First successful emergency room application of resuscitative endovascular balloon occlusion of the aorta (REBOA) in severe postpartum hemorrhage in South Korea: a case report

Background: Postpartum hemorrhage (PPH) is a critical obstetric emergency that may lead to significant maternal morbidity and mortality. Severe PPH, defined as substantial blood loss and the need for multiple blood transfusions, requires immediate and effective intervention to prevent rapid deterioration and death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a novel technique for the control of severe hemorrhage and stabilization of patients in critical conditions, including those with severe PPH. Case: We report the case of a 40-year-old primigravid patient at 40 weeks gestation who presented with uncontrollable vaginal hemorrhage following normal delivery at a rural hospital. Initial attempts at hemostasis failed, and the patient was transferred to our hospital with hemorrhagic shock. Upon arrival, her vital signs indicated severe hemodynamic instability, and arterial blood gas analysis confirmed critical acidosis and shock. An emergency medicine physician requested that the trauma team initiate REBOA. A trauma surgeon inserted a balloon catheter into the right femoral artery and positioned the balloon in zone 1, achieving immediate hemodynamic stabilization. The balloon was later repositioned to zone 3 to balance perfusion and hemorrhage control. This intervention allowed for successful surgical management, including bilateral internal iliac artery ligation and hysterectomy. Despite the postoperative development of abdominal compartment syndrome and acute kidney injury, the patient recovered under intensive care, continuous renal replacement therapy, and subsequent hemodialysis. Conclusions: REBOA is a valuable adjunct to the management of severe PPH, offering rapid hemodynamic stabilization and a critical window for surgical repair. The successful outcome in this patient demonstrates its potential as an effective emergency intervention, emphasizing the importance of rapid deployment of trained personnel to improve maternal outcomes in patients with severe obstetric hemorrhage.

Postpartum hemorrhage; Resuscitative endovascular balloon occlusion of the aorta (REBOA); Hemorrhagic shock; Emergency medical services; Surgical procedures; Operative

[1] Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health. 2014; 2: e323–e333.

[2] Ahmadzia HK, Grotegut CA, James AH. A national update on rates of postpartum haemorrhage and related interventions. Blood Transfusion. 2020; 18: 247–253.

[3] Pettersen S, Falk RS, Vangen S, Nyflot LT. Exploring trends of severe postpartum haemorrhage: a hospital-based study. BMC Pregnancy and Childbirth. 2023; 23: 363.

[4] Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. The BMJ. 2001; 322: 1089–1093.

[5] Ruppel H, Liu VX, Gupta NR, Soltesz L, Escobar GJ. Validation of postpartum hemorrhage admission risk factor stratification in a large obstetrics population. American Journal of Perinatology. 2021; 38: 1192–1200.

[6] Ahonen J, Stefanovic V, Lassila R. Management of post-partum haemorrhage. Acta Anaesthesiologica Scandinavica. 2010; 54: 1164–1178.

[7] Zheutlin AB, Vieira L, Shewcraft RA, Li SL, Wang ZC, Schadt E, et al. A comprehensive digital phenotype for postpartum hemorrhage. Journal of the American Medical Informatics Association. 2021; 29: 321–328.

[8] Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. Journal of Trauma and Acute Care Surgery. 2015; 78: 1054–1058.

[9] Viñas MT, Chandraharan E, Moneta MV, Belli AM. The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta. Clinical Radiology. 2014; 69: e345–e351.

[10] Duan XH, Wang YL, Han XW, Chen ZM, Chu QJ, Wang L, et al. Caesarean section combined with temporary aortic balloon occlusion followed by uterine artery embolisation for the management of placenta accreta. Clinical Radiology. 2015; 70: 932–937.

[11] Patek K, Friedman P. Postpartum hemorrhage-epidemiology, risk factors, and causes. Clinical Obstetrics and Gynecology. 2023; 66: 344–356.

[12] Kumar S, Gaiwal AS. Management of postpartum hemorrhage—current strategies. MGM Journal of Medical Sciences. 2022; 9: 263–267.

