Selective pelvic arterial embolization in the management of obstetric hemorrhage

OBJECTIVE: Retrospective evaluation of pelvic arterial embolization for the treatment of severe post-partum hemorrhage. METHODS: Data were collected, from our departmental clinical records, on all patients with life-threatening post-partum hemorrhage managed with arterial embolization between January 2001 and December 2003. RESULTS: During the period analyzed, there were 29,119 deliveries in our institution. Of these, 27 patients underwent pelvic arterial embolization to control severe hemorrhaging despite conservative management. Of the 27 patients, 22 (81.5%) had a vaginal delivery and 5 had a caesarean section. The major indication for embolization was uterine atony (15 women). Disseminated intravascular coagulation developed in 20 cases (74.1%). There were eight cases (29.6%) who underwent hysterectomy, seven of them pre-embolization. The most frequent vessel embolized was the uterine artery (13 cases; 38.3%). One patient (3.7%) presented complications related to the procedure. The success rate was 96.3%. CONCLUSION: Pelvic arterial embolization is a good therapeutic choice for severe post-partum hemorrhage refractory to conservative treatment measures.     

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

AIM: The purpose of this study was to evaluate the clinical success of selective arterial embolization in cases of post-partum hemorrhage due to abnormal placentation. METHODS: Six patients with persistent hemorrhage and abnormal placental implantation underwent uterine artery embolization over a period of three years. RESULTS: In four patients, the placenta was left in place after a gentle attempt at removal and post-partum hemorrhage was controlled during or shortly after the procedure. In all cases, embolization was possible even when there was previous arterial ligation (two cases). In one case, a hysterectomy was required at 21 d later due to uterus and bladder necrosis. Arterial embolization in cases of abnormal placental implantation remains an uncommon treatment and is less efficient in these cases than in normal placental implantation. CONCLUSION: Our results confirmed that even in cases of moderate bleeding, conservation treatment and embolization are possible, but that complications may be more common than in normal placentation.     

Uterine artery embolization in the treatment and prevention of postpartum hemorrhage.

OBJECTIVES: The study was conducted to evaluate the efficacy of superselective transcatheter uterine artery embolization for control of obstetric hemorrhage. METHODS: Between January 2002 and December 2005, 14 consecutive patients underwent uterine artery embolization to control postpartum hemorrhage, and two to prevent hemorrhage before second-trimester therapeutic abortion. RESULTS: Embolization was performed by transfemoral arterial catheterization. Pieces of absorbable gelatin sponge were used in all cases, with the addition of platinum coils in two cases for complete vessel occlusion. Optimal bleeding control was achieved in all cases but one--a patient who underwent hysterectomy due to embolization failure. No severe complications were observed. CONCLUSIONS: The high success rate, low morbidity rate, and possibility of preserving reproductive function have made superselective uterine artery embolization the technique of choice to control life-threatening, intractable postpartum hemorrhage in hemodynamically stable patients, provided multidisciplinary medical teams are promptly available.     

Pelvic arterial embolization in obstetric hemorrhage

AIM: To analyze safety and efficacy of pelvic arterial embolization (PAE) in preventing and treating obstetrical hemorrhage. METHODS: A consecutive study of eight cases undergoing pelvic artery embolization from January 2010 to October 2012 in Department of Obstetric and Gynecology of Maulana Azad Medical College for intractable obstetric hemorrhage was done. All embolization were carried out in cath lab of cardiology Department at associated GB Pant Hospital. RESULTS: Clinical success was defined as arrest of bleeding after PAE without need for repeat PAE or additional surgery which was 75% in our series. PAE was successful in controlling obstetrical hemorrhage in all except one who had mortality. Other had hysterectomy due to secondary hemorrhage. Five resumed menstruation. None of the women intended to conceive, hence are practicing contraception. CONCLUSION: PAE is minimally invasive procedure which should be offered early for hemostasis in intractable obstetrical haemorrhage unresponsive to uterotonic. It is a fertility sparing option with minor complications.     

Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion

OBJECTIVE: Presentation of outcomes of pelvic arterial embolization for hemorrhage after spontaneous or induced abortion. STUDY DESIGN: We collected case reports of embolization after spontaneous or induced abortion from oral presentations and from members of the National Abortion Federation. RESULTS: Pelvic arterial embolization was performed for 11 women who had hemorrhage after spontaneous or induced abortion, and it was initially successful for all women. One woman ultimately required a hysterectomy after unsuccessful repeated embolization. Prophylactic embolization was done for 8 women who were at risk for hemorrhage from placenta accreta; 4 of these women had subsequent hysterectomies. CONCLUSIONS: Selective pelvic arterial embolization may be a successful treatment for hemorrhage associated with spontaneous and induced abortion. Embolization can be considered before hysterectomy is undertaken for control of hemorrhage. There may be a role for prophylactic catheterization or embolization when there is a risk of severe hemorrhage.     

Pelvic arterial embolization for control of obstetric hemorrhage: A five-year experience

Objective: Obstetric hemorrhage is a significant cause of maternal morbidity and death. Postpartum hemorrhage that cannot be controlled by local measures has traditionally been managed by bilateral uterine artery or hypogastric artery ligation. These techniques have a high failure rate, often resulting in hysterectomy. In contrast, endovascular embolization techniques have a success rate of >90%. An additional benefit of the latter procedure is that fertility is maintained. We report our experience at Stanford University Medical Center in which this technique was used in 6 cases within the past 5 years. Study Design: Six women between the ages of 18 and 41 years underwent placement of arterial catheters for emergency (n = 3) or prophylactic (n = 3) control of postpartum bleeding. Specific diagnoses included cervical pregnancy (n = 1), uterine atony (n = 3), and placenta previa and accreta (n = 2). Results: Control of severe or anticipated postpartum hemorrhage was obtained with transcatheter embolization in 4 patients. A fifth patient had balloon occlusion of the uterine artery performed prophylactically, but embolization was not necessary. In a sixth case, bleeding could not be controlled in time, and hysterectomy was performed. The only complication observed with this technique was postpartum fever in 1 patient, which was treated with antibiotics and resolved within 7 days. Conclusions: Uterine artery embolization is a superior first-line alternative to surgery for control of obstetric hemorrhage. Use of transcatheter occlusion balloons before embolization allows timely control of bleeding and permits complete embolization of the uterine arteries and hemostasis. Given the improved ultrasonography techniques, diagnosis of some potential high-risk conditions for postpartum hemorrhage, such as placenta previa or accreta, can be made prenatally. The patient can then be prepared with prophylactic placement of arterial catheters, and rapid occlusion of these vessels can be achieved if necessary. (Am J Obstet Gynecol 1999;180:1454-60.)     

难治性产后出血干预性治疗方法的对比研究

目的探讨难治性产后出血的各种干预性措施在抢救过程中的合理应用及应用价值。方法分析1998年1月至2003年8月间，采用宫腔填塞纱布(塞纱)、盆腔动脉结扎、经导管动脉栓塞术等干预性措施的88例难治性产后出血病人的临床资料。结果全部抢救成功，其中18例宫腔塞纱者成功12例(66．7％)，12例盆腔动脉结扎中成功4例(33．3％)，30例经导管动脉栓塞术(TAE)治疗全部成功(100％)，42例一次开腹行全子宫切除术或加盆腔塞纱者成功36例(85．7％)。结论宫腔塞纱可压迫止血。TAE可替代子宫切除术。当子宫成为凝血功能障碍的病因时，主张行子宫切除．     

Transcatheter arterial embolization in the management of postpartum hemorrhage due to genital tract injury

Six patients with uncontrollable postpartum hemorrhage due to genital tract injury were treated with transcatheter arterial embolization. The causes of hemorrhage were laceration of the cervix and vagina in five cases and rupture of the uterus in one. Four cases included a large hematoma in the paravaginal and/or retroperitoneal space. Two women had a hysterectomy before arterial embolization. Angiography revealed extravasation in five cases. All six subjects had their hemorrhage arrested dramatically using transcatheter arterial embolization with gelatin sponge particles. No major complication was encountered in any case. Normal menstruation resumed in the women who did not undergo a hysterectomy. Transcatheter arterial embolization therapy seems to be the treatment of choice in patients with uncontrollable hemorrhage.     

