Location and Codependencies for Delivery of Patients at High Risk of Hemorrhage

In patients identified as at high risk of major peripartum bleeding, including abnormal placentation, deliveries should occur in institutions with experience in managing massive hemorrhage. The availability of the following services is desirable: intensive care, hematology, neonatology, interventional radiology, vascular surgery, and urology, as well as obstetrics and anesthesia. Increasingly, these specialties are colocated in major trauma and specialist centers.

The optimal location within each hospital that performs these complex cases will vary between institutions; with physical location, proximity to other services, space, and operator choice being important factors in the decision-making process. The pros and cons of using the obstetric ORs instead of the main ORs or the radiology suite must be discussed in advance, and rehearsals and drills should be undertaken regularly.

In our institution, patients believed to have abnormal placentation have their deliveries undertaken in one of the four dedicated IR suites. All elective patients have predelivery imaging with ultrasonography and MRI, with a multidisciplinary team meeting (MDT) outlining patient-specific strategies for both the intended elective delivery and any emergency presentation. When these cases are performed electively, the risks and benefits of general anesthesia (GA) can be balanced against those of regional anesthesia (RA) on an individual basis. In discussion with the patient, the mode of anesthesia can be planned, acknowledging the probable need to convert RA to GA in the event of major bleeding and the psychological distress this may cause the patient.

Our policy is to insert two large-bore sheaths, one in the common femoral artery and one in the femoral vein, once anesthesia has been achieved with a lumbar epidural block using a low-dose bupivacaine-fentanyl mixture. The arterial sheath allows rapid balloon occlusion of the aorta if massive hemorrhage occurs, whereas the venous sheath allows resuscitation via a rapid fluid transfuser system such as the Level 1 Fast Flow Fluid Warmer (Smiths Medical, Minneapolis, Minnesota, USA), while the epidural catheter is used to provide postoperative analgesia. In most cases, the patient is then given a general anesthetic according to local obstetric anesthetic practice, ensuring that surgery commences once the airway is secure following endotracheal intubation.

After delivery of the fetus, and in the event of significant bleeding, balloons may be used to occlude either the distal infrarenal aorta or common iliac or internal iliac arteries to achieve hemostasis and increase systemic vascular resistance. This helps to reduce the rate of blood loss, allowing treatment of profound hypovolemic shock, and provides an opportunity to consider the best strategy for further surgical or IR procedures. The more proximal the occlusion, the more likely hemostasis will be effective, because occlusion of the distal aorta will prevent in-line flow through the anterior division of the internal iliac arteries as well as collateral (retrograde) bleeding via the low lumbar and proximal thigh profunda femoris arterial branches. Clearly, this may cause ischemic injury and thrombosis, and one must consider this risk and balance it against the benefits occluding major blood vessels brings. There are multiple ramifications of effective further interventions beyond the scope of this chapter.