Arterial catheterization and embolization for management of emergent or anticipated massive obstetrical hemorrhage

Evaluation of Peripartum Hysterectomy in a Tertiary Care Unit and Its Effect on Patients' Long-Term Physical and Mental Wellbeing: Quest Is Not Over When You Save the Life

OBJECTIVES

Peripartum hysterectomy can be performed as an elective procedure or as a life-saving emergency procedure in obstetrics. It is associated with significant maternal morbidity and mortality. We report peripartum hysterectomies done during the study period in a tertiary referral centre, Colombo, Sri Lanka. Methodology. We collected data on all severe acute maternal morbidity and mortality events (SAMM) from June 01, 2014, to June 01, 2015, at De Soysa Hospital for Women (DSHW). We invited all women who underwent PPH to complete the 36-Item Short Form Health Survey questionnaire (SF-36) before hospital discharge and at six months after the hysterectomy date to assess their general and mental health before and after surgery. Focus group discussions (FGD) were used to further evaluate the patient experience and to identify service delivery improvements.

RESULTS

There were eleven peripartum hysterectomies done during the study period for 7160 deliveries. None were primigravida. Median age and gestation were 36 years and 37 weeks, respectively. The commonest indication for peripartum hysterectomy was a morbidly adherent placenta (seven). Nine of the deliveries were elective lower-segment caesarean section and two were vaginal deliveries. Four emergency peripartum hysterectomies were done for primary postpartum haemorrhage (PPH) and two for secondary PPH. All patients required intensive care and there were no maternal deaths. The analysis of SF-36 data revealed that all patients suffered a significant reduction in the quality of life at six months after the surgery. FGD highlighted that most patients needed further counselling and support to improve their physical, psychological, and social wellbeing. Some of the patients were willing to share their experience on voluntary basis to help those undergoing peripartum hysterectomies in the future.

CONCLUSION

Peripartum hysterectomy is an important life-saving procedure associated with severe maternal morbidity and mortality. This study reveals that the physical, psychological, and social adverse effects would remain in the long term.

Experience of a Colombian center in the endovascular management of lifethreatening postpartum hemorrhage

Introduction: Postpartum hemorrhage is a world-leading cause of morbidity and mortality. Lacerations are the second most frequent cause. Early management with appropriate treatment is essential to obtain adequate outcomes; the endovascular occlusion of pelvic vessels is among the management options. Objective: To describe the management experience with the arterial embolization of pelvic vessels. Materials and methods: We conducted a retrospective case series study based on the institutional registry of Fundación Valle del Lili (Cali, Colombia), which included patients with postpartum hemorrhage admitted between January 1st, 2011 and October 31st, 2016. Results: Out of 430 patients diagnosed with PPH, 11 were subject to embolization of pelvic vessels. Within our group, 10 patients had a vaginal delivery with severe vaginal lacerations; most of them (9 cases, 82%) were referred from other lower-complexity institutions after 20.5 hours. Occlusion was more frequent in the superior vaginal and the internal pudendal arteries. No patients showed complications associated with the procedure and only 2 showed recurrent bleeding while 3 required a hysterectomy, but no deaths occurred. Conclusion: Percutaneous management is a safe and effective third-line method for difficult-management bleedings control in patients with postpartum hemorrhage after a severe perineal tear. These results are similar to case reports published in the worldwide literature available to date.

Recent Update of Embolization of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.

Short & long term adverse outcomes after arterial embolisation for the treatment of postpartum haemorrhage: a systematic review

OBJECTIVES

Arterial embolisation (AE) plays a major role in current practice in the management of postpartum haemorrhage (PPH) that fails to respond to conservative treatment. While its benefit is well known, long-term outcomes of AE have been poorly investigated. The objective of this review is to assess its potential complications and long-term effects on the patients' quality of life.

METHODS

Using the terms "embolisation" and "postpartum haemorrhage", we searched the Cochrane Central Register of Controlled Trials, Medline and PubMed for published studies. We limited the search to articles in English and French reporting "complications", "fertility", "menstruation" or "menstrual cycle" in humans. To ensure completeness, the references of extracted articles and review articles were also searched.

RESULTS

The fertility rate in patients attempting another pregnancy reaches 70-80 %. Pregnancies following AE for PPH are not associated with a higher rate of intrauterine growth restriction. Pathological placentation (placenta accreta/increta/percreta) occurs more frequently after AE than in the general population. Psychological wellbeing, post-traumatic stress and sexual dysfunction after a life-threatening PPH requiring AE will require further investigation.

CONCLUSION

AE does not appear to adversely affect menstrual cycle, fertility and subsequent pregnancies, but may affect placentation. The experience of a life-threatening PPH, however, might prevent couples from pursuing another pregnancy.

KEY POINTS

• Embolisation for PPH does not adversely affect menstrual cycle and fertility • Experience of life-threatening PPH might prevent couples from pursuing another pregnancy • Pathological placentation seems to occur more frequently after embolisation for PPH.

