Transcatheter Arterial Embolization for Postpartum Hemorrhage: Indications, Technique, Results, and Complications

Interventional radiology for prevention and management of postpartum haemorrhage: a single centre retrospective cohort study

PURPOSE

Postpartum haemorrhage (PPH) remains a leading cause of maternal death despite current medical management. Surgical interventions are still needed for refractory bleeding. Interventional radiology (IR) can be a successful intermediary that avoids the need for hysterectomy. Nevertheless, IR outcome data in a peripartum setting are limited. The objective of this study is to document the efficacy and safety of IR.

METHODS

Retrospective study reviewed the records of consecutive patients who underwent peripartum IR from 01/01/2010 until 31/12/2020 in a tertiary academic centre. Patients were divided in a prophylactic and a therapeutic group. Information about interventions before and after IR, and IR specific complications was retrieved. Efficacy was defined by the number of transfusions and additional surgical interventions needed after IR, and safety was assessed by the incidence of IR related complications.

RESULTS

Fifty-four patients, prophylactic group (n = 24) and therapeutic group (n = 30), were identified. In both groups, IR was successful with 1.5 ± 2.9 packed cells transfused post-IR (1.0 ± 2.1 prophylactic vs 1.9 ± 3.3 therapeutic; p = 0.261). Additional surgical interventions were required in n = 5 patients (9.2%), n = 1 (4.2%) in the prophylactic vs. n = 4 (13.3%) in the therapeutic group. Complications were reported in n = 12 patients (22.2%), n = 2 (8.3%) prophylactic vs. n = 10 (33.3%) in therapeutic group. Mostly minor complications, as puncture site hematoma or bleeding, were reported in n = 4 (7.4%). Severe complications as necrosis and metabolic complications were reported in n = 2 patients (3.9%).

CONCLUSION

IR for prevention and treatment of PPH was highly successful and associated with minor complications.

Efficacy and safety of uterine artery embolization in the management of postpartum hemorrhage

OBJECTIVE

To demonstrate the safety and efficacy of endovascular treatment in postpartum hemorrhage (PPH).

MATERIAL AND METHODS

We conducted a retrospective observational study with a sample from our Interventional Vascular Radiology unit, from 2004 to 2020. Patients who developed postpartum hemorrhage treated by arterial embolization were selected. Inclusion criteria were established to standardize the study group. Variables for the study of the efficacy and safety of the technique are defined.

RESULTS

The final sample of the study was 56 patients. Technical success turned was 100%, while clinical success after endovascular treatment was 92.85%, with a hysterectomy rate due to failed arterial embolization of 7.14%, with uterine rupture observed in 3 cases as a cause of PPH and another case was a placenta accreta. No technique-related mortality was recorded. The rate of periprocedural complications was 3.56%, the same as that of late complications. No major or infectious complications were recorded. The pregnancy rate after embolization was 23.52%.

CONCLUSIONS

Selective arterial embolization of the uterine artery in PPH is a safe and effective procedure, being a therapeutic alternative in the face of failure of pharmacological and obstetric management, with preservation of fertility.

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.

Uterine Artery Embolization Versus Hysterectomy in Postpartum Hemorrhage: A Systematic Review With Meta-Analysis

PURPOSE

The objective of this study is to perform a meta-analysis comparing the effectiveness of uterine artery embolization (UAE) versus peripartum hysterectomy for acute refractory postpartum hemorrhage (PPH) control.

MATERIALS AND METHODS

We systematically searched 6 medical databases for studies comparing UAE and hysterectomy in PPH. Outcomes examined were mortality, hospitalization duration (HD) in days, and red blood cells (RBC) units utilization. Statistical analysis used RevMan 5.1.7 and random-effects models. Odds ratios (OR) and mean differences (MDs) with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively.

RESULTS

We included 833 patients from 4 cohort studies, with 583 (70%) undergoing UAE. The UAE population required fewer RBC units (MD: -7.39; 95% CI: -14.73 to -0.04; p=0.05) and had shorter HD (MD: -3.22; 95% CI: -5.42 to -1.02; p=0.004). Lower mortality rates were noted for UAE in the pooled analysis, but no statistical significance. Uterine artery embolization demonstrated lower procedural complications (16.45% vs. 28.8%), in which UAE had less ureter and bladder lesions (OR: 0.05; 95% CI: 0.01-0.38; p=0.004 and OR: 0.02; 95% CI: 0.00-0.15; p<0.001, respectively). Only 35 (6%) required conversion to hysterectomy, while 27 (4.6%) underwent re-embolization with 100% bleeding control. Uterine artery embolization did not hinder fertility, with normal menstruation restored in 19 patients with postoligomenorrhea.

