Postpartum haemorrhage due to genital tract injury after vaginal delivery: safety and efficacy of transcatheter arterial embolisation

Vaginal artery pseudoaneurysm after a hysterectomy: A case report and review of the literature

Key clinical message

This was the first report of a pseudoaneurysm in a vaginal artery after hysterectomy, unlike other published studies that were of pseudoaneurysms in uterine or vaginal arteries after delivery.

Abstract

A 51-year-old woman presented with massive vaginal bleeding 7 days after a hysterectomy, which caused hemoglobin to drop. The patient was suspicious of having a vaginal artery pseudoaneurysm according to the sonography. Her bleeding was stopped after the ligation of her left internal iliac artery.

Vaginal haematoma as a postpartum complication: a case report

do uzupełnienia

Transcatheter Arterial Embolization (TAE) Using N-Butyl-2-cyanoacrylate (NBCA) as the First Choice for Postpartum Vulvovaginal Hematoma; Case Series and Reviews of the Literature

Transcatheter arterial embolization (TAE) has long been reported to be safe, effective, and to have a high clinical and technical success rate for vulvovaginal hematoma. We used a permanent embolic material, diluted N-butyl-2-cyanoacrylate (NBCA), for the first choice intervention for six cases of vulvovaginal hematoma, in order to confirm the effectiveness of NBCA. Regarding post-embolization adverse events, we did not observe any fever nor necrosis or pain in the vaginal wall or vulva, in all cases. The use of NBCA as a first-line treatment for TAE of vulvovaginal hematoma is considered to be effective, in the following two ways: First, hemostasis can be achieved by adjusting the mixing ratio of NBCA and lipiodol, according to the distance between the tip of the catheter and the site of injury. Second, NBCA does not cause complications such as pain, necrosis, or infection, and it can be used safely. There are no reports clearly recommending NBCA as the first choice in the treatment of TAE for vulvovaginal hematoma. This is the first report to examine the efficacy and safety of NBCA as the first-line intervention for such cases.

Protective Effects of Engineered Lactobacillus crispatus on Intrauterine Adhesions in Mice via Delivering CXCL12

Endometrial injury is the main cause of intrauterine adhesions (IUA), and there is currently no effective prevention and treatment. Immune cells play an important role in damage repair by sensing the change in the microenvironment. Exogenous CXCL12 can promote tissue regeneration and repair by recruiting immune cells, but its effect and possible mechanism on endometrial regeneration and repair have not been reported. In the present study, we constructed an engineered a Lactobacillus crispatus strain by transforming a pMG36e plasmid carrying a CXCL12 gene into the bacterium, and developed two animal models, the intrauterine adhesion mice with or without diabetes to evaluate the positive effects of this strain on the prevention of IUA after accepting intrauterine surgery in normal and diabetic mice. The results showed that vaginal application of L. crispatus-pMG36e-mCXCL12 strains significantly diminished the levels of pro-inflammatory factors interleukin-1β (IL-1β) and tumour necrosis factor-α (TNF-α) in serum and uterine tissues of IUA mice, and resulted in the inhibition of the inflammatory (toll-like receptor 4/nuclear factor-κb, TLR4/NF-κB) and fibrotic (transforming growth factor-β1/smads, TGF-β1/Smads) signalling pathways in the uterine tissues. The high-throughput sequencing results further indicated that treatment with L. crispatus-pMG36e-mCXCL12 strains greatly increased the abundance of Lactobacillus spp. and reduced that of the pathogenic Klebsiella spp. in IUA mice. Furthermore, among intrauterine adhesion mice with diabetes, we obtained similar results to non-diabetic mice, that is, L.crispatus-pMG36e-mCXCL12 significantly improved fibrosis and inflammation in the uterine cavity of diabetic mice, and restored the vaginal microbiota balance in diabetic mice. Therefore, we speculated that vaginal administration of L. crispatus-pMG36e-mCXCL12 strains can effectively alleviate intrauterine adhesions by restoring the microbial balance and reducing inflammation and fibrosis caused by surgery.

Two Case Studies on Inferior Mesenteric Artery Embolization for Primary Postpartum Hemorrhage

Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective treatment option for PPH. Among the vessels embolized, the inferior mesenteric artery (IMA) is usually not the first choice for TAE, because it is a rare source of bleeding in PPH. In this report, we describe our experience with two patients with PPH, in whom the IMA was selected on the basis of contrast-enhanced computed tomography (CECT) findings, and prompt hemostasis was achieved with TAE. CECT can provide useful clues as to the culprit artery based on the anatomical location of the hematoma and extravasation. These useful findings of CECT allow prompt TAE of rare sources of bleeding in PPH, such as the IMA.

