Effects of descending aortic occlusion for massive obstetric hemorrhage: Nationwide analysis of maternal death in Japan

OBJECTIVE: To evaluate the effects of aortic occlusion (AO) on severe postpartum hemorrhage (PPH)-a leading cause of preventable maternal mortality-using a nationwide maternal death registry in Japan. METHODS: A nationwide retrospective observational study of hemorrhage-related maternal deaths was conducted in Japan between 2010 and 2024. Patients were classified into an AO group (resuscitative endovascular balloon occlusion of the aorta [REBOA] and/or resuscitative thoracotomy with aortic cross-clamping [RT-ACC]) and a non-AO group. The primary outcome was the achievement of definitive hemostatic procedures. Secondary outcomes included 24-h survival. RESULTS: Among 109 hemorrhage-related maternal deaths, 19 patients underwent AO (13 REBOA, six RT-ACC). Patients in the AO group were more frequently transferred to tertiary care centers than those in the non-AO group (84.2% (16/19) vs 43.3% (39/90), P < 0.01). Achievement of definitive hemostasis was significantly higher in the AO group (78.9% (15/19) vs 42.2% (38/90), P < 0.01), as were 24-h survival (42.1% (8/19) vs 15.6% (14/90), P = 0.02). Approximately 90% of AO procedures (17/19) were performed at tertiary centers, and only 16% (3/19) were initiated before cardiopulmonary arrest. CONCLUSION: AO, including REBOA and RT-ACC, was associated with higher rates of hemostasis and short-term survival among cases of maternal death due to severe PPH. Earlier application of AO before cardiopulmonary arrest may be critical to improving outcomes.