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(Radiology. 1999;212:385-389.)
© RSNA, 1999

Vascular and Interventional Radiology

Secondary Postpartum Hemorrhage: Treatment with Selective Arterial Embolization1

Jean-Pierre Pelage, MD, Philippe Soyer, MD, PhD, Danielle Repiquet, MD, Denis Herbreteau, MD, PhD, Olivier Le Dref, MD, Emmanuel Houdart, MD, Denis Jacob, MD, Mourad Kardache, MD, Patrick Schurando, MD, Jean-Bernard Truc, MD and Roland Rymer, MD

1 From the Departments of Vascular Imaging (J.P.P., P. Soyer, D.H., O.L.D., E.H., M.K., R.R.), Obstetrics and Gynecology (D.R., D.J., J.B.T.), and Critical Care (P. Schurando), Hôpital Lariboisière, AP-HP, 2 rue Ambroise Paré, 75475 Paris 10, France. Received June 11, 1998; revision requested July 30; revision received September 10; accepted February 12, 1999. Address reprint requests to J.P.P. (e-mail: jean-pierre.pelage@lrb.ap-hop.paris.fr).


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To evaluate the efficacy and safety of selective arterial embolization of the uterine arteries in the management of intractable delayed postpartum hemorrhage.

MATERIALS AND METHODS: Fourteen consecutive women with secondary postpartum hemorrhage were treated with selective embolization of the uterine arteries. In all cases, hemostatic embolization was performed because of intractable hemorrhage that could not be controlled with the administration of uterotonic drugs or with uterine curettage.

RESULTS: The causes of bleeding included genital tract tears in four women and endometritis in eight women; the endometritis was associated with proved, retained portions of placenta in four women. In two women, no evident cause of bleeding was found before angiography. Angiography revealed extravasation in three women. A false aneurysm of the uterine artery was found in two women. In one patient, an arteriovenous fistula was observed. Immediate resolution of external bleeding was observed in all women. No complication related to embolization was found. Normal menstruation resumed in all women.

CONCLUSION: Selective arterial embolization of the uterine arteries is a safe and effective means of controlling secondary postpartum hemorrhage.

Index terms: Arteries, therapeutic blockade, 98.1264, 98.41 • Arteries, uterine, 98.1264, 98.41 • Pregnancy, complications, 854.41, 854.82, 854.8255 • Uterus, hemorrhage, 854.41, 854.8255, 854.8269


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Postpartum hemorrhage remains one of the major worldwide causes of maternal mortality (1). The postpartum period is typically defined as the 6 weeks after delivery of the infant (2,3). Postpartum hemorrhage may occur immediately or several hours or days after delivery. In most published studies about puerperal bleeding, primary and secondary postpartum hemorrhage were treated in the aggregate when clinical presentations, causes, and maternal mortality rates were different.

Postpartum hemorrhage that occurs during the first 24 hours following delivery is termed primary, or early, postpartum bleeding (4,5). Secondary, or delayed, postpartum hemorrhage is usually defined as excessive bleeding from the genital tract, with a blood loss of 500 mL or more, that occurs after the first 24 hours following delivery until the 6th week of the puerperium (4,5).

This uncommon complication, which affects 1%–3% (4) of all deliveries, is underestimated because of difficulties in evaluating blood loss by only visual observation (6,7). In most cases, postpartum hemorrhage can be managed with conservative treatment by using uterotonic drugs. Curettage is both a diagnostic and a therapeutic tool in the management of delayed postpartum hemorrhage. However, in the case of persistent bleeding, vascular ligation or hysterectomy may be needed (3). For these reasons, transcatheter embolization of the uterine arteries may be an interesting alternate treatment for intractable bleeding.

The goal of our study was to evaluate the efficacy and safety of selective arterial embolization of the uterine arteries in the management of intractable delayed postpartum hemorrhage.


