Uterine Artery Embolization in Postabortion Hemorrhage

Vacuum-induced management of hemorrhage using intrauterine foley catheter: A report of two cases

Hemorrhage is a common postpartum complication which can also occur during abortion. Most cases can be managed with uterine evacuation and uterotonics, but some require additional procedures. We present cases of hemorrhage following dilation and evacuation, and delayed postpartum hemorrhage, where a Foley catheter was used for vacuum-induced hemorrhage control.

Management of blood loss in second-trimester abortion

PURPOSE OF REVIEW

While major complications in second-trimester abortion are rare, blood loss and hemorrhage are among the most common and have the potential for high morbidity. Here, we review the current literature on risk factors, prevention, and treatment of blood loss in second-trimester abortion.

RECENT FINDINGS

A comprehensive approach to hemorrhage during second-trimester abortions is essential. Understanding hemorrhage risk factors, prevention strategies, and treatment options makes second-trimester abortion safer. Some pharmacologic methods may both prevent and treat excessive blood loss. Mechanical methods are primarily used for treatment. Key risk factors include prior uterine scars, gestational duration, insufficient cervical preparation, high BMI, procedural inexperience, fetal demise, and halogenated anesthetics. Developing evidence-based protocols for and further research into hemorrhage related complications are crucial for improving safety in second-trimester abortion care.

SUMMARY

Prevention of hemorrhage improves outcomes. However data are limited. For treatment, this includes using pharmacological interventions and mechanical methods. Identifying high-risk patients and implementing preprocedural optimization are proactive measures that aid in decreasing the occurrence and severity of blood loss and hemorrhage.

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.

Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.

Uterine venous malformations in the puerperium: 2 Atypical cases and literature review

Uterine arteriovenous malformations (AVMs) is a rare but high-risk cause of uterine bleeding. The clinical management of this condition is challenging, as the ultrasound picture can sometimes be unambiguously interpreted. Moreover, in the puerperium in which acquired AVMs are most frequently formed, it is necessary to discuss the correct management in a multidisciplinary and personalized manner. We present two cases of AVMs developing in the puerperium, both with a vaginal delivery and spontaneous and complete secondment. The symptom of onset was an episode of bright red blood loss in the puerperium, on the 14th and 21st postpartum days, respectively. Transvaginal ultrasound showed a hypervascularized lesion in the myometrium with turbulent vascular flow, confirmed by transabdominal ultrasound and angiography. To date, there are no guidelines on the management of MAVs. In our cases we opted for a conservative approach, in order to preserve the fertility of the patient. These experiences reported have the purpose of enriching a literature still sparse on the subject and in the future to be able to represent a fulcrum for official recommendations.

Post-abortion Complications: A Narrative Review for Emergency Clinicians

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Impact of anesthetic agents on the amount of bleeding during dilatation and evacuation: A systematic review and meta-analysis

Purpose

Patients undergo dilatation and evacuation for abortion or miscarriage. However, bleeding is sometimes problematic. Despite reports on the association between volatile anesthetics and increased bleeding during the procedure, firm evidence is lacking. Therefore, we conducted a systematic review and meta-analysis to compare the effects of volatile anesthetics and propofol on the amount of bleeding in patients undergoing dilatation and evacuation.

Methods

We conducted a systematic search of four databases, namely PubMed, Embase, Cochrane Central Register of Controlled Trials databases, and Web of Science (Clarivate Analytics), from their respective inception to April 2021. Moreover, we searched two trial registration sites. The inclusion criterion was randomized controlled trials of patients who underwent dilatation and evacuation under general anesthesia using volatile anesthetics or propofol. The primary outcome was the amount of perioperative bleeding. The mean difference of the bleeding was combined using a random-effects model. The I² statistic was used to assess heterogeneity. We assessed risk of bias with Cochrane domains. We controlled type I and II errors due to sparse data and repetitive testing with Trial Sequential Analysis. We assessed the quality of evidence with GRADE.

Results

Five studies were included in the systematic review. The amount of bleeding was compared in four studies and was higher in the volatile anesthetic group, with a mean difference of 164.7 ml (95% confidence interval, 43.6 to 285.7; p = 0.04). Heterogeneity was considerable, with an I² value of 97%. Two studies evaluated the incidence of significant bleeding, which was significantly higher in the volatile anesthetic group (RR, 2.42; 95% confidence interval, 1.04–5.63; p = 0.04).