The factors associated with the failure of transcatheter pelvic arterial embolization for intractable postpartum hemorrhage

OBJECTIVE

The transcatheter pelvic arterial embolization (TAE) is effective for postpartum hemorrhage (PPH). There has been a little information about the factors for ineffectiveness of TAE. The aim of this study was to determine factors associated with TAE failure for PPH.

STUDY DESIGN

Fifty-five women who underwent TAE for intractable PPH were included. Clinical factors involving age, history of pregnancy, gestational weeks of delivery, mode of delivery, causes of PPH, complete blood count, blood loss volume, transfusion amount, shock index and disseminated intravascular coagulation (DIC) score were compared between TAE success group (n=48) and TAE failure group (n=7).

RESULTS

The uni- and multi-variate analyses revealed that advanced maternal age (OR 1.46, 95% CI 1.12-2.18) and retained placenta as a cause of PPH (15.48, 2.04-198.12) were found to be significant factors for TAE failure.

CONCLUSION

The advanced age and retained placenta were independent factors associated with TAE failure for intractable PPH.

Transarterial embolization for the treatment of massive bleeding in gynecologic and obstetric emergencies: a single center experience

Delayed treatment of the massive bleeding in gynecologic and obstetric conditions can cause high morbidity and mortality. The aim of this study is to assess the angiographic findings and outcomes of transarterial embolization in cases of massive hemorrhage from underlying gynecological and obstetrical conditions. This is a retrospective study of 18 consecutive patients who underwent transarterial embolization of uterine and/or hypogastric arteries due to massive bleeding from gynecological and obstetrical causes from January 2006 to December 2011. The underlying causes of bleeding, angiographic findings, technical success rates, clinical success rates, and complications were evaluated. Massive gynecological and obstetrical bleeding occurred in 12 cases and 6 cases, respectively. Gestational trophoblastic disease was the most common cause of gynecological bleeding. The most common cause of obstetrical hemorrhage was primary post-partum hemorrhage. Tumor stain was the most frequent angiographic finding (11 cases) in the gynecological bleeding group. The most common angiographic findings in obstetrical patients were extravasation (2 cases) and pseudoaneurysm (2 cases). Technical and final clinical success rates were found in all 18 cases and 16 cases. Collateral arterial supply, severe metritis, and unidentified cervical laceration were causes of uncontrolled bleeding. Only minor complications occurred, which included pelvic pain and groin hematoma. Percutaneous transarterial embolization is a highly effective and safe treatment to control massive bleeding in gynecologic and obstetric emergencies.

Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature

OBJECTIVE

To investigate the most appropriate surgical technique for optimizing hemostasis and preservation of subsequent fertility after postpartum hemorrhage (PPH).

DESIGN

Systematic review of the literature.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTION(S)

Review of MEDLINE, EMBASE, ScienceDirect, and the Cochrane Library.

MAIN OUTCOME MEASURE(S)

Comparison of the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus), fertility rate (subsequent pregnancies or the return of regular menstrual cycles), complication rate of the procedure, and the outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications.

RESULT(S)

Compressive sutures and vessel embolization may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation.

CONCLUSION(S)

Pelvic vessel embolization and compressive sutures are associated with high rates of restoration of regular menses and successive pregnancies, even if the former is burdened by an increased rate of placental disorders and fetal growth restriction and the latter by an increased risk of cesarean deliveries and PPH recurrence. Randomized trials would be desirable to define the best management of PPH.

Placenta accreta

OBJECTIVE

We sought to review the risks of placenta accreta, increta, and percreta, and provide guidance regarding interventions to improve maternal outcomes when abnormal placental implantation occurs.

METHODS

Relevant documents were identified through a search of the English-language literature for publications including ≥1 of the key words "accreta" or "increta" or "percreta" using PubMed (US National Library of Medicine; January 1990 through January 2010); with results limited to studies involving human beings. Additional information was obtained from references identified within selected articles; from additional review articles; and from guidelines by organizations including the American College of Obstetricians and Gynecologists. Each included article was evaluated according to study design and quality in accordance with the scheme outlined by the US Preventative Services Task Force.

RESULTS AND RECOMMENDATIONS

Abnormal placentation--encompassing placenta accreta, increta, and percreta--is increasingly common. While randomized controlled trials and large observational cohort studies that can be used to define best practice are lacking, strategies to enhance early diagnosis, enhance preparation, and coordinate peripartum management can be undertaken. Women with a placenta previa overlying a uterine scar should be evaluated for the potential diagnosis of placenta accreta. Women with a placenta previa or "low-lying placenta" overlying a uterine scar early in pregnancy should be reevaluated in the third trimester with attention to the potential presence of placenta accreta. When the diagnosis of placenta accreta is made remote from delivery, the need for hysterectomy should be anticipated and arrangements made for delivery in a center with adequate resources, including those for massive transfusion. Intraoperatively, attention should be paid to abdominal and vaginal blood loss. Early blood product replacement, with consideration of volume, oxygen-carrying capacity, and coagulation factors, can reduce perioperative complications.

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.