Radiology: Pelvic arterial embolization effective at controlling postpartum bleeding

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Pelvic arterial embolization (PAE) is a safe and effective treatment for primary postpartum hemorrhage (PPH), with high rates of technical and clinical success, according to a study published in the September issue of Radiology.

The technique also resulted in effective bleeding control in more than 86 percent of patients after an initial session, reported authors Ha Young Lee, MD, of Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, and colleagues.

“Our results suggest that PAE should be considered early in the management of PPH and that hemodynamic instability should not be considered a contraindication for PAE,” wrote the authors. “Repeat embolization should also be considered before performing hysterectomy because of its advantage in achieving hemostasis without sacrificing the reproductive ability of the patient.”

Lee and colleagues explained that obstetric hemorrhage is one of the most important causes of maternal mortality, and PPH is responsible for a quarter of maternal deaths worldwide. While traditionally treated conservatively with transfusion, uterine massage or administration of uterotonic agents, PAE conducted by an interventional radiologist is growing in acceptance for treating acute obstetric hemorrhages. It’s an attractive alternative, they note, because it’s a rapid repeatable procedure that can be performed with only local anesthesia, not general anesthesia, and it preserves the uterus.

PAE’s effects on future menstruation and fertility were less clear, however, so Lee and colleagues devised a retrospective single-center study of PAEs performed at their institution by an interventional radiologist in a conventional angiographic suite between January 2000 and February 2011. A total of 251 cases were analyzed, with clinical success defined as cessation of bleeding after initial session without the need for another session of PAE or surgery.

A total of 217 of the 251 cases were clinically successful, for a success rate of 86.5 percent, according to the authors. Of the 34 failed cases, 12 underwent repeat PAE and 16 underwent additional surgery. Overall bleeding control was improved to 98 percent of cases with repeat PAE or surgery. The remaining three patients who didn’t undergo additional PAE or surgery recovered with a conservative management strategy.

Technical success was achieved in 89.6 percent of cases. “Major complications that resulted in prolonged hospitalization did not occur, although eight patients experienced minor side effects such as transient numbness or edema of the lower extremities and asymptomatic vascular injuries,” wrote the authors.

Overall mortality was 2 percent after the first or second session of PAE or surgery, according to the results. Long-term follow-up information was available for 113 patients, and among this group, 97.3 percent maintained a regular menstrual cycle and 11 had successful pregnancies.

Mutivariate analysis showed that patients with disseminated intravascular coagulation and massive transfusion of more than 10 red blood cell units were more likely to experience failed PAE, and the authors noted these patients “should be carefully monitored during embolization because of the potential need for repeat embolization or additional surgery.”