SIR 2009: Embolization Technique Effectively Treats Hemorrhaging After Cesarean Delivery

Kristina Rebelo

March 12, 2009

March 12, 2009 (San Diego, California) — Life-threatening bleeding episodes after cesarean delivery or after surgery for women with a condition known as invasive placenta can now be treated with minimally invasive embolization, according to a retrospective review presented here at the Society of Interventional Radiology 34th Annual Scientific Meeting.

Massive bleeding due to invasive placenta, often involving placenta accrete, placenta increta, and placenta percreta, is characterized by invasion of placental villi into the underlying muscular tissue of the uterus; pseudoaneurysms can occur up to several weeks postpartum, owing to uterine anatomy problems, retained birth products, placental abnormality, or a frank laceration, according to research. Formerly, women were treated with blood transfusions and emergency hysterectomy, and hemorrhaging was associated with high maternal morbidity and high mortality risk.

Far Too Many Hysterectomies

Dr. Michael Stecker

"There are far too many hysterectomies — no woman should be operated on for profuse postop bleeding," study coauthor Michael S. Stecker, MD, interventional radiologist at Brigham and Women's Hospital, in Boston, Massachusetts, said during a news conference. "Embolization preserves the uterus and allows future child-bearing and quick recoveries."

The retrospective review was based on 13 women, aged 28 to 44 years (mean, 35.3 years), who underwent endovascular treatment during a 21-month period for vascular complications after cesarean delivery at Brigham and Women's Hospital.

Bleeding severity ranged from mild (<500 cc) to severe (>3000 cc). Pre-embolization transfusion ranged from 0 to 6 units.

"Five subjects had positive angiographic findings, including 2 pseudoaneurysms and 3 active arterial extravasations; in the remaining 8 subjects, no arterial bleed was found and prophylactic uterine artery embolization was performed to control presumed venous bleeding or vasospasm masking arterial bleeding," according to the study abstract.

Researchers analyzed trends in treatment outcomes. They documented that some bleeds occurred immediately after surgery; however, the majority (9 of the 13 patients; 69%) presented within 24 hours.

The methods used to stop the bleeding were 1 hypogastric artery balloon occlusion, 2 coil embolizations, and 10 gelfoam embolizations. Gelfoam is an occluding agent that can be applied through catheters.

"All women in our study did well, with no recurrence of the bleeding or hemorrhaging," said Dr. Stecker. "The length of stay after embolization was usually 1 or 2 days. We save lives and uteruses — that's a big deal. What do you compare that to?"

The Goal: No Hysterectomies

Robert Vogelzang, MD, interventional radiologist and professor of radiology at Northwestern University, in Chicago, Illinois, and moderator of the session where the data were presented, said the difference in treatment was dramatic. "This is a huge difference; the goal here is to have no hysterectomies, and no one in this study had one," he said.

"Women who suffer nasty surgical complications are having their reproductive life ended unnecessarily," Dr. Vogelzang told Medscape Radiology. "To my way of thinking, the obstetric community has been beyond the curve on this, and there are way, way too many hospitals in the United States, [where] if someone is bleeding, the uterus comes out. This embolization is not mainstream enough, considering the technique has been around for more than 20 years."

He added that "the obstetric community is an insular specialty; they are very slow to grab on to 'new' procedures."

Dr. Stecker and Dr. Vogelzang have disclosed no relevant financial relationships.

Society of Interventional Radiology (SIR) 34th Annual Scientific Meeting: Abstract 173. Presented March 10, 2009.

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