The role of interventional radiology

Sylvain Terraz

Postpartum haemorrhage

1

Swiss Association of Obstetric Anaesthesia November 7, 2013

© University Hospitals of

Geneva

Postpartum haemorrhage (PPH)

2

1st uterine embolisation in 1979

severe PPH ≈ severe pelvic trauma

- haemodynamic instability

- arterial anatomy

rationale

- minimally invasive procedure

- stop / decrease of haemorrhage

- preservation of the uterus Brow BJ, Obstet Gynecol, 1979

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Geneva

3

Materials & methods

femoral access catheters embolic agents

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Geneva

Materials & methods

4

angiography room interventional

radiology © University Hospitals of

Geneva

Patient transfer

5 © University Hospitals of

Geneva

Postpartum haemorrhage (PPH)

6

primary PPH (early)

- < 24 hours

secondary PPH (late)

- > 24 hours

- < 6 weeks

major risk of PPH

- elective caesarean section

- multidisciplinary management

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Geneva

Primary PPH

7

Tone uterine atony (70-80%)

(distention, precipitous / prolonged labour, multiparity,

etc)

Trauma genital tract

(episiotomy, cervix / vagina laceration, arterial lesion, etc)

Tissue placenta

(retention, abnormal implantation, etc)

Thrombin coagulopathies

(DIVC, Von Willebrand, HELLP, etc)

Bischofberger A, Rev Med Suisse, 2011

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Geneva

Case n°1 UTERINE ATONY

8

Mrs JKA, 31-year-old

- G1, P1, 40 WA

elective caesarean section (Anemasse)

- treatment ?

transfer to the HUG

- HR = 110/min; BP = 80/60 mmHg; Hb = 54 g/l

- DIVC: 16x RBC, 3x platelets, 13x FFP; 5 mg Novoseven®

© University Hospitals of

Geneva

9

Aortography

1 s 3 s 7 s

uterine

arterie

s

extravasation

(21%-52%)

collateral

s

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Geneva

10

Left uterine artery

PA view RAO 30° selective

catheter

(Cobra

5F)

extravasatio

n

© University Hospitals of

Geneva

11

Embolisation

Gelfoam® stasis control

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Geneva

12

Right uterine artery

PA view LAO 30° selective

catheter

(Simmons II

5F)

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Geneva

Angiography & clinical control

13

before after

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Geneva

Case n°2 VAGINAL LACERATION

14

Mrs MS, 40-year-old

- G3, P2, 39 WA

- foetal macrosomia

vaginal delivery (ventouse, forceps)

- vulval haematoma, perineal tear (grade 3)

- 3-level inspection ⊖

moderate haemorrhagic shock

- HR = 130/min; BP = 100/65 mmHg; Hb = 70 g/l

- DIVC: PT = 10%, PTT = 200 s, fibrinogen 0.3 g/l

© University Hospitals of

Geneva

15

Vaginal laceration

left internal iliac

artery

left cervicovaginal

artery control

microcoil

(2 mm)

extravasatio

n

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Geneva

Technically difficult situations

16

arterial vasospasm (2-20%)

