also save a uterus.

Availability of data and materials

Not applicable.

Abbreviations

REBOA:

Resuscitative endovascular balloon occlusion of the aorta

PPH:

Postpartum haemorrhage

References

  1. Brenner M, Bulger EM, Perina DG, Henry S, Kang CS, Rotondo MF, et al. Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Trauma Surg Acute Care Open. 2018;3(1):e000154.

    Article  Google Scholar 

  2. Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, Hedeman Joosten PPA, DuBose JJ, Hörer TM, et al. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg. 2018;44(4):535–50.

  3. Stensaeth KH, Sovik E, Haig INY, Skomedal E, Jorgensen A. Fluoroscopy-free Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for controlling life threatening postpartum hemorrhage. PLloS ONE. 2017;12(3):e0174520.

    Article  Google Scholar 

  4. Feng S, Liao Z, Huang H. Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study. Anaesthesia. 2017;72(7):853–8.

    CAS  Article  Google Scholar 

  5. Peng W, Shen L, Wang S, Wang H. Retrospective analysis of 586 cases of placenta previa and accreta. J Obstet Gynaecol J Inst Obstet Gynaecol. 2020;40(5):609–13.

    Article  Google Scholar 

  6. Daley J, Morrison JJ, Sather J, Hile L. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest. Am J Emerg Med. 2017;35(5):731–6.

    Article  Google Scholar 

  7. Brede JR, Skulberg AK, Rehn M, Thorsen K, Klepstad P, Tylleskär I, et al. REBOARREST, resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest: a study protocol for a randomised, parallel group, clinical multicentre trial. Trials. 2021;22(1):511.

    Article  Google Scholar 

  8. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–33.

    Article  Google Scholar 

  9. Bienstock JL, Eke AC, Hueppchen NA. Postpartum Hemorrhage. Longo DL, editor. N Engl J Med. 2021;384(17):1635–45.

  10. Godø BN, Brede JR, Krüger AJ. Needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major haemorrhage: a cross-sectional study. Emerg Med J. 2021 May 25 [cited 2021 Dec 8]; Available from: https://emj.bmj.com/content/early/2021/08/08/emermed-2020-210808

  11. de la Cruz CZ, Thompson EL, O’Rourke K, Nembhard WN. Cesarean section and the risk of emergency peripartum hysterectomy in high-income countries: a systematic review. Arch Gynecol Obstet. 2015;292(6):1201–15.

    Article  Google Scholar 

  12. Kellie FJ, Wandabwa JN, Mousa HA, Weeks AD. Mechanical and surgical interventions for treating primary postpartum haemorrhage. Cochrane Database Syst Rev. 2020;7:CD013663.

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JRB drafted the manuscript. ES and MR reviewed the manuscript, and all authors read and approved the final manuscript.

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Correspondence to Jostein Rødseth Brede.

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ES has stock ownership and a board position in Reboa Medical AS. The other authors declare that they have no financial disclosures.

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Brede, J.R., Søvik, E. & Rehn, M. Resuscitative endovascular balloon occlusion of the aorta: the postpartum haemorrhage perspective. Crit Care 26, 57 (2022). https://doi.org/10.1186/s13054-022-03942-0

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Keywords

  • REBOA
  • Postpartum haemorrhage
  • PPH
  • Aortic occlusion