Role of Interventional Procedures in Obstetrics/Gynecology

Postpartum obstetric complications: a guide for radiologists

The puerperium refers to the 6-8 weeks following delivery, and is a dynamic period in which maternal anatomy and physiology are restored to their prepregnant state. Postpartum complications can be divided into non-obstetric and obstetric. The latter are the topic of this article and can be further classified as infectious, thrombotic, hemorrhagic or cesarean-related. Transvaginal US is often the initial modality in the evaluation of puerperal disorders. CT is probably the most valuable imaging technique when life-threatening conditions are suspected. Pelvic MRI is being increasingly used in cases of inconclusive findings or if further characterization is needed, especially in the setting of postsurgical complications or placental disorders. Diagnostic and interventional radiologists play a pivotal role in the evaluation and management of a variety of puerperal complications. Many of these conditions pose a diagnostic challenge, as imaging findings often overlap with normal postpartum changes, so keeping in mind the patient's clinical information is key.

Interventional Radiology in Obstetric Emergencies

Postpartum hemorrhage (PPH) is one of the common causes of morbidity as well as mortality among pregnant women. Obstetric hemorrhage embolization (OHE)/uterine artery embolization (UAE) is the preferred treatment for PPH which has failed medical therapy. In cases of placental accreta spectrum (PAS), balloon catheter can be prophylactically placed in internal iliac arteries (IIAs) bilaterally before delivery to enable postpartum control of bleeding. An inferior vena cava (IVC) filter can be placed under fluoroscopy for a pregnant woman with deep vein thrombosis (DVT) for whom anticoagulation is contraindicated or needs to be stopped at the time of labor. Injection of chemical into the gestational sac can be performed under ultrasonography (USG) guidance to treat ectopic pregnancy. Percutaneous or transvaginal drainage of a collection can be done by ultrasound or computed tomography (CT) guidance for puerperal sepsis. Percutaneous nephrostomy (PCN) is performed for obstructive ureterolithiasis in case of urosepsis or significant stone burden. Sonography should be used for the guidance of interventional radiology (IR) procedures whenever possible. Fluoroscopy must be used only if necessary, giving special attention to radiation-sparing maneuvers.

CIRSE standards of practice on gynaecological and obstetric haemorrhage

This CIRSE Standards of Practice document provides best practices for obstetric haemorrhage embolisation (OHE) in the management of postpartum haemorrhage (PPH). The document is aimed at interventional radiologists involved in treating postpartum haemorrhage, and has been developed by a writing group established by the CIRSE Standards of Practice Committee.

CIRSE Standards of Practice documents are not clinical practice guidelines and do not intend to impose a standard of care, rather provide reasonable approaches to and best practices for specific interventional radiology treatments and techniques.

Prevention of postpartum hemorrhage

Postpartum hemorrhage is a leading cause of severe maternal morbidity and mortality worldwide and the United States. While the rates of maternal mortality attributable to hemorrhage are declining, severe maternal morbidity continues to be a growing problem. Efforts in recent years to more appropriately identify patients at risk, define significant hemorrhage, quantify blood loss, and standardize approaches to care in pregnancy and postpartum have led to an increasing preventability of PPH. We aim to review the most current recommendation for the prevention and effective management of obstetric hemorrhage.

Role of Interventional Procedures in Obstetrics and Gynecology

Radiological guided intervention techniques are discussed in obstetric and gynecologic patients. Fallopian tube recanalization, postpartum hemorrhage control, techniques of treating uterine leiomyomas, pelvic congestion treatment, and the use of percutaneous and transvaginal ultrasonography-guided aspirations and biopsy are covered. These techniques use basic radiological interventional skills and show how they are adapted for use in the female pelvis.

Transarterial embolization for postpartum hemorrhage: lessons learned

BACKGROUND

Although transarterial embolization (TAE) can powerfully control postpartum hemorrhage (PPH), clinical failure of TAE is not uncommon.

PURPOSE

To discover whether any parameters could predict timely clinical failure of TAE, then whether a supplementary intervention could be promptly initiated.

MATERIAL AND METHODS

We retrospectively analyzed 118 TAE procedures in 113 patients with PPH performed at our institution between January 2012 and May 2015. The patients were divided into the following groups: clinically successful TAE and failed TAE. Successful TAE was defined as obviation of supplementary embolization or surgical intervention for hemostasis. Gestational conditions, angiographic factors, maternal vital signs, and laboratory data were compared between the two groups.

RESULTS

In total, 100 (84.8%) TAEs were clinically successful. Multivariate logistic regression analyses revealed independent risk factors of TAE clinical failure, including the requirement for augmented embolic agents, placental retention, and international normalized ratio > 1.3 ( P = 0.009, 0.001, and 0.005, respectively). The post-TAE shock index was significantly associated with TAE failure, using a cut-off value of 0.8.

CONCLUSION

The discovered independent risk factors of TAE clinical failure existed before or during the TAE procedure and could not reflect the post-TAE conditions. Although the post-TAE shock index was not an independent factor, it reflected the conditions after TAE and could indicate TAE clinical failure timely.

Clinical observation of fallopian tube obstruction recanalization by ozone

OBJECTIVE

To investigate the clinical effect of fallopian tube obstruction recanalization by ozone.