Transcatheter arterial embolization in the management of gynecological neoplasms

Six patients were treated with transcatheter arterial embolization (TAE). Three patients suffered from intractable genital bleeding; the other three patients were preoperative cases of a stage III adenocarcinoma of the uterine cervix and two of these had gestational trophoblastic disease. Bleeding was stopped in all three cases of intractable hemorrhage; one patient rebled after 6 days. In the three preoperative cases, transcatheter arterial embolization was thought to be effective in decreasing intraoperative blood loss. There are no other reports of application of this technique to preoperative cases to decrease intraoperative blood loss in gynecological cases.     

介入治疗在重度产后出血中的应用

目的探讨介入治疗在重度产后出血中的应用价值。方法三家医院15年间重度产后出血保守治疗无效行次全子宫切除或全子宫切除术47例为手术组,行介入治疗24例为介入组。结果介入组手术时间55.5min,明显短于手术组121.4min(P＜0.05);介入组栓塞后止血时间为(5.9±2.6)min;手术组1例行次全子宫切除后复出血转用介入治疗成功止血,余均止血成功。结论介入治疗应用于重度产后出血具有止血快、疗效确切、手术时间短、并发症少的优点。     

Operative Behandlung schwergradiger postpartaler Blutungen

Postpartum hemorrhage occurs in about 1 to 5% of deliveries. Uterine atony is the main cause (75–80%). Despite its association with well-established risk factors, atonic bleeding cannot be anticipated in up to 20% of cases. Therapy of postpartum hemorrhage varies depending on the cause. Conservative treatment of uterine atony is effective in about 90% of patients. Invasive management is needed in 1 to 3 of 1000 deliveries. Uterus-preserving techniques are preferable if contraindications can be excluded. In the literature, success rates of 40 to 100% have been reported for the various non-surgical (uterine tamponade, selective arterial embolization) and surgical methods (ligation of the uterine and hypogastric arteries, stepwise uterine devascularisation, B-Lynch technique, fundus compression suture). Emergency peripartum hysterectomy (total or supracervical) should be reserved for otherwise intractable postpartum hemorrhage, and is associated with a considerable maternal morbidity compared to elective caesarean hysterectomy.     

Percutaneous embolization in the management of intractable vaginal bleeding

AIM: To assess the effectiveness of arterial embolization in gynecological malignancies by Polyvinyl Alcohol particles. MATERIAL AND METHODS: Six patients, four with cervix carcinoma, one endometrium carcinoma, and one vaginal metastasis of ovarian carcinoma underwent percutaneous embolization due to intractable vaginal bleeding. As an embolic agent PVA particles were used. RESULTS: Cessation of the bleeding was observed immediately after the embolization. Complete embolization has been achieved in all the patients Recurrent bleeding did not occur in any of the cases. There were no complications related to the embolization procedure. CONCLUSION: Transarterial embolization is a lifesaving procedure in treating intractable vaginal bleeding. PVA particles are effective and it is a simple way in ceasing the hemorrhage due to pelvic malignancies.     

难治性产科出血时子宫切除术和子宫动脉栓塞术的临床分析

目的探讨产科急性出血性疾病治疗过程中进行子宫切除术和动脉栓塞术的临床特点以及选择时机。方法回顾性分析35例产科出血因素行子宫切除或者动脉栓塞病例的临床资料。结果16例子宫切除的患者中,胎盘因素10例,占62.5%（前置胎盘/胎盘植入7例,胎盘早剥伴有凝血功能障碍3例）,子宫异常4例（子宫收缩乏力2例、子宫切口延裂致阔韧带血肿和子宫破裂各1例）占25%;羊水栓塞致DIC后切除子宫2例占12.5%。19例行子宫动脉栓塞术中,前置胎盘3例,占15.8%,子宫收缩异常13例（原发性宫缩乏力产程中剖宫产4例、双胎4例,急产产后出血2例,巨大儿1例,巨大子宫肌瘤2例）占68.4%,剖宫产并发症3例（子宫切口延裂致阔韧带血肿和子宫动脉瘤各1例,剖宫产术后晚期产后出血1例）占15.8%,其中2例栓塞失败,分别行子宫切除术和开腹探查血肿清除术。子宫切除术平均出血量（4 593±2 727）ml,子宫动脉栓塞术时平均出血量（2 601±904）ml,两组比较差异有统计学意义（P〈0.05）。子宫切除组有11例出现了DIC表现占68.7%。行子宫动脉栓塞术时发生DIC1例,占10.5%,差异有统计学意义（P〈0.05）。结论二者均为治疗产后出血的有效手段,但是栓塞术作为保守治疗可以保留生育功能,对于改善患者的预后具有重要的意义,要求尽早采用,一旦发生了严重的DIC和休克,则失去了机会。而保守治疗不能短时间见效,应果断行子宫切除术。     

