Life-threatening Primary Postpartum Hemorrhage Treatment with by xro60491


									Jean-Pierre               Pelage,        MD                Life-threatening             Primary
Olivier Le Dref, MD
Joaquim  Mateo,  MD                                        Postpartum             Hemorrhage:
Philippe Soyer, MD, PhD
Denis Jacob, MD                                            Treatment           with    Emergency
Mourad              Kardache,           MD
Henri Dahan,
Danielle            Repiquet,
                                                           Selective        Arterial
                                                                                             .                   .
             Truc, MD
                                MD,    PhD
Jean-Jacques Merland, MD
Roland Rymer, MD
                                                                PURPOSE:             To prospectively                 evaluate       the efficacy and safety of emergency                           selective
                                                                arterial     embolization               in the       management          of intractable primary  postpartum                          hemor-
index      terms:
Arteries, therapeutic     blockade,                             MATERIALS                AND           METHODS:                  Twenty-seven          consecutively             seen        women         with
    98.1264                                                     life-threatening              primary         postpartum            hemorrhage          underwent            uterine      embolization.
Arteries, uterine, 98.1 264
Pregnancy,    complications,      854.82
                                                                In all cases, hemostatic   embolization                             was performed      because of intractable       hemor-
Uterus, hemorrhage,        854.8269                             rhage that could not be controlled                                   with vaginal    packing     and administration        of
                                                                uterotonic    drugs. The mean hemoglobin                                 level before embolization    was 7.48 g/dL ±
Radiology           1998; 208:359-362                           2.39    (74.8 gIL ± 23.9) (1 standard                                 deviation).       Hysterectomy              performed            in two
                                                                patients before embolization      failed to                          stop the bleeding.
1   From  the Departments        of Body and
Vascular     imaging    (J.P.P., O.LD.,   P.S.,
                                                                RESULTS:       Angiography       revealed      extravasation      in nine patients    and spasm of the
M.K., H.D., J.J.M., R.R.), Obstetrics and                       branches of the internal iliac artery in five. The procedure                consisted    of embolization
Gynecology (D.j., D.R., j.B.T.), and                            of uterine (n =           vaginal (n = 5), or ovarian (n = 2) arteries or anterior
                                                                                           46),                                                                 division of
Anesthesiology       and Critical Care (j.M.,
                                                                internal  iliac arteries (n = 8). Immediate              disappearance     or dramatic     diminution     of
D.P.),     H#{244}pitai ariboisi#{232}re, AP-HP,
                      L                            2 we
Ambroise Pare, 75475 Paris 10, France.                          external bleeding      was observed        in all cases. Two patients needed repeated emboliza-
Received   September    22, 1 997; revi-                        tion the next day. No major complication                 related to embolization      was found. In one
sion requested     November     25; final                       patient with placenta accreta, delayed hysterectomy                  was necessary. Normal menstrua-
revision  received   March   1 6, 1998;
accepted   March 27. Address      reprint                       tion resumed       in all women         except     the two who underwent            hysterectomy.       One
requests to           J.P.P.                                    woman     became pregnant          after embolization.
0   RSNA,      1998
                                                                CONCLUSION:                       Emergency           arterial     embolization          is a safe       and     effective        means         of
                                                                control        of    primary            postpartum               hemorrhage.         The        procedure         obviates          high-risk
                                                                surgery       and    allows          maintenance            of reproductive          ability.

                                                           Postpartum               hemorrhage            remains          a major        cause      of maternal            mortality         throughout           the
                                                           world        (1). The postpartum                 period       is typically       defined        as 6 weeks         after delivery         of an infant
                                                           (2,3). This obstetric                  complication             may occur          immediately             or several        hours      or days after
                                                           delivery.         In most published                studies       about      puerperal        bleeding,       immediate           and late postpar-
                                                           tum       hemorrhage              was treated            in the aggregate               when       clinical       presentation,           causes,     and
                                                           maternal           mortality         are different         (4). Primary          postpartum           hemorrhage            is usually       defined      as
Author     contributions:
Guarantors      of integrity of entire   study,            excessive          bleeding        from the genital              tract (ie, 500 mL or more during                       the first 24 hours           after
J.P.P., R.R.; studyconcepts,    j.P.P., O.LD.;             delivery)          (2,3). The reported                incidence          of 3%-5%          is probably         underestimated               because       of
study design, J.P.P., P.S., R.R.; definition               difficulties          in evaluation          of blood        loss by means            of visual      observation           only (1,5,6).
