Interventional radiology for critical hemorrhage in obstetrics: Japanese Society of Interventional Radiology (JSIR) procedural guidelines

Characteristics and outcomes of patients with postpartum hemorrhage undergoing transcatheter arterial embolization: A nationwide observational study

OBJECTIVE

To elucidate the demographics, clinical characteristics, and outcomes of patients with postpartum hemorrhage (PPH) who underwent transcatheter arterial embolization (TAE).

METHODS

We conducted a retrospective observational study using the Japanese Diagnosis Procedure Combination inpatient database, which covers roughly 90% of all tertiary emergency hospitals in Japan, between April 2012 to March 2020. We identified patients with PPH who underwent TAE using the Japanese medical procedure status and code, and the device or drug code. We examined the patient characteristics, interventions administered, and clinical outcomes.

RESULTS

Among 64 893 patients diagnosed with PPH, we identified 2705 (4.2%) patients with PPH who underwent TAE. The most common cause of PPH was uterine atony (68.7%), followed by disseminated intravascular coagulation after labor (30.0%) and placenta accreta spectrum disorders (23.4%). The proportion of patients who underwent repeat TAE and a hysterectomy was 64 (2.4%) and 188 (7.0%), respectively. Among hysterectomies (n = 188), 26 (13.8%) had the procedure performed before TAE, 73 (38.8%) underwent hysterectomy on the same day as TAE, and 89 (47.4%) had the procedure conducted after TAE. Of those who underwent a hysterectomy after TAE (n = 89), 33 (37%) were performed more than 1-week after initial TAE. Overall in-hospital mortality was 14/2705 (0.5%).

CONCLUSION

Even if hemostasis is achieved through TAE, one must be mindful that a hysterectomy may become necessary more than 1 week after the procedure. These results could be helpful in clinical decision making and providing patients with additional treatment options for PPH that preserve patient fertility.

Prediction of Positive Angiogram Using Enhanced Computed Tomography in Postpartum Hemorrhage: A Retrospective Multicentered Study

AIM

This study aimed to determine the accuracy of active arterial hemorrhage (AAH) on computed tomography (CT) in predicting the need for embolization in postpartum hemorrhage (PPH).

METHODS

In a multicentered retrospective observational study, we reviewed the medical records of PPH patients between April 2010 and May 2020. We included patients who initially underwent enhanced CT and were subsequently classified as AAH+ or AAH- on CT. AAH+ on angiogram and embolization was used as a positive reference standard. A multiple logistic regression model evaluated AAH on CT as a predictor for embolization. We assessed AAH+ on CT supplied by extrauterine arteries.

RESULTS

Of 231 PPH patients, 94 underwent enhanced CT. AAH+ and AAH- on CT consisted of 44 and 50 patients, respectively. Of AAH+ on CT patients, 32 (72.7%) underwent angiography and embolization. The sensitivity, specificity, and positive and negative predictive values of AAH on CT were 95.6%, 69.0%, 50.0%, and 98.0%, respectively. A multiple logistic regression model revealed that AAH on CT was an independent predictor of embolization (odds ratio=9.31, confidence interval=2.85-30.50, p<0.01). Sites of AAH on CT were the vagina (n=7), intraperitoneal (n=3), and abdominal wall (n=3), except for intrauterine sites.

CONCLUSION

Enhanced CT showed high sensitivity and had a negative predictive value for predicting AAH+ on angiogram and embolization; this may be useful in ruling out the necessity for angiography. Active arterial hemorrhage on CT may predict embolization and identify the precise bleeding site.

Uterine necrosis following uterine artery embolization as treatment for postpartum hemorrhage: A case report and literature review

Uterine necrosis is a rare complication of uterine artery embolization for postpartum hemorrhage and most patients end up having a hysterectomy. Here we report a case in which the patient experienced a recurrent fever 28 days after uterine artery embolization as treatment for postpartum hemorrhage and had no response to antibiotics. Magnetic resonance imaging of the pelvis revealed a mass which was approximately 12-cm in size with air bubbles in the uterus, suggesting necrosis with infection. Transvaginal clamping of the uterine mass was performed and necrotic tissue removed under laparoscopic monitoring, which successfully spared the necessity for a hysterectomy. The patient's subsequent progress was favorable. In the present study we review the high-risk factors of uterine necrosis following uterine artery embolization and summarize the key points of early diagnosis. In addition, we propose a strategy to successfully spare the necessity for a hysterectomy without the spread of infection or uterine perforation.

