Uterus and bladder necrosis after uterine artery embolisation for postpartum haemorrhage

Abstract

a Case reportA 32 year old primipara was admitted for premature rupture of the membranes at 37 weeks of gestation. She had a history of miscarriage with curettage in association with previous pregnancy. She delivered a healthy male child. After manual delivery of the placenta, exploration of the uterus and oxytocin was required to control bleeding. Selective uterine artery embolisation was carried out because there was an adherent placental cotyledon in the left uterine horn causing uncontrollable bleeding.Selective catheterisation of the left internal iliac artery and superselective catheterisation of the left uterine arteries were performed using a 5F cobra-shaped catheter (Cobra; Terumo, Tokyo, Japan) and a 0.035-in. diameter hydrophilic polymer-coated guide wire (Radifocus; Terumo) from the contralateral groin. The angiography showed no anastomosis between the uterine and the ovarian artery and demonstrated an arterial tear with massive extravasation of contrast material in the uterine cavity. Bilateral free-flow embolisation was performed under fluoroscopic control using iodinated contrast media mixed with gelatine sponge pledgets (Curaspon; Curaspon Healthcare, Netherlands) particles obtained by scraping a piece of gelfoam with a surgical blade. No vascular spasm was observed.On day 21, the patient was readmitted for pelvic pain and abnormal bleeding. Vaginal examination revealed that half of the uterine cervix presented an abnormal colour suggestive of ischaemia. Pelvic magnetic resonance imaging revealed a bulky uterus with a small peripheral enhancement rim. The central portion of the organ was completely necrotic.Subtotal hysterectomy was performed. Both uterine artery pedicles were filled with thrombus. Surgical exploration also revealed a 5-cm necrotic area on the bladder wall (Fig. 1). Cystoscopic examination demonstrated mucosal deterioration and the necrotic portion was excised. Cystography on day 13 was normal. Two months after surgery, the cervix and the vagina were normal.Histological examination of the surgical specimens showed massive ischaemic necrosis of the whole uterus except the deep myometrium. Plurinuclear and giant cells occupying the vessels in the lower part of the uterus had phagocytosed small foreign bodies. Some vessels contained unusual weakly coloured star-shaped structures probably corresponding to the gelatine sponge particles used for embolisation. Vessels containing those structures were less dilated, smaller in diameter and thicker-walled than other vessels. Examination of bladder tissue demonstrated complete disappearance of the mucosa together with ischaemic changes throughout the wall. DiscussionPostpartum haemorrhage is the leading cause of maternal mortality throughout the world.1 Various management strategies have been proposed including embolisation to preserve the uterus. Selective arterial embolisation allows localisation of the bleeding site even in cases involving coagulopathy and is feasible after ligation of the internal iliac artery. 2Endoluminal embolisation...

Uterine compression sutures for management of severe postpartum haemorrhage: a 5-year audit

“…Infrequently, complications such as ischaemia of the bladder and uterus have also been reported. 38 A systematic review estimated a success (avoidance of hysterectomy) rate of around 92% with uterine compression sutures, 91% after arterial embolisation, 84% after balloon tamponade, and 85% after iliac artery ligation or uterine devascularisation. 6 Randomised controlled trials of these treatment options would be difficult to perform in such life-threatening emergencies.…”

Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage

“…Intrauterine synechia may be related to endometrial ischaemia secondary to embolisation. Indeed, uterine necrosis following the isolated use of 45-150-lm 35 and 200-500-lm 36 polyvinyl alcohol particles and gelfoam pledgets, 37 or the combined use of gelfoam pledgets and 150-250-lm polyvinyl alcohol particles, 38 has been reported previously. Moreover, an experimental animal study on ewes found that polyvinyl alcohol particles were associated with more intense uterine necrosis than were calibrated microspheres, and uterine necrosis occurred more frequently with small rather than large polyvinyl alcohol particles and microspheres.…”

Interventional radiology for critical hemorrhage in obstetrics: Japanese Society of Interventional Radiology (JSIR) procedural guidelines

“…Retroperitoneal hemorrhage, endometritis, endometrial infection, vaginal necrosis, bladder necrosis, limb ischemia, muscle necrosis, cardiac pulmonary edema due to massive hemorrhage, transient renal failure. c. Permanent adverse sequelae [13,30,[32][33][34]. Uterine necrosis, vaginal fistula, Asherman syndrome.…”