International Journal of Surgery Case Reports 114 (2024) 109109

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Postpartum hemorrhage with associated placenta previa in a kidney

transplant recipient: A case report
Toshinao Suzuki a, *, Takahiro Sugiura a, Junko Okazaki a, Hiroaki Kimura b
a
Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan
b
Department of Obstetrics and Gynecology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The efficacy and safety of uterine artery embolization (UAE) and prophylactic resuscitative endo­
Postpartum hemorrhage vascular balloon occlusion of the aorta (REBOA) against postpartum hemorrhage (PPH) in pregnant women after
Placenta previa kidney transplantation have not been reported. Here, we describe a case of PPH associated with placenta previa
Kidney transplantation
in pregnancy following kidney transplantation, which was managed with UAE and prophylactic REBOA.
Uterine artery embolization
Case presentation: A 35-year-old, gravida 2, para 1 woman with total placenta previa presented with vaginal
Balloon occlusion
Case report bleeding (460 mL) at 33 weeks and 3 days of gestation. Previously, she underwent a living-donor kidney
transplantation for IgA nephropathy, and the renal artery of the transplanted kidney was anastomosed with the
right internal iliac artery. An emergency cesarean section with prophylactic REBOA was performed under general
anesthesia. A balloon catheter was introduced via the left femoral artery and positioned above the aortic
bifurcation (Aortic zone 3). Upon confirming fetal delivery, the balloon was immediately inflated, and the total
aortic occlusion time was 20 min. However, following aortic balloon deflation, atonic bleeding continued despite
Bakri balloon usage and uterotonic drug administration. Subsequently, UAE was performed for the refractory
PPH, the left uterine artery was embolized using a gelatin sponge, and hemostasis was successfully achieved. The
patient recovered uneventfully and was discharged on postoperative day 7.
Discussion and conclusion: In pregnancies following kidney transplantation, prophylactic REBOA controls
bleeding; however, it decreases blood flow to the transplanted kidney. Furthermore, uterine nutrient vasculature
alterations are observed, necessitating a thorough understanding of the uterine artery supply pathways during
UAE.

1. Introduction
The number of kidney transplant recipients is increasing yearly [1].
Despite the increased risks of complications for mother and child,
pregnancy can be achieved after kidney transplantation [2–4]. Post­
partum hemorrhage (PPH) is a major contributor to perinatal mortality
[5]; however, reports of PPH associated with pregnancies following
kidney transplantation are rare, and data regarding its incidence and
mortality rate remain unclear. The efficacy of uterine artery emboliza­
tion (UAE) as a hemostatic method for intractable PPH [6] and pro­
phylactic resuscitative endovascular balloon occlusion of the aorta
(REBOA) for mitigating bleeding during cesarean section [7,8] has been
documented. UAE and prophylactic REBOA are increasingly used to
manage PPH. However, the safety and efficacy of UAE and prophylactic
REBOA in pregnancies after kidney transplantation have not yet been
established. In this novel report, we present a case of PPH associated
with placenta previa during pregnancy following kidney transplantation
for IgA nephropathy, which was managed with UAE and prophylactic
REBOA. This case report adheres to the SCARE 2020 criteria [9].
2. Presentation of case
A 35-year-old woman, gravida 2, para 1, was scheduled for elective
cesarean section after 36 weeks of gestation due to total placenta previa.
The patient had previously undergone living-donor kidney trans­
plantation at another hospital 11 years ago due to end-stage renal failure
caused by IgA nephropathy and was treated daily with the following
triple-immunosuppressant regimen: tacrolimus (1.5 mg), azathioprine

Abbreviations: PPH, postpartum hemorrhage; REBOA, resuscitative endovascular balloon occlusion of the aorta; UAE, uterine artery embolization.
* Corresponding author.
E-mail addresses: toshinao24@gmail.com (T. Suzuki), sugiura.takahiro@navy.plala.or.jp (T. Sugiura).