Outcomes and complications of severe acute postpartum hemorrhage treated with or without transarterial embolization in a single tertiary referral center: A 20-year experience

OBJECTIVE

PPH is usually unpredictable; and such fast, urgent and sudden massive life-threating hemorrhage. This study is to assess the efficacy of transarterial embolization (TAE) in treating severe PPH in a single institution over a period of 20 years.

MATERIALS AND METHODS

From January 2000 to October 2019, all women with acute PPH more than 1500 cc and/or DIC were enrolled in this retrospective study. These women were divided into two groups according to whether they have received TAE as the second-line treatment. Group 1 (n = 27) included women without receiving TAE from January 1, 2000 to October 31, 2009, and group 2 (n = 30) included those who receiving TAE from November 1, 2009 to October 31, 2019.

RESULTS

The overall success rate of TAE in control the PPH and preserved the uterus is 80%. The hemoglobin 12 h after PPH in group 2 is significantly lower than in group 1 (7.64 ± 1.6 vs. 8.58 ± 1.9, respectively. P = 0.05). Total unit of packed red blood cell (pRBC) transfusion is significantly higher in the group 2 than group 1 (9.8 ± 5.7 vs. 6.8 ± 3.9; p = 0.03). The rate of hysterectomy is significantly higher in group 1 than group 2 (46.7 vs. 20%; p < 0.001).

CONCLUSION

In conclusion, TAE is safe and effective in control bleeding in PPH with a high success rate to preserve uterus and prevent DIC. TAE should be routinely used as a secondary line of treatment during PPH in all hospitals.

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.

Endovascular management of episiotomy site hematoma: Two cases and a brief review

Episiotomy site hematoma, though uncommon, can be associated with serious maternal morbidity. It arises mostly due to tissue trauma or injury to blood vessels, leading to the formation of a pseudoaneurysm. Sometimes, when surgical management fails, embolization of the bleeding vessel is a lifesaving option. Here, we report two cases of episiotomy site hematoma that required selective arterial embolization for management, following the failure of surgical management. A 28-year-old G6A5 woman underwent forceps delivery following which she developed a 6*6-cm right-sided vulvovaginal hematoma at the episiotomy site. After failed surgical management, arterial embolization was performed and hemostasis was achieved. A 26-year-old P2L2 woman with a history of surgical exploration for episiotomy site hematoma, presented postdelivery on postpartum day seven with profuse vaginal bleeding. Her computed tomography angiogram revealed a pseudoaneurysm of around 2.1*1 cm in length with a vaginal hematoma of 4*5 cm. Selective artery embolization performed and complete hemostasis was achieved with no complications. Selective arterial embolization is a safe therapeutic option for episiotomy site hematoma, especially if surgical management fails.

Inferior Mesenteric Artery Embolization with N-Butyl Cyanoacrylate for Life-Threatening Postpartum Hemorrhage: A Report of Two Cases and Literature Review

하장간막동맥은 산후출혈의 매우 드문 출혈 혈관이다. 저자들은 질분만 후 하장간막동맥에서 출혈이 있었던 일차성 산후출혈 두 개의 증례를 보고한다. 두 환자 모두 저혈량성 쇼크의 징후를 보이고 있었고, 파종성혈관내응고가 의심되는 상태였다. 산후출혈의 흔한 출혈 혈관인 자궁동맥을 색전한 후에도 출혈은 지속되었다. 하장간막동맥 혈관조영술에서 상직장동맥으로부터 조영제의 혈관외누출이 확인되어 N-butyl cyanoacrylate를 이용한 선택적 색전술을 시행하였다. 이 증례를 통해 산도 손상에 의한 산후출혈이 조절되지 않고 지속될 때 하장간막동맥이 출혈 동맥일 수 있다는 점을 강조하고자 한다.

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.

Transcatheter arterial embolization for gastrointestinal bleeding related to pancreatic adenocarcinoma: clinical efficacy and predictors of clinical outcome

PURPOSE

To evaluate the clinical efficacy of transcatheter arterial embolization (TAE) for managing pancreatic adenocarcinoma-related gastrointestinal (GI) bleeding, and to determine the factors associated with clinical outcomes.

METHOD

From 2001-2017, this retrospective study included 58 patients who underwent TAE for pancreatic adenocarcinoma-related GI bleeding. The technical and clinical success of TAE, clinical factors including patient characteristics and embolization details, complications, and the 30-day mortality were evaluated. Univariate analyses were performed to determine the factors related to the clinical outcomes.

