Uterine artery embolization: an effective treatment for intractable obstetric haemorrhage

Obstetrical prognosis and pregnancy outcome following pelvic arterial embolisation for post-partum hemorrhage

Post-partum hemorrhage is an obstetrical emergency. Pelvic artery embolisation offers an alternative to surgical intervention and increases the rate of conservative treatment. The objective of this review was to study the scientific literature on obstetrical outcomes following uterine-sparing arterial embolisation performed for post-partum hemorrhage in a prior pregnancy. A Medline and Sciencedirect search were performed in order to review all the French and English reports about pregnancy following pelvic arteries embolisation for post-partum hemorrhage. Nineteen articles were identified and 13 were selected for inclusion. We have included the fertility follow-up of a total of 168 women who underwent pelvic arteries embolisation for post-partum hemorrhage. We highlight the clinical success of embolisation in 154 of the 168 patients (92%). Following the embolisation procedures, 7 hysterectomies were required and 4 patients died. Two of the 4 deaths occurred in women who were transferred from an outlying institution to a tertiary referral center. In this population, 45 pregnancies were described. Among these pregnancies, 32 resulted in live births (71%), 8 were miscarriages (18%) and 5 patients carried out voluntary termination of pregnancy (11%). The cesarean section rate was 62%. Post-partum hemorrhage occurred in 6 cases leading to 2 hysterectomies. In conclusion, pelvic arterial embolisation offers a safe and conservative alternative to surgical interventions for post-partum hemorrhage in well-selected patients desiring to preserve future fertility.

The role of interventional radiology in obstetric and gynaecology practice

Interventional radiology is continuing to reshape current practice in many specialties of clinical care. It is a relatively new and innovative branch of medicine in which physicians treat diseases non-operatively through small catheters guided to the target by fluoroscopic and other imaging modalities. The aim is to provide image-guided, minimally invasive alternatives to traditional surgical and medical procedures in suitable cohorts of patients. Procedures which previously required major surgery can now be performed by interventional radiologists, sometimes on an outpatient basis, with little patient discomfort. In this review, we highlight the importance of interventional radiology in treating a comprehensive range of obstetric and gynaecological pathologies.

Obstetric and gynecologic emergencies: a review of indications and interventional techniques

There are many interventional techniques that can be used to aid the obstetrician or gynecologist in caring for their patients in the acute setting. Embolization can be life saving in the case of postpartum hemorrhage. Bleeding related to cervical cancer or the threat of bleeding from cervical ectopic pregnancy is amenable to embolization as is hemorrhage related to uterine arteriovenous malformations. Postpartum women are also at a uniquely high risk for deep vein thrombosis and pulmonary emboli and may benefit from consultation and treatment by an interventional radiologist. The goal of this article is to discuss the valuable role that the interventional radiologist plays in the treatment of these obstetric and gynecologic conditions.

Menses recovery and fertility after artery embolization for PPH: a single-center retrospective observational study

To evaluate long-term effects of arterial embolization (AE) for postpartum hemorrhage (PPH) on menses recovery and subsequent pregnancies. One hundred thirteen consecutive patients, recruited from 1999 to 2006, who had undergone AE for severe PPH were evaluated in a retrospective monocentric study. As embolization agents, pledgets of absorbable gelatine sponge (Curaspon) were used in 106 cases, Curaspon powder in 3 cases, and inert microparticles in 4 cases. In 111/113 cases (98.1%), AE was successful in controlling PPH. In two cases (1.7%), the AE was unsuccessful and required a total abdominal postembolization hysterectomy. Concerning fertility, 6 patients were lost to follow-up and 107 were available. The average time to follow-up was 46.4+/-21.8 months. Of the 107 patients, 99 had recovery of menses (92.5%). Of the 107 (61%) patients, 66 reported regular menstruation with normal delay after the delivery. Thirty-three patients (31%) reported subjective changes in the frequency and amount of menses. Six patients (5.6%) had documented amenorrhea after AE and developed diffuse uterine synechiae at the hysteroscopic investigation. Out of 29 patients who desired and attempted conception, 18 patients (62%) reported a total of 19 pregnancies at the end of the follow-up. One miscarriage at 12 weeks of gestation was reported. The 18 pregnancies at term were uneventful until delivery, but 3 cases of further PPH (15%) occurred due to abnormal placentation requiring a further AE. All full-term newborns were healthy. AE is a feasible, safe, and reproducible technique to control PPH, allowing a very high resumption of menses and subsequent pregnancies; in these cases, considering the elevated incidence of further PPH due to abnormal placentation, an accurate ultrasonographic monitoring during pregnancy seems appropriate.

