Uterine artery embolization versus surgical management in primary atonic postpartum hemorrhage: A randomized clinical trial

AbstractBackgroundPostpartum hemorrhage is the leading cause of severe maternal morbidity and death. A prompt management of uterine atony is life saving. Surgery can be needed in many cases. Uterine artery embolization (UAE) is a safe procedure and can be tried to be alternative to surgical approach.ObjectiveTo evaluate the clinical effectiveness and safety of uterine artery embolization (UAE) in comparison with stepwise devascularization and compression sutures in the treatment of postpartum hemorrhage (PPH).MethodsRandomized controlled parallel-group trial included twenty-three women with postpartum hemorrhage who were treated with either selective embolization of the uterine arteries or stepwise devascularization and compression sutures after failure of conservative measures.ResultsTechnical success was achieved in 9 patients (81.8%) of cases with complete cessation of the bleeding, while 2 cases (18.2%) suffered DIC and needed hysterectomy in the UAE group, while the other group (12 patients) had stepwise devascularization and compression sutures done after failure of the conservative measures, with 3 cases who needed hysterectomy after failure of these methods.ConclusionsUterine artery embolization is a safe, minimally invasive and effective method for treatment of postpartum hemorrhage and is alternative to surgical management

An analysis of the efficacy of uterine artery embolization in obstetrical hemorrhage

Background: Obstetrical hemorrhage is the single most important cause of maternal morbidity and mortality. The study is conducted at a tertiary-care hospital to assess the efficacy of uterine artery embolization as a treatment for obstetrical uterine hemorrhage. It examines various aspects such as the outcome of the procedure, need of blood and blood products, need of secondary procedures post intervention and the possibility of future pregnancies. Methods: It was a retrospective observational study conducted with sample size of 20 patients with obstetrical hemorrhage at the Department of Obstetrics and Gynecology of Bhagwan Mahaveer Jain Hospital, Bengaluru in India between January 2011 to July 2019. Results: Records of 20 patients with obstetrical hemorrhage were assessed. The study indicates that 11 patients experienced postpartum hemorrhage (PPH), 5 postabortal bleeding & 4 bleeding due to scar ectopic. Out of 20 patients, hemodynamic stability was achieved in 17 cases (85%), hysterectomy was needed in 2 cases (10%) and 1 (5%) patient died after the procedure. Of total 20 cases, 18 (90%) required secondary procedures post-intervention like dilatation and evacuation 6 cases (33.3% of total cases), vaginal suturing and packing 10 cases (55.5% of total cases) and supportive measures like PPH and Disseminated intravascular coagulation (DIC) management in 2 cases (11.1% of total cases). Blood transfusion was given in 15 cases (75%) after the procedure. Future pregnancy was attained in 8 cases (47%) after considering the history of the patients, loss of follow-up, possibility of complications, family planning and hysterectomy performed. Conclusions: Uterine artery embolization is a very effective method to control obstetric hemorrhage with high success and low complication rate and hysterectomy can be avoided to preserve fertility

Obstetrical and Fertility Outcomes Following Transcatheter Pelvic Arterial Embolization for Postpartum Hemorrhage: A Cohort Follow-Up Study.

Objectives: Management of severe postpartum hemorrhage (PPH) includes transcatheter pelvic arterial embolization (TAE). Data regarding subsequent fertility and obstetrical outcomes is limited, as most fertility outcomes derive from TAE in uterine fibroma. The purpose of our study was to evaluate the long-term outcomes of patients undergoing TAE, particularly concerning subsequent fertility and following pregnancies. Material and methods: We included 28 patients who underwent TAE for PPH at our institution between 2009 and 2018 in a retrospective cohort study. Data were assessed by reviewing patients' charts and by contacting the patients. Results: Ten patients had prophylactic balloon occlusion before cesarean section because of anticipated PPH, with planned hysterectomy by placenta increta/percreta. All these patients were excluded from the analysis regarding fertility. 16 (73%) patients reported having regular menstruation after TAE. In total, 11 women had no desire for subsequent pregnancy. Seven of the remaining 11 patients (63.6%) had a total of 13 spontaneous pregnancies, nine of these resulted in miscarriages. Four patients delivered a live baby (36.4%). Two of these (50%) had recurrent PPH and treatment was conservative. Of the patients with infertility (n = 4, 36.4%), two (18.1%) underwent assisted infertility treatment without success. Conclusion: Our study suggests that the fertility of patients undergoing TAE due to PPH is limited. In women who conceive, the risk for first trimester miscarriage as well as recurrent PPH seems to be increased. If this is a consequence of the underlying cause of PPH or the TAE remains unknown. Larger follow-up cohorts are needed. In the meantime, patients who desire pregnancy after TAE should be counseled accordingly

