Uterine Artery Embolization for Secondary Postpartum Hemorrhage

The anatomy of the anterior division of the internal iliac artery: a computed tomography angiography analysis with implications for surgical and endovascular procedures

INTRODUCTION

The anterior division of the internal iliac artery (ADIIA) is a crucial vascular structure that supplies blood to the pelvic organs, perineum, and gluteal region. The present study demonstrates practical data concerning the anatomy of the ADIIA and its branches. It is hoped that the results of the current study may aid in localizing the pelvic arteries effectively.

METHODS

The present study is a retrospective analysis that was carried out to determine the anatomical variations, prevalence, and morphometric data of the ADIIA and its branches. Ultimately, 148 ADIIAs from 73 patients met the necessary criteria and were evaluated in 45 categories.

RESULTS

The most prevalent branch of the ADIIA was found to be the internal pudendal artery, as it was present in 134 of the studied cases (90.5%). The most common first branch of the ADIIA was found to be the umbilical artery (48.5%), whereas the most common last branch of the ADIIA was found to be the inferior gluteal artery (68.4%). The median distance between the origin of the ADIIA and the origin of the uterine artery was found to be 12.00 mm (LQ = 7.49; HQ = 18.63). The median diameter of the ADIIA at its origin was found to be 5.76 mm (LQ = 4.80; HQ = 6.45), whereas the median cross-sectional area at the same point was set to be 24.77 mm2 (LQ = 17.65; HQ = 31.95).

CONCLUSION

It is hoped that the results of the present study will assist in the localization of the branches of the ADIIA in cases of pelvic hemorrhage and during various pelvic surgeries, including laparoscopic hysterectomies.

Uterine artery embolization in the management of postpartum hemorrhage

BACKGROUND

Postpartum hemorrhage (PPH) is one of the leading preventable causes of maternal morbidity and mortality causing one-fourth of all maternal deaths. We aimed to study the role of uterine artery embolization (UAE) in controlling PPH and its impact on the need for hysterectomy.

METHODS

We studied patients who were diagnosed with primary PPH between February 2012 and March 2020 at Al Ain Hospital, United Arab Emirates. We studied the characteristics and outcomes of those undergoing interventional radiology via UAE. Logistic regression analysis was done to define the factors that predict the need for emergency UAE.

RESULTS

Out of 79 patients who had elective (n = 53) or emergency (n = 26) embolization, the placenta previa accreta (69.8% vs. 23.1%) and placenta previa (24.4% vs. 3.8%) were the common indications for elective versus emergency UAE (p < 0.001). The indication for UAE was the most significant factor for predicting an emergency procedure (p = 0.002) with placenta previa being significantly different from other indications (p < 0.001). Bleeding stopped in 78/79 patients (success rate of 98.7%) following UAE. Those who failed stopping of the bleeding were similar between the elective and emergency IR, (1/53 (1.9%) compared with 0/26 (0%), p = 0.99 Fisher's Exact test). Overall, eight patients (10%) had hysterectomy, one of them was needed as the final solution to stop bleeding. There were no maternal deaths.

CONCLUSIONS

Interventional radiological UAE is very efficient in controlling postpartum hemorrhage. It should be recommended as the first line of treatment for significant bleeding when expertise and facilities are available. It increases survival, reduces hysterectomy rate, without a difference if done as an emergency or elective procedure.

Novel concepts and improvisation for treating postpartum haemorrhage: a narrative review of emerging techniques

BACKGROUND

Most treatments for postpartum haemorrhage (PPH) lack evidence of effectiveness. New innovations are ubiquitous but have not been synthesized for ready access.

NARRATIVE REVIEW

Pubmed 2020 to 2021 was searched on 'postpartum haemorrhage treatment', and novel reports among 755 citations were catalogued. New health care strategies included early diagnosis with a bundled first response and home-based treatment of PPH. A calibrated postpartum blood monitoring tray has been described. Oxytocin is more effective than misoprostol; addition of misoprostol to oxytocin does not improve treatment. Heat stable carbetocin has not been assessed for treatment. A thermostable microneedle oxytocin patch has been developed. Intravenous tranexamic acid reduces mortality but deaths have been reported from inadvertent intrathecal injection. New transvaginal uterine artery clamps have been described. Novel approaches to uterine balloon tamponade include improvised and purpose-designed free-flow (as opposed to fixed volume) devices and vaginal balloon tamponade. Uterine suction tamponade methods include purpose-designed and improvised devices. Restrictive fluid resuscitation, massive transfusion protocols, fibrinogen use, early cryopreciptate transfusion and point-of-care viscoelastic haemostatic assay-guided blood product transfusion have been reported. Pelvic artery embolization and endovascular balloon occlusion of the aorta and pelvic arteries are used where available. External aortic compression and direct compression of the aorta during laparotomy or aortic clamping (such as with the Paily clamp) are alternatives. Transvaginal haemostatic ligation and compression sutures, placental site sutures and a variety of novel compression sutures have been reported. These include Esike's technique, three vertical compression sutures, vertical plus horizontal compression sutures, parallel loop binding compression sutures, uterine isthmus vertical compression sutures, isthmic circumferential suture, circumferential compression sutures with intrauterine balloon, King's combined uterine suture and removable retropubic uterine compression suture. Innovative measures for placenta accreta spectrum include a lower uterine folding suture, a modified cervical inversion technique, bilateral uterine artery ligation with myometrial excision of the adherent placenta and cervico-isthmic sutures or a T-shaped lower segment repair. Technological advances include cell salvage, high frequency focussed ultrasound for placenta increta and extra-corporeal membrane oxygenation.