CONCLUSION

Uterine artery embolization for the control of PPH is associated with lower use of RBC units and HD, but similar rates of mortality are noted when compared to hysterectomy. These results associated with uterine preservation could support its importance for refractory PPH management.

CLINICAL IMPACT

Uterine Artery Embolization is associated with a shorter hospitalization duration and reduced use of red blood cell units when compared with hysterectomy in refractory postpartum hemorrhage. Although demonstrating similar mortality rates, these findings, together with fertility preservation, support the method incorporation as a valuable option in obstetric services.

Primary and secondary postpartum haemorrhage: a review for a rationale endovascular approach

Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.

Crucial factors for implementing treatment strategies in intractable atonic postpartum haemorrhage: early phase contrast medium extravasation on dynamic CT

AIM

To identify the relationship between contrast medium extravasation (CME) on dynamic contrast-enhanced computed tomography (DCT) and clinical information in intractable atonic postpartum haemorrhage (PPH) and its relevance to treatment with uterine artery embolisation (UAE).

MATERIALS AND METHODS

Of 90 patients who underwent DCT to diagnose PPH, 60 diagnosed with intractable atonic PPH were investigated retrospectively. Maternal background and clinical indicators were analysed to compare the positive and negative factors of early phase CME. Regression analysis was used to investigate the factors associated with CME. The sensitivity, specificity, and positive and negative predictive values of early phase CME for predicting UAE were calculated. Clinical outcomes were compared between the two groups according to the timing of the decision to undergo UAE.

RESULTS

Of the 60 patients with intractable atonic PPH, 21 underwent UAE, 20 of whom had early phase CME on DCT. Pre-DCT clinical parameters and clinical indices were not significantly different in presence of early phase CME. Early phase CME was associated with UAE performance, with a sensitivity of 95%, specificity of 87%, positive predictive value of 80%, and negative predictive value of 97%. In cases where UAE was performed after conservative management, there was a significant increase in blood loss and transfusion volume.

CONCLUSION

Early phase CME is not indicated by background factors or clinical findings. UAE is not required when CME cannot be detected in the uterine cavity. If early phase CME is present, UAE should be considered immediately.

Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines

OBJECTIVE

To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH.

DESIGN

Comparative study.

SETTING

High-resource countries.

POPULATION

Women with PPH.

METHODS

Systematic comparison of guidance on PPH from eight high-income countries.

MAIN OUTCOME MEASURES

Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour.

CONCLUSIONS

Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines.

RESULTS

Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.

Ipsilateral Uterine Artery Access Through Unilateral Transfemoral Approach Using Simple-Curve Catheter

Uterine artery embolization (UAE) is a technique for management of various obstetrical and gynecological problems. Transfemoral approach (TFA) is preferred which can be unilateral or bilateral; however, unilateral puncture is preferred due to lesser chances of puncture-related complications as compared to bilateral puncture. UAE through unilateral TFA is possible with use of reverse loop catheters (Roberts uterine catheter [RUC] or Gandras catheter) to access ipsilateral uterine artery. Other way of cannulating the ipsilateral uterine artery is by maneuvering catheters to form Waltman's loop/Simmon's reverse loop. With advent of RUC, unilateral TFA became standard of care. In the recent past, RUC was retracted from Indian market and its nonavailability had mandated use of either bilateral TFA or use of catheters and techniques used in the past for unilateral TFA. Herein, we describe a technique of doing UAE by unilateral TFA using simple gentle curve catheter (Picard) by making a reverse curve loop.

The use of IVF/ICSI and risk of postpartum hemorrhage: A retrospective cohort study of 153,765 women in China

Objective

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. Identifying women who are at high risk of PPH is crucial for implementing early preventive and interventive strategies. This study aimed to examine whether there is an association between the use of in vitro fertilization (IVF) /intracytoplasmic sperm injection (ICSI) and increased risk of PPH.

