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1
Service de Radiologie Hôpital Tenon, 20 Rue de
la Chine, 75020 Paris, France.
2
Service de Gynécologie
Obstétrique
Hôpital Tenon, 75020 Paris, France.
Received October 30, 2000;
accepted after revision December 20, 2000.
Address correspondence to F. Boudghène.
Abstract
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MATERIALS AND METHODS. Twenty-five women with intractable postpartum hemorrhage underwent uterine embolization in our institution during a 6-year period.
RESULTS. Angiography revealed arterial extravasation in 13 patients (52%). Sixty-nine arteries were embolized. External bleeding resolved immediately or was markedly decreased in 24 women. In one patient, embolization failed to control the bleeding, and surgical treatment was required. No major complication of embolization therapy was observed. Ten women were followed up for an average of 2 years. Menstruation resumed in all patients, and one woman became pregnant.
CONCLUSION. Embolization of acute postpartum hemorrhage is a safe and effective alternative to hysterectomy.
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Mean age of the women was 32.4 ± 6.1 years (age range, 21-42 years). Twelve women (48%) were primiparous, and 13 women (52%) were multiparous. Initial assessment and resuscitation were performed in the primary care unit of our institution. The initial assessment was based on the volume of blood loss, hemodynamic status, and presence or absence of disseminated intravascular coagulation. The hemodynamic parameters were maintained with IV administration of crystalloid or colloid substances and transfusion of specific blood units. Uterine atony was treated with uterine massage, vaginal packing, and administration of IV oxytocin (Syntocinon; Laboratoires Sandoz, Rueil-Malmaison, France) and prostaglandin E2 analogue, sulprostone (Nalador; Laboratoires Schering, Lys-Les-Lannoy, France). Treatment of intravascular coagulopathy was based on fresh-frozen plasma, platelet infusion, and fibrinogen. Obstetric assessment included inspection of the vagina, cervix, and perineum for lower genital tract lacerations and exploration of the uterine cavity for retained products, perforation, or rupture.
The decision to perform embolization was made after discussions with obstetricians, intensive care physicians, and vascular radiologists for patients with active hemorrhage despite treatment, degradation of hemodynamic status, reduction of hemoglobin levels despite transfusions, or deterioration of clotting disorders.
Digital subtraction angiography was performed by a vascular radiologist. A unilateral right femoral approach was used and a 5-French femoral arterial introducer was inserted. Initial aortoiliac angiography was performed in all patients to detect the site of bleeding from the pelvic arteries. A 5-French multipurpose catheter (Cordis Multipurpose; Cordis, Roden, The Netherlands) was used (50% of patients) with a hydrophilic polymer-coated 0.035-inch guidewire (Radifocus Guide Wire; Terumo, Tokyo, Japan) (all patients). Contralateral internal iliac angiography was then performed. Highly selective angiography of the uterine artery was attempted in all patients except in the presence of uterine artery spasm. The ipsilateral internal iliac artery and uterine artery were also catheterized with the same catheter and via the same puncture site. Highly selective catheterization of vaginal arteries, pudendal arteries, or ovarian arteries was performed when necessary. Pledgets of absorbable gelatin sponge (Gelfoam; Upjohn, Kalamazoo, MI) for the first 19 women or nonbovine sponge (Curaspon; Laboratoires Medical Concept Services, La Queue En Brie, France) for the last six women, approximately six for each side, were introduced under radioscopic control. Postembolization angiography was performed to confirm the absence of residual extravasation of contrast agent. All except two patients were transferred to the intensive care unit for observation after the procedure.
After the procedure, a detailed questionnaire was sent to 10 patients to obtain precise follow-up information regarding menses and fertility (i.e., subsequent pregnancies).
Results are presented as mean ± standard deviation.
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All women delivered infants: seven women (28%) by cesarean delivery and 18 women (72%) vaginally. Twenty-two neonates were healthy after delivery, two neonates died at birth because of abruptio placentae, and one neonate died 5 days after delivery of unknown causes.
All women received IV uterotonic drugs: oxytocin (Syntocinon) alone in 11 women (mean dose, 20 units) or oxytocin (20 units) in combination with 500 or 1000 µg of prostaglandin E2 analogue, sulprostone (Nalador) in 14 women. All women received IV administration of colloid or crystalloid solution. Vaginal packing was performed systematically. Eighteen women (72%) underwent manual exploration of the uterine cavity. All except three patients required blood transfusions and received an average of 6.32 ± 5.04 units of blood (range, 2-16 units of blood) per patient. Tracheal intubation and assisted ventilation were necessary in two women. The mean hemoglobin level before embolization was 8.18 ± 2.13 g/dL (range, 4-12.8 g/dL). Nineteen patients (76%) presented with disseminated intravascular coagulopathy: platelet count, 125.2 ± 81 x 103/µL, hypofibrinogenemia (fibrinogen level, 1.93 ± 0.82g/dL), and elevated prothrombin time.
