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

Abstract

Postpartum hemorrhage (PPH) is a potentially life-threatening condition, which needs multidisciplinary management. Uterine atony represents up to 80 % of all causes of PPH. Transcatheter arterial embolization (TAE) has now a well-established role in the management of severe PPH. TAE allows stopping the bleeding in 90 % of women with severe PHH, obviating surgery. Pledgets of gelatin sponge as torpedoes are commonly used for safe TAE, and coils, glue, and microspheres have been primarily used in specific situations such as arterial rupture, pseudoaneurysm, and arteriovenous fistula. TAE is a minimally invasive procedure with a low rate of complications, which preserves future fertility. Knowledge of causes of PPH, potential risks, and limitations of TAE is essential for a timely decision, optimizing TAE, preventing irreversible complications, avoiding hysterectomy, and ultimately preserving fertility.

Delayed postpartum hemoperitoneum due to uterine artery pseudoaneurysm rupture

“…There are no randomized controlled trials to guide management of postpartum hemorrhage. But TAE is now well-accepted procedure for the management of postpartum hemorrhage [14]. Indications for TAE in women with postpartum hemorrhage include uterine atony, UAP, invasive placentation and genital tears [14].…”

“…But TAE is now well-accepted procedure for the management of postpartum hemorrhage [14]. Indications for TAE in women with postpartum hemorrhage include uterine atony, UAP, invasive placentation and genital tears [14]. TAE should be preferred to other techniques after vaginal birth and in secondary postpartum hemorrhage [14].…”

“…Indications for TAE in women with postpartum hemorrhage include uterine atony, UAP, invasive placentation and genital tears [14]. TAE should be preferred to other techniques after vaginal birth and in secondary postpartum hemorrhage [14]. Surgery is preferred when failure of conservative treatments and complex uterine rupture are suspected [14].…”

Conventional MRI features for predicting the clinical outcome of patients with invasive placenta

“…Some authors advocate placement of arterial catheters before delivery because of the possibility of intractable hemorrhage (3-6); however, this is not a systematic procedure and only restricted to specific situations because of the risk of catheter displacement and because less than 50% of women with invasive placenta actually require transcatheter arterial embolization (30). In our department, the prophylactic UAE procedure was selectively performed on those patients who were suspected to experience significant hemorrhage due to invasive placenta previa.…”

Antepartum hemorrhage from previous-cesarean-sectioned uterus as a potential sign of uterine artery pseudoaneurysm

“…The failure of color Doppler sonography to diagnose UAP in our case could be explained by the sensitivity of the sonography. Additionally, emergency transcatheter arterial embolization of the uterine arteries is a well-established technique (Soyer et al, 2008;2015;Dohan et al, 2013) once rupture of UAP is highly suspected or diagnosed via the color Doppler sonography or computed tomography (CT) imaging. In our case, although the color Doppler did not confirm UAP, the risk factors involved in this patient as well as the intractable primary PPH unresponsive to conservative treatment still rendered the ruptured UAP in the priority list of differential diagnosis, and thus emergent digital subtraction angiography (DSA) was performed identifying the cause, and corresponding treatment with embolization was followed successfully.…”