Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization

Abstract

The purpose of this retrospective study was to evaluate the role of transcatheter arterial embolization in the management of severe postpartum haemorrhage due to a ruptured pseudoaneurysm and to analyse the clinical symptoms that may suggest a pseudoaneurysm as a cause of postpartum haemorrhage. A retrospective search of our database disclosed seven women with severe postpartum haemorrhage in whom angiography revealed the presence of a uterine or vaginal artery pseudoaneurysm and who were treated using transcatheter arterial embolization. Clinical files were reviewed for possible clinical findings that could suggest pseudoaneurysm as a cause of bleeding. Angiography revealed extravasation of contrast material in five out of seven patients. Transcatheter arterial embolization allowed to control the bleeding in all patients and subsequently achieve vaginal suture in four patients with vaginal laceration. No complications related to transcatheter arterial embolization were noted. Only two patients had uterine atony, and inefficiency of sulprostone was observed in all patients. Transcatheter arterial embolization is an effective and secure technique for the treatment of severe postpartum haemorrhage due to uterine or vaginal artery pseudoaneurysm. Ineffectiveness of suprostone and absence of uterine atony should raise the possibility of a ruptured pseudoaneurysm.

Transcatheter Arterial Embolization for Postpartum Hemorrhage: Indications, Technique, Results, and Complications

“…Other causes of primary PPH include cesarean section, invasive placentation, congenital or acquired coagulation disorders, uterine rupture or inversion, bladder flap hematoma, retention of blood clots or placental fragments, and fibroids [13,24,31,36]. The main causes of secondary PPH are retained placenta, abnormal placentation, uterine subinvolution, coagulopathies, and ruptured pseudoaneurysm [21,22,34,37]. Pseudoaneurysms are usually located on the uterine artery after cesarean section and on the lower genital arterial tree after vaginal delivery [21,22].…”

“…Uterine atony accounts for the majority of causes of PPH and is the most common indication for TAE [20]. However, as experience accumulates, other indications for TAE are now well-recognized, including uterine artery pseudoaneurysms [21,22], invasive placentation [23][24][25][26][27], genital tears [28,29], and other rarer causes [30][31][32].…”

Uterine Artery Pseudoaneurysm Manifesting as Delayed Postpartum Hemorrhage after Precipitous Delivery: Three Case Reports

“…The efficacy and safety of selective arterial embolization of the uterine artery have also been improved in women with delayed postpartum hemorrhage. The success rate following embolization is 97-100% [9,10]. Gelatin sponge and metallic coils are effective for the treatment of ruptured pseudoaneurysms [11].…”

Persistent postpartum haemorrhage after failed arterial ligation: value of pelvic embolisation

“…For the remaining 20%, when arterial ligation fails to stop the bleeding, guidelines from the American College of Obstetricians and Gynaecologists indicate that hysterectomy should be the favoured option [7]. Surprisingly, the use of pelvic embolisation is not suggested, even though this technique has proven efficacy for the treatment of postpartum haemorrhage [8][9][10][11][12]. In addition, researchers have reported return to normal menses and multiple cases of pregnancy after pelvic embolisation, whereas hysterectomy definitively eliminates future fertility [13][14][15].…”