Conclusion

Choosing propofol over volatile anesthetics during dilatation and evacuation might reduce bleeding and the incidence of excessive bleeding. However, the quality of the evidence was very low. This necessitates further trials with a low risk of bias.

Trial registration

PROSPERO (CRD42019120873).

Laparoscopic hysterectomy to manage uterine rupture due to placenta percreta in the first trimester: A case report

Placenta percreta causing uterine rupture is a rare complication of pregnancy. It is most commonly diagnosed after the second trimester and can lead to significant morbidity necessitating abdominal hysterectomy of a gravid or immediately postpartum uterus. We describe a patient who presented with abdominal pain at 13 weeks of gestation and was diagnosed with placenta percreta during laparoscopy for presumed appendicitis. Intraoperatively, placenta was seen perforating the uterine fundus and 1 l of hemoperitoneum was evacuated. However, the uterus was hemostatic and the patient was stable, so the procedure was terminated. The patient was then transferred to a tertiary care center, where she ultimately underwent an uncomplicated laparoscopic gravid hysterectomy. We conclude that placenta percreta can occur in the first trimester even in patients without traditional risk factors. In stable patients, it is appropriate to consider minimally invasive hysterectomy with utilization of specific techniques to minimize intraoperative blood loss.

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Uterine rupture due to placenta percreta can present in the first trimester.

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Minimally invasive laparoscopic hysterectomy can provide definitive treatment with decreased surgical morbidity and shorter convalescence.

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Blood loss and allogenic transfusion can be minimized with appropriate hemostatic techniques and surgical planning.

No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

OBJECTIVE

This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.

INTENDED USERS

Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.

TARGET POPULATION

Women with an unintended or abnormal first or second trimester pregnancy.

EVIDENCE

PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.

VALUES

The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.

Screening for morbidly adherent placenta in early pregnancy

OBJECTIVE

To estimate the diagnostic accuracy of a two-stage strategy for early prediction of morbidly adherent placenta (MAP). In the first stage, at 11-13 weeks' gestation, women with low-lying placenta and history of uterine surgery are classified as being at high risk for MAP and, in the second stage, at 12-16 weeks, these high-risk pregnancies are assessed at a specialist MAP clinic.

METHODS

This was a prospective study in women having an ultrasound scan at 11-13 weeks' gestation as a part of routine pregnancy care. Women with low-lying placenta and a history of uterine surgery were followed up at a specialist MAP clinic at 12-16 weeks' gestation, 20-24 weeks and 28-34 weeks. At each visit to the MAP clinic, an ultrasound scan was carried out and the following features suggestive of MAP were recorded: non-visible Cesarean section scar; bladder wall interruption; thin retroplacental myometrium; presence of intraplacental lacunar spaces; presence of retroplacental arterial-trophoblastic blood flow; and irregular placental vascularization demonstrated by three-dimensional power Doppler.

RESULTS

Screening at 11-13 weeks was carried out in 22 604 singleton pregnancies, 1298 (6%) of which were considered to be at high risk of MAP because they had previous uterine surgery and low-lying placenta. At the MAP clinic at 12-16 weeks, the diagnosis of MAP was suspected in 14 cases and this was confirmed at delivery in 13. In the rest of the population, there were no cases of MAP.

CONCLUSION

Accurate prediction of MAP can be achieved by ultrasound examination at 12-16 weeks' gestation. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The Treatment of Cesarean Scar Pregnancy with Uterine Artery Embolization and Curettage as Compared to Transvaginal Hysterotomy

OBJECTIVES

To investigate the outcome and menstrual status in patients after treatment of cesarean scar pregnancy (CSP) by transvaginal hysterotomy or uterine artery embolization combined with uterine curettage.

STUDY DESIGN

A retrospective cohort study. An analysis of CSP patients was performed using records from Shanghai First Maternity & Infant Hospital affiliated with Tongji University for the period between July 16, 2014 and January 22, 2016. Twenty-seven patients were treated with transvaginal hysterotomy and in this group, 49 patients received uterine curettage after UAE. The clinical information on these patients and clinical outcomes especially the status of menstruation were reviewed.

