Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution

Clinical outcomes and future fertility after uterine artery embolization for postpartum and post-abortion hemorrhage

BACKGROUND

Postpartum hemorrhage (PPH) and post-abortion hemorrhage (PAH) are life-threatening conditions.

PURPOSE

To evaluate the efficacy and safety of uterine arterial embolization (UAE) for PPH and PAH and to investigate future fertility after UAE.

MATERIAL AND METHODS

This study included 57 consecutive patients (mean age = 34 years) who underwent UAE for PPH (n = 46) and PAH (n = 11) at our institution between January 2011 and December 2022. Technical success, non-visualization of the peripheral portion of bilateral uterine arteries on angiography, and clinical success, complete hemostasis after UAE, were assessed. UAE-associated complications and factors related to clinical success were analyzed. Pregnancy outcomes after UAE and complications during subsequent pregnancy were investigated in 16 patients who desired fertility and were followed up for >1 year.

RESULTS

The technical and clinical success rates were 100% and 84.2%, respectively. Sepsis (n = 1) and uterine empyema (n = 1) were observed as severe complications. Placental disorder, bleeding within 24 h after delivery or abortion, ≥1.5 shock index, ≥6 units of transfusion erythrocytes, and ≥8 obstetrical disseminated intravascular coagulation score were significantly associated with unfavorable clinical outcomes. In total, 16 pregnancies were observed in 12 patients after UAE, three of which were miscarriages and 13 were successful live births. During pregnancy, uterine rupture (n = 1) and accreta (n = 1) were observed.

CONCLUSION

UAE is an effective treatment for PPH and PAH. Although UAE could preserve future fertility, careful attention should be paid to perinatal management for unusual complications.

Fertility after Transcatheter Arterial Embolization for Obstetric Hemorrhage: An Urban Health Care System Observational Study

OBJECTIVE

This study aimed to investigate pregnancy rate, pregnancy outcomes, and resumption of menses after transcatheter arterial embolization (TAE) for obstetric hemorrhage (OH).

STUDY DESIGN

Sixty-seven patients who underwent TAE for OH from 2006 to 2020 within an urban, multihospital health care system were identified retrospectively. Selected patients were interviewed by phone to complete a survey with a primary outcome of self-reported pregnancy in those seeking pregnancy. Secondary outcomes included pregnancy outcomes and resumption of menses. Univariate testing of association of pregnancy and miscarriage rate with embolic agent was performed using Fisher's exact test.

RESULTS

Thirty-three of 50 patients (66%) meeting the inclusion criteria completed the survey on fertility, a median of 47 (range, 13-123) months after TAE for OH. Of the 13 patients who attempted pregnancy, there was a pregnancy rate of 77% and miscarriage rate of 38%. Those who delivered live newborns conceived spontaneously, carried to term, and delivered a healthy newborn via cesarean section at a weight appropriate for gestational age. Thirty (91%) patients resumed menstruation, and the majority with unchanged frequency. Most patients underwent bilateral uterine artery embolization with radial artery access (54%). The most common embolic agents used were gelfoam only (30%) and glue only (24%). There was no statistically significant association between embolic agent and pregnancy or miscarriage rate.

CONCLUSION

Spontaneous pregnancy with live birth and resumption of menses can occur in a majority of patients after TAE for OH.

KEY POINTS

· Most patients who attempted pregnancy after TAE for OH achieved pregnancy.. · Most patients who became pregnant conceived spontaneously and delivered healthy newborns at term.. · Most patients resumed menstruation after TAE for OH.. · There was no significant association between type of embolic and pregnancy or miscarriage rate..

Safety and efficacy of pelvic arterial embolization for primary postpartum hemorrhage in hemodynamically stable and hemodynamically unstable patients: Is it "time" for a paradigm change?

BACKGROUND

Pelvic artery embolization (PAE) is an effective and safe technique for treating postpartum hemorrhage (PPH) with hemodynamic stability. However, its use in hemodynamically unstable patients remains controversial.

PURPOSE

To determine the safety and efficacy of pelvic arterial embolization (PAE) according to the hemodynamic state of primary postpartum hemorrhage (PPH) patients.

METHODS

This cohort study was conducted retrospectively, using data from January 2004 to December 2021, in a resource-rich setting at a tertiary Level 1 trauma academic center. A total of 437 patients were diagnosed with PPH during the study period. Of these 437 patients, 161 with primary PPH who underwent PAE were enrolled in the study. The outcomes assessed included the clinical success rate, mortality, the overall success rate, predictive factors for failed PAE, and time-dependent changes in hemodynamic parameters, such as systolic blood pressure (SBP), heart rate (HR), and shock index (SI). Propensity score (PS) matching analysis was performed to assess the influence of specific variables or conditions on the outcomes.

RESULTS

Of the 161 patients who underwent PAE for primary PPH (mean age, 32.9 ± 4.3 [SD]), 85 were retrospectively categorized as having hemodynamic stability (mean age, 32.6 ± 4.1 [SD]), while 76 were categorized as having hemodynamic instability (mean age, 33.3 ± 4.4 [SD]). This study showed PAE for primary PPH had a success rate of 91.9 %, with no significant difference in mortality rates between the groups. The clinical success rate was 98.8 % for patients with hemodynamic stability and 84.2 % for those with hemodynamic instability (p < .001). The overall success rate was 98.8 % for hemodynamic stability and 89.5 % for hemodynamic instability (p = .014). After propensity score matching, the clinical success rate was higher in hemodynamically stable patients than in unstable ones (100 % vs. 86.3 %, p = .013). However, there was no significant difference in the overall success rate (100 % vs. 90.2 %, p = .056). Among the PS-matched population, predictive factors for the failed PAE in primary PPH were hemodynamic instability (adjusted odds ratio [aOR] 21.22, 95 % CI 1.27-355.76; p = .034) and emergency Cesarean delivery with accompanying hemorrhag (aOR 54.00, 95 % CI 11.93-244.56; p = .008). In three groups within a PS-matched population - hemodynamically stable, unstable with successful outcomes, and unstable with unsuccessful outcomes, a generalized linear mixed model (GLMM) analysis for time-dependent changes in hemodynamic parameters revealed a statistically significant difference in SBP, HR, and SI at various time points.

CONCLUSION

Pelvic arterial embolization of primary postpartum bleeding in hemodynamic instability has been identified as an alternative, safe, and effective life-saving procedure for multidisciplinary treatment in resource-rich environments even after the baseline characteristics are balanced by the PS matching, suggesting it is a primary care option.