Course of pregnancy and birth in a patient with Bernard-Soulier syndrome--a case report

Bernard-Soulier syndrome is a rare autosomal recessive bleeding disorder characterized by platelet dysfunction, the presence of giant platelets, and a prolonged bleeding time. Absent or reduced expression of the platelet glycoprotein (GP) Ib-IX receptor results in the Bernard-Soulier syndrome and is characterized by severe bleeding and macrothrombocytopenia. To our knowledge only ten pregnant patients with this disease have been previously reported. In some patients the pregnancy course was uneventful while in others post-partum hemorrhage and resulting hysterectomy was the most common complication. We present a primiparous female with Bernard-Soulier syndrome who had delayed post-partum hemorrhage and review the literature.     

Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage*

BACKGROUND. To evaluate indications, efficacy, and complications associated with arterial embolization and prophylactic balloon catheterization in the management of obstetric hemorrhage at a university hospital. METHODS. Twenty-two women underwent arterial embolization between February 2001 and November 2003 for the treatment for primary postpartum hemorrhage resulting from abnormal placentation (n=11), uterine atony (n=7), paravaginal laceration (n=3), and disseminated intravascular coagulopathy (n=1). Blood loss was between 3.2 and 15 l. In seven patients, abnormal placentation was diagnosed prenatally and in these patients balloon catheterization was performed prophylactically before elective cesarean section. RESULTS. Of the seven patients, who underwent prophylactic catheterization, embolization was successful in five resulting in adequate hemostasis. Hysterectomy was performed in three, in two patients for uncontrolled hemorrhage and in one patient for placental invasion to bladder. There were no complications associated with prophylactic catheterization and embolization. The other 15 patients were treated in an emergency setting. In eight patients, embolization was performed as a primary surgery, and it was successful in six. In the other seven patients, hysterectomy was performed as an emergency surgery, but bleeding continued. Of these, in six patients, hemostasis was achieved with embolization. Complications associated with emergency embolization were observed in three patients. These were thrombosis of left popliteal artery, vaginal necrosis, and paresthesia of the right leg. CONCLUSIONS. Arterial embolization is of significant value in treating obstetric hemorrhage. Prophylactic insertion of balloon catheters before cesarean section seems to be a safe and effective method in controlling anticipated bleeding. In patients with persistent bleeding following cesarean section and hysterectomy, embolization could be a primary procedure before re-surgery.     

选择性子宫动脉栓塞术治疗难治性产后出血13例临床分析

目的探讨子宫动脉栓塞术治疗难治性产后出血的时机、疗效及并发症。方法对北京大学人民医院13例难治性产后出血患者,利用数字减影造影（DSA）技术选择子宫动脉及其分支行栓塞治疗。结果 13例产后出血患者分娩时出血量为150～4000ml,平均出血量1200（1200±1215）ml。产后出血总量870～4000ml,平均2555（2555±995）ml。13例患者栓塞前均行按摩子宫,卡孕栓肛塞及欣母沛宫体注射促进子宫收缩,2例剖宫产术中出血患者已行子宫动脉上行支结扎、B-Lynch缝合以及宫腔填纱止血,效果均不佳,经子宫动脉栓塞后12例均成功止血,仅1例未能止血而行全子宫切除术。13例产后出血行子宫动脉栓塞术前存在不同程度的凝血功能异常,在积极纠正凝血功能异常同时行栓塞术。栓塞术后无严重并发症发生,发热为最为常见并发症,但应警惕感染。结论凝血功能障碍并非子宫动脉栓塞术的禁忌证,只要把握好子宫动脉栓塞的时机,子宫动脉栓塞术能有效治疗产后出血,并且并发症少。     

Rupture of a pseudoaneurysm as a rare cause of severe postpartum hemorrhage: analysis of 11 cases and a review of the literature

Objective

To clarify the clinical features of severe postpartum hemorrhage (PPH) resulting from a ruptured pseudoaneurysm and to determine the efficacy of selective arterial embolization as a method of management.