RESULTS

There was only one complication in transvaginal hysterotomy group, while 3 cases of villus residue occurred in UAE group. Nineteen patients (70.4%) in transvaginal hysterotomy group self-assessed their menstrual volumes, which had no remarkable changes; 6 patients (22.2%) felt that their menstrual volumes had decreased. Thirty-five patients in UAE group (71.4%) reported that their menstrual volumes decreased (P<0.05). The range of pictorial blood loss score was 55-82 in transvaginal hysterotomy group and 9-74 in UAE group, and the mean pictorial blood loss score was decreased from 68.4 to 65.8 in transvaginal hysterotomy group (a 3.2±4.4% reduction) and from 66.4 to 38.8 in UAE group (a 41.7±26.4% reduction) (P<0.05).

CONCLUSIONS

Transvaginal hysterotomy appears to be more advantageous than UAE combined with uterine curettage. The menstrual interval and duration changed significantly in UAE group.

Efficacy of Prophylactic Uterine Artery Embolization before Obstetrical Procedures with High Risk for Massive Bleeding

OBJECTIVE

To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE) before obstetrical procedures with high risk for massive bleeding.

MATERIALS AND METHODS

A retrospective review of 29 female patients who underwent prophylactic UAE from June 2009 to February 2014 was performed. Indications for prophylactic UAE were as follows: dilatation and curettage (D&C) associated with ectopic pregnancy (cesarean scar pregnancy, n = 9; cervical pregnancy, n = 6), termination of pregnancy with abnormal placentation (placenta previa, n = 8), D&C for retained placenta with vascularity (n = 5), and D&C for suspected gestational trophoblastic disease (n = 1). Their medical records were reviewed to evaluate the safety and efficacy of UAE.

RESULTS

All women received successful bilateral prophylactic UAE followed by D&C with preservation of the uterus. In all patients, UAE followed by obstetrical procedure prevented significant vaginal bleeding on gynecologic examination. There was no major complication related to UAE. Vaginal spotting continued for 3 months in three cases. Although oligomenorrhea continued for six months in one patient, normal menstruation resumed in all patients afterwards. During follow-up, four had subsequent successful natural pregnancies. Spontaneous abortion occurred in one of them during the first trimester.

CONCLUSION

Prophylactic UAE before an obstetrical procedure in patients with high risk of bleeding or symptomatic bleeding may be a safe and effective way to manage or prevent serious bleeding, especially for women who wish to preserve their fertility.

Cesarean Scar Pregnancy: Comparing the Efficacy and Tolerability of Treatment with High-Intensity Focused Ultrasound and Uterine Artery Embolization

The aim of this study was to investigate the clinical efficacy of high-intensity focused ultrasound (HIFU) for the treatment of a cesarean scar pregnancy compared with uterine artery embolization (UAE) and intra-arterial methotrexate infusion combined with uterine curettage. In this retrospective cohort study, 31 patients were treated with HIFU (HIFU group), and 45 patients were treated with UAE (UAE group). We compared the treatment and recovery of the patients, including follow-up. After UAE treatment, serum levels of the β subunit of human chorionic gonadotropin declined significantly on the first day, and the residual lesions disappeared in 3-17 wk. One patient underwent hysterectomy; intrauterine adhesions were found by hysteroscopic examination after 6 mo in 2 patients, whose menstrual function did not return to normal. The remainder of the 42 patients recovered normal menstrual functioning during the 3- to 18-wk follow-up. In the patients who underwent HIFU treatment, serum β-HCG levels did not decline rapidly; serum β-HCG levels increased in many patients and then declined to normal steadily within 2-12 wk. Lesions detached in 3-14 wk in all patients, and menstrual functioning was recovered in 3-9 wk without uterine curettage. Compared with the UAE group, the HIFU group had less pain and fewer complications; the patients in the HIFU group were not hospitalized or anesthetized and had lower costs. HIFU is an efficient, tolerable and non-invasive treatment.

Loss of Limb by Inadvertent Embolization of the Persistent Sciatic Artery

Persistent sciatic artery (PSA) is a rare anatomic variant and is normally clinically silent. It can be found occasionally during uterine arteries embolization (UAE) and can lead to technical failure or complications. The authors present a patient with bilateral PSAs who was referred for emergency UAE because of uncontrollable postabortion hemorrhage. Inadvertent embolization of the right PSA led to unsalvageable ischemia and amputation of the right lower limb 12 days later.

Bleeding after dilatation and curettage: the efficacy of transcatheter uterine artery embolisation

AIM

To evaluate safety and clinical outcomes of uterine artery embolisation (UAE) for bleeding after dilatation and curettage (D&C) performed for abortion or termination.