Endometritis risk factors after arterial embolisation for postpartum haemorrhage

Various complications of arterial embolisation (AE) for postpartum haemorrhage (PPH) are reported. Endometritis (EM) frequently causes abscesses, increasing hysterectomy risk. However, risk factors for EM after AE for PPH are unclear. We explored these risk factors. We included patients who underwent AE for PPH in our hospital from 2005 to 2020 and compared those who did (EM group) and did not develop EM after AE (non-EM group) in a case-control study. Twenty patients met the study criteria; eight patients (40%) had EM. There were no differences in risk factors between groups involved in infection, such as premature rupture of membranes. However, the contrast medium extravasation rate on computed tomography scans before the AE procedure was significantly higher in the EM group (p=.019) compared to the non-EM group. The greatest EM risk factor was contrast medium extravasation before AE for PPH, determined by classification and regression tree modelling (relative risk: 4.5).Impact StatementWhat is already known on this subject? Reportedly, the clinical success rate of arterial embolisation (AE) for critical haemorrhage in obstetrics is high, around 90%. However, information regarding AE complications is limited. Endometritis is one of these complications, which not only causes prolonged hospitalisation but may also require further treatment, such as hysterectomy. However, the incidence rate and risk factors for EM remain unknown.What do the results of this study add? In this study, 40.0% of patients developed EM after AE for PPH. Extravasation of contrast medium was the top risk factor (relative risk: 4.5 compared to those without EM, p=.019). The second-leading risk factor was a bleeding volume greater than 2500 mL (relative risk: 4.5 compared to those without EM, p=.019).What are the implications of these findings for future clinical practice and/or future research? We created an EM prediction model using extravasation and a bleeding volume greater than 2500 mL. The model was 87.5% sensitive and 66.7% specific. This prediction model allows for the early detection and treatment of EM by recognising high-risk patients and providing intensive postpartum management.

Patient blood management to minimize transfusions during the postpartum period

Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.

Hysterectomy Sparing Management of Uterine Necrosis following Uterine Artery Embolization for Postpartum Hemorrhage

Background

Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Uterine artery embolization (UAE) is an effective procedural intervention for controlling PPH. Uterine necrosis (UN) is a rare complication of UAE and its management usually results in hysterectomy. We highlight a case of UAE complicated by UN managed conservatively without hysterectomy.

Case

This is the case of a 30-year-old patient who had a cesarean section delivery and subsequently developed PPH due to uterine atony. The estimated blood loss (EBL) was 2500 ml; despite the use of uterotonic medications and trial of intrauterine balloon tamponade. She successfully underwent a UAE with no immediate complications. The remainder of her postnatal course was uncomplicated, and she was discharged on postoperative day 4. On postoperative day 28, the patient presented with fever, vaginal discharge, and abdominal pain. An abdomino-pelvic computed tomography scan revealed areas of necrosis within the uterus secondary to recent UAE. After minimal clinical improvement, the patient underwent a dilation and curettage with ultrasound guidance. The patient improved clinically and was discharged home to complete a 14-day course of antibiotics.

Conclusion

UAE is an important minimally invasive approach to the management of PPH. UN following UAE can present a clinical challenge to physicians, with the underlying pathophysiology being use of small embolizing particles during UAE and lack of arterial collaterals to embolized areas. A total of 19 cases of UN post-UAE have been described of which most of these cases were managed with a hysterectomy. In this case, an alternative treatment plan was successfully implemented via dilation and curettage under ultrasound guidance for removal of organized necrotic tissue. This was sufficient to improve the patient's symptoms and clinical outcome and saved the patient from the morbidity and mortality risks associated with a hysterectomy.

Interventions of Postpartum Hemorrhage

Postpartum hemorrhage is a common and potentially life-threatening obstetric complication, with successful management relying heavily on early identification of hemorrhage and prompt intervention. This article will review the management of postpartum hemorrhage, including initial steps, exam-specific interventions, medical therapy, minimally invasive, and surgical interventions.

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage

Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

Usefulness of transcatheter arterial embolization for eighty-three patients with secondary postpartum hemorrhage: Focusing on difference in angiographic findings

BACKGROUND

Transcatheter arterial embolization (TAE) has been widely used as an effective and a safe treatment method and was often used as an alternative to the surgical management, but there are limited studies on the efficacy and the safety for patients undergoing their secondary postpartum hemorrhage (PPH).

AIM

To evaluate the usefulness of TAE for secondary PPH focusing on the angiographic findings.

METHODS

We conducted a research from January 2008 to July 2022 on all 83 patients (mean: 32 years, range: 24-43 years) presented with secondary PPH and they were treated with TAE in two university hospitals. The medical records and angiography were retrospective reviewed in order to evaluate the patients’ characteristics, delivery details, clinical status and peri-embolization management, angiography and embolization details, technical/clinical success and complications. The group with active bleeding sign and the group without it were also compared and analyzed.

RESULTS

On angiography, 46 (55.4%) patients showed active bleeding signs such as contrast extravasation (n = 37) or pseudoaneurysm (n = 8) or both (n = 1), and 37 (44.6%) patients showed non-active bleeding signs such as only spastic uterine artery (n = 2) or hyperemia (n = 35). In the active bleeding sign group there were more multiparous patients, low platelet count, prothrombin time prolongation, and high transfusion requirements. The technical success rates were 97.8% (45/46) in active bleeding sign group and 91.9% (34/37) in non-active bleeding sign group, and the overall clinical success rates were 95.7% (44/46) and 97.3% (36/37). An uterine rupture with peritonitis and abscess formation occurred to one patient after the embolization, therefore hysterostomy and retained placenta removal were performed which was a major complication.

CONCLUSION

TAE is an effective and a safe treatment method for controlling secondary PPH regardless of angiographic findings.

Uterine Perforation as a Complication of the Intrauterine Procedures Causing Omentum Incarceration: A Review

OBJECTIVE

Omentum involvement resulting from uterine perforation is a rare complication following intrauterine procedures that might require immediate intervention due to severe ischemic consequences. This review examines the prevalence of this complication, risk factors, the mode and timing of diagnosis, the proper management and the outcome.

METHODS

A systematic literature search was conducted on PubMed, PubMed Central and Scopus using uterine perforation, D&C, abortion and omentum as keywords. The exclusion criteria included the presence of the uterus or placenta's malignancy and uterine perforation following delivery or caused by an intrauterine device.

RESULTS

The review included 11 articles from 133 screened papers. We identified 12 cases that three evaluators further analysed. We also present the case of a 32-year-old woman diagnosed with uterine perforation and omentum involvement. The patient underwent a hysteroscopic procedure with resectioning the protruding omentum into the uterine cavity, followed by intrauterine device insertion.

CONCLUSION

This paper highlights the importance of a comprehensive gynaecological evaluation following a D&C procedure that includes a thorough clinical examination and a detailed ultrasound assessment. Healthcare providers should not overlook the diagnosis of omentum involvement in the presence of a history of intrauterine procedures.