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Fourteen consecutive women with uncontrollable secondary postpartum hemorrhage who were referred for pelvic angiography and possible treatment with selective arterial embolization were included in the study. The mean age of the women was 29.8 years ± 4.1 (SD; age range, 24–36 years). The women were referred to our department of radiology between July 1994 and December 1997.

Initial evaluation and resuscitation, when needed, were performed in the intensive care unit of our institution before the patient was transferred to the department of radiology. The evaluation of the seriousness of the hemorrhage was based on the clinical and hemodynamic status of the women. The decision to perform embolization was made on the basis of active continuing hemorrhage in spite of appropriate medical and obstetric treatment. No patient underwent vascular ligation before the procedure. The potential risks and benefits of the procedure were explained, and informed consent was obtained in all cases.

Digital subtraction angiography (iohexol [Omnipaque 300]; Nycomed, Paris, France) was performed by a vascular radiologist (J.P.P., P. Soyer, D.H., O.L.D., E.H., M.K.), who used a right-sided unifemoral approach in all cases. Contralateral internal iliac angiography and selective study of the anterior division of the internal iliac artery were then performed with a 5-F cobra-shaped catheter (Cobra; Terumo, Tokyo, Japan) and a 0.032-inch-diameter hydrophilic polymer–coated guide wire (Radifocus; Terumo) for the analysis of the uterine arteries. Superselective angiography of the left uterine artery was achieved in all cases.

Other anastomotic vessels, such as the vaginal branches, were studied when necessary. The ipsilateral internal iliac artery and the right uterine artery were also systematically catheterized. Pledgets of absorbable gelatin sponge (Gelfoam; Pharmacia and Upjohn, Bridgewater, NJ) of increasing sizes were introduced under fluoroscopic control in a free-flowing manner (Table). In one patient with a false aneurysm, n-butyl-2-cyanoacrylate (Embucrilate Histoacryl; Braun, Melsungen, Germany) was chosen as the embolic material because the lesion would not have been treated satisfactorily by using pledgets of absorbable gelatin sponge, in view of the difficulty to completely fill a false aneurysm with a resorbable agent. A postembolization angiographic study was performed to ensure the complete occlusion of the vessels.


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  		Patient Data, Treatment, and Findings
 

   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
The time of onset of the bleeding was 16.3 days ± 11.6 after delivery. The major clinical indication for transcatheter embolization was endometritis, which was encountered in eight women (57%) and which was associated with histopathologically proved retained portions of placenta in four women (Table). Genital tract lacerations were encountered in four women. In two women, no cause of bleeding was found before angiography. In six women (43%), babies were born by means of cesarean delivery, and in eight women (57%), babies were born by means of spontaneous vaginal delivery. All children were liveborn and were in good health at the time this article was written.

At the time of admission to our institution, seven women presented with symptoms of severe hypovolemic shock; disseminated intravascular coagulopathy was biologically present in five of these seven women.

Medical management consisted of intravenous administration of uterotonic drugs, oxytocin or prostaglandin-E2 analogues (sulprostone), in all women. Obstetric procedures consisted of manual exploration of the uterus in all women and curettage of the uterine cavity in nine women. Antibiotics were administered to 11 women.

Angiography showed no extravasation in eight (57%) women (Fig 1). Active bleeding was shown in three women; the bleeding arose from the uterine artery (n = 3) (Fig 2) and/or from the vaginal artery (n = 1). A false aneurysm of the uterine artery was found in two women (Fig 3), and an arteriovenous fistula was found in one woman.



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  		Patient 1. (a) Right uterine angiogram in a 25° left anterior oblique projection shows uterine hypervascularity (arrowheads) but no extravasation. (b) Postembolization angiogram shows complete occlusion (arrow) of the right uterine artery.

 


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  		Patient 1. (a) Right uterine angiogram in a 25° left anterior oblique projection shows uterine hypervascularity (arrowheads) but no extravasation. (b) Postembolization angiogram shows complete occlusion (arrow) of the right uterine artery.