CONCLUSIONS

Knowledge of innovative methods can equip clinicians with last-resort options when faced with haemorrhage unresponsive to conventional methods.

Short-term outcomes of uterine artery embolization for urgent or emergent abnormal uterine bleeding

PURPOSE

To evaluate the outcomes of uterine artery embolization (UAE) for patients with urgent or emergent abnormal uterine bleeding (AUB).

MATERIALS AND METHODS

Retrospective review of all patients from 1/2009-12/2020 who were treated urgently or emergently with UAE for AUB. Urgent and emergent cases were defined as those requiring inpatient admissions. Demographic data were collected for each patient including hospitalizations related to bleeding and length of stay (LOS) for each hospitalization. Hemostatic interventions other than UAE were collected. Hematologic data were collected before and after UAE including hemoglobin, hematocrit, and transfusion products. Data specific to the UAE procedure included complication rates, 30-day readmission, 30-day mortality, embolic agent, site of embolization, radiation dose, and procedure time.

RESULTS

52 patients (median age: 39) underwent 54 urgent or emergent UAE procedures. The most common indications for UAE were malignancy (28.8%), post-partum hemorrhage (21.2%), fibroids (15.4%), vascular anomalies (15.4%), and post-operative bleeding (9.6%). There were no procedure-related complications. Following UAE, 44 patients (84.6%) achieved clinical success and required no additional intervention. Packed red blood cell transfusion decreased from a mean of 5.7 to 1.7 units (p < 0.0001). Fresh frozen plasma transfusion decreased from a mean of 1.8 to 0.48 units (p = 0.012). 50% of patients received a transfusion prior to UAE, while only 15.4% were transfused post-procedure (p = 0.0001).

CONCLUSIONS

Emergent or urgent UAE is a safe and effective procedure to control AUB hemorrhage secondary to a variety of etiologies.

Evidences in Uterine Artery Embolization: A Radiologist's Primer

Uterine artery embolization is an established minimally invasive therapy for symptomatic fibroids. It has also been used for other diseases of the uterus, including adenomyosis, uterine arteriovenous malformation, ectopic pregnancy, abnormal invasive placenta, and postpartum hemorrhage. In this review, we provide an updated and comprehensive review of uterine artery embolization based on the evidence published. We review the indications, the role of MRI, technical aspects, and complications of the procedure. The issues with a future pregnancy, risk of infertility, and fetal radiation are discussed as well.

Recurrent postpartum hemorrhage at subsequent pregnancy in patients with prior uterine artery embolization: angiographic findings and outcomes of repeat embolization

OBJECTIVE

To evaluate angiographic findings and outcomes of uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in a subsequent pregnancy in patients with a history of prior UAE.

METHODS

Between March 2004 and February 2021, UAE was performed for PPH with gelatin sponge slurry in 753 patients. Among these, 13 underwent repeat UAE for recurrent PPH after subsequent delivery. The causes of PPH, angiographic findings, hemostasis, and adverse events were evaluated.

RESULTS

The causes of recurrent PPH included retained placental tissue (n = 9) and uterine atony (n = 4). On angiography, unilateral or bilateral uterine arteries were obliterated due to prior UAE in 10 patients (76.9%). The uterine collateral vessels were embolized (anterior division of the internal iliac artery [n = 10], round ligament [n = 5], and ovarian [n = 4] artery). In the remaining three patients with recanalized or patent (not embolized at prior UAE) uterine arteries, both uterine arteries were embolized. Immediate hemostasis was achieved in nine patients (69.2%). The remaining four patients (30.8%) with obliterated uterine arteries required hysterectomy. There were three mild adverse events (pelvic pain [n = 2] and fever [n = 1]).

CONCLUSION

UAE with gelatin sponge slurry frequently causes permanent uterine artery obliteration. In cases of recurrent PPH occurring in subsequent pregnancy, repeat UAE may be less likely to achieve hemostasis (69.2%).

ADVANCES IN KNOWLEDGE

1. UAE with gelatin sponge slurry frequently caused permanent uterine artery obliteration.2. In recurrent PPH occurring in subsequent pregnancy, the repeat UAE may be less likely to achieve hemostasis than initial UAE.