What is the role of angiographic embolization in the treatment of postpartum hemorrhage (PPH)?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Answer

Angiographic embolization in the management of PPH was first described more than 30 years ago. [68] As with all of the surgical and most of the medical treatments of PPH, no RCTs regarding its effectiveness have been conducted. This is likely to remain the case for some time given the relative rarity of intractable PPH. Several case series suggest that selective arterial embolization may be useful in situations in which preservation of fertility is desired, when surgical options have been exhausted, and in managing hematomas. [69] Follow-up of women undergoing successful embolization for severe intractable PPH reports that women almost invariably have a return to normal menses and fertility. [70]

The major drawbacks of the procedure are the requirement for 24-hour availability of radiological expertise and the time required to complete the procedure. Patients must be stable to be candidates for this procedure. Complications include local hematoma formation at the insertion site; infection; ischemic phenomena, including uterine necrosis in rare instances; and contrast-related adverse effects. Currently, most PPH cases requiring hysterectomy are related to placenta previa. These patients are commonly diagnosed before delivery and are usually delivered by elective cesarean birth. This planning may allow increased use of invasive radiological services in the management of such cases.

A retrospective study by Park et al indicated that transcatheter arterial embolization (TAE) is safe and effective for secondary PPH. In the study, the procedure was clinically successful in 47 of 52 patients (90.4%) being treated for secondary PPH (caused in 23 cases by retained placenta). Gelatin sponge particles were used in 48 patients, either alone or in combination with permanent embolic materials (eg, microcoils, N-butyl cyanoacrylate); embolization was performed with permanent materials alone in the remaining four patients. Regular menstruation returned in the 44 patients who were followed up (for a mean 12.6-month period), and five patients were known to become pregnant. [71]


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