Current Status and Management Strategies of Obstetric Hemorrhage Using Contrast-enhanced Dynamic Computed Tomography in a Representative Tertiary Perinatal Medical Center in Japan

Abstract

Introduction: Obstetric hemorrhage is a leading cause of pregnancy-related mortality. Our hospital protocol states that patients with obstetric hemorrhage undergo initial imaging with contrast-enhanced dynamic computed tomography (CE-dCT) to ascertain the presence and location of active bleeding, followed by tailored therapeutic interventions. Herein, we aimed to elucidate the prevailing status and clinical outcomes of obstetric hemorrhage cases at our institution, which are characterized by a distinctive, methodical treatment approach.

Methods: This retrospective observational study included 150 patients with obstetric hemorrhage. Clinical information, including bleeding volume, hemorrhage etiology, therapeutic intervention, transfusion quantity, patient outcome, and CE-dCT findings, were explored.

Results: The leading cause of obstetric hemorrhage was atonic bleeding (55%), followed by vaginal hematoma (13%) and retained placenta (11%). The median amount of bleeding was 2,803 mL, and the median volume of red blood cells (RBC) and fresh frozen plasma (FFP) required was 6 units. Blood loss and transfusion volume were similar regardless of the cause of obstetric hemorrhage. Conservative management, such as uterotonics or balloon tamponade, achieved hemostasis in 57% of patients, whereas 43% required invasive interventions, such as transcatheter arterial embolization. CE-dCT was performed on 85% of patients, and extravasation was detected in 53%. Moreover, "PRACE," characterized by Postpartum hemorrhage, Resistance to treatment, and Arterial Contrast Extravasation on CE-dCT scans, potentially requires massive blood transfusions and invasive treatment.

Conclusions: Although obstetric hemorrhage encompasses a diverse array of pathologies, medical practitioners must recognize that approximately 3,000 mL of blood is lost and at least 6 units of RBC and FFP are required, irrespective of the cause. CE-dCT plays a pivotal role in elucidating the etiology of obstetric hemorrhage and guiding therapeutic interventions.

Keywords: atonic bleeding; balloon tamponade; contrast-enhanced dynamic computed tomography; obstetric hemorrhage; transcatheter arterial embolization.

Figure 1.

Causes of obstetric hemorrhage (A) and treatment types (B) TAE: transcatheter arterial embolization.

Figure 2.

Patient flow chart based on CE-dCT and treatment types CE-dCT: contrast-enhanced dynamic computed tomography, PRACE: Postpartum hemorrhage, Resistance to treatment, and Arterial Contrast Extravasation on dynamic computed tomography scans, TAE: transcatheter arterial embolization.