Efficacy and Complications of Emergent Transcatheter Arterial Embolization for the Management of Intractable Uterine Bleeding

Objective：Transcatheter arterial embolization（TAE）, including uterine artery embolization（UAE）, is effective for the management of obstetric and gynecologic hemorrhage. Some adverse effects have been reported with TAE, such as amenorrhea, endometrial trauma, and subsequent infertility. Herein we report the efficacy and complications of emergent TAE for the management of severe intractable uterine bleeding at our institute.Methods：From 2010 to 2019, thirty-eight patients underwent emergent TAE for intractable uterine bleeding. We evaluated the efficacy and complications of TAE, including a change in menstruation, fertility, and pregnancy outcomes in perinatal patients（group A；n＝23）, and in patients with gynecologic hemorrhage（group B；n＝15）.Results：In group A, 7 cases of retained placenta, 4 cases of postpartum hemorrhage, 2 cases of placenta accrete, 2 cases of uterine artery pseudoaneurysm, 2 cases of cervical pregnancy, 1 case of cesarean scar pregnancy, and 5 cases of unexplained hemorrhage were included. The median age of the group A was 37. In group B, 4 cases of uterine artery pseudoaneurysm, 2 cases of uterine arteriovenous malformation, 3 cases of uterine fibroids, 1case of adenomyosis, and 5 cases of unexplained hemorrhage were included. The median age of the group B was 39. The first attempt at TAE successfully controlled hemorrhage in 33 of 38 patients （86.8％）without major complications, and the remaining 5 patients required an additional attempt at TAE to control hemorrhage. One patient（2.6％）had transient buttock pain and foot ischemia. Among the 33 patients who had adequate follow-up care, all patients resumed regular menstruation. The median time to resume regular menstruation after TAE was 3 months （range, 1-13 months）in group A（n＝20）and 1 month（range, 1-6 months）in group B（n＝13）. Four of patients had 6 pregnancies in total：3 full-term live births, 2 missed abortions, and 1 artificial abortion. Among the 13 patients who desired pregnancy, 3（23％）conceived spontaneously.Conclusions：This retrospective study showed that emergent TAE may be effective and safe in treating intractable uterine bleeding with a high success rate. Ovarian and endometrial function were preserved based on the relatively early return of menstruation. Further prospective investigations with large number of patients are needed to confirm the preservation of ovarian function, fertility, and pregnancy outcome in reproductive-aged women

Clinical outcomes and future fertility after uterine artery embolization for postpartum and post-abortion hemorrhage

Background: Postpartum hemorrhage (PPH) and post-abortion hemorrhage (PAH) are life-threatening conditions. Purpose: To evaluate the efficacy and safety of uterine arterial embolization (UAE) for PPH and PAH and to investigate future fertility after UAE. Material and methods: This study included 57 consecutive patients (mean age = 34 years) who underwent UAE for PPH (n = 46) and PAH (n = 11) at our institution between January 2011 and December 2022. Technical success, non-visualization of the peripheral portion of bilateral uterine arteries on angiography, and clinical success, complete hemostasis after UAE, were assessed. UAE-associated complications and factors related to clinical success were analyzed. Pregnancy outcomes after UAE and complications during subsequent pregnancy were investigated in 16 patients who desired fertility and were followed up for >1 year. Results: The technical and clinical success rates were 100% and 84.2%, respectively. Sepsis (n = 1) and uterine empyema (n = 1) were observed as severe complications. Placental disorder, bleeding within 24 h after delivery or abortion, ≥1.5 shock index, ≥6 units of transfusion erythrocytes, and ≥8 obstetrical disseminated intravascular coagulation score were significantly associated with unfavorable clinical outcomes. In total, 16 pregnancies were observed in 12 patients after UAE, three of which were miscarriages and 13 were successful live births. During pregnancy, uterine rupture (n = 1) and accreta (n = 1) were observed. Conclusion: UAE is an effective treatment for PPH and PAH. Although UAE could preserve future fertility, careful attention should be paid to perinatal management for unusual complications.journal articl

Management of obstetric hemorrhage; an observational study highlighting the efficacy of uterine artery ligation