Method

This retrospective cohort study was conducted using medical record data from women who delivered at a tertiary hospital in Shanghai, China, between January 1, 2013 and April 30, 2019. Logistic regression analysis was used to estimate the associations between the use of IVF/ICSI and the risk of PPH.

Results

A total of 153,765 pregnant women were included, of which 6,484 conceived through IVF/ICSI and147,281 conceived naturally. The incidence of PPH was 1.9% in this cohort. The incidence of PPH in women who conceived through IVF/ICSI was significantly higher than those in women who conceived naturally (3.4% vs. 1.7%, p < 0.01). The use of IVF/ICSI was associated with an increase in the amount of postpartum blood loss. Compared to women who conceived naturally, the average amount of postpartum blood loss increased by 42.1 mL (β = 42.1, 95% CI, 38.2-46.0) for women who conceived through IVF/ICSI. In addition, women who conceived through IVF/ICSI were at higher risk of maternal PPH. The adjusted odds ratio (OR) of PPH in women who conceived through ART was 2.7 (OR = 2.7, 95% CI, 2.3-3.1).

Conclusion

Our findings demonstrated that women who conceived through IVF/ICSI were at higher risk of PPH and suggested to obstetricians and midwives to identify and implement early preventative strategies for PPH among pregnant women who conceived through IVF/ICSI.

Interventional Radiology in Obstetric Emergencies

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

How B-Lynch suture and bilateral internal iliac artery ligation saved the uterus of a young patient with severe postpartum haemorrhage

Obstetric haemorrhage is the leading cause of maternal death worldwide (27.1%) and more than 66% of its deaths were classified as postpartum haemorrhage (PPH). The most common cause of PPH is uterine atony. Obstetrician should be skillful in managing obstetric emergencies; especially pertaining to PPH. Application of the B-Lynch suture on an atonic uterus is one of the surgical options in PPH patients who wish to conserve the uterus and it has a very high success rate.We present a primigravida patient who developed massive primary PPH followed by disseminated intravascular coagulation, which was successfully managed with B-Lynch suture and bilateral internal iliac artery ligation. We described in detail regarding the management of massive PPH and application of these surgical procedures on the atonic uterus with an attempt to preserve the uterus and future fertility in this young patient.

Uterine Artery Embolization for Secondary Postpartum Hemorrhage

Postpartum hemorrhage (PPH) affects approximately 14 million women yearly, accounts for 25% of delivery-related deaths in the world and is the main cause of emergency peripartum hysterectomy. Traditionally, PPH is defined as at least 500 mL of blood loss after vaginal delivery or 1000 mL of blood loss after cesarean-section. However, several authors have suggested a simpler definition to include women who experience hemodynamic instability after birth regardless of amount of blood loss. Secondary PPH is defined as bleeding that occurs after 24 hours to 12 weeks from delivery, and can fail medical management. It is imperative that the clinical team recognize the signs and symptoms of secondary PPH and, if necessary, consult the interventional radiology service for a minimally invasive option of uterine artery embolization, which has shown up to 95% success rate.

The Emergent Pelvic Artery Embolization in the Management of Postpartum Hemorrhage: A Systematic Review and Meta-analysis

IMPORTANCE

Postpartum hemorrhage (PPH) is an emergent obstetric complication and the leading cause of maternal mortality. Pelvic arterial embolization (PAE) is an effective treatment for intractable PPH. However, a unique protocol has not been accepted in obstetrical practice.

OBJECTIVE

To evaluate its efficiency, safety, complications, and outcomes, we conducted a systematic review and meta-analysis of PAE for PPH in the literature.

EVIDENCE ACQUISITION

The Medline, the database of abstract of reviews, the index to allied health literature, and the Chinese database Sino-Med were searched on March 31, 2020, for studies on PAE for PPH. The data for PAE indication, agents, arteries, success rate, complications, and outcomes were extracted and syncretized for meta-analysis.

RESULTS

From 1075 identified articles, 113 abstracts or full articles were retrieved and 43 studies were finally identified as meeting the including criteria. The results demonstrated that the indications for PAE were as follows: uterine atony, placental abnormality, delivery tract injury, disseminated intravascular coagulation, arteriovenous malformation, and vaginal hematoma. The embolization agents mostly in order were gelatin sponge particles, polyvinyl alcohol particles, Gelfoam, N-butyl cyanoacrylate, microcoil, and glue; for arteries, they were mostly uterine artery and internal iliac artery. The clinical success rate was 90.5%, whereas the technical success rate was 99.3%. The most common complications of PAE were postembolization syndrome and menstrual abnormality.