The mean interval between onset of bleeding and embolization was 7.84 ± 5.07 hr (range, 1-24 hr).
Initial angiography showed extravasation of contrast agent in 13 women (52%), arising from 12 vaginal arteries in 10 women, three pudendal arteries in two women, and one false aneurysm of the uterine artery in one woman.
Sixty-nine arteries were embolized (Fig. 1A,1B): 34 uterine arteries, 18 vaginal arteries, eight internal iliac arteries, four anterior divisions of internal iliac arteries, three pudendal arteries, and two ovarian arteries (Table 2). Embolization was bilateral in all except two patients (92%).
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In the absence of extravasation on the initial angiogram (12 women), bilateral embolization of the uterine arteries (11 patients) or anterior division of internal iliac arteries (one patient) was performed, associated with bilateral vaginal artery embolization in three patients.
In patients with extravasation from the uterine artery, bilateral internal-iliac-artery embolization was performed to shorten procedure time because of hypovolemic shock during the procedure. In patients with bleeding from vaginal arteries (10 women, 12 arteries), highly superselective catheterization and embolization were performed in seven women: five bilateral vaginal embolizations (associated with bilateral uterine embolizations in all except one patient) and two unilateral vaginal embolizations. In three women with vaginal extravasation, bilateral internal iliac embolization was affected only because of proximal vascular spasms. Three pudendal arteries were embolized (two women) because of contrast extravasation associated with a bilateral uterine embolization in each patient.
In two patients, bleeding persisted after bilateral uterine embolization, and a second session was necessary. An extravasation of contrast agent from a distal vaginal artery was noticed in one patient, and bleeding stopped after bilateral embolization of the anterior division of internal iliac arteries. In the other patient, a partial revascularization of uterine arteries by ovarian arteries was detected, and bleeding stopped after bilateral embolization of ovarian arteries.
Spasms of the uterine artery or anterior division of the internal iliac artery were observed in five women (20%) during the procedure. Selective intraarterial administration of a vasodilator drug, buflomedil (Fonzylane; Laboratoires Lafon, Maisons-Alfort, France) (one woman) or reduction of the adrenaline infusion (one woman) relieved the spasm and allowed bilateral selective uterine catheterization. In three patients, selective uterine arterial embolization was not possible, and bilateral internal iliac artery embolization was performed.
Five patients (20%) who presented in unstable hemodynamic states during the procedure were successfully embolized. One woman developed hypovolemic shock during embolization, which was rapidly corrected after bilateral internal iliac embolization. In all five patients, intensive care physicians were present in the radiology room during the procedure.
No extravasation of contrast agent was noted on the final pelvic angiography in all patients. The embolization procedure lasted an average of 86 ± 33 min (range, 40-150 min).
External bleeding resolved in 22 patients (88%) and was markedly decreased in three patients (12%). Persistent bleeding was noticed in two women after bilateral uterine embolization. A second embolization session was performed, and a bilateral anterior division of internal iliac arteries (n = 1) or ovarian arteries (n = 1) stopped bleeding. External bleeding persisted in one woman after a unilateral vaginal artery embolization, and surgical exploration was performed. A vaginal tear was repaired, and a retroperitoneal hematoma was evacuated.
Twenty-three women stayed in the intensive care unit for 27 ± 13 hr (range, 12-72 hr) after embolization. Clotting disorders improved in 20 ± 8 hr (range, 12-72 hr) after embolization. Only three women required blood transfusions after the procedures and received 2 units of blood each. Women were discharged in an average of 8 ± 2.7 days (range, 5-17 days). No major complication was noted. Fever and abdominal pain lasting 24 hours were noted in two women.
Ten women were followed up after embolization for an average of 25.2 ± 9.6 months (range, 12-36 months). Menstruation resumed in all patients, and one woman became pregnant.
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Hysterectomy is performed when all other treatments have failed. This procedure is associated with a high morbidity and loss of subsequent fertility [15].
Percutaneous embolization was initially performed to control traumatic [16] or tumor bleeding [17, 18]. Recently embolization has been proposed as an alternative treatment for uterine myofibromas [19]. The first reported use of transcatheter arterial embolization of postpartum hemorrhage was described by Brown et al. [20] in 1979. These researchers catheterized and embolized a pudendal artery. In the last 20 years, more than 110 cases have been reported in the literature [21,22,23,24,25,26]. However, to our knowledge, only one large series has been published [24], as shown in Table 3. The embolized arteries reported in the literature are uterine arteries, vaginal arteries, pudendal arteries [27], and ovarian arteries [24]. When a surgical procedure was performed before embolization, arteries such as lumbar, sacral, medial circumflex, or pelvic arteries were also embolized [28, 29].
