Pelvic Arterial Embolization for the Control of Intractable Pelvic Hemorrhage: Retrospective Analysis of 13 Cases

Abstract

Background: Obstetric hemorrhage is one of the most important causes of maternal mortality. Severe postpartum hemorrhage is known to raise the mortality rate. There is a higher incidence of death from obstetric hemorrhage in developing countries as opposed to developed countries Objective: To emphasize the role of interventional radiology in the management of obstetric and gynaecological haemorrhage in under developed countries like Pakistan. Methods: The retrospective data of all patients requiring pelvic artery embolization for the control of pelvic hemorrhage was studied at Ziauddin University Hospital during the period from April 2011 to June 2014. Main outcome measure was the effectiveness to control hemorrhage. Technical success was defined as the cessation of bleeding on the post embolization angiogram and cessation of vaginal bleeding at speculum inspection performed immediately after PAE. Clinical success was said when the bleeding stopped completely after the first course of PAE and no additional PAE or surgery was required. Results: A total of 13 patients underwent pelvic artery embolization (PAE) during this period. Five patients had primary postpartum haemorrhage (PPH), in which 3 patients had PPH after caesarean sections, one due to uterine atony secondary to triplets delivery, second had placenta praevia and third had placenta accreta. Two patients had uterine rupture, one following the normal vaginal delivery & other had previous 2 caesarean sections, uterine scar ruptured at 28 weeks of gestation. Two patients had secondary PPH, one due to uterine artery pseudo aneurysms after caesarean section and other had normal vaginal delivery. Six patients underwent pelvic artery embolization due to gynaecological cause i.e. heavy menstrual bleeding & pain secondary to fibroids. One patient had total abdominal hysterectomy and bilateral salpingoopherectomy due to fibroids but she continued to have bleeding from vaginal vault .Laparotomy was done twice but she continued to bleed so finally underwent pelvic arterial embolization after which bleeding stopped. All patients underwent selecti ve embolization of the uterine artery or anterior divisional branch of the internal iliac artery with successful haemorrhage control and no immediate complications. PAE when done, in Gynae patients with fibroid resulted in severe abdominal pain immediately after the procedure for which analgesic medicines were given and the pain settled. These patients were followed in clinics and found to have significant decrease in their symptoms like 88% reduction in menorrhagia &100% improvement in pain in six months period after procedure. Imaging scans were also done to follow the size of fibroid that were found reduced 17 -63%. Conclusion: Selective pelvic embolization is a safe and effective treatment for acute obstetric or gynaecological haemorrhage and should be part of the management algorithm for PPH and for the treatment of symptomatic fibroids in females who especially want to conserve their uterus . Key Words: Uterine Artery Embolization, Postpartum Haemorrhage, Fibroid.