RESULTS

On angiography, bleeding foci were detected in 47 patients (81%), while the other 11 patients showed tumor staining. Technical success rate was 98%, and first session and overall clinical success rates were 79% and 88%, respectively. N-butyl cyanoacrylate (NBCA) was the most commonly used embolic agent (53%). Stent-related bleeding was shown in 22 patients with characteristic angiogram such as arterial cut-off (13/22) and arteriobiliary fistula (5/22), with comparable clinical success rate (82%). Bleeding from the superior mesenteric artery (n = 3) at the first session of angiography and complications (n = 2), such as ischemic hepatitis and small bowel infarction, were all associated with a 30-day mortality. The overall 30-day mortality rate was 22%. Univariate analysis showed that massive transfusion and TNM stage 4 were related to clinical failure (P = 0.035 and 0.038, respectively).

CONCLUSIONS

TAE was effective and safe for pancreatic adenocarcinoma-related GI bleeding. Stent-related bleeding was not uncommon, and associated with vascular abnormality amenable to TAE. Massive transfusion and TNM stage 4 were related to clinical failure.

Establishing a Treatment Algorithm for Puerperal Genital Hematoma Based on the Clinical Findings

Postpartum hemorrhage within 24 hours after delivery remains the leading cause of maternal mortality worldwide. Puerperal genital hematoma (PGHA) is a rare complication of postpartum hemorrhage, and PGHA can be life-threatening if hemostasis is not properly achieved. However, a reliable management algorithm for PGHA based on the clinical findings has not been developed. The objectives were to evaluate the management strategies for PGHA and identify the clinical findings that help select the treatment for PGHA. The medical records of women who were treated for PGHA in our department were reviewed, and data regarding the clinical findings and the treatment strategy for PGHA were analyzed. Thirty-four women who underwent treatment for PGHA were identified and divided into three groups according to the final procedure that achieved hemostasis: conservative management (CM) (n = 9), surgical management (SURG) (n = 15), and arterial embolization management (AEM) (n = 10). Regarding the clinical findings on initial evaluation, the shock index was significantly higher in the AEM group than in the CM or SURG group; and initial platelet count and fibrinogen level were significantly lower in the AEM group than in the CM group. There was no significant difference in any computed tomography (CT) finding among the three groups. In conclusion, this study clearly shows the difference in clinical findings among treatment strategies for PGHA. We suggest that the clinical findings of shock index, platelet count, and fibrinogen level together with CT findings are helpful and valuable for selecting the treatment strategy for PGHA.

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.

Inferior mesenteric artery embolization for persistent postpartum hemorrhage after sufficient bilateral iliac arteries embolization: safety and efficacy in eight patients

OBJECTIVE

To assess the safety and efficacy of transcatheter arterial embolization (TAE) of the inferior mesenteric artery (IMA) for the management of post-partum hemorrhage (PPH).

METHODS

A retrospective analysis was performed regarding eight patients (mean age, 34.4 y; age range, 31 - 40 y) who underwent TAE of the IMA for PPH between March 2001 and September 2018. Obstetric records, including maternal characteristics, clinical manifestations, complications, and clinical outcomes, as well as TAE details were obtained.

RESULTS

All eight patients had primary PPH and the vaginal delivery mode. CT scans of two patients showed active bleeding from the lower uterus or hematoma and with the origin of contrast extravasation abutting the adjacent rectum. In seven patients, an aortogram or IMA arteriogram following persistent vaginal bleeding after sufficient embolization of the bleeding focus from the bilateral iliac arteries, found the bleeding focus of the IMA, while in one patient, the IMA bleeding focus was found at the second session 4 h after the first session. TAE of the IMA was technically successful in all eight patients and cessation of bleeding without repeated TAE or additional hemostatic surgery was achieved in all patients after TAE of the IMA. There were neither procedure-related complications nor bowel ischemia during follow-up.

CONCLUSION

TAE of the IMA for PPH was safe and effective with successful hemostasis. Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries.

ADVANCES IN KNOWLEDGE

Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries.

[Embolization of the hypogastric artery in postpartum haemorrhage. Case report]

Selective embolization of the hypogastric artery is nowadays commonly used for the haemostasis of gynaecological cancer patients. Also re-embolization is possible in the cases of repeated bleedings. We present this method based on the summary of three obstetrical patients in our hospital. In these patients, primary management failed to control bleeding after parturition caused by anatomic reasons which made it difficult to access the bleeding and to achieve haemostasis. During intervention we catheterized the visceral branch of the internal iliac artery selectively via an access in the common femoral artery. Thereafter we blocked the artery with Spongostan fillings. We had one patient, where we applied embolization in retroperitoneal haemorrhage after Caesarean section and supravaginal amputation of the uterus. In two other cases we successfully managed vaginal haematoma by embolization, whereas multiple surgical treatments were unsuccessful. The advantage of this method is that it does not require laparotomy or vaginal exploration. The disadvantage is that a well-equipped laboratory of angiography and an interventional radiologist are also required. Orv Hetil. 2018; 159(39): 1602-1606.