Multidisciplinary management of placenta percreta complicated by embolic phenomena

Hemorrhage and thrombosis are major causes of maternal mortality. This case discusses the management of a woman with placenta percreta complicated by intraoperative pulmonary embolism. A 39-year-old gravida 3 with two previous cesarean deliveries presented at 34 weeks of gestation with an antepartum hemorrhage. Magnetic resonance imaging confirmed placenta percreta. The multidisciplinary group including obstetricians, gynecological oncologists, interventional radiologists and anesthesiologists developed a delivery plan. Cesarean delivery was performed with internal iliac artery occlusion and embolization catheters in place. After the uterine incision our patient experienced acute hypotension and hypoxia associated with a drop in the end-tidal carbon dioxide and sinus tachycardia. She was resuscitated and the uterus closed with the placenta in situ. Postoperatively, uterine bleeding was arrested by immediate uterine artery embolization. With initiation of embolization, hypotension and hypoxia recurred. Oxygenation and hemodynamics slowly improved, the case continued and the patient was extubated uneventfully at the end of the procedure. Computed tomography revealed multiple pulmonary emboli. The patient was anticoagulated with low-molecular-weight heparin and returned six weeks later for hysterectomy. Placenta percreta with invasion into the bladder can be catastrophic if not recognized before delivery. The chronology of events suggests that this may have been amniotic fluid emboli. An intact placenta with abnormal architecture, such as placenta percreta, may increase the risk of amniotic fluid embolus. The clinical findings and co-existing filling defects on computed tomography may represent a spectrum of amniotic fluid embolism syndrome.

Major obstetric hemorrhage

Major obstetric hemorrhage remains the leading cause of maternal mortality and morbidity worldwide, and is associated with a high rate of substandard care. A well-defined and multidisciplinary approach that aims to act quickly and avoid omissions or conflicting strategies is key. The most common etiologies of hemorrhage are abruptio placenta, placenta previa/accreta, uterine rupture in the antepartum period and retained placenta, uterine atony, and genital-tract trauma in the postpartum period. Basic treatment of postpartum hemorrhage relies on manual removal of the placenta or manual exploration of the uterus plus bladder emptying and oxytocin administration. If this does not arrest bleeding, or if there is any suspicion of genital-tract trauma, examination of the vagina and cervix with appropriate valves and analgesia/anesthesia must follow quickly. Postpartum uterine atony resistant to oxytocin must be treated with prostaglandin within 15 to 30 minutes; uterine balloon tamponade can be also useful at this stage. Aggressive transfusion therapy and resuscitation are mandatory in major obstetric hemorrhage. Specific invasive treatment must be considered within no more than 30 to 60 minutes, if previous measures have failed -- and even earlier in some particular etiologies. The two main options are radiologic embolization and surgical artery ligations. Recombinant factor VIIa may also be considered, but should not delay the performance of a life-saving procedure such as embolization or surgery. Hysterectomy must be implemented when all other interventions have failed.

Results of endovascular treatment in cases of abnormal placentation with post-partum hemorrhage

AIM

The purpose of this study was to evaluate the clinical success of selective arterial embolization in cases of post-partum hemorrhage due to abnormal placentation.

METHODS

Six patients with persistent hemorrhage and abnormal placental implantation underwent uterine artery embolization over a period of three years.

RESULTS

In four patients, the placenta was left in place after a gentle attempt at removal and post-partum hemorrhage was controlled during or shortly after the procedure. In all cases, embolization was possible even when there was previous arterial ligation (two cases). In one case, a hysterectomy was required at 21 d later due to uterus and bladder necrosis. Arterial embolization in cases of abnormal placental implantation remains an uncommon treatment and is less efficient in these cases than in normal placental implantation.

CONCLUSION

Our results confirmed that even in cases of moderate bleeding, conservation treatment and embolization are possible, but that complications may be more common than in normal placentation.

Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta

OBJECTIVE

The objective of the study was to compare outcomes of women with placenta accreta who underwent cesarean hysterectomy with and without prophylactic intravascular balloon catheters.

STUDY DESIGN

Case-control study of women at risk for placenta accreta identified using hospital databases and billing records from January 1995 to January 2006. Subjects with preoperative intravascular balloon catheter (BC) placement plus hysterectomy were compared with those that had hysterectomy alone.