CONCLUSIONS AND RELEVANCE

The emergent PAE is a safe and effective method with high success rate in life-threatening PPH management. Gelatin sponge granules measuring 500 to 1000 μm in diameter have safe results. Pelvic arterial embolization may affect the recovery of menses and increase PPH in the subsequent pregnancy, but there was no noted correlation with fetal growth restriction.

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.

Embolization for acute arterial bleeding: use of the triaxial system and N-butyl-2-cyanoacrylate

PURPOSE

The aim of this study was to evaluate the usefulness of transcatheter arterial embolization (TAE) using the triaxial system with N-butyl-2-cyanoacrylate (NBCA) for acute arterial bleeding in comparison to TAE using the triaxial system with gelatin sponges (GS)　and/or coils.

MATERIAL AND METHODS

Between October 2013 and November 2018, 95 patients with acute arterial bleeding underwent emergency TAE using the triaxial system. Six patients underwent multiple TAEs and thus, 104 TAEs using the triaxial system were performed. In 26 of the 104 cases, TAE were performed with NBCA (NBCA group), and in the remaining 78 cases, TAE were performed with GS and/or coils (control group).

RESULTS

Hemorrhagic shock and coagulopathy more often occurred in the NBCA group. Procedure time was shorter in the NBCA group. The technical success rate was 100% in both groups (p > 0.99). The clinical success rate in the NBCA and control groups was 92% and 96%, respectively (p = 0.6). There was one minor complication (4%, 1/26) of liver dysfunction in a patient of the NBCA group, but no complication in the control group (p = 0.26).

CONCLUSION

TAE using the triaxial system with NBCA may be useful for acute arterial bleeding, especially in patients with hemorrhagic shock and coagulopathy.

Modified sandwich embolization technique for postpartum hemorrhage caused by uterine artery pseudoaneurysm: a case series

PURPOSE

Uterine artery pseudoaneurysm (UAP) is rare but can cause life-threatening postpartum hemorrhage (PPH). To evaluate a novel sandwich embolization technique as a treatment for PPH caused by UAP.

METHODS

This retrospective study included 10 patients with PPH caused by UAP who were treated using a modified sandwich embolization technique at the Radiology Department, Third Affiliated Hospital of Guangzhou Medical University between April 2009 and September 2018. Baseline clinical characteristics, intraoperative data (including treatment effectiveness) and postoperative data (including re-bleeding events and complications) were extracted from the medical records.

RESULTS

Uterine arterial angiography showed cystic shadowing of the vascular wall during the arterial phase in all patients. Spraying of contrast agent into the pseudoaneurysm was observed for large UAPs, and the pseudoaneurysm disappeared in the venous phase. The pseudoaneurysm blood supply was from the uterine artery in 9 patients (90%) and the uterine, superior vesical, internal pudendal and nameless little arteries in 1 patient (10%). Bleeding symptoms were completely relieved in all patients after sandwich embolization. Eight patients experienced painful contractions in the perioperative period, but there were no other postoperative complications. During the 1-year postoperative follow-up, 9 patients (90%) had no re-bleeding symptoms/signs. One patient (10%), who had a pseudoaneurysm supplied by the uterine, superior vesical, internal pudendal and nameless little arteries, experienced re-bleeding 20 days after surgery and was treated by hysterectomy.

CONCLUSION

Modified sandwich embolization is an effective treatment for PPH caused by UAP.

Conservative management of uterine artery pseudoaneurysm occurring during treatment of gestational trophoblastic disease: A case report

Uterine artery pseudoaneurysm (UAP) is a rare disease that causes genital bleeding during the postpartum period after cesarean section. Uterine artery embolization (UAE) is an effective procedure for UAP. UAP was unexpectedly encountered in a patient with gestational trophoblastic disease; however, this patient was conservatively managed without UAE. UAP can occur during treatment for gestational trophoblastic disease. Since asymptomatic UAP may spontaneously disappear, in the selection of conservative treatment, it is important to carefully monitor patients using transvaginal ultrasonography focusing on the size of the UAP and the speed of internal blood flow.

