Selective Arterial Embolization of the Uterine Arteries in the Management of Intractable Post-Partum Hemorrhage

Abstract

The effectiveness of selective uterine artery embolization in controlling severe, intractable postpartum bleeding and its safety were assessed in 35 women, 25 with primary postpartum hemorrhage and 10 with delayed bleeding. The major cause of immediate bleeding was an atonic uterus; genital tract lacerations were less frequent. Delayed hemorrhage was due chiefly to retained placental fragments or endometritis. In two women, even hysterectomy had failed to stop the bleeding. After correcting hypovolemic shock and treating disseminated intravascular coagulation when present, oxytocin and sulprostone were administered if the uterus was atonic. The uterus was manually explored and usually massaged. Digital subtraction angiography was performed, followed by superselective examination of the uterine artery. Pledgets of absorbable gelatin sponge, polyvinyl alcohol particles, or n-butyl-2-cyanoacrylate were introduced under fluoroscopic control during free flow. All but two patients had bilateral embolization. All but 2 of the 25 women with primary postpartum hemorrhage had selective embolization of both uterine arteries, most often with gelatin sponge particles of increasing size. External bleeding ceased immediately in 92 percent of women and decreased markedly in the other two cases. Treatment was repeated in two cases because of slight recurrent bleeding. Coagulation disorder resolved within hours of embolization. Only three women required blood transfusion after embolization. One woman had ischemia of the foot, and another with placenta accreta required hysterectomy when bleeding recurred. Eight of 10 patients with secondary postpartum hemorrhage had both uterine arteries embolized. In all of these women, external bleeding stopped immediately and did not recur. Hemodynamic stability was restored in women who initially were in hypovolemic shock. Selective arterial embolization should be the preferred approach to intractable postpartum hemorrhage when more conservative measures fail. Not only are complications infrequent and morbidity minimal, but women managed in this way retain their reproductive potential. Acta Obstet Gynecol Scand 1999;78:698–703