RESULTS

Sixty-nine subjects had cesarean hysterectomy performed for placenta accreta; 19 subjects had balloon catheters plus hysterectomy and 50 subjects had hysterectomy alone. No significant differences were noted in estimated blood loss (P = .79), transfused blood products (P = .60), operative time (P = .85), and postoperative hospital days (P = .85). There were no significant differences in secondary outcomes between groups. Three of the 19 BC subjects (15.8%) had complications from catheter placement; 2 required stent placement and/or arterial bypass.

CONCLUSION

Prophylactic intravascular balloon catheters did not benefit women with placenta accreta undergoing cesarean hysterectomy.

Systematic Review of Conservative Management of Postpartum Hemorrhage: What to Do When Medical Treatment Fails

We performed a systematic review to identify all studies evaluating the success rates of treatment of major postpartum hemorrhage by uterine balloon tamponade, uterine compression sutures, pelvic devascularization, and arterial embolization. We included studies reporting on at least 5 cases. All searches were performed independently by 2 researchers and updated in June 2006. Failure of management was defined as the need to proceed to subsequent or repeat surgical or radiological therapy or hysterectomy, or death. As the search identified no randomized controlled trials, we proceeded to search for observational studies. This identified 396 publications, and after exclusions, 46 studies were included in the systematic review. The cumulative outcomes showed success rates of 90.7% (95% confidence interval [CI], 85.7%-94.0%) for arterial embolization, 84.0% (95% CI, 77.5%-88.8%) for balloon tamponade, 91.7% (95% CI, 84.9%-95.5%) for uterine compression sutures, and 84.6% (81.2%-87.5%) for iliac artery ligation or uterine devascularization (P = 0.06). At present there is no evidence to suggest that any one method is better for the management of severe postpartum hemorrhage. Randomized controlled trials of the various treatment options may be difficult to perform in practice. As balloon tamponade is the least invasive and most rapid approach, it would be logical to use this as the first step in the management.

Hypogastric artery ligation for severe hemorrhage in obstetric patients

Ligation of the hypogastric arteries (HAL) was first introduced into surgery by the end of the 19(th) century to control intractable hemorrhage from the uterus of women with advanced cervical cancer. At present, HAL is one in a spectrum of operative methods to control life-threatening postpartum hemorrhage before hysterectomy. Bilateral ligation of the internal iliac artery does not result in complete blockage of but to a significant decrease in blood supply to the female pelvic organs. Soon after ligation three previously existent collateral circulations will develop. Due to the smaller caliber of these arteries, the arterial pulse and pulse pressure are virtually eliminated. The effectiveness of HAL in avoiding hysterectomy for postpartum hemorrhage has been reported in up to 50% of cases. HAL has no adverse effect on subsequent fertility or pregnancy outcome, however, assessment for intrauterine fetal growth restriction is recommended. This safe and effective procedure should be taught during obstetric and gynecologic training.

Uterine artery embolization in the treatment and prevention of postpartum hemorrhage

OBJECTIVES

The study was conducted to evaluate the efficacy of superselective transcatheter uterine artery embolization for control of obstetric hemorrhage.

METHODS

Between January 2002 and December 2005, 14 consecutive patients underwent uterine artery embolization to control postpartum hemorrhage, and two to prevent hemorrhage before second-trimester therapeutic abortion.

RESULTS

Embolization was performed by transfemoral arterial catheterization. Pieces of absorbable gelatin sponge were used in all cases, with the addition of platinum coils in two cases for complete vessel occlusion. Optimal bleeding control was achieved in all cases but one--a patient who underwent hysterectomy due to embolization failure. No severe complications were observed.

CONCLUSIONS

The high success rate, low morbidity rate, and possibility of preserving reproductive function have made superselective uterine artery embolization the technique of choice to control life-threatening, intractable postpartum hemorrhage in hemodynamically stable patients, provided multidisciplinary medical teams are promptly available.

Conservative management of placenta increta with selective arterial embolization preserves future fertility and results in a favorable outcome in subsequent pregnancies

OBJECTIVE

To present a case of selective arterial embolization for the treatment of placenta increta in a patient with subsequent pregnancy.

DESIGN

Case report and literature review.

SETTING

Community-based hospital.

PATIENT(S)

A 31-year-old G2P1 woman with placenta increta presenting with delayed postpartum hemorrhage.

INTERVENTION(S)

Selective uterine artery embolization.

MAIN OUTCOME MEASURE(S)

Cessation of uterine hemorrhage, future pregnancy.