Application of Indirect Signs of Magnetic Resonance Imaging (MRI) in Prenatal Diagnosis of Abnormally Invasive Placenta

BACKGROUND The aim of this study was to assess the value of indirect MRI signs in the prenatal diagnosis of abnormally invasive placenta (AIP). MATERIAL AND METHODS This study involved the retrospective analysis of indirect signs of 109 patients with AIP and 59 patients without AIP. The numbers of cases of placenta increta, accreta, and percreta confirmed by surgical and pathological results were 54, 19, and 36, respectively. The indirect signs included the following: dark intraplacental bands in T2WI sequence, focal outward bulging of the placenta, abnormal placental vascularity, and heterogeneous placental signal intensity. RESULTS There were significant differences in dark intraplacental bands in T2WI sequence, focal outward bulging of the placenta, and abnormal placental vascularity between the AIP and the non-AIP groups. There was no significant difference in dark intraplacental bands in T2WI sequence between the placenta percreta and increta groups, but there was a significant difference between the other 2 AIP groups and the placenta accreta group. Focal outward bulging of the placenta was significantly different between the percreta group and the placenta accreta group, but there was no significant difference between the other 2 AIP groups and the placenta increta group. There were no significant differences in abnormal placental vascularity among the3 subtypes of AIP. CONCLUSIONS The indirect signs of dark intraplacental bands in T2WI sequence, focal outward bulging of the placenta, and abnormal placental vascularity are reliable signs of AIP. The indirect sign of dark intraplacental bands in T2WI sequence may be used to distinguish placental accreta from the other 2 subtypes of AIP.

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.

Transcatheter arterial embolization for postoperative arterial complications after pelvic or hip surgery

PURPOSE

We aimed to study the technical and clinical outcome of urgent transcatheter arterial embolization (TAE) for postoperative arterial complications after pelvic or hip surgery, and to accumulate additional experience about the role of embolization for these injuries.

METHODS

Patients who received TAE procedure for arterial complications after pelvic or hip surgery between September 1st, 2002 and December 1st, 2014 were screened on medical records and included in the analysis. Angiographic findings included active contrast agent extravasation, pseudoaneurysm formation, arteriovenous fistula, and other suspicious signs such as sighting of coarse margin or distortion of vessels. Embolic agents consisted of coils, gelatin sponge, and polyvinyl alcohol. Technical success was defined as complete occlusion of targeted artery through angiography, and clinical success as sustained resolution of symptoms.

RESULTS

A total of 22 patients (15 males, 19-76 years old) were enrolled. Prior to TAE, 12 patients developed hemorrhagic shock and the remaining 10 patients had hemorrhage-related pain, hematoma, or anemia. Contrast agent extravasation occurred in 12 cases, pseudoaneurysm formation in 5 cases, and other suspicious signs in 5 cases. Injury occurred in the internal iliac artery stem in 6 cases, inferior gluteal artery in 6 cases and superior gluteal artery in 6 cases. Multiple vascular lesions appeared in 5 cases. After TAE, technical success occurred in 22 patients and clinical success in 21 patients (95.5%). A 36-year-old woman died of irreversible multiple organ failure; no other severe procedure-related complications were recorded.

CONCLUSION

TAE is safe and effective for postoperative arterial complications after pelvic or hip surgery.

A proposal for standardized magnetic resonance imaging (MRI) descriptors of abnormally invasive placenta (AIP) - From the International Society for AIP

Abnormally invasive placenta (AIP) is used to describe a placenta that does not separate naturally after delivery and cannot be extirpated without causing abnormally high blood loss. Recently, the use of a standardized terminology for descriptors of AIP signs seen on ultrasound has been prosed but to date no such unified descriptors have been developed for magnetic resonance imaging (MRI). The purpose of this paper is to propose a unified terminology based on a consensus opinion from the members of the International Society for AIP (IS-AIP) that include obstetricians, gynecologists, radiologists, pathologists, anesthesiologists and basic science researchers. We assume that using these standardized MRI descriptors for AIP will be useful for clinical use, education, teaching and future research projects, thus assumably improving care of patients with this condition. In addition, using a uniform terminology for AIP should become the first step of a standardized MRI report.

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.

