Deshpande PS*, Prasad M**, Gupta AS***
(*Third year Resident, **Assistant Professor, ***Professor and Head of the Unit, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai.)
In modern obstetrics, the use of vascular interventional radiology has proven to be of great benefit in situations where blood loss is anticipated or has occurred. Here we present a case of secondary postpartum hemorrhage that was successfully managed by uterine artery embolization thus reducing the surgical morbidity that the patient would otherwise be subjected to.
Uterine artery embolization is a radiological procedure where the uterine arteries are selectively catheterized under fluoroscopy guidance and small particles are delivered to block the flow through them. This conservative technique of reducing blood flow to the uterus in conditions where massive blood loss is expected has been used successfully perioperatively in fibroids, adenomyosis, dysfunctional uterine bleeding, placenta accreta, uterine artery pseudo aneurysms, uterine arterio-venous malformations, and for other indications. Use of uterine artery embolization for controlling postpartum hemorrhage (PPH) was first reported in 1979. Since then this procedure is gaining popularity as a non-invasive option for treatment of PPH.
A 24 year old, primigravida was referred to our tertiary care center on day 8 of emergency LSCS done for twin pregnancy at term. The twins weighed 2.1 and 1.1 kg respectively, and were doing well at the time of admission. She was referred because she had persistent abdominal pain and fever; and ultrasonography suggested ascites. On arrival, she was febrile, pulse and blood pressure were 100 beats per minute and 110/70 mm of Hg respectively. Cardiovascular and respiratory system were normal. Pallor was present. Abdomen was soft with diffuse tenderness, and uterus was just palpable on abdominal examination. Pfannenstiel scar had healed well. There was no foul smelling lochia. Uterus was well retracted. Hemoglobin was 6.1 gm%. Complete blood count was 12,500 cells/cc. Differential counts were within normal range. Neutrophils, lymphocytes and eosinophils were 76, 20, and 4 % respectively. Liver and renal function parameters were normal. Coagulation profile was normal. Prothrombin time was 14.4 and the control was 13.1. International normalized ratio was 1.0. One unit of packed red blood cells was transfused. Ultrasonography (USG) showed moderate amount of hemoperitoneum. An angiography by contrast enhanced computerized tomography (CECT) was done. It also showed hemoperitoneum. A blush, suggestive of active bleeder, near the left uterine artery was seen, in the arterial phase. In view of relative hemodynamic stability of the patient, conservative mode of treatment was preferred and interventional radiologist team was involved. They suggested angiography, localization of the bleeder, embolization or coil placement for hemostasis. Written, valid, informed consent was taken from the patient and her husband after explaining the risks, success rate, need for emergency exploration in case of failure. The procedure was done under antibiotic cover and local anesthesia. Catheterization of the femoral artery was done by Seldinger technique and a 5 French catheter with guide wire was inserted into the aorta. A non-selective aorto-iliogram (figure 1) was done to look for the pelvic bleeder. Dye was seen oozing out near the left uterine artery area with tortuous collateral's.(figure 2) Selective uterine artery catheterization (by Roberts uterine artery catheter) was done on left side and 500 micron size polyvinyl alcohol particles were injected mixed with equal amount of contrast. Similar procedure was repeated on the right side. Post embolization repeat angiography performed showed significant reduction in extravasation of the dye from the site of initial leak. The procedure took approximately 90 minutes. She recovered uneventfully and subsequently maintained a good hemodynamic status. Strict immobilization was implemented for 12 hours and puncture site was checked after 2 days. Clinical and laboratory parameters remained normal and she was discharged on day 7 of the procedure.
Figure 1. Aorto-iliogram.
Figure 2. Active blush in the left uterine artery region.
Figure 3. Stent in the uterine artery.
Figure 4. Digital subtraction angiography. Post-embolization image showing reduced vascularity.
Secondary or late postpartum hemorrhage is defined as bleeding 24 hours to 12 weeks after delivery. It is mostly seen within 1-2 weeks and in 1% cases. Apart from sub-involution of the uterus and retained products of conception, sepsis, uterine artery pseudoaneurysm with bleeding from the tortuous uterine plexus are other causes of secondary PPH. Our case had two high risk factors for secondary PPH; twin pregnancy and cesarean section. Selective arterial embolization is a minimally invasive, non surgical technique of uterine devascularisation. Management options in our case included surgical exploration with step-wise devascularisation procedures or use of vascular interventional radiology.
Debating about the two available options, subjecting the patient to re-surgery increases the morbidities associated with the same. Also placing hemostatic sutures in the presence of sepsis which is inadvertently going to be there can be hazardous. Due to the intricate pelvic architecture of arteries and veins, if it is not possible to locate the bleeder, then the chances of hysterectomy are high. This problem is solved using a real time diagnostic modality like angiography which can accurately locate the bleeder. In addition, interventional radiology procedures are done under local anesthesia and hence the regional/ general anesthesia complications are also avoided.
Thus, in a tertiary care center, with available interventional radiology facilities, hemodynamically stable case, with no signs of peritoneal irritation like guarding, rigidity and rebound tenderness and USG suggestive of moderate amount of hemoperitoneum which could resolve over time, a conservative mode of management seems to be a better option.
Touboul et al in 2008 described selective arterial embolization in 102 patients with life-threatening PPH with an overall success rate of 71.5%. In 2009, Kirby et al published a retrospective multi center study evaluating 43 patients who underwent arterial embolization for PPH and found clinical success of approximately 80%. Kim et al in 2013 published a retrospective study of 257 consecutive patients who underwent pelvic arterial embolization for PPH and confirmed this procedure to be a safe and effective alternative to surgical intervention. 
A review conducted previously had concluded that among the various options available, namely arterial embolization and iliac artery ligation, no particular procedure was better than the other. It was also acknowledged that performing randomized controlled trials in such situations may not be feasible.
A recent review by Sathe et al have stated evidence regarding long term problems like infertility is not sufficient. Also, since only a small number of patients have been reported (2100 in their review), even to this date, evidence is insufficient to choose any one particular procedure in precedence of the other. Clinical decision making should be based on severity of the situation and the available facilities.
Secondary PPH usually indicates presence of infection. There is no last word in the literature discussing the pros and cons of uterine artery embolization in the presence of overt or covert infection as randomized controlled trials are difficult to design due to various causes of the same.
This case is presented to highlight the fact that even in resource-constrained countries like India; PPH can be effectively managed in tertiary care center using uterine artery embolization. Appropriate patient selection for the same is of utmost importance, and avoids surgical exploration and hysterectomy.
Dr. Dev Thakkar, Assistant Professor, Department of Radiology, KEM Hospital, Mumbai for performing the procedure and Dr. Hemant Deshmukh, Head of the Department of Radiology, KEM Hospital, Mumbai) for allowing us to publish this case.
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Deshpande PS, Prasad M, Gupta AS. Management Of Secondary Postpartum Hemorrhage By Uterine Artery Embolization. JPGO 2017. Volume 4 No.7. Available from: