Uterine Artery Embolization Following Internal Iliac Arteries Ligation in a Case of Post-Partum Hemorrhage: A Technical Challenge

Postpartum hemorrhage with associated placenta previa in a kidney transplant recipient: A case report

INTRODUCTION

The efficacy and safety of uterine artery embolization (UAE) and prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA) against postpartum hemorrhage (PPH) in pregnant women after kidney transplantation have not been reported. Here, we describe a case of PPH associated with placenta previa in pregnancy following kidney transplantation, which was managed with UAE and prophylactic REBOA.

CASE PRESENTATION

A 35-year-old, gravida 2, para 1 woman with total placenta previa presented with vaginal 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.

Ipsilateral Uterine Artery Access Through Unilateral Transfemoral Approach Using Simple-Curve Catheter

Uterine artery embolization (UAE) is a technique for management of various obstetrical and gynecological problems. Transfemoral approach (TFA) is preferred which can be unilateral or bilateral; however, unilateral puncture is preferred due to lesser chances of puncture-related complications as compared to bilateral puncture. UAE through unilateral TFA is possible with use of reverse loop catheters (Roberts uterine catheter [RUC] or Gandras catheter) to access ipsilateral uterine artery. Other way of cannulating the ipsilateral uterine artery is by maneuvering catheters to form Waltman's loop/Simmon's reverse loop. With advent of RUC, unilateral TFA became standard of care. In the recent past, RUC was retracted from Indian market and its nonavailability had mandated use of either bilateral TFA or use of catheters and techniques used in the past for unilateral TFA. Herein, we describe a technique of doing UAE by unilateral TFA using simple gentle curve catheter (Picard) by making a reverse curve loop.

Anatomical basis for the uterine vascular control: implications in training, knowledge, and outcomes

The efficiency of uterine vascular control depends on the precise management of its arterial pedicles and anastomotic network. Although all specialists know the uterine and ovarian arteries, only a few are familiar with the anatomy of the inferior supply system and the connections of the pelvic vessels. For this reason, specific proven inefficient hemostatic procedures are still used worldwide. The pelvic arterial system is extensively interconnected with the aortic, internal iliac, external iliac, and femoral anastomotic components. Most uterine vascular control methods act on the blood supply to the uterus and ovary but rarely on the anastomotic network of the internal pudendal artery. Therefore, the effectiveness of vascular control procedures depends on the topographic area in which they are performed. In addition, the procedure's effectiveness depends on the skill and experience of the operator, among other factors. From a practical point of view, the uterine arterial supply is divided into 2 sectors, sector S1, which involves the uterine body, supplied by the uterine and ovarian arteries, and sector S2, which includes the uterine segment, the cervix, and the upper part of the vagina, provided by pelvis subperitoneal pedicles arising from the internal pudendal artery. As both sectors receive different arterial pedicles, the hemostatic procedures for one or the other are also different. The urgent nature of obstetrical hemorrhage, correct application of a specific technique, surgeon experience, time to provide accurate informed consent in a person under a life-threatening condition, lack of precise or possible harmful consequences of the proposed method, lack of randomized controlled trials or multiple phase II trials, epidemiologic data, qualitative data, and reports from the field from clinicians using an intervention multiple other aspects could be impossible to randomize all patients to obtain more precise information. Apart from actual effectiveness, there are no reliable morbidity data, as most complications are rarely published for various reasons. However, a simple and current presentation of pelvic and uterine blood supply and its anastomotic system allows readers to understand the value of different hemostatic procedures.

Ovarian reserve after internal iliac artery ligation

AIM

Ligation of major vessels supplying ovaries may alter hormones and ovarian reserve due to disturbances of vascular circulation. Our purpose is to measure serum anti-Müllerian hormone (AMH) levels and ovarian volume in patients who had internal iliac artery ligation (IIAL) and/or IIAL plus hysterectomy due to uterine atony.

METHODS

Patients who underwent IIAL and IIAL+ hysterectomy were evaluated 6 months after their operations and were compared with the control group. The hormones, ovarian volume and antral follicle count (AFC) were measured in each group.

RESULTS

Serum AMH levels in the post-partum 6th month interval were lower in the IIAL group than in the control group and were the lowest in the IIAL+ hysterectomy group. Similar to AMH results, AFC and ovarian volumes were also lowest in the IIAL+ hysterectomy group.

CONCLUSION

IIAL and hysterectomy are lifesaving interventions during peripartum hemorrhage; however, they might alter ovarian reserve in the short term.