Effectiveness of endovascular procedures in severe life threatening post partum hemorrhage in preventing peripartum hysterectomy

Monday, March 6, 2023

12:00 PM – 1:00 PM

Location: Phoenix Convention Center, North Ballroom 120 D

Poster Presenter(s)

Amir Ata Rahnemai-Azar, MD

Independent IR resident
Washington University in Saint Louis

Disclosure(s): No financial relationships to disclose

Author/Co-author(s)

AL

Aynaz Lotfinaghsh, MD

Research fellow
Washington University School of Medicine
FG

Francisco Gortes, MD

IR resident
Mallinckrodt Institute of Radiology, Washington University School of Medicine
AN

Adam Nygard, MD

Independent IR resident
Mallinckrodt Institute of Radiology, Washington University School of Medicine
Naganathan Mani, MD (he/him/his)

Associate Professor
Mallinckrodt Institute of Radiology, Washington University School of Medicine

Disclosure(s):

Amir Ata Rahnemai-Azar, MD: No financial relationships to disclose

Naganathan Mani, MD: No financial relationships to disclose

Purpose: To determine efficacy of interventional radiology procedures in management of patients with severe peri-partum hemorrhage (PPH).

Materials and Methods: Consecutive patients that underwent endovascular procedures for management of severe PPH in a tertiary care hospital between January 2015 to June 2022 were included. Multiple variables, including patients’ demographics, peri-partum related history, as well as factors related to endovascular procedures were reviewed. Outcome and potential complications from the procedure were also recorded.

Results: A total of 26 patients (mean age 27.4 ± 5.9 years) underwent endovascular procedures for management of PPH in the study period.

Endovascular embolization was performed in 23 patients in the setting of Cesarean section (n=11, 47%) or vaginal delivery (n=12, 53%). Only in 17% (n=4) cross sectional imaging was available to review before the procedure. In 61% (n=14), procedural sedation/anesthesia was provided by anesthesiologist and in 39% (n=9) conscious sedation (average length: 101 ± 29 minutes) was administered by interventional radiologist. In all patients except one (radial access), a femoral artery access was used. In 91% (21/23) of patients that underwent trans-catheter embolization, a microcatheter was used. In majority (70%, 16/23) of patients that underwent trans-catheter embolization, no identifiable source of bleeding was seen except for routine hyperdense uterine parenchymal blush, and prophylactic embolization was performed utilizing gelfoam slurry with or without tris acryl gelatin microspheres (300-500um and 500-700um, n=6). In 30% (7/23), an identifiable source was seen (3 uterine artery active bleeding, 2 uterine artery PSA, 2 internal pudenda artery active bleeding) and combination of gelfoam with or without coil (n=4) and glue (n=2) was used. Technical success was achieved in 91% (21/23) of these patients, except two. One of these patients underwent subsequent hysterectomy and one responded to conservative management.

Conclusion: Endovascular embolization was efficacious in preventing hysterectomy in patients with PPH. In patients without an identifiable bleeding source, prophylactic embolization of bilateral uterine arteries with nonpermanent material (e.g. gelfoam) could help to readily control the critical condition. Future large size trials could help to determine the effect of permanent embolic material (e.g. microspheres and coils) on long term outcome factors such as fertility or premature menopause.