 


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  		Patient 13. (a) Left uterine angiogram in a right anterior oblique projection shows massive extravasation (arrow) of iodinated contrast material. (b) Postembolization angiogram shows the left uterine artery is occluded (arrow) and the extravasation has disappeared.

 


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  		Patient 13. (a) Left uterine angiogram in a right anterior oblique projection shows massive extravasation (arrow) of iodinated contrast material. (b) Postembolization angiogram shows the left uterine artery is occluded (arrow) and the extravasation has disappeared.

 


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  		Patient 8. (a) Left uterine arteriogram with a right anterior oblique projection demonstrates a false aneurysm (arrowhead) of the uterine artery (arrow). (b) Postembolization angiogram confirms complete occlusion (arrow) of the left uterine artery.

 


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  		Patient 8. (a) Left uterine arteriogram with a right anterior oblique projection demonstrates a false aneurysm (arrowhead) of the uterine artery (arrow). (b) Postembolization angiogram confirms complete occlusion (arrow) of the left uterine artery.

 
Selective embolization of both uterine arteries was performed in 12 women (86%). In two women (14%), unilateral embolization of a false aneurysm (n = 1) or the arteriovenous fistula (n = 1) was performed. Absorbable gelatin sponge that was cut into particles of increasing sizes was used as the embolic material in 13 women. n-butyl-2-cyanoacrylate was used in one woman with a false aneurysm.

The embolization procedure lasted 50–80 minutes. In all women, external bleeding disappeared immediately. In all cases of severe initial bleeding, hemodynamic stability and immediate correction of the coagulopathy was obtained. No general or local complications were noticed.


   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
In our study, we found that selective arterial embolization of the uterine arteries is an effective and safe treatment for the control of secondary postpartum hemorrhage. Uterine atony, which accounts for 75% of reported cases, is the main cause of primary postpartum hemorrhage, which is often associated with life-threatening situations (8,9). In contrast, secondary postpartum bleeding is most commonly caused by retained placental fragments (4,5). Delayed postpartum bleeding may also be caused by endometritis and vaginal or uterine tears. Hypofibrinogenemia (10) and endometrial carcinoma (11) may also be responsible for late postpartum bleeding.

In our article, we report two uncommon causes of delayed hemorrhage. False aneurysm and arteriovenous fistula are sometimes associated with menorrhagia and postpartum bleeding (12,13). These lesions, which developed following cesarean delivery, are probably of posttraumatic origin related to hysterotomy (12).

Until now, secondary postpartum hemorrhage had received little attention, probably because of its low incidence and because it tended to be more frequently associated with maternal morbidity rather than mortality (4). However, secondary postpartum bleeding may sometimes become nearly fatal, as we noticed in six of the women. Bleeding occurs most frequently between the 8th and the 14th day of the puerperium, so the patient often will have been discharged from the hospital and will require readmission (4).

In the case of hypovolemic shock and coagulopathy, initial resuscitation with volume replacement and blood transfusion is required. Uterotonic drugs, such as oxytocin and prostaglandin-E2 analogues, are commonly used (2). If endometritis is suspected, a combination of ampicillin and metronidazole is administered (4,5). The lower genital tract should be carefully inspected to rule out laceration or to find placental fragments (4). In such a case, suction evacuation and curettage is often successful in stopping the hemorrhage, but it may also increase placental bleeding (2).

For women whose condition is still deteriorating, ligation of the internal iliac artery or its branches (14) or even hysterectomy is often considered the ultimate therapeutic option (15). However, vascular ligation often fails to stop the bleeding because ligation is proximal, so collateral vessels, such as the middle sacral, the last lumbar, and the inferior epigastric arteries, can provide an alternate blood supply to the uterus (16).

Many reports have emphasized the usefulness of transcatheter embolization in the control of intractable bleeding that is associated with pelvic trauma (17), tumors (18,19), or vascular malformation (20,21). Arterial embolization has also been successfully used for the management of postoperative (22), postabortion (23), and postpartum (19,24–26) intractable bleeding. To our knowledge, the first case of uterine embolization in the management of severe postpartum hemorrhage was reported by Brown et al (27) in the obstetrics and gynecology literature.