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Several studies report high success rates of embolization [24, 29, 30] with few major complications [29]. Fertility seems to be preserved [30], and pregnancies have been reported after pelvic embolization [29].
Our findings of uterine atony support the literature as the most common cause of postpartum hemorrhage [5]. We noted that uterine atony and lower genital tract lacerations were frequently associated. We hypothesized that the association of these two clinical conditions could be the origin of intractable hemorrhage because a vaginal tear provokes initial bleeding and atony impedes its arrest, leading to frequently observed clotting disorders that could have a fatal outcome.
We reported a relatively long interval (7 hr, 48 min) between onset of bleeding and embolization in our study because of most of our patients had been transferred to our hospital from other centers. Currently, because of the limited number of centers that can perform emergency pelvic embolization, patients with postpartum hemorrhage are either transferred or treated by hysterectomy. A rapid transfer is critical for persistent bleeding after delivery.
In 52% of patients, initial pelvic angiography revealed extravasation of contrast agent, which arose more frequently from a vaginal artery (75%) than from a pudendal (19%) or a uterine artery (6%). The percentages of extravasation of contrast agent on initial angiography reported in the literature are higher and range from 69% [24] to 100% [30]. Furthermore, one group of researchers has reported higher rates of extravasation from uterine arteries than from vaginal arteries [24].
In the absence of extravasation on initial angiography, we performed bilateral embolization of uterine or anterior division arteries in all except one patient because negative findings on angiography do not exclude bleeding, which must exceed 0.5 mL/min to be detected on angiography [31].
We used gelatin foam for embolization, which ensured a transient devascularization; this procedure was useful to preserve fertility. Furthermore, clotting disorders generally disappeared rapidly after embolization.
Our 96% success rate (one failure in 25 patients) can be compared with the 85-95% success rates reported in previous series [24, 29, 30]. All bilateral embolizations were successful. One woman (4%) continued to bleed after embolization and required surgery; a vaginal tear was repaired. In this patient observed early in our experience, we had performed unilateral embolization (vaginal artery), which is one of the causes of failure of embolization reported in the literature [24]. We now systematically perform bilateral embolization and have never observed persistent bleeding after this procedure. Furthermore, suture of vaginal tears must be achieved before proposing embolization. Other causes of failure reported in the literature are proximal embolization because of collateral vessels [12], bleeding from placenta accreta, and bleeding after cesarean delivery [22, 24].
All except two patients were treated by a single embolization session. Embolization can be repeated to control persistent or recurrent bleeding after the first embolization session [24]. This procedure can improve the success rate, as we reported in two patients.
Vascular spasms were relatively frequent in our study (20% of patients) and have been reported in other studies [24]. They can make selective catheterization difficult and seem more frequent when women are treated with adrenaline. A vasodilator agent injected via the catheter into the spastic artery can relieve the spasm and allow selective catheterization, as we reported in one patient. It could also be used to reduce vasopressor infusion at the beginning of embolization to limit spasms.
In our study, clotting disorders improved rapidly after embolization, as mentioned in other reports [24]. We hypothesize that uterine embolization facilitates uterine contractions that lead to secondary liberation of procoagulant factors into circulation. Embolization could be proposed as a site-specific treatment to break the vicious circle of acute hemostatic and vascular disorders. Furthermore, women requiring blood transfusions after embolization were rare.
No major complications were observed in our series, but one minor complication, already reported in the literature [24, 32], was noted in two patients. Other minor complications reported in the literature are local hematomas and pelvic pain [33]. Rare major complications are vaginal abscess [33], small-bowel infarct, and external iliac artery perforation [29].
In our study, menstruation resumed in all patients as mentioned in the literature [30, 34]. We reported one pregnancy, which confirms that maternal fertility is preserved after uterine embolization. To our knowledge, only four other pregnancies after uterine embolization for obstetric hemorrhage have been reported in the literature [24, 34].
Our study confirms the efficacy and safety of embolization in patients with severe postpartum hemorrhage and indicates that this technique should be proposed before surgery. Preservation of the uterus remains an indisputable advantage of uterine embolization for women desiring another pregnancy. Temporary occlusion of uterine arteries can be considered as an advantage to definitive surgical ligation. Rapid improvement of clotting disorders after embolization is another advantage. Therefore, surgical exploration in rare case of failure is not precluded. It is necessary to improve multidisciplinary treatment of these patients to facilitate a rapid decision to perform embolization: this change would probably increase the number of emergency arterial embolizations for postpartum hemorrhage performed each year and the number of patients that could benefit from this minimally invasive treatment.
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