of intellectual           content,     j.P.P., O.LD.,           Rapid       identification           of the source               and control          of bleeding           are necessary           because       the
J.B.T.,     D.P.,     J.J.M.,   R.R.; literature     re-
                                                           situation           is potentially         life-threatening.               In most       cases,     primary         postpartum           hemorrhage
search,   j.P.P., D.R., D.j.; clinical studies,
J.P.P.; data acquisition,         j.P.P., O.L.D.,          can be managed            with conservative                treatment         involving        vaginal       packing       and administra-
D.R., D.J., M.K., j.M.; data analysis,                     tion of uterotonic           drugs.     With      persistent         bleeding,       vascular      ligation      or hysterectomy          may
j.P.P., O.LD., H.D., M.K.; manuscript                      be needed      (3). Surgical           treatment,           however,         sometimes          may be technically              difficult    to
preparation,      J.P.P., O.LD., D.R.; manu-
                                                           perform     and may fail to control                hemorrhage.             For these      reasons,      transcatheter        embolization
script editing,       J.P.P., P.S.; manuscript
review, P.S., J.P.P., JiM.                                 of the uterine      arteries      may represent             an interesting          alternate      technique          in the treatment       of
                                                           intractable    bleeding,         preserving         future      fertility.     The goal of our study               was to prospectively

evaluate     the efficacy       and safety of emer-                                       sion of specific               blood      units,    treatment       of              women            and       with        retained           portions            of
gency    arterial    embolization          in the man-                                    disseminated                 intravascular           coagulation                    placenta    in two women.             Other      causes        of
agement       of intractable       primary      postpar-                                  with    fresh-frozen               plasma        and with     units                 bleeding    were a genital         tract lesion         (vagi-
tum hemorrhage.                                                                           of platelets        or fibrinogen              when       needed,                   nal or cervical   tears) without          uterine      atony
                                                                                          and management                  of uterine          atony      with                 in seven    women        and placenta           accreta       in
                                                                                          pharmacologic              measures         and early intro-                        two. All women        delivered       infants     at 37-42
MATERIALS                        AND          METHODS                                     duction      of intravenous             oxytocin        (Syntoci-                   weeks    of gestation.          Six women              (22%)
                                                                                          non;     Laboratoires           Sandoz,        Rueil-Malmai-                        delivered        infants        by means          of cesarean
During          a 30-month          period, 27 consecu-                                   son, France) and prostaglandin-E                         analogue                   section,      and 21 women                (78%)       delivered
tively       seen women            who had uncontrol-                                     (sulprostone          [Nalador];        Laboratoire          Scher-                 infants      vaginally.         Twenty-seven            children
lable        primary       postpartum       hemorrhage                                    ing,     Lys-Les-Lannoy,               France)         and     with                 were      in good        health      at the time           of this
and were referred            for emergency            uterine                             manual       uterine        massage.        The decision            to              writing.       One full-term              fetus      died;       the
angiography          and     treatment         with      selec-                           perform        embolization             was made on the                             cause was unexplained.