Endometritis risk factors after arterial embolisation for postpartum haemorrhage

Various complications of arterial embolisation (AE) for postpartum haemorrhage (PPH) are reported. Endometritis (EM) frequently causes abscesses, increasing hysterectomy risk. However, risk factors for EM after AE for PPH are unclear. We explored these risk factors. We included patients who underwent AE for PPH in our hospital from 2005 to 2020 and compared those who did (EM group) and did not develop EM after AE (non-EM group) in a case-control study. Twenty patients met the study criteria; eight patients (40%) had EM. There were no differences in risk factors between groups involved in infection, such as premature rupture of membranes. However, the contrast medium extravasation rate on computed tomography scans before the AE procedure was significantly higher in the EM group (p=.019) compared to the non-EM group. The greatest EM risk factor was contrast medium extravasation before AE for PPH, determined by classification and regression tree modelling (relative risk: 4.5).Impact StatementWhat is already known on this subject? Reportedly, the clinical success rate of arterial embolisation (AE) for critical haemorrhage in obstetrics is high, around 90%. However, information regarding AE complications is limited. Endometritis is one of these complications, which not only causes prolonged hospitalisation but may also require further treatment, such as hysterectomy. However, the incidence rate and risk factors for EM remain unknown.What do the results of this study add? In this study, 40.0% of patients developed EM after AE for PPH. Extravasation of contrast medium was the top risk factor (relative risk: 4.5 compared to those without EM, p=.019). The second-leading risk factor was a bleeding volume greater than 2500 mL (relative risk: 4.5 compared to those without EM, p=.019).What are the implications of these findings for future clinical practice and/or future research? We created an EM prediction model using extravasation and a bleeding volume greater than 2500 mL. The model was 87.5% sensitive and 66.7% specific. This prediction model allows for the early detection and treatment of EM by recognising high-risk patients and providing intensive postpartum management.

A Case of Preeclampsia with Uterine Necrosis after Uterine Artery Embolization for Postpartum Hemorrhage

Uterine necrosis is a rare complication in uterine artery embolization (UAE) for postpartum hemorrhage (PPH). Preeclampsia (PE) is a condition characterized with systemic endothelial damage and intravascular volume depletion. Whether a patient with PE is at high risk for uterine necrosis after UAE for PPH has been unknown. A 30-year-old primipara woman was diagnosed with PE based on hypertension and proteinuria during delivery. UAE was performed for PPH after forceps delivery. After UAE, the patient presented with pleural effusion and massive ascites as well as persistent fever unresponsive to antibiotics. Ultrasonography and contrast-enhanced magnetic resonance imaging (MRI) led to the diagnosis of uterine necrosis, for which we performed total laparoscopic hysterectomy. It should be kept in mind that patients with PE associated with massive ascites may be at high risk for uterine necrosis after UAE due to decreased uterine perfusion. Therefore, it is important to pay attention to persistent symptoms such as fever and abdominal pain after UAE to diagnose uterine necrosis.

The Efficacy of Transarterial Embolization for Postpartum Hemorrhage Complicated with Disseminated Intravascular Coagulation: A Single-Center Experience

Indications for the use of transarterial embolization (TAE) for postpartum hemorrhage (PPH) have been established. However, the efficacy of TAE for PPH complicated by disseminated intravascular coagulation (DIC) remains controversial. In this study, we investigated the efficacy of TAE for PPH complicated by DIC. A database review was conducted to identify patients who were treated with TAE for PPH at our hospital. TAE was performed in 41 patients during the study period. Effective hemostasis was achieved in all cases, but additional procedures, such as re-embolization or hysterectomy, were required in five patients (12.2%). The typical causes of PPH included uterine atony (18 cases), placenta previa (15 cases), amniotic fluid embolism (DIC-type) (11 cases), and placenta accreta spectrum (10 cases). The mean blood loss was 3836 mL. The mean obstetrical DIC and the International Society on Thrombosis and Hemostasis DIC scores were 7.9 and 2.6, respectively. The efficacy of hemostasis was comparable between patients with and without DIC. However, the complete success rate of TAE was lower in patients with DIC as the condition worsened than that in non-DIC patients. Overall, TAE is effective as a minimally invasive treatment for PPH complicated by DIC.

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.

Cesarean Section for Placenta Previa and Placenta Previa Accreta Spectrum

According to the increase in the rate of cesarean section and the increase of high-aged pregnancy, we seem to more often encounter cases with placenta previa and placenta previa accrete spectrum. There are concerns about these cases, such as difficulty in controlling bleeding from the separation surface of placenta previa, the need for hysterectomy as a life-saving procedure, systemic management and hemostasis during massive hemorrhage, and treatment of disseminated intravascular coagulation (DIC). These cases are most frequently associated with cesarean hysterectomy.

Management of disseminated intravascular coagulation associated with placental abruption and measures to improve outcomes

Placental abruption is a condition that should be carefully considered in perinatal management because it is associated with serious events in both the mother and neonate, such as intrauterine fetal death, cerebral palsy, obstetric critical bleeding, and uncontrollable bleeding. The concomitant presence of disseminated intravascular coagulation (DIC) more easily causes critical bleeding that may necessitate hysterectomy or multi-organ failure resulting in maternal death. Therefore, early management should be provided to prevent progression to serious conditions by performing both hemostatic procedures and DIC treatment. To take measures to improve the outcomes in both the mother and neonate, health guidance for pregnant women, early diagnosis, early treatment, development of the emergency care system, and provision of a system for transport to higher-level medical institutions should be implemented.