From the Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O., R.M-N., P.F., M.P.N.), Clinical Research Center (R.M-N., A.F.G., F.R.), Fundacion Valle del Lili, Cali, Colombia; Department of Trauma Critical Care (M.W.P.), Broward General Level I Trauma Center, Fort Lauderdale, Florida; F. Edward Hebert School of Medicine, "America's Medical School" (T.E.R.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Obstetric Critical Care Unit, Department of Gynecology and Obstetrics (A.J.N., P.F., J.A.C., J.M.B., M.F.E-V.), Fundacion Valle del Lili, Cali, Colombia; and Center for Surgery and Public Health, Department of Surgery (J.P.H-R.), Brigham & Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
J Trauma Acute Care Surg. 2018 May;84(5):809-818. doi: 10.1097/TA.0000000000001821.
We describe intraoperative and postdischarge outcomes of a case series after the prophylactic use of resuscitative endovascular balloon occlusion of the aorta (REBOA) during elective cesarean delivery in pregnant women with morbidly adherent placenta (MAP). We furthermore performed a systematic review and meta-analysis to investigate the safety and effectiveness of the use of REBOA during elective cesarean delivery in pregnant women with MAP.
Descriptive case series of REBOA (December 2015 to June 2017) used during elective cesarean delivery in pregnant women with MAP. The systematic review was conducted following PRISMA guidelines. We included studies involving pregnant women with a diagnosis of MAP who underwent an elective cesarean delivery with prophylactic REBOA placement. A meta-analysis was performed to assess the overall amount of transfusions and intraoperative hemorrhage of REBOA compared to NO-REBOA cases.
A total of 12 patients with MAP underwent elective cesarean delivery with REBOA deployment. The median (interquartile range) of packed red blood cells transfused during the first 24 hours following surgery was two units (0-3.5). The median (interquartile range) of intraoperative blood loss was 1,500 mL (900-2,750). At 28 days, all patients were alive, and no adverse outcomes were observed. Four articles were included in the systematic review and meta-analysis. These articles included a total of 441 patients. Quantitative synthesis (meta-analysis) found that the use of REBOA as prophylaxis for the prevention of major hemorrhage was associated with a lower amount of intraoperative hemorrhage (in milliliters) (weighted mean difference, -1,384.66; 95% confidence interval, -2,141.74 to -627.58) and lower requirements of blood products transfusions (in units) (weighted mean difference, -2.42; 95% confidence interval, -3.90 to -0.94).
We provide clinical data supporting the use of REBOA in the management of pregnant women with MAP undergoing elective cesarean delivery. Our findings demonstrate the feasibility of REBOA as a prophylactic intervention to improve outcomes in women at risk of catastrophic postpartum hemorrhage.
Therapeutic study, level V; Systematic Review, level IV.
我们描述了在患有严重粘连性胎盘（MAP）的孕妇行择期剖宫产时预防性使用主动脉球囊复苏（REBOA）的一系列病例的术中及出院后结果。我们还进行了系统评价和荟萃分析，以研究在患有 MAP 的孕妇行择期剖宫产时使用 REBOA 的安全性和有效性。
在患有 MAP 的孕妇行择期剖宫产时使用 REBOA 的描述性病例系列（2015 年 12 月至 2017 年 6 月）。系统评价遵循 PRISMA 指南进行。我们纳入了诊断为 MAP 的孕妇行择期剖宫产且预防性放置 REBOA 的研究。对 REBOA 与非 REBOA 病例的总体输血量和术中出血量进行荟萃分析。
共有 12 例 MAP 孕妇行择期剖宫产并进行了 REBOA 置管。术后 24 小时内输注的浓缩红细胞中位数（四分位距）为 2 单位（0-3.5）。术中出血量的中位数（四分位距）为 1500 毫升（900-2750）。28 天时，所有患者均存活，未观察到不良结局。系统评价和荟萃分析共纳入 4 篇文章，共 441 例患者。定量合成（荟萃分析）发现，使用 REBOA 作为预防大出血的手段与术中出血量（毫升）减少相关（加权均数差，-1384.66；95%置信区间，-2141.74 至-627.58）和减少血制品输注量（单位）相关（加权均数差，-2.42；95%置信区间，-3.90 至-0.94）。
我们提供了支持在患有 MAP 的孕妇行择期剖宫产时使用 REBOA 的临床数据。我们的发现表明，REBOA 作为一种预防性干预措施，可改善有发生灾难性产后出血风险的女性的结局。
治疗性研究，等级 V；系统评价，等级 IV。