tive arterial      embolization           were     included                               basis     of active,         continuing           hemorrhage                            At admission              to our       institution,            all
in the study.      The mean         age of the women                                      despite       the     treatment           just     mentioned.                       patients       had      a measured            blood       loss of
was 32.7 years           ± 4.9 (1 standard              devia-                            The potential             risks     and     benefits        of the                  more than         1,000 mL. The mean                 hemoglo-
tion).    Fourteen        women        (52%)      were       pri-                         procedure         were explained,               and informed                        bin level was 7.48 g/dL ± 2.39 (74.8 g/L ±
miparas,           and 13 (48%)                     were          multiparas.             consent     was obtained        in all cases                             from       23.9). The presence         of disseminated         intra-
There          was          one          multiple                 pregnancy.              the patient     or her family.                                                      vascular     coagulopathy           was confirmed
Twenty-one                  women               (78%)            were        trans-          Digital    subtraction      angiography                                was       with laboratory      tests showing         thrombocy-
ferred       from         another             institution,                and six         performed      by a vascular     radiologist                           U.P.P.,      topenia    (platelet      count,     73,740/mm3            ±
delivered           infants          in our hospital.                      During         O.L.D.,         P.S., M.K., H.D.) on an emergency                                   56,860         [73,740           x i09/L           ± 56,860]),                an
the same             period,            58 patients                 (including            basis      using         a right-sided               unifemoral              ap-    elevated         prothrombin                  time,       and hypofi-
those        who          underwent                    embolotherapy)                     proach.          Contralateral               internal          iliac angi-          brinogenemia                    (fibrinogen                level,          1.15
were      referred           to our institution                          for pos-         ography           and selective                study       of the ante-             g/L ± 1 . 1 1). Coagulopathy                         was present               in
sible      treatment                with         arterial            emboliza-            nor division               were then              performed              in all     20 patients            (74%) before              embolization.
tion. Despite              the severity                of the condition                   cases with a 5-F cobra-type                              catheter          (Co-         Tracheal          intubation             and assisted               venti-
of the          patients,              they         had          been        trans-       bra Radifocus;               Terumo,           Tokyo,        Japan)         and     lation      were necessary                in 12 women.                  Emer-
ported       to our institution                      for the following                    a hydrophilic               polymer-coated                   0.032-inch             gency        management                  of cardiac           arrest        was
reasons:         frequent            impossibility                  to provide            guide        wire        (Radifocus;             Terumo)            to ana-         necessary            in four           women.             All patients
more       efficient           care in the initial                       hospital         lyze      the uterine                arteries.         Superselective               needed         blood        transfusion             because            of hy-
and the advantages                         offered          by the French                 angiography                 of the          uterine          artery         was     povolemic              shock.         The        average          transfu-
prehospital               Service           d’Aide           M#{233}dicale Ur-            attempted             in all cases. Other                 anastomotic               sion      before         embolization                involved              12.1
gente,        which             include             ambulances                   that     vessels,         such       as vaginal              branches,             were      units      ± 7.3 of blood                   per patient.               In pa-
always        have a physician                        trained           in medi-          studied          when          necessary.             The ipsilateral               tients     with disseminated                     intravascular               co-
cal resuscitation                      and        emergency                  medi-        internal          iliac       artery        and        uterine          artery      agulopathy,                fresh-frozen                  plasma              (21
cine,     a nurse,              and one or two specially                                  were also catheterized                        by use of the same                    women),            fibrinogen              (four      women),               and
trained         ambulance                 drivers          (7). Resuscita-                puncture             site and            the same            cobra-type             platelet       units       (six women)               were adminis-
tion     of a patient                    can then                be continu-              catheter.          Pledgets            of absorbable                  gelatin       tered.       Pharmacologic                   control         or preven-
ously       performed                  during            transportation.                  sponge           (Gelfoam;              Upjohn,             Kalamazoo,              tion of uterine              atony        consisted          of intrave-
Thus,        in our             study,          early          transfer           was     Mich)        in increasing              sizes were freely intro-                    nous administration                       of oxytocin             alone        in
possible         in all patients.                                                         duced        with fluoroscopic                   guidance.            Polyvi-       five patients,             with        a cumulative                 dose of
     In all cases,            the protocol                   for treatment                nyl alcohol              dehydrated               particles         (Ivalon;        20 units,        and in combination                       with prosta-
was determined                      by means                  of consensus                Nycomed,               Paris,      France)           with       diameters           glandin-E2            analogue            in a total           dosage          of
among          the anesthesiologist,                            obstetrician,             of 300-600              p.m were used during                       a period          1,000 jig (two injections                        of 500 i.g each)
and interventional                          radiologist                available          of a few weeks,                      before         the      nonbovine              in nine          women.              Sulprostone               was used
on a 24-hour                     basis         in our             institution.            origin       of the gelatin               sponge         was certified.             alone       as a first-line            therapy          (one to three
Initial      evaluation                 and resuscitation                       were      Embolization                was bilateral              in all patients.             doses of 500 jig) in 1 1 women.