Effectiveness of Uterine Arterial Embolization and Risk Factors Associated with Its Failure in Patients with Primary Postpartum Hemorrhage After Cesarean Section

Background: Postpartum hemorrhage (PPH), a serious labor-related complication, is the leading cause of maternal mortality, which requires an emergent intervention. Uterine arterial embolization (UAE) is an effective treatment for hemostasis of intractable PPH. Several risk factors have been reported for the failure of UAE. Objectives: To evaluate the clinical outcomes of UAE for the treatment of primary PPH following cesarean section (CS) and to determine the risk factors associated with the failure of this procedure. Methods: This retrospective, single-center study was approved by the institutional review board, and the requirement to obtain informed consent was waived. All patients referred to a tertiary care center, who underwent UAE for primary PPH between January 2018 and December 2020, were included. The patients’ medical records and radiological findings, including the patients’ characteristics, mode of delivery, initial vital signs and laboratory findings after hospitalization, procedure details, and embolization outcomes, were evaluated for data collection. Technical success was defined as appropriate embolization of target vessels on a completion angiogram. Clinical success was defined as adequate cessation of bleeding after the first embolization, without any need for subsequent embolization or surgical intervention. Statistical analysis was performed to determine factors related to the clinical failure of UAE in CS cases. Results: UAE was performed for 25 patients (mean age, 37.2 years; range, 25 - 45 years). The technical success rate was estimated at 100% (n = 25), and the clinical success rate was 76% (n = 19). There were no patients with permanent adverse sequelae or death. The univariate analyses showed that hemodynamic instability (P = 0.006), lower hemoglobin levels (P = 0.02), and prolonged activated partial thromboplastin time (aPTT) (P = 0.017) were related to clinical failure. The logistic regression analysis adjusted for age showed that the area under the curve (AUC) was 0.86 for hemoglobin (95% CI: 0.7 - 1; cutoff value: 0.667), 0.816 for aPTT (95% CI: 0.625 - 1; cutoff value: 0.411), and 0.868 for hemodynamic instability (95% CI: 0.661 - 1; cutoff value: 0.622). Conclusions: UAE is a safe and effective treatment for primary PPH following CS. Hemodynamic instability, low hemoglobin levels, and prolonged aPTT can be predictive factors for the poor outcomes of UAE in CS patients. These factors are rapid and straightforward criteria, which can be simply applied, even in emergency situations.

Procedural techniques to control postpartum hemorrhage

Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. Treatment procedures include obstetric, surgical, and radiologic techniques. In addition to availability and experience with the techniques, two important aspects must be considered in the selection process: the type of delivery and the cause of the hemorrhage. In particular, the distinction between pregnancies with or without disturbed placentation from the placenta accreta spectrum is crucial. From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.

Evidences in Uterine Artery Embolization: A Radiologist's Primer

Uterine artery embolization is an established minimally invasive therapy for symptomatic fibroids. It has also been used for other diseases of the uterus, including adenomyosis, uterine arteriovenous malformation, ectopic pregnancy, abnormal invasive placenta, and postpartum hemorrhage. In this review, we provide an updated and comprehensive review of uterine artery embolization based on the evidence published. We review the indications, the role of MRI, technical aspects, and complications of the procedure. The issues with a future pregnancy, risk of infertility, and fetal radiation are discussed as well.

Transcatheter arterial embolization for hemorrhage after gynecologic hysterectomy: a multicenter study

BACKGROUND

Transcatheter arterial embolization (TAE) is not common for hemorrhagic complications after gynecologic hysterectomy.

PURPOSE

To evaluate the effectiveness and safety of TAE for hemorrhage after hysterectomy for gynecologic diseases.

MATERIAL AND METHODS

This is a retrospective, multicenter study, which investigated 11 patients (median age = 45 years) who underwent TAE for hemorrhage after gynecologic hysterectomy between 2004 and 2020.

RESULTS

The median interval between surgery and angiography was one day (range = 0-82 days). Hemodynamic instability and massive transfusion were present in 6 (54.5%) and 4 (36.4%) patients, respectively. CT scans (n = 7) showed contrast extravasation (n = 5), pseudoaneurysm (n = 1), or both (n = 1). On angiography, the bleeding arteries were the anterior division branches of the internal iliac artery (IIA) (n = 6), posterior division branch (lateral sacral artery, n = 1), and inferior epigastric artery (n = 1) in eight patients with active bleeding. In the remaining three patients, angiographic staining without active bleeding foci was observed at the vaginal stump, and the feeders for staining were all anterior division branches of the IIA. Technical and clinical success rates were 100% and 90.9% (10/11), respectively. In one patient, active bleeding focus was successfully embolized on angiography, but surgical hemostasis was performed for suspected bleeding on exploratory laparotomy. Postembolization syndrome occurred in one patient.

CONCLUSIONS

TAE is effective and safe for hemorrhage after hysterectomy for gynecologic diseases. Angiographic findings are primarily active bleeding, but angiographic staining is not uncommon. A bleeding focus is possible in any branch of the IIA, as well as the arteries supplying the abdominal wall.

Resuscitative endovascular balloon occlusion of the aorta for life-threatening postpartum hemorrhage: A nationwide observational study in Japan

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used for postpartum hemorrhage (PPH) which is one of the leading causes of maternal mortality worldwide; however, its utility in the obstetrics setting remains unclear. Thus, this study aimed to describe the characteristics, demographics and mortality of patients with PPH who underwent REBOA.

METHODS

We used the Japanese Diagnosis Procedure Combination inpatient database to identify patients with PPH who underwent REBOA from April 2012 to March 2020. We examined the patients' characteristics, interventions administered and in-hospital mortality.

RESULTS

We identified 143 patients with PPH who underwent REBOA. The most common cause of PPH was atonic postpartum hemorrhage (52.4%), followed by disseminated intravascular coagulation (29.4%) and amniotic fluid embolism documented (11.2%). Among patients who delivered at hospitals in which REBOA was performed (n = 55), 38.2% of patients experienced preterm births and 70.9% delivered via cesarean section. The proportion of patients who underwent transcatheter arterial embolization and hysterectomy was 53.8% and 16.1%, respectively. In-hospital mortality was 7.0%.

CONCLUSION

The results of the present study could be helpful in clinical decision-making and providing patients and families with additional treatment options for PPH.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Uterine Artery Embolization as an Effective Management and Diagnostic Tool for Puerperal Uterine Inversion with Severe Postpartum Bleeding: A Case Report

Acute puerperal uterine inversion is a rare postpartum obstetric complication; however, without rapid diagnosis and appropriate management, it is life-threatening. Substantial bleeding hinders the verification of a partially inverted uterus, possibly delaying the treatment. Herein, we present the report of a 32-year-old female presenting with massive postpartum bleeding managed by uterine artery embolization. The peculiar course of the uterine artery bowing inferiorly along the inverted fundus during embolization could uncover the uterine inversion, which was not diagnosed by physical examination and CT. In conclusion, uterine artery embolization is not only an effective therapeutic strategy for postpartum hemorrhage but also a valuable tool for diagnosing uterine inversion.

Postpartum hemorrhage - what the interventional radiologist should know

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality around the world and can be caused by multiple etiologies. Distinguishing between the various etiologies that lead to PPH and identifying high risk features are crucial to implementing effective clinical management. In this review, the diagnostic imaging features and management principles of some of the most important causes of postpartum hemorrhage are discussed, with an emphasis on the pearls and pitfalls when minimally invasive treatment via interventional radiologic techniques are employed.

