Pelvic Artery Embolization for Treatment of Postpartum Hemorrhage

Abstract

Postpartum hemorrhage (PPH) is the leading cause of maternal perinatal morbidity and mortality worldwide. Defined as greater than 500 mL blood loss after vaginal delivery, and greater than 1,000 mL blood loss after cesarean delivery, PPH has many causes, including uterine atony, lower genital tract lacerations, coagulopathy, and placental anomalies. Correction of coagulopathy and identification of the cause of bleeding are mainstays of treatment. Medical therapies such as uterotonics, balloon tamponade, pelvic artery embolization, and uterine-sparing surgical options are available. Hysterectomy is performed when conservative therapies fail. Pelvic artery embolization is safe and effective, and is the first-line therapy for medically refractory PPH. A thorough knowledge of pelvic arterial anatomy is critical. Recognition of variant anatomy can prevent therapeutic failure. Pelvic embolization is minimally invasive, has a low complication rate, spares the uterus, and preserves fertility.

Keywords: embolization; fertility; interventional radiology; postpartum hemorrhage; uterine artery.

Fig. 1

Medically refractory postpartum hemorrhage from uterine atony in a 16-year-old hemodynamically unstable female who presented by ambulance with estimated 2,350 mL blood loss after dilation and evacuation abortion at 22.5 weeks. The patient was refractory to multiple medical therapies as well as Bakri balloon tamponade and vaginal packing. She was brought emergently to IR, where angiography and selective bilateral uterine artery embolization were performed. Clinical success was attained, and the patient had an uneventful postprocedural course. ( a ) Selective right uterine artery (arrow) angiography before embolization. Contrast extravasation was not appreciated; such lack of extravasation is commonly the case. ( b ) Right uterine artery angiography after embolization with gelatin sponge pledgets to stasis (arrow).

Fig. 2

Infected uterine artery pseudoaneurysm causing secondary postpartum hemorrhage in a 32-year-old woman who underwent cesarean delivery. Primary postpartum hemorrhage attributed to uterine atony was treated conservatively with medications and transfusion. The patient presented to the emergency department 10 days after delivery with fevers, leukocytosis, and hematuria. ( a ) Transvaginal ultrasound demonstrated a uterine artery pseudoaneurysm (arrow). ( b ) CTA confirms left uterine artery pseudoaneurysm (arrow). ( c ) Selective left uterine artery angiography immediately prior to embolization shows large pseudoaneurysm (arrow) arising from the mid to distal left uterine artery. ( d ) Left internal iliac arteriography after embolization with gelatin sponge pledgets to stasis. There is no residual filling of the pseudoaneurysm. The procedure was clinically successful, and the patient recovered after a course of antibiotics.