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ORIGINAL RESEARCH |
From the Department of Radiology, Interventional Radiology Section, Yale University School of Medicine, and Yale–New Haven Hospital, New Haven, Connecticut.
Address reprint requests to: Michael Tal, MD, Department of Vascular and Interventional Radiology, Yale University School of Medicine and Yale–New Haven Hospital, 20 York Street, Room 2-323, New Haven, CT 06520; E-mail: michael.tal{at}yale.edu.
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ABSTRACT |
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METHODS: Twenty-eight consecutive patients who underwent pelvic embolization for postpartum hemorrhage between the years 1977 and 2002 were included in the study. Chart review and telephone interviews were conducted to gather data regarding the type of delivery, causative factors of the bleeding, preembolization treatments, total blood loss, length of time between delivery and embolization, complications, long-term side effects, and subsequent pregnancies.
RESULTS: The average (± standard deviation) time to follow-up was 11.7 ± 6.9 years. The most common causes of hemorrhage were vaginal/cervical laceration, placenta accreta, and placenta previa. In only one case was the embolization unsuccessful, during which there was an accidental perforation of an internal iliac artery resulting in a retroperitoneal hematoma and subsequent total abdominal hysterectomy. All of the interviewed patients that desired to get pregnant after embolization were able to do so. Six patients reported a total of six uncomplicated pregnancies and deliveries in the years after their embolization. Of the remaining patients interviewed, none made subsequent attempts to get pregnant. The most commonly reported long-term side effects were transient buttock numbness (n = 2) and urinary frequency (n = 2). In no patients were the side effects severe enough to seek further medical attention.
CONCLUSION: Pelvic arterial embolization is a safe and effective procedure and offers patients a fertility-preserving alternative to hysterectomy for treatment of intractable postpartum hemorrhage.
Postpartum hemorrhage (PPH) is a potentially fatal obstetrical emergency that can occur up to 6 weeks after a vaginal or cesarean delivery.1 Despite recent advances in the treatment of PPH, it continues to be one of the top five causes of maternal deaths in the developed world.2 Nonfatal PPH can result in serious morbidity if the blood loss is considerable; hypovolemic shock, disseminated intravascular coagulation, renal failure, hepatic failure, and adult respiratory distress syndrome are common complications.3
Successful control of bleeding can often be achieved medically if uterine massage is ineffective. Uterotonics, including oxytocin, ergometrine, 15-methyl prostaglandin F2
, and misoprostol are now commonly used, and hemostatics such as tranexamic acid have also been shown to be effective.4 If conservative measures fail, however, it is often necessary to intervene surgically with uterine or internal iliac artery ligation, uterine compression sutures, or hysterectomy. Selective transcatheter embolization of the pelvic arteries was developed as an alternative to these more invasive procedures, and it has shown promise as a uterus-sparing technique. Although the safety and efficacy of embolotherapy have been reported,5–8 its long-term effects have not received equal attention. This study intends to build on and update the work of Greenwood et al,9 who tracked the progress of the first nine cases of gynecologic hemorrhage treated with embolization at this institution. The objective of this study, therefore, was to determine the long-term sequelae and outcomes of pelvic embolization for PPH, particularly its effect on fertility.
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MATERIALS AND METHODS |
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Patients were asked the following questions: 1) Have you had any pregnancies since the time of your pelvic embolization? If yes, were they term or preterm? Vaginal or cesarean delivery? 2) If no, were you attempting to get pregnant, or do you have a history of infertility? 3) Have you reached menopause yet? 4) If no, would you consider your menses to be regular? 5) Have you had any miscarriages or abortions? 6) Do you have a history of pelvic pain, bladder problems, or leg/buttock pain? 7) Have you had any surgeries or medical interventions since the time of your embolization?
Twenty patients were contacted directly by telephone. The obstetric histories of patients who could not be contacted directly were obtained from their medical record. Relevant patient data are summarized in Table 1
.