Clinical characteristics and haemodynamic state of patients undergoing interhospital transfer for postpartum haemorrhage: A study of a single-centre helicopter emergency medical service

OBJECTIVE

Uterine artery embolization is an attractive option for the management of postpartum haemorrhage, however it is not available in every hospital. We compared the clinical characteristics and haemodynamic state of patients with postpartum haemorrhage, before and after helicopter transfer to a tertiary hospital for possible uterine artery embolization. We also analysed whether the type of treatment could modify the outcome.

STUDY DESIGN

Between 1999 and 2019 in Switzerland, we retrospectively found 82 consecutive patients with postpartum haemorrhage who were transferred by a physician-staffed helicopter emergency medical service to the tertiary hospital for potential uterine artery embolization. The collected data included the type of delivery, estimated blood loss, shock index and blood lactate levels before transfer and at destination, uterine artery embolization rate and hospital mortality rate. Our primary outcome was to describe the clinical characteristics, outcomes and haemodynamic state of the patients with postpartum haemorrhage before and after helicopter transfer. Our secondary outcome was to report the treatments performed at the tertiary hospital. The collected data were analysed with Stata version 14 (Stata Corporation, College Station, TX, USA). Continuous data are compared by using the Student's t-test or the Mann-Whitney U test, as appropriate.

RESULTS

We included 69 patients. Postpartum haemorrhage occurred after vaginal delivery in 38 cases (55%). Blood loss prior to transfer exceeded 2 L in 34% of cases. The median shock index was 1 (IQR 0.8-1.1) before transfer and 0.9 (IQR 0.8-1.1) after transfer (p = 0.41). The median lactate level was 2.9 mmol/L (IQR 2.1-6.8) before, and 2.1 mmol/L (IQR 1.55-3.5) after transfer (p = 0.90). Forty-four patients underwent uterine artery embolization (64%), with an overall success rate of 93%. One patient died (1.4%), from a haemorrhagic shock of abdominal origin.

CONCLUSIONS

Interhospital helicopter transfer of patients with postpartum haemorrhage to a tertiary hospital seems to be safe in our setting, despite a significant proportion of patients exhibiting signs of haemodynamic instability. Decision criteria would be helpful to better guide choices regarding the transfer of patients with postpartum haemorrhage.

Successful repeated uterine artery embolization in postpartum hemorrhage with disseminated intravascular coagulation: a case report and literature review

Background

Postpartum hemorrhage (PPH) is a potentially fatal condition requiring urgent and appropriate intervention. Uterine artery embolization (UAE) has a high hemostatic capacity for PPH, but it may fail. Disseminated intravascular coagulation (DIC) has been reported as a risk factor associated with the failure of UAE.

Case presentation

A 37-year-old primigravida with dichorionic diamniotic twins and placenta previa underwent cesarean section. The blood loss during surgery was 4950 mL. Hemostasis was achieved using an intrauterine balloon tamponade device. However, she lost a further 2400 mL of blood 5 h after surgery. We embolized both uterine arteries using gelatin sponges and confirmed hemostasis. She was suffering from DIC and received ample blood transfusions. However, a further 1300 mL of blood was lost 18 h after surgery and we performed repeated UAE, with complete recanalization of the uterine arteries on both sides and re-embolization with gelatin sponges. Her DIC was treated successfully by blood transfusions at this time, and she showed no further bleeding after the repeated UAE.

Conclusions

DIC is a risk factor for the failure of UAE. Repeated UAE may be effective after sufficient improvement of the hematological status in patients with PPH and DIC.

Uterine artery Embolization: Interventional Radiologist's Perspective in Management of Uncontrolled Obstetric Hemorrhage

Purpose

To study the efficacy and safety of uterine artery embolization in treatment of obstetric hemorrhage.

Methods

This ethically approved prospective study was conducted between November 2017 and October 2019, and written informed consent was obtained from all patients. Consecutive patients presenting with uncontrolled obstetric hemorrhage were evaluated. Fifty-three patients with uncontrolled bleeding underwent uterine artery embolization (UAE) and were followed up.

Results

Spectrum of patients encountered in this study was arteriovenous malformations (AVMs) (n = 25), retained products of conception (RPOC) (n = 16), RPOC with secondary AVMs (n = 5), ectopic pregnancy (n = 5) and iatrogenic trauma to cervix or vagina (n = 2). A total of 57 UAE procedures were performed in these 53 patients as repeat sessions were required in four patients. Most common embolic agent used was polyvinyl alcohol (PVA) particles with gelfoam followed by cyanoacrylate glue as second most common agent. Technical success was achieved in 57 (100%) of 57 UAE procedures. Primary clinical success was achieved in 49 (92%) of 53 patients and secondary clinical success in 52 (98%) patients. Clinical failure was observed in one patient who underwent hysterectomy.

Conclusion

Uterine artery embolization is a safe and effective procedure in the management of uncontrolled obstetric hemorrhage.

Imaging evaluation of uterine perforation and rupture

Uterine perforation and rupture, denoting iatrogenic and non-iatrogenic uterine wall injury, respectively, are associated with substantial morbidity,and at times mortality. Diverse conditions can result in injury to both the gravid and the non-gravid uterus, and imaging plays a central role in diagnosis of such suspected cases. Ultrasound (US) is the initial imaging modality of choice, depicting the secondary signs associated with uterine wall injury and occasionally revealing the site of perforation. Computed tomography can be selectively used to complement US findings, to provide a more comprehensive picture, and to investigate complications beyond the reach of US, such as bowel injury. In certain scenarios, magnetic resonance imaging can be an important problem-solving tool as well. Finally, catheter angiography is a valuable tool with both diagnostic and therapeutic capability, with potential for fertility preservation. In this manuscript, we will highlight the clinical and imaging approach to uterine perforation and rupture, while emphasizing the value of various imaging modalities in this context. In addition, we will review the multi-modality imaging features of uterine perforation and rupture and will address the role of the radiologist as a crucial member of the management team. Finally, a summary diagrammatic depiction of imaging approach to patients presenting with uterine perforation or rupture is provided.

Three-dimensional computed tomography is effective in diagnosing uterine arterial pseudoaneurysm, a cause of secondary postpartum hemorrhage: A case report

Uterine artery pseudoaneurysm is a rare cause of secondary postpartum hemorrhage. Herein, we report a case of uterine artery pseudoaneurysm, with postpartum hemorrhage commencing 22 days after uncomplicated vaginal delivery. Intermittent bleeding occurred during conservative observation. Transvaginal ultrasound color Doppler imaging revealed swollen vascular structures that suggested arteriovenous malformations, and a saccular dilatation of blood vessels. However, it was insufficient to definitively diagnose the condition as pseudoaneurysm. Meanwhile, the three-dimensional computed tomography angiogram was effective in demonstrating a pseudoaneurysm in the uterus, and an absent early venous return sign, leading to the final diagnosis of a pseudoaneurysm. The patient was successfully treated with transarterial embolization using gelatin sponge pledgets. No bleeding or recurrence of the pseudoaneurysm was observed 2 months after embolization.