performed               in the intensive                      care unit be-               Postembolization                      angiography                 was per-              The         obstetric             procedure                 included
fore the patient                      was transferred                       to the        formed          to ensure           the complete                occlusion           manual          exploration               of the uterus                  in 19
interventional                 radiology             room.          The evalu-            of the vessels.                  All patients               were        trans-      women           and manual                  uterine         massage            in
ation was based                   on the clinical                  and hemo-              ferred        to the intensive                   care unit           for fur-        13 women.              A subtotal            hysterectomy                  was
dynamic           status of the patient.                         The amount               ther observation                   and coagulation                    studies       performed             in two women                    before          admis-
of blood          loss was classified                      according              to a    with       the arterial             femoral           introducer             left   sion to our hospital                     but failed           to control
subjective            assessment                made           by the medi-               in place         until      coagulation               disorders          were       the bleeding.
cal team.          Evaluation                of the seriousness                      of   corrected.                                                                               Angiography                showed           no extravasation
the hemorrhage                      was based                on the quan-                                                                                                     of contrast           material          in 18 patients                (67%).
tity of drugs              and fluids              required             to main-                                                                                              Bleeding,           shown           in 1 1 arteries                in nine
tam      hemodynamic                        parameters                 and bio-           RESULTS                                                                             patients,        arose        from the uterine                   artery        in
logic condition                   (2).                                                                                                                                        six (left in three                 and right           in three)            and
     Medical           treatment               was aimed                 at three         The major         clinical    indication        for trans-                          from a vaginal                 branch          in five. Spasms                 of
goals:       correction                of hypovolemic                         shock       catheter      embolization         was uterine       atony                          the branches              of the anterior               division           were
with intravenous                       administration                     of crys-        (18 women          [67%]),   which       was associated                             observed          in five patients.
talloid       or colloid             substances                 and transfu-              with     uterine        or cervical       tears    in five                               Selective         embolization                of both           uterine

360      ‘   Radioiogy              August
                                 #{149}            1998                                                                                                                                                                                     Pelage      at al
arteries        was     performed       in 23 women                                 accounts     for 67% of our cases, is the main                                      the first case of embolization                          of the medial
(85%),       including        the 18 patients    without                            cause of primary       postpartum        hemorrhage                                 circumflex    artery  providing                         anastomotic
identifiable         extravasation.      In four women                              (8,9).   Other    causes     of bleeding        include                             flow      to the       internal         pudendal             artery       in a
(15%),   bilateral      embolization           of the ante-                         lower     genital       tract laceration            or hema-                        patient   who previously             underwent          bilat-
nor division         of the internal            iliac artery                        toma,     retained        placental        tissue,    and rup-                      eral hypogastric       arterial      ligation      and hys-
was performed.           Five vaginal        arteries      were                     ture of the uterine              body      (2,8,9).     Second-                     terectomy      for severe      primary        postpartum
also selectively        embolized          because        of ac-                    ary postpartum                hemorrhage            occurring                       bleeding.
tive bleeding.        Gelatin     sponge       was used as                          more than 24 hours after delivery                    is mainly                          This case illustrates          the advantages             of
the embolic         material       in 23 women               and                    related     to retained           gestational         products                      selective  embolization           over surgery;         selec-
was used in association                with     particles       of                  and tends        to be associated             with maternal                         tive embolization           helps       to localize         the
polyvinyl      alcohol       in one woman.              Polyvi-                     morbidity        rather      than    mortality        (4).                          bleeding    site by means         of extravasation            of
nyl alcohol         alone      was administered                 in                         Primary      postpartum             hemorrhage          is usu-              contrast           material            outside          the      vascular
four   women.          The      embolization             proce-                     ally       controlled        with        specific     surgical      re-             space        and       is a less invasive                     procedure
dure lasted           60-i 10 minutes.                                              pair in case of vaginal                      or cervical         tears,             than       surgery         (24). If the bleeding                    is slow
     External          bleeding            disappeared                in 25         with curettage,             and with vaginal                packing                 or intermittent                or in case of atonic                 uterus,
women            (92%)           and      decreased             dramati-            (2). Atonic         uterus       is often        managed          satis-            however,            angiography               may        often        fail to
cally in two. Slight                  repeated         bleeding           was       factorily         with       intravenous              administra-                   demonstrate                active        bleeding.            Emboliza-
observed           in three          women.           Two of them                   tion of oxytocin               drugs as a first-line             treat-             tion should             be performed               as selectively             as
were       referred          for repeated              angiography                  ment        and prostaglandin-E2                     analogues           if         possible,         either        in the abnormal                 vessel        or
the next          day, and the bleeding                          stopped            oxytocin         is ineffective          in controlling           hem-              in the uterine              artery       even when             no active
spontaneously                   in the         remaining,               third       orrhage        (2, 10). Prostaglandin-E2                  analogue                  bleeding          is detected.
woman.           In one woman,                    the uterine               ar-     (the      most      commonly               used      drug      in Eu-                   Thus,         in our           study,       embolization                  of
tery was patent                   and      repeated          emboliza-              rope) is highly           successful           in the treatment                     both       uterine        arteries        in patients           who had
tion      stopped             the      hemorrhage.                  In the          of atony (10).                                                                      atonic uterus                 has proved              the ability             to
woman           who        had previously                  undergone                     For patients           whose          condition         contin-                stop external                bleeding          immediately                and
hysterectomy,                 embolization               was needed                 ues to deteriorate,               ligation        of the internal                   correct       coagulopathy                 when        medical         treat-
in both           ovarian           arteries        that       provided             iliac artery        or its branches              (1 1, 12) or even                  ment        has failed.          In case of severe              vasocon-
arterial      flow to the bleeding                     site. Biologic               hysterectomy              is often         the favored           treat-             striction,          however,            embolization                 of the
coagulation               disorders            improved               mark-         ment       (3,13). Ligation              of the internal            iliac           anterior         division           of the internal               iliac ar-
edly      within          a few hours                 and        without            artery,       however,            may        fail to stop             the           tery (25), which                     maintains            flow       to the
recurrence           in all women.                No subsequent                     bleeding         in 50% of cases (1 1). The reason                                  branches            of the posterior                division,           is an
transfusion            was necessary               in 22 patients.                  is that bilateral             ligation         of the proximal                      alternative              technique               that        permits            a
Five women              needed          only 2 units of blood                       segment         of the internal              iliac    artery        re-             shorter         procedure             and reduces              radiation
after embolization.                                                                 duces blood           flow by only              48% and the                         exposure           without           any important                compli-
     Local complications                     included          transient            average        pressure       by 24%            (14).    Surgical                   cation.       More studies               are needed.
foot      ischemia             in one woman.                       In one           ligation      is proximal         so that collateral             yes-                    Pledgets         of gelatin           sponge,          which         pro-
woman,            a hysterectomy                   was needed                 5     sels can supply            blood      to the uterus,             and                vide a temporary                     occlusion,            are particu-
days after embolization                        because         of persis-           the bleeding           can recur (15). Ligation                      of             larly suitable              because         the injury            and co-
tent hemorrhage                    due to placenta                accreta.          uterine      arteries       seems to be efficient                    in             agulopathy              should         be resolved             in a rela-
General         complications                  were      cardiogenic                cases     of moderate            bleeding          if it is per-                    tively       short       period         (17,21-23).             We used
pulmonary                edema            related         to hemor-                 formed        at the time           of cesarean            section                  polyvinyl            alcohol          particles           in four           pa-
rhagic       shock,        vasoconstrictive                 drugs,        and       (12).                                                                               tients     in whom         we feared       transmission           of
excessive            fluid         replacement                in three                  Hysterectomy              of a full-term                gravid                  Creutzfeldt-Jakob               disease       by means           of
women          and death             in one woman                   caused          uterus     carries     with it a high operative                   risk              gelatin      sponge.       Polyvinyl       alcohol      is also a
by cerebral              hemorrhage                due to severe                    and morbidity,           including        secondary          bleed-                 short-term          occlusive        agent      with     a more
eclampsia.           This complication                    was not re-               ing due to edematous                      tissues       and       dis-              limited       potential       for recanalization             (18).
lated       to the          embolization.                 The         mean          torted     anatomy         (13). An extrauterine                  site              The use of particles               of large diameter             to
length   of stay in the intensive                            care unit              of bleeding          or inadequate               arterial       ligation            preserve         the smaller               branches         and collat-
was 2.47 days    ± 1 .86. Women                              were dis-              may account              for failure           of hysterectomy                      eral vessels, however,           has proved       its value
charged    on the 10th day after                            emboliza-               to stop         the bleeding.               Finally,         hysterec-              in our patients         with no side effects.           Steel
tion (9.63 days ± 4.72).                                                            tomy        prevents        future       reproductive                func-          coils may be useful          in case of injury        to the
                                                                                    tion.     Because         selective        arterial         emboliza-               genital  tract with identified           extravasation
                                                                                    tion preserves             the uterus,             this technique                   (23).