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In seven patients, coils were placed in addition to gelatin sponge pledgets. In those cases, nonspecific embolization of the internal iliac arteries was performed. The coils were placed in the superior gluteal arteries to protect the muscle bed from infarction and necrosis induced by extensive, nontargeted embolization. In some cases, distal collateral vessels resulted in persistent bleeding after embolization, surgical ligation, or hysterectomy. The technique used to embolize vessels after internal iliac artery ligation or hysterectomy is not very different from the standard procedure. The duration of the procedure is often longer, however, and more extensive embolization is usually needed to effectively embolize all collaterals.
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RESULTS |
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for a list of causative factors in each patient). A total of eight women had documented coagulopathies that were contributing factors: six developed disseminated intravascular coagulation associated with preeclampsia, and two had von Willebrand disease. Seven of the 28 PPH patients (patients 22–28 in Table 1) underwent a hysterectomy as a preembolization attempt to stop the bleeding, during which three had one or both internal iliac arteries ligated. Two women underwent a hysterectomy after the embolization was completed (patients 20 and 21). In one patient, a pathology report from a previous dilation and curettage revealed fragments of adipose tissue. The patient underwent an exploratory laparotomy for possible uterine perforation, and a total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. In the other case, the embolization was unsuccessful because of an accidental perforation of an internal iliac artery. This was the only unsuccessful embolization performed and the only complication due to a technical error.
Three additional complications occurred. In one case, a patient with von Willebrand disease was readmitted 16 days after her embolization for light rebleeding. This was treated successfully, however, with intravenous conjugated estrogens (Premarin, Wyeth-Ayerst Laboratories, Philadelphia, PA) and a 50-mg estrogen pill. She also developed a partially occluding thrombus in the right common femoral, which was later treated with surgical thrombectomy.
The two other ischemic complications occurred in patients who underwent internal iliac artery ligation before embolization. One of these patients required resection of a necrotic segment of small bowel 1 week after the embolization. It was thought that her operative procedures and prolonged shock-induced vasoconstriction of mesenteric vasculature resulted in the small bowel infarction. The other patient developed right buttock claudication as her activity level increased after discharge from the hospital. However, no long-term side effects were reported.
One death occurred 2 months after embolization as a result of complications of preexisting conditions (patient 16). This patient’s preembolization course was characterized by peripartum hypertension, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, acute fatty liver of pregnancy resulting in florid disseminated intravascular coagulation, renal insufficiency, and bleeding from her suture lines and vagina. Despite stabilization after embolization, she later developed adult respiratory distress syndrome with bilateral effusions and acute renal failure resulting from hypovolemia. She underwent two exploratory laparotomies, during which a pelvic hematoma and abdominal free blood were found. She developed sepsis and eventually died as a result of multisystem organ failure.
The average time to follow-up was 11.7 ± 6.9 years (SD; follow-up range, 8 months to 25 years). Twenty patients were contacted directly by telephone. Two patients who retained the possibility of fertility were completely lost to follow-up and had no subsequent obstetric history listed in their medical record. However, patient 18 was reported to have regular menses by Greenwood et al.9 Five patients (patients 17, 20, 23, 24, and 25) who underwent tubal ligation or hysterectomy before or after their embolization were unreachable by telephone, and their medical records were searched for subsequent long-term outcomes. The remaining patient was patient 16, discussed above, who died. The most common long-term side effects reported at follow-up were mild buttock numbness (n = 2) and urinary frequency (n = 2). In no patients were side effects severe enough to seek further medical attention. Two patients who underwent a preembolization hysterectomy reported incontinence.
All of the interviewed patients that desired to get pregnant after their embolization were able to do so. Six women reported a total of six uncomplicated full-term pregnancies and deliveries in the years after their embolization (patients 1–6). There were four vaginal deliveries and two cesarean sections. Two patients became pregnant unintentionally and underwent elective abortions to terminate the pregnancies. One patient (patient 2) who had additional children reported a total of two miscarriages. Of the remaining patients interviewed, none made subsequent attempts to get pregnant. Four women reported menses irregularities, though these irregularities are unlikely to be related to the embolization. One no longer menstruated after she received chemotherapy for breast cancer; one is menopausal now but reported regular menses9 in the study by Greenwood et al in 1978; one reported irregular menses before her embolization; and one reported irregular menses (without birth control) due to polycystic ovaries.