The Efficacy of Transarterial Embolization for Postpartum Hemorrhage Complicated with Disseminated Intravascular Coagulation: A Single-Center Experience

Indications for the use of transarterial embolization (TAE) for postpartum hemorrhage (PPH) have been established. However, the efficacy of TAE for PPH complicated by disseminated intravascular coagulation (DIC) remains controversial. In this study, we investigated the efficacy of TAE for PPH complicated by DIC. A database review was conducted to identify patients who were treated with TAE for PPH at our hospital. TAE was performed in 41 patients during the study period. Effective hemostasis was achieved in all cases, but additional procedures, such as re-embolization or hysterectomy, were required in five patients (12.2%). The typical causes of PPH included uterine atony (18 cases), placenta previa (15 cases), amniotic fluid embolism (DIC-type) (11 cases), and placenta accreta spectrum (10 cases). The mean blood loss was 3836 mL. The mean obstetrical DIC and the International Society on Thrombosis and Hemostasis DIC scores were 7.9 and 2.6, respectively. The efficacy of hemostasis was comparable between patients with and without DIC. However, the complete success rate of TAE was lower in patients with DIC as the condition worsened than that in non-DIC patients. Overall, TAE is effective as a minimally invasive treatment for PPH complicated by DIC.

Comparison of a novel isthmic circumferential suture and Bakri balloon technique for the treatment of uterine atony during cesarean section

BACKGROUND

Postpartum bleeding is a life-threatening obstetric complication. The most common cause is uterine atony. There is no method that can treat PPH with 100% effectiveness and therefore, efforts for the development of more effective conservative treatment methods continue. The aim of the study is to compare the effectiveness of the isthmic circumferential suture technique and the Bakri balloon tamponade in the treatment of postpartum bleeding due to uterine atony during cesarean operation.

METHODS

This study was conducted by retrospectively evaluating the cases who developed uterine atony during cesarean section. Group 1 (n = 15) consisted of the patients who had undergone the isthmic circumferential suture technique, and Group 2 (n = 15) comprised patients who had undergone the Bakri balloon tamponade. The two groups were compared with regard to obstetric characteristics, operative time, preoperative and postoperative features, and neonatal outcomes.

RESULTS

The groups were similar with regard to age, obstetric characteristics, preoperative complete blood count, neonatal outcomes and there was no statistically significant difference between groups. The operative time was significantly shorter in Group 1 (61.86 ± 6.7 vs. 69.53 ± 3.2 min; p < .05). The amount of intraoperative bleeding was lower in Group 1, although there was no statistically significant difference (1793.66 ± 323.96 versus 1886.33 ± 343.23 ml; p > .05). The postoperative blood loss was significantly less in Group 1 compared to Group 2 (101.37 ± 64.6 versus 169.32 ± 50.0 ml; p < .05). The postoperative 24-hour Htc values were significantly higher in Group 1 (28.83 ± 2.1 versus 27.08 ± 2.1 g/dl; p < .05).

CONCLUSION

Both methods are effective in the uterine atony during cesarean section. However, due to the shorter operative time and less pre-operative blood loss, the isthmic circumferential suture technique may be a better alternative.

Efficacy of superselective transcatheter arterial embolization for intractable postpartum hemorrhage due to genital tract trauma after vaginal delivery

Purpose

To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) for intractable postpartum hemorrhage (PPH) due to genital tract trauma (GTT) after vaginal delivery.

Methods

We evaluated 27 patients who underwent TAE for intractable PPH due to GTT after vaginal delivery at our institution between January 2008 and December 2020. Patients were divided into two groups according to TAE procedure; TAE performed as close as possible to the bleeding point, at least more peripherally than the second branch of the anterior division of the internal iliac artery, was defined as superselective TAE (S-TAE). TAE performed from the proximal segment of the internal iliac artery was defined as proximal TAE (P-TAE). Patient characteristics, pre-procedural contrast-enhanced computed tomography (CE-CT), procedure details, technical/clinical success, and complications were evaluated separately for the S-TAE and P-TAE groups.

Results

The combined technical/clinical success rate was 92%. No major procedure-related complications were seen (mean follow-up: 6.12 ± 3.93 days). The combined technical/clinical success rate of S-TAE was 100% and of P-TAE was 67% (p = 0.04). S-TAE was performed more frequently in patients with pre-procedural CE-CT (p = 0.01) and use of permanent embolic materials (p = 0.003).

Conclusion

S-TAE is safe and effective for intractable PPH due to GTT. Pre-procedural CE-CT may be useful for detecting the culprit artery and be helpful in performing S-TAE.

Uterine Artery Embolization for Primary Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a common source of morbidity and mortality for delivering mothers worldwide, resulting in greater than 100,000 deaths per annum. Pathologic postpartum hemorrhage is defined as blood loss greater than 500 mL for vaginal deliveries and 1,000 mL for caesarean births, which occurs in up to 10% of deliveries. Severe postpartum hemorrhage can progress to shock, disseminated intravascular coagulation (DIC) and death. PPH is further characterized by time of onset; primary PPH occurs within 24 hours of parturition, and secondary PPH beyond that. Secondary hemorrhage is discussed in a separate article in this issue, this article will exclusively explore primary postpartum hemorrhage. PPH arises from a number of etiologies, including uterine atony, birth canal/perineal lacerations and intrapelvic arterial injuries. PPH is primarily managed by standard medical obstetric maneuvers including uterotonics, fundal massage, intrauterine (Bakri) balloon tamponade and direct control of hemorrhage where applicable. Definitive control with hysterectomy is preserved for hemorrhage refractory to conservative and minimally-invasive management. First described in 1979, angiography and trans-catheter embolization represent valuable tools in the control of postpartum hemorrhage of most etiologies. Embolization is an acceptable, effective alternative to hysterectomy, particularly in patients who desire future fertility. It has high clinical success rates and a body of literature supporting preserved post-embolization fertility.

Large concealed paravaginal haematoma: A case report of an occult postpartum haemorrhage

Paravaginal haematomas are common but rarely do they cause severe postpartum haemorrhage. While surgical evacuation is classically recommended for large haematomas, conservative management may be an appropriate strategy. We present the case of a 30-year-old primiparous woman with a large paravaginal haematoma causing a postpartum haemorrhage managed conservatively. The patient became hypotensive to 80/40 mmHg three and a half hours after forceps delivery, despite minimal vaginal bleeding. On examination she had a palpable mass at the right vaginal wall and uterine fundus deviated to the right, above the umbilicus. A computerised tomography examination of the pelvis demonstrated two paravaginal haematomas, the largest measuring 7 cm × 8 cm × 12 cm, extending superiorly into the supralevator and extraperitoneal space. The patient's haemoglobin fell from 13.2 g/dL to 7.1 g/dL. She was managed conservatively with analgesia, intravenous fluid resuscitation and one unit of packed red blood cells, and was discharged home three days postpartum. This case supports the conservative management of even large paravaginal haematomas, which may extend into the supralevator space, making surgical evacuation technically difficult.

