Title: Management of postpartum Hemorrhage with uterine artery embolisation.

Introduction:

Primary PPH is defined as blood loss of more than 500 mL in the first 24 hours following birth.

Secondary PPH is defined as blood loss of more than 500 mL after the first day and up to six

weeks after birth.Obstetric hemorrhage is one of the major causes of maternal mortality. Initial

conservative treatment methods for postpartum hemorrhage (PPH) include administration of

uterotonic agents, uterine massage, and vaginal packing. Recently, intrauterine balloon

tamponade has been attempted. However, when the conservative treatments fail, surgery or

transcatheter arterial embolization (TAE) should be considered as they have been accepted as

one of the most effective treatments for intractable PPH, with high success rates.The most

commonly used material in UAE for PPH is gelatin sponge particles, and these help in

spontaneous resolution within three to six weeks preventing negative impact on fertility owing to

permanent devascularization of the uterus.

Case report Case1 :

Case of 39 year old G2 P1 L1 37 weeks previous Caesarean with Central placenta previa with

severe preeclampsia. In this case postpartum haemorrhage was anticipated.Preoperative

Balloon stenting of bilateral uterine arteries were done. Immediately after delivery of baby,

during Caesarean balloon catheters were inflated. Blood loss was minimal due to occlusion of

both uterine arteries.Haemostasis was double checked after placenta delivery and slowly

catheter balloon was deflated and checked again for haemostasis. Meanwhile, routine

prophylactic drugs were given to control the atonic uterus. Uterus was conserved . Catheters

were removed in the immediate post-operative period.

Placement of bilateral uterine artery balloon catheters placed before proceeding for cesarean in Placenta praeviaBlood leakage from the Uterine artery before embolisation in secondary PPHAfter embolisation of uterines - leak totally

stopped.

Case report 2:

A 37 year old P2L2 POD-9 case of Caesarean operation.Indication for cesarean was - previous

2 Caesareans with GDM and preeclampsia. Patient came to emergency with severe secondary

postpartum haemorrhage. Uterus was subinvoluted and palpable per abdomen at 20 weeks

size.Patient was passing large clots per vaginum. Clinically patient was very pale, complaining

of dizziness,hemodynamically stable and severe weakness with considerable drop in

haemoglobin of about 5 gms from 12 gm/dl to 8gm post operatively.Did not respond to all the

routine uterotonic agents. Ultrasound was done and found an intrauterine collection of blood

about 900ml. Immediately blood work up was done, blood and blood product transfusion were

arranged.Interventional radiologist was consulted, opinion taken and counselled the patient for

uterine artery catheterization and embolisation.Patient was shifted to the in house cath lab and

leakage found from tributaries of uterine arteries. Uterine arteries were catheterized and

bilateral embolisation done. In the same sitting, gentle intrauterine suction evacuation was done

to evacuate all the collected blood clots. Bleeding stopped instantly, and as the uterus was

evacuated, the uterus contracted and retracted well. Prophylactic routine uterotonic given

during evacuation.Patient was stable and discharged after 48 hours. Hb at discharge was 10

gm/dl.Followed up weekly until 2 months.Discussion:

In selected high risk cases, preoperative planning of elective uterine artery catheterization, quick

control of blood loss is possible through embolization or balloon inflation of the uterine arteries.

We defined technical success as complete embolization of the target arteries, and clinical

success as the cessation of bleeding on vaginal examination without need for additional surgical

management during the patient’s admission period.Related massive blood transfusions and

associated surgical morbidity can be prevented. In some cases, severe blood loss can be

anticipated prior either during delivery or during a procedure. Elective caesarean in Central

placenta Previa is one of them; another emergency scenario is a secondary PPH due to uterine

subinvolution.Postpartum hemorrhage in cases of termination of pregnancy with a

pre-diagnosed arteriovenous malformations at previous cesarean scar site. Usually these

cases require large doses of medication to control PPH and Massive blood transfusions to

replace the blood loss in spite of diagnosing the risk factor well ahead. The related morbidity is

unavoidable. Surgical morbidity can occur due to laparotomy and cesarean hysterectomy. Also,

these are time taking procedures which involve huge blood loss. Though cesarean

hysterectomy is life saving ,inevitable loss of fertility is another major concern associated with

it.Hence selected high cases which are picked up well ahead can be shifted to higher centres

with inhouse Gynae department and a cath lab for prophylactic uterine artery stenting and

balloon placement.

Conclusion:

Preoperative placement of uterine artery balloon catheter allows intraoperative inflation and

reduces blood loss.Quick control over the emergency situation is possible. Blood transfusion is

associated with morbidity and mortality especially when transfusions are multiple.Hysterectomy

can be avoided as blood loss is quickly controlled. Catheter can be removed after deflating the

balloons before or after embolisation., Antenatal identification and segregation of cases at risk

of severe postpartum haemorrhage will allow us to transfer antenatal full term patients to a

facility where multidisciplinary team and cath lab is available.Major advantages of this kind of

planned emergency intervention helps in avoiding multiple blood transfusions and allows us to

save the uterus.

1. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of

maternal death: a systematic review. Lancet 2006;367:1066-1074

2. Pelage JP, Le Dref O, Mateo J, Soyer P, Jacob D, Kardache M, et al. Life-threatening primary

postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology

1998;208:359-362

3. Ganguli S, Stecker MS, Pyne D, Baum RA, Fan CM. Uterine artery embolization in the

treatment of postpartum uterine hemorrhage.J Vasc Interv Radiol 2011;22:169-176

4. Park JK, Shin TB, Baek JC, Shin JK, Choi WJ, Lee SA, et al. Failure of uterine artery

embolization for controlling postpartum hemorrhage. J Obstet Gynaecol Res 2011;37:971-978

5. Gonsalves M, Belli A. The role of interventional radiology in obstetric hemorrhage.

Cardiovasc Intervent Radiol 2010;33:887-895

6. Matsubara S, Sato T, Nakata M. Vaginal artery embolization with a permanent embolic agent

for intractable postpartum hemorrhage. J Obstet Gynaecol Res 2011;37:377-378