[13] Chlela M, Dawkins J, Lewis G. Hysterectomy sparing management of uterine necrosis following uterine artery embolization for postpartum hemorrhage. Case Reports in Obstetrics and Gynecology. 2023; 2023: 8276110.

[14] Manzano-Nunez R, Escobar-Vidarte MF, Naranjo MP, Rodriguez F, Ferrada P, Casallas JD, et al. Expanding the field of acute care surgery: a systematic review of the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in cases of morbidly adherent placenta. European Journal of Trauma and Emergency Surgery. 2018; 44: 519–526.

[15] Webster LA, Little O, Villalobos A, Nguyen J, Nezami N, Lilly M, et al. REBOA: expanding applications from traumatic hemorrhage to obstetrics and cardiopulmonary resuscitation, from the AJR special series on emergency radiology. American Journal of Roentgenology. 2023; 220: 16–22.

[16] Ordoñez CA, Manzano-Nunez R, Parra MW, Rasmussen TE, Nieto AJ, Herrera-Escobar JP, et al. Prophylactic use of resuscitative endovascular balloon occlusion of the aorta in women with abnormal placentation: a systematic review, meta-analysis, and case series. The Journal of Trauma and Acute Care Surgery. 2018; 84: 809–818.

[17] Kyozuka H, Yasuda S, Murata T, Sugeno M, Fukuda T, Yamaguchi A, et al. Prophylactic resuscitative endovascular balloon occlusion of the aorta use during cesarean hysterectomy for placenta accreta spectrum: a retrospective cohort study. Journal of Maternal-Fetal and Neonatal Medicine. 2023; 36: 2232073.

[18] Masamoto H, Uehara H, Gibo M, Okubo E, Sakumoto K, Aoki Y. Elective use of aortic balloon occlusion in cesarean hysterectomy for placenta previa percreta. Gynecologic and Obstetric Investigation. 2009; 67: 92–95.

[19] Stensaeth KH, Sovik E, Haig INY, Skomedal E, Jorgensen A. Fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta (REBOA) for controlling life threatening postpartum hemorrhage. PLOS ONE. 2017; 12: e0174520.

[20] Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. The Journal of Trauma. 2011; 71: 1869–1872.

[21] Kamijo K, Nakajima M, Shigemi D, Kaszynski RH, Ohbe H, Goto T, et al. Resuscitative endovascular balloon occlusion of the aorta for life-threatening postpartum hemorrhage: a nationwide observational study in Japan. The Journal of Trauma and Acute Care Surgery. 2022; 93: 418–423.

[22] Alarhayem A, Myers J, Dent D, Liao L, Muir M, Mueller D, et al. Time is the enemy: mortality in trauma patients with hemorrhage from torso injury occurs long before the “golden hour”. The American Journal of Surgery. 2016; 212: 1101–1105.

[23] Hilbert-Carius P, McGreevy D, Abu-Zidan FM, Hörer TM; ABOTrauma Registry research group. Successfully REBOA performance: does medical specialty matter? International data from the ABOTrauma Registry. World Journal of Emergency Surgery. 2020; 15: 62.

[24] Cralley AL, Moore EE, Dubose J, Brenner ML, Schaid TR, DeBot M, et al. Outcomes following zone 3 and zone 1 aortic occlusion for the treatment of blunt pelvic injuries. Shock. 2023; 59: 685–690.

[25] Eliason JL, Myers DD, Ghosh A, Morrison JJ, Mathues AR, Durham L, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA): zone I balloon occlusion time affects spinal cord injury in the nonhuman primate model. Annals of Surgery. 2021; 274: e54–e61.

[26] Cralley AL, Moore EE, Sauaia A, Carani PH, Schaid TR, DeBot M, et al. REBOA for the treatment of blast polytrauma: zone 3 provides cerebral perfusion, attenuates organ dysfunction and reperfusion coagulopathy compared to zone 1 in a swine model. The Journal of Trauma and Acute Care Surgery. 2023; 94: 718–724.