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LETTER TO THE EDITOR

Anesthesia for Interventional Radiology in Parturients at Risk of Major Hemorrhage at Cesarean Section Delivery

Department of Anesthesia; Brigham and Women’s Hospital; Boston, MA; mharnett{at}partners.org

To the Editor:

Fuller et al. (1) described the anesthetic management of parturients at risk of major hemorrhage by placing a balloon occlusion catheter in anticipation before cesarean delivery. Intraarterial balloon occlusion catheters are used with increasing frequency for prophylaxis against, and treatment of, obstetric hemorrhage (2). In the past 2 yr, we have performed 19 of these procedures, all under regional anesthesia.

On the basis of this experience we strongly recommend placing the epidural catheter before placing the balloon catheter for several reasons:

1. If the balloon catheter is placed before the epidural catheter, then hip flexion while positioning the patient for epidural placement may dislodge the balloon, occluding the artery and possibly leading to thrombosis.
   
2. Epidural anesthesia can provide patient comfort during placement of the balloon catheter.
   
3. Because small amounts of heparin are sometimes used during balloon catheter placement it is preferable to have the epidural catheter in place before heparin use (3).
   
4. In the event of fetal distress, vessel rupture, or other obstetric emergency, the previously placed epidural catheter allows rapid augmentation of the anesthesia for emergency surgery.
   

At our institution we occasionally perform cesarean delivery in the interventional radiology suite for parturients who desire preservation of fertility, but are at risk of major hemorrhage. To date, we have performed three such cases. Interventional radiology allows us to visualize and embolize major contributing and collateral vessels involved in the hemorrhage, while avoiding vessels not involved in the hemorrhage. In two of the cases, we determined that embolization of certain target vessels would likely result in lower extremity ischemia. Such unfortunate outcomes in obstetric patients have been previously reported (4).

We support using balloon occlusion catheters in obstetric patients at risk for major hemorrhage, but only after an appropriate anesthetic evaluation and consideration of preprocedure epidural catheter placement. We anticipate that collaboration between obstetricians, interventional radiologists, and anesthesiologists will reduce the risk of hemorrhage while preserving fertility for those patients desiring a future pregnancy (5–7).

REFERENCES

1. Fuller AJ, Carvalho B, Brummel C, Riley ET. Epidural anesthesia for elective cesarean delivery with intraoperative arterial occlusion balloon catheter placement. Anesth Analg 2006;102:585–7.[Abstract/Free Full Text]
2. Mayer DC, Spielman FJ, Bell EA. Antepartum and postpartum hemorrhage. In: Chestnut DH, ed. Obstetric anesthesia: principles and practice. Philadelphia, PA: Elsevier Mosby, 2004:662–82.
3. Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (2nd ASRA consensus conference on neuraxial anesthesia and anticoagulation). Reg Anesth Pain Med 2003;28:172–97.[Web of Science][Medline]
4. Ojala K, Perala J, Kariniemi J, et al. Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage. Acta Obstet Gynecol Scand 2005;84:1075–80.[Web of Science][Medline]
5. O’Rourke N, McElrath TF, Baum RA, et al. Planned cesarean delivery in a patient with placenta accreta in the interventional radiology suite. Anesthesiology 2004;100(Supp 1):A137.
6. Carpenter TT, Walker WJ. Pregnancy following uterine artery embolization for symptomatic fibroids: a series of 26 completed pregnancies. Br J Obstet Gynecol 2005;112:321–5.
7. Ornan D, White R, Polak J, Tal M. Pelvic embolization for intractable postpartum hemorrhage: long-term follow-up and implications for fertility. Obstet Gynecol 2003;102:904–10.[Web of Science][Medline]

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