Role of interventional radiology in placenta accreta spectrum (PAS) disorders

Placenta accreta spectrum (PAS) disorders are rare but potentially life-threatening obstetric conditions, which can result in severe post-partum haemorrhage (PPH). Traditional management necessitates peripartum hysterectomy, but this carries high rates of morbidity and mortality. More recently, interventional radiology techniques have been developed in order to reduce morbidity and preserve fertility. This article summarises and compares the various reported interventional radiology techniques. Arterial embolisation performed to treat PPH is the therapeutic option which is supported by the highest degree of evidence. The role of preventative procedures, such as temporary balloon occlusion of the internal iliac arteries or distal aorta, continues to be debated due to conflicting outcome data and concerns regarding associated morbidity. The choice of which, if any, interventional radiological technique is utilised is determined by local expertise, available resources and the planned obstetric approach. The most complex patients are likely to benefit from multidisciplinary management in high-volume centres.

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.

Transcatheter Arterial Embolization in the Management of Postpartum Hemorrhage due to Genital Tract Injury after Vaginal Delivery

PURPOSE

To evaluate efficacy and safety of transcatheter arterial embolization (TAE) in managing postpartum hemorrhage (PPH) due to genital tract injury after vaginal delivery and to investigate factors associated with outcome of TAE.

MATERIALS AND METHODS

A retrospective review of 43 women (mean age, 32.6 years) who underwent TAE to manage PPH secondary to genital tract injury after vaginal delivery was performed at a single institution between January 2007 and December 2018. Clinical data and outcomes were obtained. Patients were classified into clinical success (n = 39) and failure (n = 4) groups, and comparisons between the groups were performed.

RESULTS

The clinical success rate of TAE for PPH due to genital tract injury was 90.7%. In the clinical failure group, transfusion volumes were higher (failure vs success: packed red blood cells, 14 pt ± 3.37 vs 6.26 pt ± 4.52, P = .003; platelets, 10.33 pt ± 4.04 vs 2.92 pt ± 6.15, P = .036); hemoglobin levels before the procedure were lower (failure vs success: 7.3 g/dL vs 10.7, P = .016). Periprocedural complications included pulmonary edema (25.6%), fever (23.3%), and pain (9.3%). Twenty-four patients were either followed for > 6 months or answered a telephone survey; 23 (95.8%) recovered regular menstruation, and pregnancy was confirmed in 11 (45.8%). Regarding fertility desires, 7 women attempted to conceive, 6 of whom (85.7%) became pregnant.

CONCLUSIONS

TAE is an effective and safe method for managing PPH due to genital tract injury after vaginal delivery. Lower hemoglobin levels before the procedure and higher transfusion volumes were associated with clinical failure of TAE.

Clinical results of transarterial embolization for post-partum hemorrhage in 62 patients

AIM

The pathology of post-partum hemorrhage (PPH) differs depending on its cause, background and timing of bleeding, and the effectiveness of transarterial embolization (TAE) is thought to vary based on these characteristics. The aim of this study is to evaluate the treatment outcomes of TAE for PPH.

METHODS

Technical success, initial clinical success (hemostasis without repeat TAE or surgical treatment after initial TAE) and final clinical success (hemostasis with or without repeat TAE, but without surgical treatment) were assessed in 62 Japanese patients. Factors affecting final clinical success were analyzed using univariate analysis. Values of P < 0.05 were considered statistically significant. Further, the clinical course and factors associated with rebleeding, return of menstruation and fertility, and complications of TAE were assessed.

RESULTS

Final clinical success rate was significantly lower in cases with obstetrical disseminated intravascular coagulation (DIC) or the International Society on Thrombosis and Hemostasis (ISTH) DIC (P = 0.01, 0.03). Rebleeding (n = 9, 14.5%) was more common in patients with retained products of conception (RPOC) (P = 0.006). On long-term follow-up in 23 patients, return of menstruation was confirmed in 17 (73.9%) of these patients. Subsequent pregnancy was confirmed in seven patients (30.4%). TAE-related complications were seen in 6 patients (9.0%). There were no maternal deaths.

CONCLUSIONS

Obstetrical and ISTH DIC reduced the success rate of TAE for PPH (P = 0.01, 0.03). Rebleeding, which is observed significantly more frequently in PPH caused by RPOC (P = 0.006), can be effectively treated by repeat TAE.

Clinical applications of digital angiography with the harmonization function in body interventional radiology

Digital subtraction angiography (DSA) is frequently applied in interventional radiology (IR). When DSA is not useful due to misregistration, digital angiography (DA) as an alternative option is used. In DA, the harmonization function (HF) works in real time by harmonizing the distribution of gray steps or reducing the dynamic range; thus, it can compress image gradations, decrease image contrast, and suppress halation artifacts. DA with HF as a good alternative to DSA is clinically advantageous in body IR for generating DSA-like images and simultaneously reducing various motion artifacts and misregistrations caused by patient body motion, poor breath-holding, bowel and ureter peristalsis, and cardiac pulsation as well as halation artifacts often stemming from the lung field. Free-breath DA with HF can improve body IR workflow and decrease the procedure time by reducing the risk of catheter dislocation and using background structures as anatomical landmarks, demonstrating reduced radiation exposure relative to DSA. Thus, HF should be more widely and effectively utilized for appropriate purposes in body IR. This article illustrates the basic facts and principles of HF in DA, and demonstrates clinical advantages and limitations of this function in body IR.

Postpartum hemorrhage with uterine artery embolization: the risk of complications of uterine artery embolization

INTRODUCTION

The purpose of this study was to evaluate the efficacy and adverse effects of uterine artery embolization (UAE) to treat postpartum hemorrhage (PPH) and determine the factors associated with clinical outcomes.

MATERIAL AND METHODS

This study included 117 patients who underwent UAE for PPH between January 2010 and November 2018. Their medical records were retrospectively reviewed to assess the mode of delivery, causes of bleeding, detailed laboratory results, clinical outcomes, time from delivery to UAE, and embolizing material used.

RESULTS

The clinical UAE success rate was 99.1%. Late complications were found in 11 patients. Two total hysterectomies were performed. Most PPH cases treated with UAE had early-onset PPH caused by uterine atony. Late-onset PPH was caused by placenta-related problems (remnant placenta, placenta accreta). Body mass index, cesarean section, the use of mixed embolizing materials, placenta abruption as the cause of PPH, and transferred patients were associated with uterine necrosis. Age, re-embolization, and the use of mixed embolizing materials were associated with adverse complications.

CONCLUSIONS

Although UAE is a safe and effective way to manage PPH, a long-term follow-up is needed to determine the complications of UAE. When uterine necrosis is suspected, prompt and adequate treatment should be performed due to the effects of necrosis on menstrual cycles, fertility, and subsequent pregnancies.