Postpartum hemorrhage from non-uterine arteries: clinical importance of their detection and the results of selective embolization

Background Identification of the source of postpartum hemorrhage (PPH) is important for embolization because PPH frequently originates from non-uterine arteries. Purpose To evaluate the clinical importance of identifying the non-uterine arteries causing the PPH and the results of their selective embolization. Material and Methods This retrospective study enrolled 59 patients who underwent embolization for PPH from June 2009 to July 2016. Angiographic findings and medical records were reviewed to determine whether non-uterine arteries contributed to PPH. Arteries showing extravasation or hypertrophy accompanying uterine hypervascular staining were regarded as sources of the PPH. The results of their embolization were analyzed. Results Of 59 patients, 19 (32.2%) underwent embolization of non-uterine arteries. These arteries were ovarian (n = 7), vaginal (n = 5), round ligament (n = 5), inferior epigastric (n = 3), cervical (n = 2), internal pudendal (n = 2), vesical (n = 1), and rectal (n = 1) arteries. The embolic materials used included n-butyl cyanoacrylate (n = 9), gelatin sponge particles (n = 8), gelatin sponge particles with microcoils (n = 1), and polyvinyl alcohol particles (n = 1). In 13 patients, bilateral uterine arterial embolization was performed. Re-embolization was performed in two patients with persistent bleeding. Hemostasis was achieved in 17 (89.5%) patients. Two patients underwent immediate hysterectomy due to persistent bleeding. One patient experienced a major complication due to pelvic organ ischemia. One patient underwent delayed hysterectomy for uterine infarction four months later. Conclusion Non-uterine arteries are major sources of PPH. Detection and selective embolization are important for successful hemostasis.

Efficacy of Automated Supplying Artery Tracking Software Using Multidetector-Row Computed Tomography Images for Emergent Transcatheter Arterial Embolization

PURPOSE

To assess the reliability of a prototype automated supplying artery tracking software (ASATS) using multidetector-row CT (MDCT) images in emergent TAE.

MATERIALS AND METHODS

Consecutive 53 patients underwent 57 sessions of emergent TAE during 7 months. Twenty-one cases were excluded due to a lack of CT data (n = 12) or negative angiographic findings (n = 9). Remaining 34 sessions of TAE and MDCT images in 32 patients (mean age 62.9 years; age range 37-92 years) were enrolled. ASATS was retrospectively conducted for the identification of supplying arteries which were confirmed with angiography (automated method). Manual modification was added as needed (semi-automated method). Two observers independently reviewed the MDCT images to detect supplying arteries (manual method). Detectability of supplying artery and time to analysis were compared among the automated, semi-automated, and manual methods by both observers.

RESULTS

A total of 64 bleeding sites were demonstrated on angiography. The detectability was 28 (43.8%) for automated method, 53 (82.8%) for semi-automated method, 55 (85.9%) for observer 1, and 58 (90.6%) for observer 2. Detectability of semi-automated method was significantly better than of automated method (P = 0.000) and comparable with manual method by both observers (P = 0.193 and 0.081). Average time to analysis was 185.4 s for automated method, 297.2 s for semi-automated method, 186.2 s for observer 1, and 243.7 s for observer 2.

CONCLUSION

ASATS has a sufficient ability to identify supplying arteries of bleeding by adding manual modification as needed and can be used for emergent TAE.

LEVEL OF EVIDENCE

Level 4, Case Control Study.

Recent Update of Embolization of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.

Delayed postpartum hemoperitoneum due to uterine artery pseudoaneurysm rupture

A 30-year-old woman experienced severe abdominal pain 8 days after vaginal delivery. The patient was diagnosed with hemoperitoneum due to rupture of the left uterine artery pseudoaneurysm, which was confirmed via ultrasound with color Doppler and computed tomography scans. This patient was treated with bilateral uterine artery embolization to maintain fertility. A uterine artery pseudoaneurysm that causes delayed postpartum hemorrhage can occur after cesarean section or vaginal delivery. A uterine artery pseudoaneurysm can be fatal, so its detection and diagnosis are critical. Herein, we report a case of delayed postpartum hemoperitoneum due to uterine artery pseudoaneurysm rupture.