Study design

Eleven women who underwent selective arterial embolization for treatment of severe hemorrhage due to a ruptured pseudoaneurysm were identified from 2 hospitals within the past 5 years. A retrospective analysis was performed to identify the clinical characteristics of the hemorrhage and to evaluate the efficacy of arterial embolization.

Results

Nine women delivered by cesarean delivery. Eight of the 11 women had late PPH with onset of bleeding occurring 6–100 days (median, 11.5) after delivery. The average volume of transfusion was 3196 ml of packed red blood cells (range, 1600–8980 ml). Uterine atony occurred in only one patient and was accompanied by an intrauterine abscess. Administration of uterotonic agents did not diminish the bleeding. Only one patient out of 11 underwent re-embolization.

Conclusion

If late PPH without uterine infection or retained placenta occurs after cesarean delivery, one should suspect the possibility of a ruptured pseudoaneurysm. Selective arterial embolization may be considered as a primary means of treatment.     

产后出血的干预性治疗

目的：探讨产后出血干预治疗的合理方案。方法：回顾性分析15例行干预性治疗的严重产后出血患者的临床特点及方法。结果：15例患者中子宫切除者9例，行动脉栓塞治疗7例（2例切除子宫后双行栓塞治疗），行病灶挖除术1例。需行干预性治疗的产后出血的原因依次为：弥漫性血管内凝血（DIC），子宫动－静脉瘘及血管畸形，胎盘异常，子宫肌瘤及子宫裂伤。结论：应针对产后出血的不同原因、部位及性质选择合理有效的干预治疗，以抢救患者生命，保留生育功能，尽可能减少创伤。     

Place of embolization of the uterine arteries in the management of post-partum haemorrhage: a study of 12 cases

OBJECTIVE: To assess the current place of embolization of the uterine arteries in the treatment of severe post-partum haemorrhages. MATERIALS AND METHODS: A retrospective study of 13,160 deliveries in a level III maternity unit between January 1996 and December 2001. Five hundred and forty-nine post-partum haemorrhages were diagnosed. Seventeen (0.13%) patients had a haemorrhage which did not respond to treatment using obstetric manoeuvres and uterotonic drugs. Twelve patients aged between 19 and 34 years old benefited from embolization of the uterine arteries. Nine patients had delivered by Caesarian section and three vaginally. The aetiologies found were uterine atony (n=8), placenta praevia (n=1), placenta accreta (n=1), abruptio placentae (n=1) and uterine myomas (n=1). RESULTS: The success rate of embolization was 91.6%. One failure, resulting from cardiovascular shock during the procedure, led to the patient being transferred as an emergency to the operating theatre for a haemostasis hysterectomy. It was due to placenta increta. No maternal deaths were reported. No complications because of the technique used were noted. One patient successfully delivered, following a normal pregnancy, one year after embolization. CONCLUSION: Embolization of the uterine arteries is indicated in severe post-partum haemorrhage, irrespective of the aetiology or the type of delivery. It should be offered as soon as primary management measures undertaken for haemorrhage are judged as ineffective. Its place in the treatment strategy, is in all cases before embarking on surgery, which is the final recourse in the case of failure. It is a fairly uninvasive procedure, which preserves the potential for future pregnancies.     

Transcatheter Arterial Embolization for Severe Secondary Hemorrhage after Hysterectomy

Four of 1237 patients who underwent abdominal, laparoscopic, and vaginal hysterectomy between October 2013 and May 2015 had severe secondary hemorrhage after hysterectomy (2 conventional multiport total laparoscopic hysterectomies, 1 single-port access hysterectomy, and 1 total abdominal hysterectomy). The median time interval between hysterectomy and secondary hemorrhage was 28.4 days (range, 16–52 days). All 4 cases were treated with transcatheter arterial embolization (TAE), all of whom required blood transfusions to maintain vital functions before TAE. The mean operative time was 90 minutes. The median length of hospital stay after TAE was 12 days (range, 4–24 days), and the patients were discharged without complications or additional surgery. These cases show the value of minimally invasive TAE for patients experiencing severe secondary hemorrhage after hysterectomy.