Multiple complications following the use of prophylactic internal iliac artery balloon catheterisation in a patient with placenta percreta

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Complications of internal iliac balloon catheters

30. Sewell MF, Rosenblum D, Ehrenberg H. Arterial embolus during common iliac balloon catheterization at cesarean hysterectomy. Obstet Gynecol 2006;108:746–8. 31. Greenberg J, Suliman A, Iranpour P, Angle N. Prophylactic balloon occlusion of the internal iliac arteries to treat abnormal

placentation: a cautionary case. Am J Obstet Gynecol 2007;470:e1–4. 32. ACOG Committee Opinion. Placenta accreta no.266, Jan 2002. American College of Obstetricians and Gynecologists. Int J Gynecol Obstet 2002;77:77–8.



0959-289X/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2010.07.007

Multiple complications following the use of prophylactic internal iliac artery balloon catheterisation in a patient with placenta percreta S. Bishop,a K. Butler,a S. Monaghan,a* K. Chan,b G. Murphy,c L. Edoziend a

Department of Anaesthesia, St. Mary’s Hospital, Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK b Department of Fetal and Maternal Medicine, St. Mary’s Hospital, Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK c Department of Interventional Radiology, St. Mary’s Hospital, Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK d Department of Obstetrics and Gynaecology, St. Mary’s Hospital, Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK ABSTRACT The incidence of placenta praevia/accreta is increasing, placing women at significant risk of postpartum haemorrhage with associated morbidity and mortality. National guidelines recommend prophylactic placement of internal iliac artery balloon occlusion catheters for women with abnormal placentation. We describe an elective caesarean delivery in a patient with placenta percreta who underwent this technique. She developed bilateral pseudoaneurysms, unilateral arterial rupture and compromised vascular supply to her right leg secondary to thrombus formation, and suffered massive haemorrhage, both despite and as a result of intervention. This is the first case report of multiple complications in an obstetric patient after temporary internal iliac balloon occlusion in an elective setting. c 2010 Elsevier Ltd. All rights reserved.



Keywords: Placenta accreta, percreta; Interventional radiology; Balloon catheters; Internal iliac artery; Complications

Introduction Placenta percreta is characterised by placental villous invasion of the myometrium and attachment to adjacent organs.1 If bladder invasion is present, maternal mortality is reported to be as high as 20% with a perinatal mortality of 30%.2 National guidelines recommend the use of interventional radiology (IR) with prophylactic placement of internal iliac artery balloon occlusion catheters Accepted September 2010 *Correspondence to: Suna Monaghan, Department of Anaesthesia, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK. E-mail address: [email protected]

(IIABOCs) to reduce intraoperative bleeding during caesarean section for women with abnormal placentation.3 We describe a case of a patient with placenta percreta who underwent an elective caesarean section and in whom this technique was used.

Case report A 36-year-old parturient (G2P1) with a body mass index 21 kg/m2 and a past history of emergency caesarean section (CS) under spinal anaesthesia for failed induction of labour, was scheduled for an elective CS at 37 weeks of gestation. The indication was placenta percreta with bladder invasion diagnosed on ultrasound scan at 35

S. Bishop et al. weeks. She was otherwise fit and well. Massive haemorrhage was anticipated, so a multidisciplinary team of obstetricians, anaesthetists, radiologists, haematologists and cell salvage technicians planned her care. The patient wanted to be awake for delivery but was aware that the risk of conversion to general anaesthesia was high. After neuraxial anaesthesia had been established, internal iliac catheters were inserted via the femoral arteries (7 F sheath, 8 mm diameter), the balloons were inflated to confirm placement, then deflated and left in situ. Invasive blood pressure monitoring was via the right femoral sheath because cannulation of both radial and brachial arteries had been unsuccessful. Placenta percreta was found to extend to the bladder base and the uterine lower segment could not be distinguished from the bladder. The baby was delivered through the placenta in good condition, following which there was massive haemorrhage. The internal iliac balloons were immediately inflated and general anaesthesia was induced. The placenta was adherent to the bladder base and was removed in pieces. The patient was haemodynamically unstable requiring rapid transfusion of blood, blood products, and a noradrenaline infusion given via a central venous catheter. The uterine body was atonic but not bleeding and oxytocin was given (5 IU bolus followed by an infusion of 10 IU/h), together with two 250-lg doses of carboprost. The lower uterine segment was then located, clamped and repaired. The uterine arteries were ligated, a B-Lynch compression suture applied and defects in the bladder wall repaired. An angiogram performed due to ongoing bleeding from the bladder and deep pelvic structures showed that the left internal iliac balloon had deflated. After its replacement, a small hole was found in the original balloon. Shortly after surgical haemostasis and abdominal closure, the patient again became haemodynamically unstable. A further angiogram showed a leaking pseudoaneurysm at the origin of the right internal iliac artery (Fig. 1). An endovascular repair was attempted using embolisation with gel foam and insertion of a Gortex covered metal stent into the common iliac artery (Fig. 2). Haemodynamic control was achieved, acidosis and coagulopathy improved and inotrope requirements diminished. The total estimated blood loss was in excess of 15 L. Before transfer to the critical care unit, a sudden loss of the arterial trace from the right femoral arterial sheath in conjunction with a pale pulseless leg prompted removal of the right femoral sheath, which was found to have a blood clot on the proximal end. Postoperative Duplex and Doppler studies of the right lower limb suggested proximal iliac occlusion. The patient was managed conservatively with dual anti-platelet therapy and discharged on day 12. Two days later she returned to the hospital with a painful left groin swelling, and was found to have a left femoral

