Angiographic embolisation in the management of pelvic haemorrhage

Abstract

Haemorrhage from pelvic veins during obstetric and gynaecological surgery is a major cause of morbidity and mortality. In a recent commentary entitled The Seven Surgeons of King's: a fable by Aesop', surgeons from different specialties used techniques peculiar to their own practice to treat a woman with intractable haemorrhage. Could transcatheter arterial embolisation be the 'eighth surgeon'? We describe two cases where embolisation was used to control bleeding when local surgical measures had failed and discuss the use of embolisation in obstetrics and gynaecology. Case report 1A 35 year old woman underwent a Burch colposuspension. During the operation, after the sutures for the colposuspension had been placed, bleeding was seen to come from the right side of the pelvis. The sutures on the right side of the colposuspension were removed to investigate the bleeding. Attempts at controlling the bleeding with further sutures were unsuccessful and after two hours the pelvis was packed and the advice of an interventional radiologist was sought. Emergency balloon tamponade of both internal iliac arteries was carried out, and the woman was transferred to the angiography suite, still under general anaesthesia. Selective bilateral internal iliac arteriography showed there was extravasation of dye from the anterior division of the right internal iliac artery (Fig. 1). Gelfoam pledgets were injected until haemostasis was confirmed radiologically (Fig. 2) and then a metallic coil inserted. She was then transferred for 36 hours to the intensive care unit. Before extubation the following day the pelvic packs were removed. Her recovery was complicated by parasthesia and lack of power in her right leg, which has gradually improved. Nerve conduction studies suggested that this was neuropraxia and a full recovery is likely. Case report 2A 34 year primigravid woman was admitted to our hospital at 26 weeks of gestation with increasingly severe abdominal pain. Investigations, including magnetic resonance imaging, showed a mass measuring 12 cm in diameter in the rectovaginal pouch. While undergoing Correspondence: Dr K. Lingam, 3, Bourne Court, Commerce Street, Melbourne, Derbyshire DE73 lFT, UK. evaluation of this mass she collapsed with sign of intraabdominal haemorrhage. A laparotomy was performed when the peritoneal cavity was found to be full of blood. A classical caesarean section was carried out, a little boy weighing 1.06 kg being born. Only after the delivery was it possible to ascertain that the origin of the bleeding was spontaneous rupture of a left ovarian cyst. The cyst was impacted in the pelvis and bound to the side wall by adhesions. Attempts to remove the cyst provoked free bleeding. We consulted the interventional radiologist who successfully occluded both iliac arteries with balloon catheters. Angiography showed that the bleeding area was supplied by both internal iliac arteries which were successfully embolised by gelfoam. Postoperatively, there was evidence of continued intraabdominal haemorrhage, but this w...

Retrospective multicentre study of the new minimally invasive mesh repair devices for pelvic organ prolapse

“…Multiple approaches might be needed in these women including packing, vascular clips and selective arterial embolisation. The later has been shown to be safe and effective in the management of severe perioperative bleeding following urogynaecology surgery 17–21 . Angiography allows complete mapping of the pelvic vessels to identify the bleeders with the benefit of avoiding general anaesthesia, further major surgery and therefore shorter recovery time.…”

“…The later has been shown to be safe and effective in the management of severe perioperative bleeding following urogynaecology surgery. [17][18][19][20][21] Angiography allows complete mapping of the pelvic vessels to identify the bleeders with the benefit of avoiding general anaesthesia, further major surgery and therefore shorter recovery time. However, it is important to emphasise that selective arterial embolisation will not always be successful and is not readily available in all units due to financial implications or geographical restrictions, therefore alternative strategies and surgical expertise must be in place to deal with such cases.…”

Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage*

“…Reported complications include postoperative fever (10), artery perforation (11), pelvic abscess (10), and groin hematoma. Only patients with single ischemic complications, such as uterine necrosis (12,13), bladder gangrene, femoral artery subtotal occlusion (14), buttock ischemia (11,14), and transient sciatic nerve ischemia, have been reported related to postpartum treatment (15,16).…”

Angiographic Embolization of a Postpartum Vulvovaginal Hematoma in a Patient with Situs Inversus Totalis: An Effective Second-Line Treatment

“…Arteriographic embolization has been used successfully in treating pelvic hemorrhage: bleeding from carcinoma of the cervix, postoperative hemorrhage after hysterectomy or cesarean section, or with postpartum bleeding [8]. With increasing success, uterine artery embolization has been used in occluding the vascular supply of fibroids [9, 10].…”