DISCUSSION                                                                          should         be considered                 first       in cases           of          Our success        rate is comparable            to the
                                                                                    severe       postpartum            bleeding.                                        85%-95%         reported       in previous,         shorter
The widespread                  use of and         recent     im-                        Transcatheter              embolization                has been                studies  (22,23).       In our series, initial       embo-
provements            in angiographic          catheters      and                   used to control              intractable            bleeding          asso-         lization    failed in three women.                  In two
embolic          particles        make      it necessary        to                  ciated        with     pelvic        trauma            (16) and           tu-       women,      repeated        embolization         was suc-
reassess       the role of selective           embolization                         mors        (17,18).       Arterial        embolization                  has        cessful.   In a third woman,          however,      surgi-
of the uterine           arteries    in the management                              also been          successfully          employed              in short             cal treatment         was necessary         because        of
of primary          postpartum          hemorrhage.         Mul-                    trials     for the management                        of postopera-                  placenta     accreta.    These      causes     of failure
tidisciplinary             management           is necessary                        tive (19), postabortion                    (20), and postpar-                       are similar     to those     reported      in previous
to select patients            for treatment       with embo-                        tum      (1 7,21-23)           intractable             bleeding.           To       studies      (22). Placenta     accreta                  is one of the
lization       techniques.         Uterine     atony,     which                     our knowledge,                Brown        et al (24) reported                      major       causes of hysterectomy                         after embo-

Volume        208        Number
                      #{149}           2                                     Life-threatening           Primary        Postpartum            Hemorrhage:             Emergency         Selective        Arterial       Embolization                361
lization         because            of    persistent             bleeding           follow,           with     maintenance          of reproductive                 nonmalignant               gynecologic             bleeding:
(13). Failures      are also likely to occur            with                        ability.                                                                        treatment         with     angiographic           emboliza-
                                                                                                                                                                    tion. Radiology          1987;     164:155-159.
unilateral     treatment         (19) and in patients
                                                                                                                                                              18.   Lang EK. Transcatheter                   embolization           of
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                                                                                               of active compression-decompression                    car-          al. Transcatheter            arterial embolization              of
bleeding          who underwent                     arterial       emboli-
                                                                                               diopulmonary          resuscitation       as a prehospi-             obstetric and gynaecological                   bleeding:       ef-
zation        after      ligation         of the internal                 iliac                                                                                     ficacy    and clinical           outcome.         Br J Radiol
                                                                                               tal advanced       cardiac life support.         Circula-
artery       was unsuccessful                       (17).       Other         re-              tion     1997; 95:955-961.                                            1994; 67:530-534.
ported        complications                after pelvic            emboli-           8.        Combs CA, Murphy             EL, Laros RK. Factors             24.   Brown       BJ, Heaston              DK, Poulson             AM,
                                                                                               associated      with postpartum        haemorrhage                   Gabert HA, Mineau                DE, Miller FJ. Uncon-
zation        were       always         found          in elderly           pa-
                                                                                               with vaginal birth. Obstet Gynecol               1991;               trollable     postpartum            bleeding:      a new ap-
tients (27,28).                                                                                                                                                     proach       to hemostasis               through         angio-
     Embolization               allows       preservation              of the        9.        Combs CA, Murphy             EL, Laros RK. Factors                   graphic        arterial       embolization.             Obstet
mother’s          life and future             reproductive              func-                  associated       with hemorrhage         in cesarean                 Gynecol       1979; 54:361-365.