Antepartum hemorrhage from previous-cesarean-sectioned uterus as a potential sign of uterine artery pseudoaneurysm

Postpartum hemorrhage (PPH), a leading cause of maternal mortality, can occur within 24 h of delivery (primary PPH), or during the period from 24 h after delivery to Week 6 of puerperium (secondary PPH). It requires health professionals to be alert to the symptoms to ensure prompt diagnosis and treatment, especially in the case of rupture of a uterine artery pseudoaneurysm (UAP) due to its life-threatening consequence (Baba et al., 2014). Most of the published case reports or case serials describe UAP as a possible cause of delayed PPH after traumatic procedures during delivery or pregnancy termination, including cesarean section (CS), manual removal of the placenta, or dilation and curettage (D&C) (Wald, 2003). Herein, we report a case of prior CS-related UAP manifesting as primary PPH after an uncomplicated vaginal delivery. This case required emergency embolization and is notable for several reasons. Antepartum hemorrhage of the previously scarred uterus was a potential sign of the ruptured UAP, and color Doppler sonography sometimes deceived the physician as the characteristic features of UAP did not appear to be present.

Conventional MRI features for predicting the clinical outcome of patients with invasive placenta

PURPOSE

We aimed to evaluate whether morphologic magnetic resonance imaging (MRI) features could help to predict the maternal outcome after uterine artery embolization (UAE)-assisted cesarean section (CS) in patients with invasive placenta previa.

METHODS

We retrospectively reviewed the MRI data of 40 pregnant women who have undergone UAE-assisted cesarean section due to suspected high risk of massive hemorrhage caused by invasive placenta previa. Patients were divided into two groups based on the maternal outcome (good-outcome group: minor hemorrhage and uterus preserved; poor-outcome group: significant hemorrhage or emergency hysterectomy). Morphologic MRI features were compared between the two groups. Multivariate logistic regression analysis was used to identify the most valuable variables, and predictive value of the identified risk factor was determined.

RESULTS

Low signal intensity bands on T2-weighted imaging (P < 0.001), placenta percreta (P = 0.011), and placental cervical protrusion sign (P = 0.002) were more frequently observed in patients with poor outcome. Low signal intensity bands on T2-weighted imaging was the only significant predictor of poor maternal outcome in multivariate analysis (P = 0.020; odds ratio, 14.79), with 81.3% sensitivity and 84.3% specificity.

CONCLUSION

Low signal intensity bands on T2-weighted imaging might be a predictor of poor maternal outcome after UAE-assisted cesarean section in patients with invasive placenta previa.

Embolization of iatrogenic uterine pseudoaneurysm

Uterine artery pseudoaneurysms (UAPs) are rare vascular lesions that may be life threatening if not diagnosed and properly treated. The clinical presentation of UAPs includes a spectrum of symptoms that are often associated with other and more frequent gynecologic/obstetric pathologies, both with and without vaginal bleeding, and may span from postpartum hemorrhage to the absence of symptoms. We report cases of two patients with UAP, both of whom were diagnosed with ultrasonography and contrast-enhanced computed tomography and successfully treated with transcatheter embolization. The first patient presented delayed hypovolemic shock following surgery for endometriosis, whereas the second patient suffered from postpartum hemorrhage after cesarean section. Diagnosis of UAPs relies on noninvasive imaging; transcatheter arterial embolization is an effective treatment to control bleeding in both hemodynamically stable and unstable patients.

Diagnosis of gynecological pseudoaneurysms and embolization with cyanoacrylate

Pseudoaneurysms of the uterine artery are an uncommon cause of severe gynecological bleeding secondary to surgical manipulation of the pelvis or to instrumental delivery. The different imaging techniques are of vital importance in the diagnosis. Angiography is the technique used for confirmation and also for treatment in many cases. Endovascular treatment by embolizing the pseudoaneurysm has become established as the treatment of choice, making it possible to avoid hysterectomy in women of childbearing age. This article presents two cases of gynecological bleeding due to pseudoaneurysms (one secondary to surgery and one secondary to childbirth) that were embolized in a novel way using cyanoacrylate.

Short & long term adverse outcomes after arterial embolisation for the treatment of postpartum haemorrhage: a systematic review

OBJECTIVES

Arterial embolisation (AE) plays a major role in current practice in the management of postpartum haemorrhage (PPH) that fails to respond to conservative treatment. While its benefit is well known, long-term outcomes of AE have been poorly investigated. The objective of this review is to assess its potential complications and long-term effects on the patients' quality of life.