https://doi.org/10.1016/j.ijscr.2023.109109
Received 3 November 2023; Received in revised form 22 November 2023; Accepted 2 December 2023
Available online 8 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
T. Suzuki et al.
(100 mg), and prednisolone (5 mg). Laboratory test results revealed a
serum creatinine level of 0.91 mg/dL, a hemoglobin level of 10.0 g/dL,
and no evidence of coagulopathy (platelets, 162,000/μL; prothrombin
time, 10.3 s; activated partial thromboplastin time, 26.8 s). At 33 weeks
and 3 days of gestation, 460 mL of vaginal bleeding was observed,
leading to an emergency cesarean section with prophylactic REBOA.
Before the cesarean section, a 7-Fr REBOA device (Rescue Balloon ER®,
Tokai Medical Products, Aichi, Japan) was introduced and positioned
with an 8-Fr sheath in the left femoral artery using sonography. The
balloon placement above the aortic bifurcation (Aortic zone 3) was
confirmed using fluoroscopy. Subsequently, general anesthesia was
administered, and the cesarean section was performed. The REBOA was
inflated immediately upon confirmation of fetal delivery. Total aortic
occlusion via REBOA was confirmed through the disappearance of
arterial pressure in the femoral sheath used for REBOA. The placenta
was delivered successfully without complications. Finally, oxytocin
(intramuscular and intravenous administration of 5 and 20 units,
respectively) and 1 g tranexamic acid were administered. Due to
persistent atonic bleeding, compression was applied using a Bakri
balloon. REBOA was deflated after the Bakri balloon was inflated (aortic
occlusion time was 20 min). Although the Bakri balloon initially
controlled the bleeding, the bleeding persisted due to complicated
coagulopathy with low fibrinogen levels (fibrinogen, 113.1 mg/dL),
leading to the decision to perform endovascular embolization. After
performing a temporary abdominal closure, the patient was transported
to the angiography room, where endovascular embolization was per­
formed. The balloon occlusion catheter was removed, and angiography
was performed through the left femoral sheath.
Pelvic angiography revealed that the left internal iliac artery pro­
vided blood flow to the transplanted renal artery, whereas collateral
circulation from the right external iliac artery supplied blood to the right
uterine artery (Fig. 1). The left uterine artery was selectively cathe­
terized and embolized with a gelatin sponge (Fig. 2A). Additionally, the
feeding vessels connected to the uterus, which originated from branches
of the inferior gluteal and lateral sacral arteries (Fig. 2B and C), were
meticulously identified and subsequently embolized. Following embo­
lization, external bleeding ceased, and the procedure was concluded
with embolization on the left side only. The newborn had a birth weight
of 2246 g and Apgar scores of 1, 8, and 10 at 1, 5, and 7 min, respec­
tively. The delivery of the fetus and placenta occurred at 4 and 5 min,
respectively, following the initiation of surgery. Subsequently, myo­
metrial suturing was performed, and temporary closure of the abdomen
required 41 min from the outset. Following this, the patient was trans­
ferred to the angiography room. Vascular embolization was accom­
plished within 43 min, and an additional 54 min were necessary to verify
hemostasis and perform wound closure in the operating room. The total
blood loss was 4305 mL, and intraoperative blood transfusions included
12, 10, and 12 units of red blood cells, fresh frozen plasma, and
Fig. 1. Pelvic aortography before embolization.
A) Pelvic aortography reveals the right-sided location of the kidney within the
pelvis (asterisk) while visualizing blood flow from the right internal iliac artery
(arrow).
B) In the later phase of pelvic angiography, the right external iliac artery pro­
vides blood flow to the right uterine artery (arrowhead).
2
International Journal of Surgery Case Reports 114 (2024) 109109
Fig. 2. Angiography reveals the uterus being perfused by a branch vessel
stemming from the left internal iliac artery.
A) Selective angiography from the left uterine artery. B) Angiography con­
ducted after the embolization of the left uterine artery confirms the presence of
blood flow to the uterus originating from a branch of the inferior gluteal artery.
C) Selective angiography of the lateral sacral artery additionally confirms the
presence of blood flow to the uterus.
cryoprecipitate, respectively. Finally, a total of 45 units of oxytocin and
0.2 mg of methylergometrine were administered intraoperatively. The
histological examination of the placenta revealed no evidence of
placenta accreta spectrum. The postoperative course was uneventful,
with no decline in creatinine levels. The patient was discharged on day 7
of hospitalization. Following the preference of the patient, hysterectomy
was successfully avoided, thereby preserving the possibility of fertility.
Subsequently, the newborn was admitted to the general ward, and no
postnatal complications occurred.
3. Discussion
PPH is the leading cause of maternal mortality worldwide [5].
Nevertheless, data pertaining to the incidence and mortality rates of
PPH in pregnancies following kidney transplantation are lacking despite
the increasing number of kidney transplantation cases [1]. Therefore,
PPH should be considered in pregnancies after kidney transplantation.
Here, we described a case of PPH associated with placenta previa in a
kidney transplant recipient who was successfully treated with prophy­
lactic REBOA and endovascular embolization.