RESULT(S)

The patient's uterine bleeding immediately resolved. She subsequently delivered a healthy neonate at term without recurrence of abnormal placentation.

CONCLUSION(S)

Arterial embolization is effective for treating placenta increta in women who wish to preserve fertility. A review of the literature demonstrates a 76.9% success rate and an 11% complication rate.

Prise en charge des hémorragies graves du post-partum: indications et techniques de l’embolisation artérielle

Pluridisciplinary management of women with postpartum hemorrhage is mandatory in order to precisely assess initial seriousness, to maintain hemodynamic parameters and to confirm the cause of bleeding. Embolization should be offered only after exploration of the uterine cavity, inspection of the vagina, cervix and perineum and failure of uterotonic drugs. Embolization should be carried out in an angiography suite under constant monitoring of the patient by the anesthesiologist. Indications to perform arterial embolization include uterine atony particularly following a vaginal delivery, cervico-uterine hemorrhage, cervicovaginal lacerations (previously repaired or if surgical repair has failed) and vaginal thrombus, particularly in case of associated coagulopathy. Arterial embolization is effective in about 85% of cases. Placenta acccreta can also be successfully managed with arterial embolization as an alternative to hysterectomy. Unilateral femoral approach allows selective study of both internal iliac arteries and branches. Selective embolization of both uterine arteries should be ideally performed. In case of spasm or difficult catheterization, embolization of the anterior division of both internal iliac arteries should be considered. In case of bleeding from the cervico-vaginal region, selective evaluation and embolization of cervicovaginal branches should be performed. In case of failure or recurrence of bleeding, ovarian and round ligament arteries should be evaluated. In most cases, resorbable gelatin sponge pledgets should be used to perform embolization. The use of microcatheters and non resorbable embolization agents should be considered by trained interventional radiologists in case of placenta accreta or vascular lesions. After embolization, the patient should be transferred to the intensive care unit for further observation in order to offer emergent surgical procedure or another session of embolization in case of recurrence of bleeding.

Anaesthetic implications of uterine artery embolisation in management of massive obstetric haemorrhage

The latest triennial report on maternal deaths has recommended the consideration of uterine artery embolisation in management of cases of massive obstetric haemorrhage. We have been using interventional radiology to manage both expected and unanticipated postpartum bleeding in our centre. Three case reports are presented to highlight the value of this technique and issues relating to the anaesthetic and postoperative management of these patients are discussed.

Epidural Anesthesia for Elective Cesarean Delivery with Intraoperative Arterial Occlusion Balloon Catheter Placement

Obstetric hemorrhage is a leading cause of maternal mortality. We describe the anesthetic management of elective cesarean delivery in patients at high risk for hemorrhage. The utility and limitations of intraarterial balloon catheter placement and epidural anesthesia are described.

Acquired uterine vascular malformations: radiological and clinical outcome after transcatheter embolotherapy

The purpose of this retrospective study is to assess the radiological and clinical outcome of transcatheter embolization of acquired uterine vascular malformations in patients presenting with secondary postpartum or postabortion vaginal hemorrhage. In a cohort of 17 patients (mean age: 29.7 years; standard deviation: 4.23; range: 25-38 years) 18 embolization procedures were performed. Angiography demonstrated a uterine parenchymal hyperemia with normal drainage into the large pelvic veins ("low-flow uterine vascular malformation") in 83% (n=15) or a direct arteriovenous fistula ("high-flow uterine vascular malformation") in 17% (n=3). Clinically, in all patients the bleeding stopped after embolization but in 1 patient early recurrence of hemorrhage occurred and was treated by hysterectomy. Pathological analysis revealed a choriocarcinoma. During follow-up (mean time period: 18.8 months; range: 1-36 months) 6 patients became pregnant and delivered a healthy child. Transcatheter embolization of the uterine arteries, using microparticles, is safe and highly effective in the treatment of a bleeding acquired uterine vascular malformation. In case of clinical failure, an underlying neoplastic disease should be considered. Future pregnancy is still possible after embolization.

Maternal deaths from anaesthesia. An extract from Why Mothers Die 2000–2002 , the Confidential Enquiries into Maternal Deaths in the United Kingdom † †This article is accompanied by the Editorial

This is the first of two extracts from Why Mothers Die 2000-2002, issued on 12 November 2004 by the Confidential enquiry into Maternal and Child Health (CEMACH), reproduced with permission. The full report can be accessed via their web site: http://www.cemach.org.uk/