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DISCUSSION |
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Transcatheter embolization has been used successfully to control hemorrhage associated with tumors,15 vascular malformation,16,17 pelvic trauma,18 and abortion.19,20 Uterine artery embolization was first described as a treatment for PPH in 1979 by Brown et al21 and has been gaining in popularity ever since because of reports of high success rates relative to ligation and hysterectomy.5,7,9,22,23 According to the review by Badawy et al,24 the success rate of 138 cases of embolotherapy for PPH between 1979 and 1999 was 94.9%. There is a relatively low complication rate of 8.7%, with the most common complications being fever, foot ischemia, bladder and rectal wall necrosis, nerve injury, and late rebleeding.24–26 This interventional radiologic procedure represents an efficient solution if the PPH is thought to originate in the corpus of the uterus and the woman is hemodynamically stable.
A less well established advantage of embolotherapy for PPH is the preservation of fertility in treated women. Numerous pregnancies have been reported after embolization for uterine fibroids27,28 and uterine vascular malformations.29 Stancato-Pasik et al30 reported the long-term effects (follow-up range, 1–6 years) of selective embolotherapy on menses and subsequent pregnancy in 12 women treated for both antepartum and PPH. Normal menses resumed in all but one, and all three patients who desired a subsequent child were able to conceive and deliver full-term, healthy infants. Pelage et al6 evaluated 35 patients treated with uterine artery embolization for PPH, and normal menses resumed in all women but two, who underwent hysterectomy. One woman became pregnant during the 4-year follow-up period, but the outcome was not stated. Another study from the same group evaluated 14 women treated with embolization for secondary PPH, and again, normal menses resumed in all women.7
However, there have been reports suggesting problems associated with subsequent pregnancies in women treated with pelvic embolization for PPH. Cordonnier et al31 reported fetal growth retardation in a case in which a patient conceived 17 months after being embolized for PPH with gelatin sponge pledgets. At 33 weeks, the weight of the fetus was in the third percentile, and placental ischemic necrosis was noted on histological examination after emergency cesarean section. It has therefore been suggested that embolization-induced ischemia can result in later complications, even if the recommended gelatin sponge pledgets are used as the embolic material.
To our knowledge, the mean follow-up time of our study (11.7 ± 6.9 years) is the longest on record. Our results confirm the findings of previous studies–namely, that pelvic arterial embolization with gelatin sponge pledgets is safe, effective, and has no long-term negative effects on menstruation or fertility. In our study, all but four women who did not undergo hysterectomy resumed normal menstruation. As discussed above, these four cases of disrupted menses are unlikely to be the result of the embolization. In addition, all women who desired to become pregnant were able to do so. Six patients reported a total of six full-term, uncomplicated pregnancies and deliveries, and an additional two patients underwent elective abortions to terminate unwanted pregnancies. Although we did not specifically ask how long it took to get pregnant after embolization, none of the patients reported any difficulty or frustration, and one woman actually became pregnant 3 months after her procedure. Although patient 2 miscarried twice before her successful delivery, she was older than 35 at the time of her miscarriages, and she had a history of one spontaneous abortion and one ectopic pregnancy before her embolization. It could be argued that her problematic obstetric history predisposed her to subsequent miscarriages. It therefore appears that fertility was not adversely affected in these patients.
In conclusion, our results provide long-term evidence that pelvic arterial embolization is safe and effective. This procedure offers women a minimally invasive, fertility-preserving alternative to hysterectomy for treatment of intractable PPH, and it should be considered when more conservative measures to control hemorrhage fail.
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Footnotes |
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Received April 22, 2003. Received in revised form June 17, 2003. Accepted June 17, 2003.
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REFERENCES |
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