MATERIALS AND METHODS

The outcomes were analysed in 11 patients who underwent UAE for bleeding after D&C for missed abortions (n=8), caesarean scar pregnancies (n=2), or planned termination (n=1) between October 2001 and December 2013. Angiograms and medical records were retrospectively reviewed in order to obtain the patients' baseline characteristics, technical/clinical success rate, complications, and follow-up data regarding menstruation.

RESULTS

Technical success, defined as successful catheterisation of both uterine arteries with embolisation to haemostasis, was 100%, whereas clinical success, defined as cessation of bleeding after the initial session of UAE and without the need for additional UAE or surgery for the purpose of haemostasis, was 81.8% (nine of 11). In the two patients with clinical failure due to recurrent vaginal bleeding after UAE, one patient underwent repeat UAE and showed a successful outcome, whilst the other patient required hysterectomy with pathological results of placenta increta. Two other patients underwent hysterectomy for placenta percreta or hydatidiform mole-mimicking remnant placenta. None of the patients included in the present series had procedure-related complications. Menstruation resumed in all eight patients with an intact uterus during the mean follow-up period.

CONCLUSION

UAE may be a safe and effective treatment for bleeding after D&C, especially for women who wish to preserve their fertility; however, hysterectomy may be indicated for patients with a placental abnormality.

A Case Report and Literature Review of Midtrimester Termination of Pregnancy Complicated by Placenta Previa and Placenta Accreta

Objective Concurrent placenta previa and placenta accreta increase the risk of massive obstetric hemorrhage. Despite extensive research on the management of placenta previa (including placenta accreta, increta, and percreta), the number and quality of previous studies are limited. We present a case of placenta accreta requiring an induced second-trimester abortion because of premature rupture of the membranes (PROM). Study Design Case report and review of the literature. Results A 41-year-old female presented at 20 weeks of gestation with placenta previa and PROM. Ultrasonography revealed placenta accreta with multiple placental lacunae. She then developed massive hemorrhaging just prior to a planned termination of pregnancy. We performed a hysterectomy with the intent of preserving life because of the failure of the placenta to detach and blood loss totaling 4,500 mL. Conclusion Previous studies suggest that second-trimester pregnancy terminations in cases of placenta previa which are not complicated with placenta accreta do not have a particularly high risk of hemorrhage. However, together with our case, the literature suggests that placenta previa complicated with placenta accreta presents a significant risk of hemorrhage both during delivery and intraoperatively. Further reports are needed to evaluate the most appropriate treatment options.

Risk factors for intraoperative hemorrhage at evacuation of a cesarean scar pregnancy following uterine artery embolization

OBJECTIVE

To determine risk factors associated with massive uterine bleeding during dilation and suction curettage (D&C) after uterine artery embolization (UAE) for the treatment of cesarean scar pregnancy (CSP).

METHODS

Data from 128 CSP patients treated with D&C after UAE were analyzed to assess risk factors associated with massive uterine bleeding (blood loss 500mL or more) during D&C after UAE.

RESULTS

In total, 15 CSP patients had massive bleeding during D&C after UAE. Univariate analysis showed that a greater gestational age (GA), a larger CSP mass size, a thinner myometrium at the implantation site, a GA of 8weeks or more, a CSP mass diameter of 6cm or more, and evidence of fetal heartbeat were risk factors for massive bleeding (P<0.05). In a binary logistic regression analysis, GA of 8weeks or more and CSP mass diameter of 6cm or more remained as the only significant risk factors for massive bleeding (OR 11.49 [95% CI 1.08-122.13] and OR 96.59 [95% CI 6.20-150.57], respectively; P<0.05).

CONCLUSION

For CSP masses with a GA of 8weeks or more and a diameter of 6cm or more, the outcome of surgical evacuation after UAE tends to be unsatisfactory.

Caesarean scar pregnancy: comparative efficacy and safety of treatment by uterine artery chemoembolization and systemic methotrexate injection

OBJECTIVES

The aim of this study was to investigate the efficacy and safety of uterine artery embolization (UAE) combined with intra-arterial methotrexate (MTX) infusion for the treatment of caesarean scar pregnancy (CSP), compared with systemic MTX injection combined with uterine curettage.