High-intensity focused ultrasound versus uterine artery embolization for patients with retained placenta accreta

OBJECTIVE

To compare the safety and clinical effectiveness of high-intensity focused ultrasound (HIFU) and uterine artery embolization (UAE) for retained placenta accreta.

STUDY DESIGN

A retrospective analysis was performed on women who underwent HIFU or UAE followed by hysteroscopic resection for retained placenta accreta from January 2015 to December 2019 at the Third Xiangya Hospital of Central South University.

RESULTS

A total of 63 and 31 patients who underwent HIFU and UAE followed by hysteroscopic resection, respectively, were analyzed. The baseline characteristics, including age, gravidity, parity, previous cesarean section rate, previous curettage rate, previous intrauterine adhesions rate, and delivery mode, were similar between the two groups. Vaginal bleeding was the major complaint in patients with retained placenta accreta. The number of hysteroscopy sessions, amount of intraoperative blood loss, and the length of hospital stays were also similar between the groups. No further hysterectomy was needed in either group.

CONCLUSION

Both HIFU and UAE combined with hysteroscopic resection seem to be safe and effective procedures in cases of retained placenta accreta.

The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences

Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment option for which highest degrees of evidence are available. However, other techniques have been tested, including prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion. In this systematic review, we provide an overview of the currently reported interventional radiology procedures that are used for the treatment of postpartum hemorrhage due to AIP and suggest recommendations based on current evidences. Owing to a high rate of adverse events, prophylactic occlusion of internal iliac arteries should be used with caution and applied when the endpoint is hysterectomy. On the opposite, when a conservative management is considered to preserve future fertility, uterine artery embolization should be the preferred option as it is associated with a hysterectomy rate of 15.5% compared to 76.5% with prophylactic balloon occlusion of the internal iliac arteries and does not result in fetal irradiation. Limited data are available regarding the application of systematic prophylactic embolization and no comparative studies with arterial embolization are available.

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.

Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion

PURPOSE

Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic.

METHOD

We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting.

RESULTS

PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications.

CONCLUSION

PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.

Managing post-traumatic gunshot thoraco-abdominal bleeding by intervention embolisation: A case report

We report an interesting life-threating case of post-traumatic severe bleeding in the thoraco-abdominal region. The patient was initially treated by open surgery, which failed to control bleeding in the intrahepatic and sub-diaphragmatic regions of the liver with associated haematoma collection. As bleeding continued, on the 2nd post-operative day, the patient underwent super-selective embolisation of the bleeding vessels to cease serious bleeding. The pre-embolisation arterial feeders with active bleeding and post-embolisation images by computed tomography subtraction angiography showed complete cessation of haemorrhage. Torrential haemorrhage in the thoraco-abdominal regions can be successfully managed by trained interventional radiologists in highly specialised centres.

Is there an association between postpartum hemorrhage, interventional radiology procedures, and psychological sequelae?

BACKGROUND

Postpartum hemorrhage (PPH) may cause post-traumatic psychological sequelae. Interventional radiology procedures (IRP) have been established in the management of PPH when conventional management fails. IRP is also used prophylactically in women who are at high risk for PPH in pregnancies with abnormally invasive placentation. We sought to determine if there is an association between PPH, IRP, and psychological sequelae.

OBJECTIVES

Seventy-three women who underwent IRP due to PPH or were at high risk for PPH.

METHOD

A structured questionnaire was sent to all women.

RESULTS

Overall 49 women returned the questionnaire. Two-thirds of the women developed psychological sequelae and one-third reported a lack of professional support. Nine women had symptoms of post-traumatic stress disorder. Psychological sequelae were not associated with a volume of bleeding, whether or not hysterectomy was performed, or whether the IRP was performed as an emergency procedure or prophylactically. However, women who had elective IRP and no hysterectomy performed had significantly less fear of death compared to the rest of the study population.

CONCLUSIONS

We observed a high rate of psychological sequelae associated with IRP. Lack of proper professional support may have contributed to the development of post-traumatic psychological sequelae suggesting a need for debriefing in such women.

Comparison of outcome between intrauterine balloon tamponade and uterine artery embolization in the management of persistent postpartum hemorrhage: A propensity score-matched cohort study

INTRODUCTION

The aim of this study was to compare the outcomes of women who were initially managed by intrauterine balloon tamponade or uterine artery embolization because of persistent postpartum hemorrhage demanding an immediate intervention to control bleeding.

MATERIAL AND METHODS

Propensity score-matched cohort study including women who had intrauterine balloon tamponade or uterine artery embolization as initial management strategy to control persistent postpartum hemorrhage, that is, refractory to first-line therapy combined with at least one uterotonic agent. The primary outcome measure was a composite of peripartum hysterectomy and/or maternal mortality. Secondary outcomes measures were total volume of blood loss and total number of packed red blood cells transfused.

RESULTS

Our 1:1 propensity score-matched cohort comprised of 50 women who had intrauterine balloon tamponade and 50 women who underwent uterine artery embolization at a blood loss between 1000 and 7000 mL. There was no statistically significant difference in the hysterectomy risk between the two groups (n = 6 in each group, odds ratio [OR] 1.00, 95% confidence interval [CI] .30-3.34), in total volume of blood loss (median 4500 mL, interquartile range [IQR] 3600-5400) for balloon vs 4000 mL (IQR 3250-5000) for embolization, P = 0.382) or in total units of packed red blood cells transfused (median 7 (IQR 5-10) for balloon vs 6 [IQR 4-9] for embolization, P = 0.319). Fifteen women (30%) who were initially managed by an intrauterine balloon still underwent uterine artery embolization, of whom one had an embolization-related thrombo-embolic event. Maternal mortality occurred in neither of the intervention groups.

CONCLUSIONS

No difference in the risk of peripartum hysterectomy and/or maternal death was observed between women who had intrauterine balloon tamponade and women who underwent uterine artery embolization as an initial management for persistent postpartum hemorrhage. Although this study was underpowered to demonstrate equivalence, our study design provides a framework for future research in which intrauterine balloon tamponade may prove to be a suitable intervention of first choice in the management of persistent postpartum hemorrhage.

Prophylactic catheterization of uterine arteries with temporary blood flow occlusion in patients at high risk of pospartum hemorrhage: is it a safe technique?

Background

Placenta accreta is an important factor in maternal morbidity and mortality and is responsible for approximately 64% of emergency hysterectomy cases and about 2/3 of cases of puerperal bleeding.

Objectives

To describe a series of cases of prophylactic uterine catheterization performed to prevent significant postpartum bleeding or during caesarean delivery in pregnant women with a previous diagnosis of accretion.

Methods

A retrospective analysis was conducted of medical records of cases of uterine artery catheterization performed during elective or emergency caesarean sections of patients at high risk of postpartum bleeding.