REBOA is a minimally invasive procedure involving the introduction
of a balloon occlusion catheter into the aorta to achieve endovascular
aortic occlusion [7,10]. Recently, prophylactic REBOA has been utilized
to reduce bleeding in PPH cases, and its effectiveness has been investi­
gated [7,8,11]. However, awareness of the risks associated with REBOA,
such as ischemia-reperfusion-related complications, including acute
kidney injury, limb ischemia, spinal cord ischemia, and visceral organ
dysfunction, is necessary [12,13].
In patients who have undergone kidney transplantation, performing
REBOA requires an increased awareness of atypical pelvic blood flow
dynamics. When the internal iliac artery is ligated, blood flow within the
uterine artery is sustained through collateral channels originating from
the external iliac and ovarian arteries [14,15]. Hence, even when the
internal iliac artery is treated due to kidney transplantation, REBOA
blocks the blood flow within the external iliac artery, potentially aiding
blood flow control. However, when prophylactic REBOA is conven­
tionally performed for PPH, it is frequently positioned below the renal
artery. In cases such as the one described here, where kidney trans­
plantation involves anastomosis between the internal iliac and renal
arteries, the placement of an occlusion balloon catheter may inadver­
tently obstruct renal blood flow. Considering circulatory conditions, it is
imperative to minimize ischemic time whenever possible to preserve
renal blood flow. When employing REBOA in the preparation of kidney
transplant patients to mitigate posttransplant hemorrhage, it is vital to
develop a management strategy that not only minimizes blood loss but
also circumvents any unwarranted reduction in renal blood flow,
thereby averting the deterioration of renal function. In cases involving
T. Suzuki et al.
REBOA in renal transplant recipients, it is imperative to recognize that
balloon occlusion at the level of the aortic bifurcation (Aortic zone 3)
can result in decreased renal blood flow.
REBOA serves as an adjunct and does not independently confer he­
mostatic effects. UAE proves effective in intractable PPH treatment [6].
UAE has become increasingly prevalent and plays a pivotal role in PPH
management owing to its numerous advantages, including effectiveness,
safety, minimal invasiveness, paucity of complications, and preservation
of fertility [6]. However, the effectiveness and safety of UAE for PPH
during pregnancy after kidney transplantation remain uncertain. The
utilization of the internal iliac artery is a common practice [16].
Consequently, the uterine artery, a branch of the internal iliac artery,
undergoes alterations in its supply source, which affects the blood sup­
ply to the uterus. When the internal iliac artery is involved in renal
transplantation, collateral pathways, such as the external iliac artery,
may contribute to the supply to the uterine artery [15]. In this case,
besides the blood supply originating from the left external iliac artery to
the left uterine artery, blood flow to the uterus was also confirmed from
branches of the right internal iliac artery, specifically the lateral sacral
and inferior gluteal arteries. Thus, following kidney transplantation in
pregnant women, the vascular supply to the uterus may be altered. In
this case, we performed an emergency cesarean section without
adequate preoperative evaluation. However, in cases of cesarean section
with a high risk of impending hemorrhage, it is imperative to assess the
anatomical integrity of the uterine nutrient vessels in advance.
4. Conclusion
We report a case of PPH associated with placenta previa in a preg­
nant woman following kidney transplantation, managed successfully
with prophylactic REBOA and UAE. Hysterectomy was avoided, and no
ischemic complications, such as worsening renal function, were
observed. These findings indicate that after renal transplantation in
pregnant women, prophylactic REBOA is beneficial in controlling
bleeding; however, it decreases blood flow to the transplanted kidney.
Furthermore, alterations in the uterine nutrient vasculature were
observed, highlighting the importance of a thorough understanding of
the uterine artery supply pathways during UAE.
Consent for publication
Written informed consent was obtained from the patient for publi­
cation and any accompanying images. A copy of the written consent is
available for review by the Editor-in-Chief of this journal on request.
Ethical approval
The requirement for ethical approval was waived by our institution.
The patient provided informed consent for the publication of medical
information in this case report.
Funding
This study did not receive any specific grants from funding agencies
in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Toshinao Suzuki: Conceptualization, Writing - Original Draft. Taka­
hiro Sugiura: Writing - Review & Editing. Junko Okazaki: Writing -
Review & Editing. Hiroaki Kimura: Writing - Review & Editing. All the
authors have read and approved the final version of the manuscript.
International Journal of Surgery Case Reports 114 (2024) 109109
Guarantor
Toshinao Suzuki.
Research registration number
Not applicable.
Declaration of competing interest
The authors declare that they have no competing interests.
Data availability
Not applicable.
Acknowledgments
We would like to thank Editage (www.editage.com) for the English
language editing.
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