Recent Update of Embolization of Postpartum Hemorrhage

Abstract

Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.

Keywords: Embolic materials; Postpartum hemorrhage; Transcatheter arterial embolization.

Fig. 1. Vascular anatomy relevant to PPH.

A. Schema of IIA and its branches. 1, common iliac artery; 2, external iliac artery; 3, inferior epigastric artery; 4, IIA; 5, superior vesical artery; 6, obturator artery; 7, UA; 8, internal pudendal artery; 9, inferior gluteal artery; 10, superior gluteal artery; 11, lateral sacral artery; 12, iliolumbar artery; 13, piriformis muscle; and 14, sacrospinous ligament. B. Left IIA arteriogram in right anterior oblique projection (20°). 1, IIA; 2, external iliac artery; 3, lateral sacral artery; 4, UA; 5, inferior gluteal artery; 6, internal pudendal artery; 7, obturator artery; 8, vesical artery; 9, superior gluteal artery; and 10, iliolumbar artery. IIA = internal iliac artery, PPH = postpartum hemorrhage, UA = uterine artery

Fig. 2. 35-year-old woman with primary PPH due to uterine atony.

A. Left internal iliac arteriogram in frontal projection shows typical tortuous shape of UA (arrows). B. Selective arteriogram of left UA shows enlarged UA (arrow) which supplies enlarged uterus with numerous intramural branches (arcuate arteries, arrowhead). Cobra catheter (white arrows) was used to catheterize contralateral left UA (inset). C. Right internal iliac arteriogram in frontal projection demonstrates tortuous, enlarged UA with characteristic descending (arrowhead), transverse, and ascending segments (arrow). Ipsilateral, right UA was selected with Cobra catheter using Waltman loop (white arrows in inset). Bilateral UAs were embolized using gelatin sponge particles (not shown). D. Completion arteriogram shows no visualized bilateral UAs.

Fig. 3. 34-year-old woman with primary PPH three hours after vaginal delivery.

There was vaginal laceration, which could not be controlled with vaginal packing and suture. A. Initial, right internal iliac arteriogram shows contrast extravasations (arrows) in vaginal branches from anterior division of IIA. Several bleeders, including vaginal branches, were embolized with NBCA and microcoil, after which bilateral UAs were embolized with gelatin sponge particles (not shown). However, persistent contrast extravasation was noted. Therefore, right IIA was embolized with gelatin sponge particles (not shown). B. Vaginal bleeding recurred four hours later. Axial contrast-enhanced CT scan shows active bleeding (arrow) in right paravaginal hematoma. Note vaginal packing (arrowhead). C. In second session, aortogram demonstrates contrast extravasation at lower pelvis level. Subsequent, selective inferior mesenteric arteriogram shows contrast extravasations (arrow) in distal branch which was embolized with NBCA (not shown). NBCA = N-butyl cyanoacrylate

Fig. 4. 40-year-old woman with decreased hemoglobin level following cesarean section.

However, obvious vaginal hemorrhage was not found. A. Axial enhanced CT scan shows large hematoma with active bleeding focus (arrow) within rectus abdominis muscle. Small amount of hematoma is found in endometrial cavity without active bleeding. B. Selective left inferior epigastric arteriogram demonstrates no active bleeding. However, subsequent, selective right inferior epigastric arteriogram demonstrates contrast extravasation (arrows). C. Completion, fluoroscopic image shows NBCA cast (arrows) of right inferior epigastric artery. Additional angiogram of right superior epigastric artery demonstrates no active bleeding focus.

Fig. 5. 39-year-old woman with placenta accreta, presenting with PPH after cesarean section.

A, B. Early and delayed, right internal iliac arteriograms show multiple, tortuous UA branches (arrowheads in A) and extensive trophoblastic vascularization of placental intervillous spaces (arrowheads in B). Note embolized left UA with gelatin sponge particles (arrow). There was continued vaginal bleeding after bilateral UAs embolization with gelatin sponge particles. C. Selective, right ovarian artery angiogram shows reflux into UA (arrow). Faint ovarian blush (arrowhead) is also visible. Right ovarian artery was embolized with gelatin sponge particles.

Fig. 6. 33-year-old woman with arteriovenous malformation, presenting with secondary PPH after cesarean section.

A. Arterial phase of axial enhanced CT scan shows hypervascular lesion (arrow) in uterine cavity. B. Left internal iliac arteriogram shows hypervascular lesion (arrow) with enlarged tortuous UA. C. Selective angiogram of right UA shows hypervascular lesions (arrows) and parenchymal defect (arrowhead) due to embolization of left UA. Bilateral UAs were embolized with gelatin sponge particles.

Fig. 7. 38-year-old woman with vaginal bleeding after cesarean section.

A, B. Bilateral internal iliac arteriogram in frontal projection shows hypertrophied bilateral UAs. However, vaginal bleeding was persistent after adequate embolization of both UAs using gelatin sponge particles. C. Pelvic aortography demonstrates right round ligament artery (not shown). Selective angiography of right round ligament artery (arrow) shows uterine stains (arrowhead). D. Image obtained during embolization shows right round ligament artery (arrow) and right inferior epigastric artery (arrowhead) filled with mixture of contrast medium and gelatin sponge particles. Embolization was performed at level of inferior epigastric artery because of failure of superselection of round ligament artery. Vaginal bleeding ceased after right round ligament artery embolization.