Prophylactic balloon occlusion for placental abnormalities

Prophylactic balloon occlusion of the internal iliac arteries is a preventive measure used during childbirth to manage or prevent severe postpartum hemorrhage (PPH). This procedure involves temporarily blocking the blood flow to the pelvic area by inflating balloons in the internal iliac arteries, reducing the risk of massive bleeding and its associated complications.

Indications

Prophylactic balloon occlusion of internal iliac arteries is indicated for:

1. High-Risk Pregnancies: Women with known risk factors for severe PPH, such as placenta accreta, placenta previa, or uterine atony.
2. History of PPH: Women who have previously experienced severe postpartum hemorrhage (Click here to read more on Postpartum Hemorrhage)
3. Anticipated Difficult Deliveries: Cases where the delivery is expected to be complex or involve significant bleeding risk.

Procedure

1. Pre-procedure Evaluation:
   • Antenatal Assessment: Identification of high-risk pregnancies through prenatal care and imaging studies.
   • Risk Assessment: Evaluation of maternal health, obstetric history, and potential complications.
2. Preparation:
   • Informed Consent: Explanation of the procedure, its risks, benefits, and alternatives, followed by obtaining informed consent from the patient.
   • Anaesthesia: General anaesthesia or regional anaesthesia (epidural or spinal) is typically used.
3. Catheterization:
   • A catheter is inserted through a femoral artery access site and navigated to the internal iliac artery under fluoroscopic guidance.
   • One or more balloons are advanced through the catheter and positioned in the internal iliac arteries bilaterally.
4. Balloon Inflation:
   • The balloons are inflated to temporarily occlude the blood flow to the pelvic area, including the uterus and surrounding tissues.
   • Balloon inflation pressure is carefully monitored to ensure adequate occlusion without causing damage to the arterial walls.
5. Monitoring:
   • Continuous monitoring of maternal vital signs, blood pressure, and foetal well-being during the procedure.
   • Regular assessment of balloon position and inflation status to maintain effective occlusion.
6. Delivery:
   • The obstetric team proceeds with vaginal or caesarean delivery as planned, with the balloons remaining inflated.
   • Balloon inflation is usually maintained until after delivery of the placenta and confirmation of stable maternal hemodynamics.
7. Balloon Deflation:
   • Once the risk of postpartum haemorrhage has decreased, the balloons are deflated, and blood flow to the pelvic area is restored.
   • Any potential complications related to balloon occlusion are addressed promptly.

Benefits

• Reduced Bleeding: Prevents or minimises blood loss during and after delivery, reducing the risk of severe postpartum haemorrhage.
• Improved Surgical Field: Provides a clearer surgical field during caesarean deliveries, facilitating safer and more efficient procedures.
• Preventive Measure: Prophylactic approach to manage anticipated bleeding risks in high-risk pregnancies.
• Maternal Safety: Helps prevent complications associated with massive haemorrhage, such as hypovolemic shock and organ dysfunction.

Risks and Considerations

• Arterial Injury: Risk of arterial injury during catheterization or balloon inflation.
• Ischemia: Prolonged balloon occlusion can lead to ischemia in the pelvic organs, requiring careful monitoring and timely balloon deflation.
• Displacement or Rupture: Balloon displacement or rupture may occur, necessitating immediate intervention.
• Complications of Anesthesia: Risks associated with anesthesia administration, such as respiratory depression or allergic reactions.
• Post-procedure Monitoring: Close monitoring of maternal status post-delivery to detect and manage any potential complications.

Conclusion

Prophylactic balloon occlusion of internal iliac arteries is an effective strategy to prevent severe postpartum hemorrhage in high-risk pregnancies. By temporarily blocking blood flow to the pelvic area, this procedure reduces the risk of massive bleeding and its associated complications, ensuring maternal safety during childbirth. Close collaboration between obstetricians, interventional radiologists, and anesthesiologists is essential to optimize outcomes and manage potential risks effectively.