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Fig. 1 Angiogram showing aneurysm at origin of right internal iliac artery and extravasation of contrast.

Fig. 2

Angiogram showing stent in common iliac artery.

pseudoaneurysm. Endovascular obliteration of the pseudoaneurysm with thrombin injection was attempted, but was unsuccessful. Surgical repair was performed. There was no evidence of vasculitis or connective tissue disease. Currently the patient remains symptomatic with intermittent claudication of the right leg. Computed tomography imaging confirmed right common iliac artery occlusion with a non-patent stent, right common femoral artery occlusion and filling of the internal iliac branches via collaterals.

Discussion The incidence of abnormal placentation is increasing, in line with the increasing number of caesarean sections.4,5

72 It has been recommended that all women who have had a previous caesarean delivery have their placental site documented.6 Currently management options for abnormal placentation include caesarean hysterectomy or conservative techniques in which the placenta is left in situ. Despite successful outcomes using these latter techniques, there is an associated risk of sepsis and delayed haemorrhage.7 Bilateral ligation of the internal iliac arteries (IIAs) or placement of IIABOCs under fluoroscopic guidance have been used to reduce intraoperative blood loss. Balloon inflation may reduce bleeding, while either prophylactic or therapeutic embolisation are performed if bleeding persists. Neither IIA ligation or balloon occlusion arrest blood flow to the uterus but decrease pulse pressure distal to the occlusion site. Failure of IIA ligation or balloon occlusion is often due to extensive anastomoses in the pelvic vasculature.8 National guidelines urge consideration of prophylactic placement of IIABOCs to reduce intraoperative bleeding during CS in cases of morbidly adherent placentas.3 Published results on the value of IR reflect low level evidence from individual case reports and case series. Some have noted significant reductions in intraoperative blood loss and an improved operating field following balloon inflation,9–11 while other authors have disputed its effectiveness.12,13 Randomised controlled trials are lacking and would be difficult to achieve due to the variability of abnormal placentation and its presentation. National surveillance registries of elective and emergency obstetric IR cases could provide valuable information. Complications following IR include artery perforation, popliteal artery thrombosis, vaginal necrosis, local haematoma, pelvic pain, fever and abdominal pain.10,14–17 The authors are aware of two case reports of thrombosis formation secondary to pre-emptive iliac balloon catheterisation at caesarean section.18,19 Thrombus formation in our case occurred early, within a Gortex covered stent and in the presence of coagulopathy. Loss of the arterial trace was the first sign of the developing thrombus and this emphasises the importance of vascular surveillance postoperatively. Early device removal may reduce the risk of thrombus formation. Systemic heparinisation is unnecessary for balloon placement and may exacerbate any ongoing bleeding.20 In our case, the deflated left internal iliac balloon was an equipment failure but the injury caused by the right balloon was iatrogenic. Although no arterial abnormality had been noted during initial insertion it is possible that uterine handling at delivery dragged the balloon against the end of the vascular sheath and caused a small puncture. The right iliac artery pseudoaneurysm resulted from vessel trauma caused by the occlusion balloon. It is possible that uterine handling or hip flexion to allow vaginal examination during surgery caused movement of the IIABOCs against the vessel wall. Although this may