METHODS

Using the terms "embolisation" and "postpartum haemorrhage", we searched the Cochrane Central Register of Controlled Trials, Medline and PubMed for published studies. We limited the search to articles in English and French reporting "complications", "fertility", "menstruation" or "menstrual cycle" in humans. To ensure completeness, the references of extracted articles and review articles were also searched.

RESULTS

The fertility rate in patients attempting another pregnancy reaches 70-80 %. Pregnancies following AE for PPH are not associated with a higher rate of intrauterine growth restriction. Pathological placentation (placenta accreta/increta/percreta) occurs more frequently after AE than in the general population. Psychological wellbeing, post-traumatic stress and sexual dysfunction after a life-threatening PPH requiring AE will require further investigation.

CONCLUSION

AE does not appear to adversely affect menstrual cycle, fertility and subsequent pregnancies, but may affect placentation. The experience of a life-threatening PPH, however, might prevent couples from pursuing another pregnancy.

KEY POINTS

• Embolisation for PPH does not adversely affect menstrual cycle and fertility • Experience of life-threatening PPH might prevent couples from pursuing another pregnancy • Pathological placentation seems to occur more frequently after embolisation for PPH.

Management of two placenta percreta cases

Placental invasion anomalies are divided into three according to invasion of uterine wall as placenta accreta, increta and percreta. In placenta percreta, the most severe but the least common form, the placenta invades the full thickness of the uterine wall and also it can attach to adjacent organs in the abdomen like the bladder and rectum. It is a potentially life treating condition. There is no recommended management strategy for placenta percreta. We herein report two cases managed differently and discuss the management options in the light of the literature.

Evaluation of interobserver variability and diagnostic performance of developed MRI-based radiological scoring system for invasive placenta previa

PURPOSE

To evaluate the interobserver variability and diagnostic performance of a developed magnetic resonance imaging (MRI)-based scoring system for invasive placenta previa.

MATERIALS AND METHODS

Prenatal MR images of 70 women were retrospectively evaluated, 18 of whom were diagnosed with invasive placenta. The six MR features (dark band on T2 -weighted images, intraplacental abnormal vascularity, placental bulge, heterogeneous placenta, myometrial thinning, and placental protrusion sign) were scored on 5-point Likert scale separately, and the cumulative radiological score (CRS) was defined as the sum of each score. Two more experienced radiologists (readers A and B) and two less experienced residents (readers C and D) calculated the CRS. Interobserver variability was assessed by measuring the intraclass correlation coefficient. Diagnostic performance was evaluated by means of receiver operating characteristic (ROC) analysis.

RESULTS

Interobserver variability for CRS was excellent for the more experienced radiologists (0.85), and good for all readers (0.72) and the less experienced residents (0.66). The area under the ROC curve (Az) and accuracy (Acc) for CRS were significantly higher or equivalent to those of other MR features for all readers (Az and Acc for reader A; CRS, 0.92, 91.4%; intraplacental T2 dark band, 0.83, P = 0.009, 81.4%, P = 0.03; intraplacental abnormal vascularity, 0.9, P = 0.3, 90.0%, P = 1.00; placental bulge, 0.81, P = 0.0008, 80.0%, P = 0.02; heterogeneous placenta, 0.85, P = 0.11, 74.3%, P = 0.002; myometrial thinning, 0.84, P = 0.06, 60.0%, P < 0.0001; placental protrusion sign, 0.81, P = 0.01, 81.4%, P = 0.26).

CONCLUSION

This developed MRI-based scoring system demonstrated excellent or good interobserver variability, and good diagnostic performance for invasive placenta previa. J. Magn. Reson. Imaging 2016;44:573-583.

CT diagnosis and endovascular management of spontaneous rupture of uterine artery in pregnancy

Spontaneous rupture of the uterine artery during pregnancy is an extremely uncommon condition, which presents as an acute emergency, associated with high rates of maternal and foetal mortality. This condition is challenging to diagnose and treat, as it is an uncommon entity having an acute nature of presentation. They are usually managed by emergency laparotomy and the diagnosis is rarely made preoperatively. We describe a case with CT angiographic images clearly demonstrating the uterine artery pseudoaneurysm with associated extensive haemoperitoneum, which helped us confirm this rare diagnosis. We successfully treated the patient by an endovascular approach, which has not been reported previously.