Background: Obstetrical hemorrhage is leading cause of maternal mortality. UAE is termed safe and effective method for resolving hemorrhage. objective of this study was to determine efficacy of uterine artery ligation in management of obstetrical hemorrhage.Methods: This cross sectional observational using non-probability convenient sampling technique was carried out for six months. After ethical approval, females between 18 to 35 years diagnosed with obstetrical hemorrhage, uterine atony refractory to medical treatment, having active bleeding from placental side or having normal coagulation profile were while females with post-partum hemorrhage because of retained products of conception, due to genital tract trauma or with disseminated intravascular coagulation were excluded. Analysis of data was done using SPSS version 23.0. Quantitative variables were reported as mean and standard deviation and for qualitative variables, frequency and percentages. Chi-square test was applied keeping p-value of <0.05 as statistically significant.Results: From 109 females with mean age 47±5.25 years. In comparison of parity distribution, 62 (56.88%) were multiparous and 47 (43.12%) were primiparous. Type of bleeding observed was antepartum 36(33.03%), peripartum 39 (35.78%) and postpartum in 34 (31.19%). Efficacy of uterine artery ligation in management of obstetric hemorrhage was observed to be 35 (32.11%). The efficacy of uterine artery ligation in management of obstetric hemorrhage in three categories of age groups reported significant association (p=0.0005) and type of bleeding (p=0.025).Conclusions: Efficacy of UAE in different types of obstetrical hemorrhage reported in our study was lower than expected in about one-third of females

Preservation of Fertility after Uterine Artery Embolization: A Review of Pregnancy Following Non-Surgical Intervention for Leiomyoma

Introduction: As a prevalent disease in women of childbearing age, treatment of leiomyoma is an area with many options. Hysterectomy is a common and definitive treatment but is not appropriate in women wishing to attempt pregnancy. Myomectomy surgically removes fibroids, and is the first line treatment for women wishing to preserve the uterus. Uterine Artery Embolization (UAE) is an emerging treatment option with an uncertain effect on fertility. As a less invasive procedure with good relief of symptoms and a shorter recovery period, UAE is appealing. The purpose of this review is to evaluate the current standing of UAE as a possible treatment option for women with leiomyoma wishing to preserve fertility. Methods: This literature review focuses on studies published within the last ten years which report on pregnancies after UAE in women treated for uterine fibroids. Results: Of the nine studies included, there are increased rates of spontaneous abortion, pre-term delivery, post-partum hemorrhage and abnormal placentation in a subset of the studies. These results might be due to UAE or may perhaps be explained by the advanced maternal age of the subjects, or other subfertility factors not addressed in the studies. Conclusion: The effects of UAE on subsequent pregnancy are still unclear. The paucity of large randomized controlled trials and the small number of reported cases of pregnancy (less than 200) limits the quality of the evidence. Until larger randomized trials are completed comparing myomectomy and UAE, myomectomy will continue to be the first line therapy for women who intend to become pregnant

Study of uterine artery embolization: a newer modality in secondary PPH

Background: Postpartum hemorrhage remains a major cause of both maternal mortality and morbidity worldwide. This study reflects the clinical outcomes including clinical effectiveness, and safety of uterine artery embolization (UAE) for the treatment of obstetrical uterine hemorrhage at a tertiary-care hospital, in terms of secondary PPH.Methods: The data were collected as a retrospective study from SAMC and PGI obstetric and gynecology department 12 women with secondary pph were included in the study.Results: With the use of uterine artery embolization 12 women were successfully treated amongst them maximum patients were in 26-35 yrs of age and mean age of women were 32.4yrs and gravidity of patients presenting with pph is 3 or more.Conclusions: Selective UAE is a safe and effective method to control obstetric hemorrhage. Blood product requirements after UAE were low, and the surgical risks and absolute loss of fertility associated with hysterectomy were avoided

Intrauterine Tamponade Balloon for Management of Severe Postpartum Haemorrhage: Does Early Insertion Change the Outcome? A Retrospective Study on Blood Loss

The French College of Gynecologists and Obstetricians (CNGOF) recommends the use of intrauterine tamponade balloon (IUTB) in postpartum haemorrhage for bleeding that is refractory after sulprostone before either surgery or interventional radiology. However, the elapsed time between uterotonic drug injection and the insertion of intrauterine tamponade balloon was not reliably assessed. Objective: To evaluate the role of the timing of IUTB insertion and to assess the correlation between the time of insertion and outcome. Methods: A retrospective study in two tertiary care centres, including patients transferred for severe PPH management. Results: A total of 81 patients were included: 52 patients with IUTB inserted before 15 min (group 1) and 29 patients with IUTB inserted after 15 min (group 2). The mean volume of blood loss in the group of patients with IUTB inserted before 15 min was significantly lower than in group of patients with IUTB set after 15 min. Conclusion: An IUTB could be inserted simultaneously with a uterotonic agent, within 15 min and not after 15 min as suggested by local guidelines, but further prospective studies are required to confirm this