vasodilators: nitroglycerin, nimodipine, lidocaine

microcatheters

presence of arterial collaterals

knowledge of the anatomy

sequential embolisation

previous arterial ligation / hysterectomy

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Geneva

17

Arterial vasospasm

proximal distal microcatheter 2F

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Geneva

18

Pelvic arterial collaterals

ovarian artery

round ligament artery

internal iliac artery

inferior epigastric artery

medial/lateral circumflex

artery

lumbar artery

median sacral artery

inferior mesenteric artery

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Geneva

19

Case n°3 OVARIAN COLLATERALS

Mrs GA, 30-year-old

- G1, P1, 40 WA

vaginal delivery + ventouse

- piston ⊖, partial delivery

- intractable uterine atony

haemorrhagic shock

- 15x RBC, 2x platelets, 6x FFP

- bilateral uterine embolisation

uterine

embolisation

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Geneva

Ovarian collaterals

20

aortography uterine embolisation

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Geneva

21

Ovarian collaterals

right ovarian artery left ovarian artery ovarian embolisation

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Geneva

Secondary PPH

22

causes

- retained placenta ± endometritis

- uterine / cervical / vaginal lesion

- pseudo-aneurysm, AV fistula

imaging work-up

- US-Doppler, CT, MRI

haemorrhage < primary PPH

treatment ≠ primary PPH

© University Hospitals of

Geneva

23

Case n°4 PSEUDO-ANEURYSM

Mrs RK, 34-year-old

- G1, P1, 41 WA

vaginal delivery

retained placenta

- D10: curettage

- D25: hysteroscopic resection

- D33: persistent metrorrhagia CT angiography (arterial

phase) © University Hospitals of

Geneva

24

Pseudo-aneurysm

right uterine artery control s/p embolisation

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Geneva

abnormal placenta

- accreta/increta/percreta

temporary balloon occlusion

- ↘ pelvic perfusion

± uterine embolisation

- if persistent PPH

25

Major risk of PPH

placenta increta

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Geneva

Bilateral balloon occlusion

26

diameter = 5 / 6 / 7 mm

length = 20 / 40 mm

balloon pressure = 2 bars

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Geneva

Hybrid OR-IR

27

courtesy to Dr Georges Savoldelli

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Geneva

“Prophylactic” arterial occlusion

28

controversial procedure: mixed results

multidisciplinary approach (7 cases in HUG)

- patient selection

- hybrid OR-IR

- perioperative communication

uterine embolisation > balloon occlusion ? Dilauro MD, Clin Radiol, 2012

© University Hospitals of

Geneva

29

Results of uterine embolisation

technical success: 79-100%

clinical success = bleeding

stop without subsequent

surgical treatment: 65-97%

Gonsalves MD, Cardiovasc Intervent Radiol, 2010

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Geneva

Failure of uterine embolisation

30

technical limitations (vasospasm, collaterals, ligations, etc)

aetiology of PPH

- uterine atony: 0-20%

- abnormal placentation: 20-50%

- vaginal tear: 50-60%

mode of delivery

- vaginal: 0-30%

- caesarian: 20-60% Brace V, BJOG, 2007

Sentilhes L, Obstet Gynecol, 2009

© University Hospitals of

Geneva

Risk factors

31

Poujade O, Int J Gynaecol Obstet, 2012

© University Hospitals of

Geneva

Experience in HUG (2001-2013)

32

77 uterine

embolisations for

PPH

primary success

n = 71 (92%)

hysterectomies

n = 3 (4%)

failure

n = 6 (8%)

clinical success: 96% failure: 4%

secondary success

n = 3 (4%)

© University Hospitals of

Geneva

Cas n°5FAILURE OF EMBOLISATION

33

Mrs PA, 32-year-old

- G4, P2, 37 WA

- s/p uterine embolisation for PPH

elective caesarean for placenta praevia

- severe uterine atony + adherent placenta (accreta)

haemorrhagic shock

- 8x RBC, 1x platelets, 9x FFP; 7 g Haemocomplettan®

- 5 mg Novoseven®; 1200 UI Prothromplex®; 1 g Cyclokapron®

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Geneva

34

Failure of embolisation

right uterine artery cavernoma right internal pudendal

artery

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Geneva

Complications

35

global complication rate: 6-9%

- major complications: 1%

angiography

- haematoma, pseudo-aneurysm, dissection

- contrast media nephropathy / allergic reaction

post-embolisation syndrome

- abdominal pain, fever, nausea, leukocytosis

Gonsalves MD, Cardiovasc Intervent Radiol, 2010

Gangulis S, J Vasc Interv Radiol, 2011

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Geneva

36

Ischaemic complications

superior gluteal artery

- gluteal ischaemia

(numbness)

inferior gluteal artery

- sciatic nerve ischaemia

internal pudendal artery

- rectum / bladder necrosis

- fistula

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Geneva

Long-term follow-up (n=17-113)

37

menstrual menses

- oligomenorrhea: 0-21%

- amenorrhea: 0-11%

fertility ?

- desire for pregnancy: 55-100% pregnancy

subsequent pregnancy

- miscarriage, EP, IUGR, preterm birth: idem

- PPH recurrence: 6-100% Chauleur C, Hum Reprod, 2008

Malartic C, Gynecol Obstet Fertil, 2012

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Geneva

Recommendations

38

Society of Obstetricians

& Gynaecologists of

Canada

American Congress of

Obstetricians &

Gynecologists

Royal College of

Obstetricians &

Gynaecologists

Agence Nationale

d'Accréditation &

d'Evaluation en

Santé

Deutsche Gesellschaft

für Gynäkilogie &

Geurtshilfe

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Geneva

Recommendations

39 © University Hospitals of

Geneva

Recommendations

40

Bischofberger A, Rev Med Suisse, 2011

© University Hospitals of

Geneva

Conclusions

41

uterine embolisation

- stop PPH in the majority of cases

- low morbidity rate

multidisciplinary management

- experienced obstetrician: timing

- resuscitation: before/during/after

- trained interventional radiologist

© University Hospitals of

Geneva