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OBSTETRIC ANESTHESIA

Cesarean Delivery in the Interventional Radiology Suite: A Novel Approach to Obstetric Hemostasis

From the Departments of *Anesthesia, Perioperative and Pain Medicine, Obstetrics and Gynecology, and Interventional Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Address correspondence and reprint requests to Dr. Nollag O'Rourke, Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115. Address e-mail to nmorourke{at}partners.org.

	Abstract

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BACKGROUND: The adjunctive use of interventional radiology procedures to minimize and control bleeding at the time of cesarean delivery has become increasingly common. These procedures require modern imaging equipment and supplies not available in traditional operating rooms.

METHODS: We describe three women who strongly desired continued reproductive function in clinical circumstances where postpartum hemorrhage and hysterectomy were likely.

RESULTS: Cesarean delivery was performed in the interventional radiology suite after selective uterine artery balloon placement and/or embolotherapy, which successfully minimized blood loss during delivery.

CONCLUSION: We propose that this novel surgical location is feasible, and may offer advantages in select patients.

	Introduction

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Because of the increasing cesarean delivery rate, women with placental implantation abnormalities will be encountered more frequently. An increasing need for novel interventional radiology (IR) techniques in the multidisciplinary care of these patients will become an important aspect of care.

	CASE REPORTS

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Case 1
A 36-yr-old G3P2 presented at term for her third cesarean delivery. Doppler ultrasound examination raised the suspicion of a placenta accreta. The patient desired uterine preservation. A multidisciplinary team was convened to consider the feasibility of initial placement of uterine artery (UA) balloons, followed by cesarean delivery in the IR suite. This strategy would allow the evaluation and immediate management of intraoperative hemorrhage while maintaining the possibility of uterine preservation. The team included personnel from infection control, neonatology, hospital engineering, anesthesiology, IR, nursing, and obstetrical departments.

After IV and arterial line placement, lumbar epidural anesthesia to a T10 sensory level was established with 2% lidocaine to facilitate placement of bilateral ureteral stents, owing to a concern for possible bladder involvement.

Bilateral internal UA balloons were inserted via femoral sheaths and were left deflated. Epidural anesthesia was then increased to T4 level. After delivery of the fetus, and manual extraction of the placenta, a focal area of vigorous bleeding was noted in the anterior lower uterine segment. UA balloons were inflated and the bleeding ceased. The IR team performed embolization of both UAs using a Gelfoam preparation. The uterus and abdomen were then closed in the standard fashion. The approximate blood loss was 1200 mL. The patient received one unit of packed red blood cells and 500 mL of IV hetastarch in addition to 4 L IV crystalloids. The balloons and arterial catheters were removed 6 h after delivery. The patient made an uneventful recovery.

Case 2
A 30-yr-old G3P0 was admitted to the hospital at 36 4/7 wk gestation with severe preeclampsia, non-reassuring fetal heart tracing, and extensive uterine myomas. Clinical examination revealed an obstructed vaginal outlet with numerous palpable fibroids. The patient strongly desired uterine preservation.

Consultation with the interventional radiologist was sought to place bilateral balloon catheters before cesarean delivery. The patient was brought to the IR suite where lumbar epidural anesthesia was established with 2% lidocaine to facilitate placement of the bilateral UA balloons. Shortly after commencing the balloon placement, the patient's arterial blood pressure began to increase from 160/90 to 170/110 with minimal response to increments of IV labetalol. Lidocaine 2% was administered through the epidural catheter to achieve a T4 sensory level for cesarean delivery. The UA balloons were not inflated, as achieving hemostasis was not problematic. The balloons were removed 6 h after delivery, and recovery was uneventful.

Case 3
A 36-yr-old G2P1 was admitted at 38 wk gestation for an elective repeat cesarean delivery. Ultrasound imaging revealed a low-lying placenta, and suspected placenta accreta, as indicated by a blurring of the placental-myometrial interface. This patient expressed a strong desire for uterine preservation. Thus, she was brought to the IR suite, where lumbar epidural anesthesia was established to a T10 sensory level to provide analgesia for insertion of bilateral UA balloons. Epidural analgesia was then raised to a T4 sensory level. After uneventful delivery of the infant and manual extraction of the placenta, an area of brisk bleeding was noted in the lower uterine segment. The UA balloons were inflated and bleeding ceased immediately. Gelfoam packing was applied to the area of bleeding. The UA balloons were then deflated, and adequate hemostasis was confirmed. Surgical repair of the uterus was achieved with satisfactory hemostatic control, and the abdomen was closed. Estimated blood loss was 600 mL. The UA balloons were removed 6 h later, and the patient made an uneventful recovery.

	DISCUSSION

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UA balloon placement is being used with increasing frequency in patients at risk for obstetric hemorrhage (1,2). Postdelivery UA embolization is used to control hemorrhage after perineal injury, uterine atony, or uterine bleeding secondary to fibroids or placenta accreta/percreta, and to avoid hysterectomy and preserve future fertility (2–5). The usual approach to this therapeutic intervention is placement of the UA balloon catheters in the IR suite, and then transfer of the patient to the obstetric operating room. Imaging equipment in a standard operating room is not adequate to perform UA selective catheterization and embolotherapy. We describe a novel approach wherein the entire procedure is performed in the IR suite.

The IR room at our hospital has been designed to meet the size, infection control, and air circulation standards found in a standard operating room. Full anesthesiology and neonatology teams with all appropriate equipment are present in this IR suite. The perioperative management of the first case described in this report is unique, in that elective cesarean delivery was performed in the IR suite, rather than a standard operating room. Unlike the operating room with portable radiology equipment, the state-of-the-art imaging and positioning equipment in the IR suite provides ideal conditions for the interventional radiologist. The success of this case was because that the obstetricians were able to judge the efficacy of embolization before the closure of the uterus. If balloon displacement should occur, then repositioning would be a feasible option, not readily achievable in a traditional operating room.

The second and third cases indicate a growing level of comfort with this procedure. Intraoperative balloon inflation under direct radiologic visualization, and subsequent surgical repair, allowed for assurance of hemostasis before abdominal closure. Our report describes the IR suite as a feasible location to fulfill future obstetric needs. Our modern IR suite is designed to meet all the infection control and air circulation guidelines for a standard operating room. Creation of a single surgical-IR suite would produce more opportunities for new treatments and offer a superior solution for interdisciplinary work among surgeons, anesthesiologists, and radiologists. This may become a necessity in the future with the increasing need for IR techniques in the care of obstetric patients (6).

	Footnotes

 
Accepted for publication January 17, 2007.

	REFERENCES

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1. 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]
2. 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]
3. Wang H, Garmel S. Successful term pregnancy after bilateral uterine artery embolization for postpartum hemorrhage. Obstet Gynecol 2003;102:603–4.[Web of Science][Medline]
4. Carpenter TT, Walker WJ. Pregnancy following uterine artery embolisation for symptomatic fibroids: a series of 26 completed pregnancies. BJOG 2005;112:321–5.[Web of Science][Medline]
5. 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]
6. Centers for Disease Control, National Center for Health Statistics, Preliminary Births for 2004. Accessed on January 5, 2006. Available at http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths04/prelimbirths04health.htm

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