Complications of internal iliac balloon catheters be unavoidable during surgery, to reduce the risk at other times we would recommend performing neuraxial anaesthesia and urinary catheter insertion before IIABOC placement. In the non-pregnant population the risk of occlusion from iliac artery intervention is 0.5%, pseudoaneurysm 0.3%, and vessel rupture requiring intervention 0.6%.20 Arteries in pregnant women undergo vascular wall remodelling which increases compliance and may also increase susceptibility to dissection.21,22 Pregnancy is also a hypercoagulable state and the risk of thromboembolic events is increased. The complication rate may therefore be different in obstetric patients and this should be considered when consent is sought by the interventional radiologist and obstetrician. Our IR suite is an unsuitable environment for dealing with a major obstetric haemorrhage and does not currently meet the criteria suggested by Kodali.23 It is routine practice in our unit for planned IR cases to be performed in the delivery suite operating theatre with balloon placement under image intensification using a portable C arm intensifier. Endovascular repair therefore had to be performed using limited mobile imaging equipment because the patient’s condition was too unstable for transfer to the IR suite. In our case, the use of the IIABOCs resulted in significant morbidity with vessel rupture that contributed to haemodynamic instability and the formation of pseudoaneurysms. Subsequent thrombus formation compromised the vascular supply to the leg. The complications associated with the use of IIABOCs in obstetrics may not be as infrequent as previously thought and may be greater than in the general population. Patients should be selected with care after consideration of risks and benefits, and should be informed of those risks when obtaining consent. The creation of a UK surveillance programme of IR procedures in the obstetric population would be valuable in assessing the incidence and range of complications. We also strongly recommend that vascular surveillance is carried out in the perioperative period.

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14. Greenwood LH, Glickman MG, Schwartz PE, Morse SS, Denny DF. Obstetric and non-malignant gynecologic bleeding: treatment with angiographic embolization. Radiology 1987;164:155–9. 15. Gilbert WM, Moore TR, Resnik R, Doemeny J, Chin H, Bookstein JJ. Angiographic embolization in the management of hemorrhagic complications of pregnancy. Am J Obstet Gynecol 1992;166:493–7. 16. Deux J-F, Bazot M, Le Blanche AF et al. Is selective embolisation of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage? Am J Roentgenol 2001;177:145–9. 17. Yamashita Y, Harada M, Yamamoto H et al. Transcatheter arterial embolization of obstetric and gynaecological bleeding: efficacy and clinical outcome. Br J Radiol 1994;67:530–4. 18. Sewell MF, Rosenblum D, Ehrengerg H. Arterial embolus during common iliac balloon catheterisation at cesarean hysterectomy. Obstet Gynecol 2006;108:746–8. 19. Greenberg JI, Suliman A, Iranpour P, Angle N. Prophylactic balloon occlusion of the internal iliac arteries to treat abnormal placentation: a cautionary case. Am J Obstet Gynecol 2007;197:470.e1–4. 20. The Royal College of Radiologists, The British Society of Interventional Radiology Achieving standards in vascular radiology. The Royal College of Radiologists, London October 2007. ; 2010 accessed 16.06.2010. 21. Manalo-Estrella P, Barker AE. Histopathologic findings in human aortic media associated with pregnancy. Arch Pathol 1967;83:336–41. 22. Kelly BA, Bond BC, Poston L. Aortic adaptation to pregnancy: elevated expression of matrix metalloproteinases-2 and -3 in rat gestation. Mol Hum Reprod 2004;10:331–7. 23. Kodali BS. Bloodless trilogy? Anesthesia, obstetrics and interventional radiology for caesarean delivery. Int J Obstet Anesth 2010;19:131–2.



0959-289X/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2010.09.012

Sequential drug verification errors resulting in wrong drug administration during caesarean section S. Calderbank,a D.R. Uncles,a N. Burns,b H.K.C.D. Kariyawasam,a G.D.L. Allana a b

Department of Anaesthesia, Worthing Hospital, Worthing, UK Pharmacy Department, Worthing Hospital, Worthing, UK

ABSTRACT An intravenous bolus of phentolamine was inadvertently given to a parturient during an emergency caesarean section following delivery of her infant when the intention had been to give an intravenous bolus of 5 IU Syntocinon. Root cause analysis identified a series of errors originating in the hospital pharmacy when one drug package was mistakenly issued in place of another. Subsequent checks failed to detect the original mistake. The final and most important check immediately before intravenous adminis-

Accepted July 2010 Correspondence to: Dr. David R. Uncles, Department of Anaesthesia, Western Sussex Hospitals NHS Trust, Worthing Hospital, Lyndhurst Road, Worthing West Sussex, BN11 2DH, UK. E-mail addresses: [email protected] Uncles.dr@doctors. org.uk