METHODS

Total 116 cases of patients undergoing the fallopian tube obstruction were randomly divided into the experimental group and control group, with 58 cases in each group. All patients underwent the interventional fallopian tube recanalization. The patients in the experimental group underwent the fallopian tube perfusion by the ozone water. Meanwhile, the patients in the control group were treated with the conventional anti-inflammatory and anti-adhesion drugs. After the follow-up visit for 6 months, the pregnancy rate and fallopian tube re-occlusion rate were counted and compared between the two groups. Meanwhile, the symptoms were evaluated and compared between the two groups after the operation for two weeks.

RESULTS

The success rate of fallopian tube recanalization was 93.1% (54/58), the pregnancy rate was 79.3% (46/58) and the recurrence rate was 5.2% (3/58) in the experimental group. While the success rate of fallopian tube recanalization was 91.4% (53/58), the pregnancy rate was 60.3% (35/58) and the recurrence rate was 17.2% (10/58) in the control group. Analysis showed that there was no significant difference in the recanalization success rate between the two groups (P>0.05). However, the pregnancy rate and re-occlusion rate in the experimental group were significantly lower than those of the control group (P<0.05), and the difference was statistically significant. There was no significant difference in the discomfort symptoms between the experimental group and control group (P>0.05).

CONCLUSION

Fallopian tube recanalization by ozone perfusion can effectively increase the postoperative pregnancy rate and reduce the fallopian tube re-occlusion.

Pelvic Artery Embolization in the Management of Obstetrical Hemorrhage: Predictive Factors for Clinical Outcomes

PURPOSE

To evaluate clinical outcomes of pelvic artery embolization (PAE) for treatment of obstetric hemorrhage, and determine the predictive factors associated with failure.

MATERIALS AND METHODS

This retrospective study included all consecutive patients who underwent PAE for obstetric hemorrhage (not only in the post-partum setting), between January 2003 and January 2013 at three tertiary care centers. Medical records and imaging were reviewed to identify the study population and collect data on patient characteristics, PAE characteristics, and outcomes. Multiple parameters were compared between the failed and successful PAE groups, and univariate analysis was performed to determine the predictive factors for PAE failure.

RESULTS

A total of 74 PAE procedures were performed in 68 patients. Primary clinical success rate was 78%. On univariate analysis, three factors were associated with PAE failure: hemodynamic instability (p < 0.022), hemoglobin level <95 g/dL (p < 0.024), and disseminated intravascular coagulation (DIC) (p < 0.046). Other factors, including maternal characteristics, antecedent history, angiographic finding, embolic agent, operator experience, procedure done after hours, and unilateral versus bilateral embolization, did not show any statistically significant association with PAE failure. Only one major complication was encountered, which was fetal demise in a pregnant patient with a uterine arteriovenous malformations. Out of the 68 patients, there were 61 total pregnancies at follow-up.

CONCLUSION

PAE is an effective treatment for obstetric hemorrhage, with a low complication rate, and preserves fertility. Factors significantly associated with PAE failure include hemodynamic instability, hemoglobin level <95 g/dL, and DIC.

Pregnancy after uterine artery embolization: a case report in a woman with leiomyomata

Background. Several pregnancies have been reported after embolization of uterine artery. This procedure is an accepted nonsurgical treatment for symptomatic uterine fibroids but its safety in women desiring future childbearing is not well established. Case Report. We present a 40-year-old woman with leiomyomata who became pregnant after previously undergone uterine artery embolization for three times. The placenta was previa and the fetus was in transverse position. She had a cesarean delivery of an appropriately grown fetus at 37 weeks, which was followed by uterine atony requiring hysterectomy. Conclusion. Although pregnancy-related outcomes remain understudied, the available reports evidence that pregnancies after uterine artery embolization may be at significantly increased risk for postpartum hemorrhage, cesarean delivery, abnormal placentation, and malpresentation. In patients who are undergoing this type of treatment and contemplating pregnancy, the possibility of adverse complications should be taken in consideration and women should be appropriately advised.

Spontaneous Hemoperitoneum due to Rupture of Uterine Varicose Veins during Labor Successfully Treated by Percutaneous Embolization

Hemoperitoneum during pregnancy is a rare but potentially lethal clinical condition. Improvements in antenatal and intrapartum care, especially in surgical and anesthetic techniques, have reduced maternal mortality; perinatal mortality remains very high (31%). Treatment is based on the systemic correction of hypovolemia and immediate surgery via laparotomy or laparoscopy in cases in the first trimester of pregnancy for hemostatic purposes. Sometimes, hysterectomy is needed. A 35-year-old Asiatic primigravid woman at 37 weeks' gestation with otherwise uneventful pregnancy came to the hospital referring abrupt-onset lumbar and abdominal pain. A bleeding uterine superficial varicocele of about 7 cm was found on the left uterine horn during Caesarean section. Interventional radiologic embolization of both uterine arteries was successfully performed. Posterior evolution of the patient was favorable. Percutaneous vascular embolization of the uterine arteries is an effective alternative treatment for many obstetrical and gynecological causes of bleeding. The main advantage of this technique is the low rate of serious complications and the preservation of reproductive function. To our knowledge, this is the first case of spontaneous intrapartum hemoperitoneum treated with this technique. An early diagnosis and a rapid indication of this therapeutic option are essential. Hemodynamic stability is needed to decide this conservative management.