Results

The catheterization of uterine arteries procedure was performed in fourteen patients. Mean duration of surgery and hospital stay were 214.64 minutes (± 42.16) and 7 days, respectively. All patients underwent obstetric hysterectomy. No patient required embolization. There was no bleeding or need to revisit any patient and there were no complications related to puncture. There was one fetal death and no maternal deaths.

Conclusions

In this study, prophylactic uterine artery catheterization with temporary occlusion of blood flow proved to be a safe technique with low fetal mortality, no maternal mortality, and a low rate of blood transfusion and can be considered an important and effective therapeutic strategy for reduction of maternal morbidity and mortality, especially in pregnant women with anomalous placental attachment. Furthermore, the possibility of uterine preservation with the use of this method is an excellent contribution to therapeutic management of this group of patients. However, randomized clinical trials are needed to evaluate the effectiveness of routine use of the technique.

The efficacy of pelvic arterial embolisation for the treatment in massive vaginal haemorrhage in obstetric and gynaecological emergencies: a single-centre experience

This study aimed to identify the role, efficacy and safety of pelvic arterial embolisation (PAE) in the management of massive vaginal haemorrhage occurring in 25 patients with obstetric and gynaecological emergencies where bleeding could not be controlled by conservative treatment methods. Nine of the cases had disseminated intravascular coagulation (DIC) and eight were haemodynamically unstable. PAE was successful in 23 of 25 patients without any major complication. Vascular blush was the most common (100%) angiographic finding. Active extravasation was observed in 9 of 25 of the cases. Permanent embolic agents including polyvinyl alcohol (PVA) particles or N-butyl-2-cyanoacrylate (NBCA) were used in all cases. Technical success in patients with disseminated intravascular coagulation (DIC), and in patients who were haemodynamically unstable were 9 of 11 and 6 of 8 cases, respectively. PAE was successful in all seven patients who had hysterectomy before PAE. PAE is a safe and effective alternative to surgical hysterectomy in obstetric and gynaecological emergencies when conservative management failed to control haemorrhage. It is an effective treatment option in cases of coagulation impairment and when bleeding cannot be controlled despite hysterectomy. Impact statement What is already known on this subject: Postpartum haemorrhage (PPH) is one of the most common causes of maternal morbidity and mortality worldwide. Most patients with PPH are treated conservatively but where this approach fails, hysterectomy is the standard option with loss of reproductive ability. During the past 20 years, pelvic arterial embolisation (PAE) has emerged as a safe, effective and preferred minimally invasive technique in most tertiary centres as an alternative to surgical treatments including hypogastric artery ligation and hysterectomy. The reported success rate of PAE using temporary and permanent embolic agents is 75-90% in cases of massive vaginal bleeding due to obstetric and gynaecological reasons. What the results of this study add? PAE showed high success rate in patients with coagulation disorders and in haemodynamically unstable patients. Permanent embolic agents such as polyvinyl alcohol particles (PVAs) or, N-butyl-2-cyanoacrylate (NBCA) should be used for embolisation in coagulation disorders or haemodynamic instability. The most important advantage of NBCA is that the embolisation effect occurs independently of the inherent coagulation cascade. What are the implications of these findings for clinical practice and/or further research? PAE is an effective and minimally invasive treatment option in cases of coagulopathy and in patients with bleeding that cannot be controlled despite hysterectomy. Our results suggest that haemodynamic instability and DIC should not be considered a contraindication for PAE. Embolic agent selection and the long-term effects of permanent embolic agents on fertilisation is an important issue requiring further investigation.

Variation in severe postpartum hemorrhage management: A national vignette-based study

OBJECTIVES

To assess variations in management of severe postpartum hemorrhage: 1) between obstetricians in the same situation 2) by the same obstetrician in different situations.

STUDY DESIGN

A link to a vignette-based survey was emailed to obstetricians of 215 maternity units; the questionnaire asked them to report how they would manage the PPH described in 2 previously validated case-vignettes of different scenarios of severe PPH. Vignette 1 described a typical immediate, severe PPH, and vignette 2 a less typical case of severe but gradual PPH. They were constructed in 3 successive steps and included multiple-choice questions proposing several types of clinical practice options at each step. Variations in PPH were assessed in a descriptive analysis; agreement about management and its timing between vignette 1 and vignette 2 was assessed with the Kappa coefficient.

RESULTS

Analysis of complete responses from 119 (43.4%) obstetricians from 53 (24.6%) maternity units showed delayed or inadequate management in both vignettes. While 82.3% and 83.2% of obstetricians (in vignettes 1 and 2, respectively) would administer oxytocin 15 minutes after PPH diagnosis, only 52.9% and 29.4% would alert other team members. Management by obstetricians of the two vignette situations was inconsistent in terms of choice of treatment and timing of almost all treatments.

CONCLUSION

Case vignettes demonstrated inadequate management as well as variations in management between obstetricians and in different PPH situations. Protocols or procedures are necessary in all maternity units to reduce the variations in practices that may explain a part of the delay in management that leads to PPH-related maternal mortality and morbidity.

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.

Prophylactic Transcatheter Arterial Embolization Helps Intraoperative Hemorrhagic Control for REMOVING Invasive Placenta

Objectives: The purpose of this article is to investigate the estimated blood loss in pregnant women undergoing cesarean section and placental extirpation to treat abnormal placentation and compare the outcomes of those who underwent prophylactic transcatheter arterial embolization (TAE) with those who did not. Methods: A retrospective study was conducted on 17 pregnant women diagnosed with abnormal placentation in 2001–2018 in a single tertiary center. The patients were diagnosed by surgical finding, ultrasound, or magnetic resonance imaging (MRI). These patients were divided into two groups: a prophylactic TAE group (11 patients) and a control group (6 patients). In the former group, prophylactic TAE of the bilateral uterine artery (UA) and/or internal iliac artery (IIA) was performed immediately after delivery of the infant. The placenta was removed in both groups. The primary outcomes were estimated blood loss (EBL), units of packed red blood cell (pRBC) transfusion, operative time, whether hysterectomy was performed, whether the patient was transferred to the intensive care unit (ICU), and hospitalization days. The secondary outcome was maternal complications. Results: Patients who received prophylactic TAE had significantly reduced intraoperative blood loss (990.9 ± 701.7 mL vs. 3448.3 ± 1767.4 mL, p = 0.018). Units of pRBC transfusion, operative time, hysterectomy, transfer to the ICU, and postoperative hospitalization days were not significantly different between the two groups. Thirteen patients (9 in the TAE group and 4 in the control group) received a blood transfusion during the operation. Three patients underwent a hysterectomy (1 in the TAE group and 2 in the control group). Five patients were transferred to the ICU (3 in the TAE group and 2 in the control group) for maternal complications or monitoring. In the prophylactic TAE group, 3 patients (27%) had a subsequent pregnancy within the next 5 years. Conclusions: Prophylactic TAE was safe and effective for reducing intraoperative hemorrhage from removing an invasive placenta in patients with abnormal placentation.