tion.      Numerous              cases of pregnancy                      after                 deliveries.      Obstet   Gynecol      1991; 77:77-            25.   Alvarez M, Lockwood                  CJ, Ghidini        A, Dot-
                                                                                               82.                                                                  tino P, Mitty HA, Berkowitz                 RI. Prophylac-
ligation         of the internal               iliac arteries            have
                                                                                    10.        Goffinet       F, Haddad       B, Carbonne      B, Se-               tic and emergent              arterial     catheterization
been reported                (29). Likewise,                 after pelvic                                                                                           for selective           embolization            in obstetric
                                                                                               bann E, Papiernik          E, Cabrol     D. Practical
embolization,                  pregnancies                are possible                         use of sulprostone          for the treatment         of             hemorrhage.          Am J Perinatol            1992; 9:441-
even though             follow-up          is shorter         (1 7,30,3 1).                    postpartum         hemorrhage.       J Gynecol     Ob-               444.
                                                                                               stet Biol Reprod (Paris) 1995; 24:209-216.                     26.   Collins     CD, Jackson            JE. Pelvic arterial
In our study,                all patients               who       did not
                                                                                               [French]                                                             embolization         following        hysterectomy         and
undergo             hysterectomy                 had normal                   re-                                                                                   bilateral     intemal      iliac artery ligation             for
                                                                                    1 1.       Evans 5, McShane          P. The efficacy of inter-
sumption            of menstruation                  after emboliza-                           nal iliac artery ligation in obstetric hemor-                        intractable       primary       postpartum          haemor-
tion (31). One woman                          had become                preg-                  rhage.      Surg Gynecol        Obstet    1985; 160:                 rhage. Clin Radiol 1995; 50:710-714.
                                                                                               250-253.                                                       27.   Braf ZF, Koontz           WW. Gangrene               of blad-
nant by the time of this writing.
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     In conclusion,                  our study              shows         that                                                                                      embolization.         Urology       1977; 9:670-671.
                                                                                               with uterine       ligation.    Contemp        Obstet
selective         arterial        embolization                 should         be               Gynecol     1986; 28:13-16.                                    28.   Hare WS, Lond FR, Holland                       CJ. Paresis
the treatment                  of choice             for severe            pri-     13.        Zelop CM, Harlow            BL, Frigoletto    FD, Sa-                following       internal      iliac artery emboliza-
mary        postpartum               hemorrhage                 in case of                     fon LE, Saltzman        DH. Emergency        peripar-                tion. Radiology          1983; 146:47-5          1.
                                                                                               turn hysterectomy.          Am J Obstet     Gynecol            29.   Mengert      WF, Burchell          RC, Blumstein           RW,
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                                                                                               1993; 168:1443-1448.
tidisciplinary              management                   for these           pa-    14.        Burchell    RC. Physiology        of internal      iliac             tion of the internal                iliac and ovarian
tients should              be realized          in highly           special-                   artery ligation.J     Obstet Gynaecol        Br Corn-                arteries.     Obstet      Gynecol          1969; 34:664-
ized       centers          open        24 hours                a day          to              monw 1968; 75:642-651.                                               666.
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provide         lower-risk          conditions             for the angi-                                                                                            A, Baert A. A pregnancy                 after transcathe-
                                                                                               eral arterial   circulation    in the pelvis: an
ographer.            Our        experience              confirms            the                angiographic       study. AJR 1968; 102:392-                         ter embolization            of a uterine          arteriove-
usefulness            of hemostatic                 embolotherapy                              400.                                                                 nous malformation.               Am J Obstet Gynecol
                                                                                    16.        Margolies     MN, Ring EJ, Waltman       AC, Kerr                    1987; 156:1179-1180.
to control             intractable             primary            postpar-
                                                                                               WS, Baum S. Artenography          in the manage-               31.   Stancato-Pasik      A, Mitty HA, Richard      HM,
tum       hemorrhage                if it is applied               early       in                                                                                   Eshkar     N. Obstetric     embolotherapy:       ef-
                                                                                               ment     of hemorrhage       from pelvic      frac-
the course            of events.          If our principles                  are                                                                                    fects on menses and pregnancy.             Radiol-
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mal morbidity                 and complications                      should                    PE, Morse 55, Denny         DR Obstetric       and

362        Radiology
        #{149}                 ‘   August1998                                                                                                                                                                       Pelage et al

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