STUDY DESIGN

A retrospective cohort study. An analysis of CSP patients was performed using records from the Department of Obstetrics and Gynecology in Renji Hospital for the period between January 1, 2000 and December 30, 2010. Twenty-two patients received UAE combined with intra-arterial MTX infusion and in this group 16 patients received uterine curettage after UAE, whereas 25 patients received intramuscular MTX injection and subsequent uterine curettage. The clinical information on these patients and clinical outcomes were reviewed.

RESULTS

All patients in the UAE group were treated successfully and 2 patients in the non-UAE group had to undergo hysterectomy or uterine repair. No patients in the UAE group had recurrent vaginal bleeding of more than 100ml/day after treatment, while 8 patients in the non-UAE group did, and this difference was significant. The blood loss during uterine curettage in the UAE group was much less than in non-UAE group. The serum β-hCG level in the UAE group recovered more quickly than in the non-UAE group, and hospital stay was significantly shorter in the UAE group.

CONCLUSIONS

UAE combined with intraarterial MTX infusion turned out to be an effective and safe treatment for CSP.

Interventional radiology to treat severe obstetric hemorrhages

The author discusses the recent role of interventional radiology to prevent postpartum hemorrhagic complications that represent an important cause of maternal morbidity and mortality all over the world. Hence, hemorrhage control is mandatory. Traditional management and recent minimally invasive radiological procedures by means of inserting occluding balloons into appropriate vessels are analyzed. It is advisable that maternity hospitals have protocols for the management of obstetric hemorrhage by means of interventional radiology, either in their own departments or in association with other large healthcare units that may have proper equipment and trained staff. However, the evidence related to its efficacy is limited to series of cases analyzed in tertiary centers. This is a promising technique that may be applied to severe obstetric hemorrhages and may bring beneficial results in the majority of cases.

The role of interventional radiology in obstetric hemorrhage

Obstetric hemorrhage remains a major cause of maternal morbidity and mortality worldwide. Traditionally, in cases of obstetric hemorrhage refractory to conservative treatment, obstetricians have resorted to major surgery with the associated risks of general anesthesia, laparotomy, and, in the case of hysterectomy, loss of fertility. Over the past two decades, the role of pelvic arterial embolization has evolved from a novel treatment option to playing a key role in the management of obstetric hemorrhage. To date, interventional radiology offers a minimally invasive, fertility-preserving alternative to conventional surgical treatment. We review current literature regarding the role of interventional radiology in postpartum hemorrhage, abnormal placentation, abortion, and cervical ectopic pregnancy. We discuss techniques, success rates, and complications.

Complications of surgical abortion

Surgical abortion is one of the most common procedures performed in reproductive-aged women and when performed by a skilled provider in the appropriate setting, it is one of the safest surgeries. Though the risk of complications is low, it increases exponentially with gestational age. Factors increasing risk of morbidity may be demographic, such as increasing patient age; medical, such as prior cesarean delivery; and procedural, such as inadequate dilation. This chapter will provide information on how to recognize factors that increase risk, steps to minimize risk, and to identify and manage complications promptly.

Ovarian artery embolization supplementing hypogastric-uterine artery embolization for control of severe postpartum hemorrhage: report of eight cases

Although transcatheter uterine artery embolization has been proved to be a life-saving technique in serious obstetrical hemorrhage, it does not always control bleeding. The causes of treatment failure may be multifactorial and vary in individual cases, but incomplete embolization of the blood supply from other sources may play an important role. Herein, the authors describe eight patients with massive postpartum hemorrhage that was not controlled with conventional hypogastric-uterine artery embolization. Their continued hemorrhage was due to an additional blood supply arising from ovarian arteries, which was confirmed with selective ovarian artery angiography and subsequently successfully embolized.

Scheduled hysterectomy for second-trimester abortion in a patient with placenta accreta

BACKGROUND

As cesarean deliveries increase, so does placenta accreta. There is little evidence regarding management of patients with known or suspected abnormal placentation seeking abortion.

CASE

A medically complicated patient with evidence of placenta increta on magnetic resonance imaging presented for pregnancy termination at 15 weeks of gestation. Scheduled hysterectomy was performed to avoid hemorrhage and subsequent complications. The patient did well postoperatively; her course was complicated only by a wound infection treated as an outpatient. Pathology was consistent with placenta increta.

CONCLUSION

Placenta accreta has increased 13-fold in the past 30 years. In select patients with evidence of abnormal placentation, scheduled hysterectomy for termination of pregnancy is an option that may be considered.