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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,
MD
MD
Selective Arterial
. .
Didier
Jean-Bernard
Payen,
Truc, MD
MD, PhD
Embohzation
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-
rhage.
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
359
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
#{149}
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
who have undergone bilateral ligation of References pelvic vessels for control of intractable
the hypogastric artery before emboliza- 1. Gilbert L, Porter W, Brown VA. Postpar- hemorrhage. Radiology 1981; 140:33 1-
tion (1 7). Successful embolization via pel- turn haemorrhage: a continuing problem. 339.
vic collateral vessels, however, has al- BrJ Obstet Gynecol 1987; 94:67-71. 19. Rosenthal DM, Colapinto R. Angiographic
2. Biehl DR. Antepartum and postpartum arterial embolization in the management
ready been reported (17,24,26). of post-operative vaginal hemorrhage. Am
hemorrhage. In: Shnider SM, Levinson C.
Although no complication was encoun- Anesthesia for obstethcs. 2nd ed. Balti- J Obstet Gynecol 1985; 151:227-231.
tered in our series, arterial embolization is more, Md: Williams & Wilkins, 1987; 20. Haseltine FP, Glickman MG, Marchesi 5,
not free of side effects. Even if complica- 385-394. Spitz R, Dlugi A, DeCherney AA. Uterine
3. Herbert WP, Afalo RC. Management of embolization in a patient with postabor-
tions are minimal in skilled hands, the tal hemorrhage. Obstet Gynecol 1984;
postpartum hemorrhage. Clin Obstet Gy-
size and number of emboli, the location necol 1984; 27:139-145. 63(suppl):78S-80S.
of the injection, and the material used for 4. King PA, Duthie SJ, Dong ZG, Ma HK. 21. Duvauferrier R, Priou G, Tasson D, Laur-
embolization may influence the safety of Secondary postpartum haemorrhage. Aust ent MC, Ram#{233}e . EmergencyA uterine
N Z J Obstet Gynaecol 1989; 29:394-398. artery embolization for immediate post-
the procedure. Technical problems re- partum hemorrhage secondary to coagu-
5. Ghares EE, Albert SN, Dodek SM. Intrapar-
lated to arterial catheterization should be lation disorder. J Radiol 1984; 65:285-
turn blood loss measured with Cr 51-
virtually absent in young and healthy tagged erythrocytes. Obstet Gynecol 1962; 288. [French]
women. In addition, a high degree of flow 19:455-462. 22. Mitty HA, Sterling KM, Alvarez M, Gen-
6. Newton M, Mosey LM, Egli GE, Gifford dler R. Obstetric hemorrhage: prophylac-
to the uterine arteries tends to protect
WB, Hull CT. Blood loss during and imme- tic and emergency arterial catheterization
against unexpected reflux of the embolic and embolotherapy. Radiology 1993; 188:
diately after delivery. Obstet Gynecol
material. Ischemic complications were 1961; 17:9-18. 183-187.
found in two women with postpartum 7. Plaisance P, Adnet F, Vicaut E, et al. Benefit 23. Yamashita Y, Harada M, Yamamoto H, et
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-
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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-
77:69-76.
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.
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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
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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-
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362 Radiology
#{149} ‘ August1998 Pelage et al
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