Angiographic study helps to localize the bleeding site in the case of extravasation of iodinated contrast material. If the bleeding is intermittent or is in a patient with endometritis, angiography may often fail to demonstrate active bleeding (28). Embolization should be selective, either in the pathologic vessel or in the uterine artery, even when no active bleeding is detected. Embolization of the vaginal artery should be performed in the case of identified extravasation.

In other situations, bleeding related to a genital tract tear is usually controlled after embolization of both uterine arteries because the cervicovaginal branches often originate from the arches of the uterine arteries. In our study, embolization of both uterine arteries in the cases of endometritis immediately stopped the external bleeding.

Several agents for embolization are currently available. They include gelatin sponge pledgets, polyvinyl alcohol particles, steel coils, and n-butyl-2-cyanoacrylate. Most authors use gelatin sponge as the embolic material because of semipermanent occlusion of the vessels with a potential for recanalization 3 weeks later (25,26). Particles of increasing sizes are particularly suitable for leaving the capillary bed intact. Inert particles of polyvinyl alcohol are also short-term occlusive agents at the level of the small arteries, but they have a limited potential for restoring vascular continuity (20). Steel coils were used in several studies (20,24,28). n-butyl-2-cyanoacrylate may be suitable when more definitive devascularization is required, especially in the case of a false aneurysm (21).

The use of arterial embolization to control hemorrhage has a reported success rate of 90%–95%, which is even higher in our series. In the literature, failures are likely to occur in cases of unilateral treatment (22) and in women who have undergone bilateral hypogastric arterial ligation before embolization (19). In this last situation, it is likely that prior surgical ligation obliterates the direct access route for the embolization catheter. However, successful embolization via the pelvic collateral vessels has already been reported (19,27,29,30).

Although no complication was noted in our study, arterial embolization is not side-effect free. The size of the particles used and the location of the injection during embolization influence the safety of the procedure. Arterial catheterization is easy in young and healthy women. In addition, high blood flow in the uterine arteries tends to protect against the unexpected reflux of embolic material. However, the interventional radiologist should be aware of possible variations in pelvic vascular anatomy and anastomotic channels (31).

Ischemic complications were reported in two women with postpartum bleeding who underwent arterial embolization after unsuccessful internal iliac artery ligation was performed (19). Other complications following pelvic embolization have been reported in the literature. They include muscle pain (22), neurologic damage (32), bladder necrosis (33), and vesicovaginal fistula (34). All of these complications were found in elderly women with pelvic neoplasm or who had previously received radiation therapy of the pelvis.

Numerous cases of pregnancy after ligation of the internal iliac arteries have been reported in the literature (35). Pregnancies are also possible after pelvic embolization (19,36).

In conclusion, our results show that selective arterial embolization of the uterine arteries should be the preferred treatment for intractable secondary postpartum hemorrhage when conservative treatment fails. Even though retention of gestational products and endometritis are the most frequent causes of secondary postpartum bleeding, angiographic exploration often demonstrates a bleeding artery that is related to previously unsuspected genital tract lesions. We have reported three cases in which acquired false aneurysm or arteriovenous fistula caused postpartum bleeding.


   Footnotes
 
Author contributions: Guarantors of integrity of entire study, J.P.P., R.R.; study concepts, J.P.P., D.R.; study design, J.P.P., P. Soyer, R.R.; definition of intellectual content, J.P.P., O.L.D., J.B.T., R.R.; literature research, J.P.P., D.H., D.R., D.J.; clinical studies, J.P.P., O.L.D., D.H., E.H., P. Soyer, M.K., D.J., D.R., P. Schurando; data acquisition, J.P.P., O.L.D., D.R., D.J., P. Schurando; data analysis, J.P.P., O.L.D., D.H.; manuscript preparation, J.P.P., D.R.; manuscript editing and review, J.P.P., P. Soyer.


   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

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