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Excerpt
If conservative methods for controlling postpartum hemorrhage (PPH) fail, surgical treatment includes ligation of the uterine or hypogastric arteries, insertion of uterine sutures, and hysterectomy, and since 1979, pelvic arterial embolization. This study evaluated the indications, efficacy, and complications associated with therapeutic and prophylactic arterial embolization and balloon catheterization with peripartal hemorrhage.
Twenty-two women underwent arterial embolization because of massive hemorrhage resulting from abnormal placentation (n=11), uterine atony (7), paravaginal laceration (3), and disseminated intravascular coagulopathy (1). Ten women delivered vaginally, 8 had an elective cesarean section, and 4 required emergency cesarean delivery. In seven, placenta previa was diagnosed in the third trimester; balloon catheters were placed into internal iliac arteries before elective cesarean section. After delivery, the occlusion balloons were inflated with saline and their position confirmed under c-arm fluoroscopy. Embolization was continued until flow in the treated arteries stopped. This group of patients was considered the prophylactic group. Fifteen women (emergency group) had unanticipated PPH and were treated with arterial embolization in an emergency setting. Selective catheterization of the uterine artery or the anterior trunk of the internal iliac artery was performed via a transfemoral route. Embolization was started from the most obvious site of bleeding and was always done bilaterally.
Hemorrhage was severe in all women, with blood loss ranging from 3100 mL to 15,000 mL. Twenty of the women received red blood cells (mean, 11.8 U) and 16 also received fresh-frozen plasma. Embolization was successful in 5 of the 7 women in the prophylactic group and resulted in adequate hemostasis. In 1 woman with placenta accreta and one with placenta previa, embolization failed and hysterectomy was required. No complications were associated with prophylactic catheterization and embolization. Among the 15 women in the emergency group, embolization was performed as a primary surgery in eight and was successful in six. In the other 7 women, hysterectomy was performed as an emergency surgery, but bleeding continued. Hemostasis was achieved with embolization in six. Three patients had complications associated with emergency embolization. In one woman, intrauterine fetal death was diagnosed at 33 wk. After vaginal delivery, massive hemorrhage necessitated a hysterectomy. Disseminated intravascular coagulation and vaginal necrosis developed. She was managed conservatively with antibiotics and topical treatment; she recovered completely. A second woman had iatrogenic thrombosis of the left popliteal artery; the artery was treated surgically and the leg recovered completely. The third complication was ischemia of the sciatic nerve. Embolization was performed twice. The patient recovered gradually.
Angiographic embolization seems to be an effective method in treating obstetric hemorrhage. Insertion of balloon catheters before cesarean section controls anticipated bleeding. In those with persistent bleeding after cesarean section and hysterectomy, embolization may be useful and may avoid the need for a second-look laparoscopy. Prophylactic use of balloon catheterization is promising but requires additional investigation.
