ARTERIAL EMBOLIZATION

POST-PARTUM HEMORRHAGE

Introduction

Last updated: apr 5, 2023

Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation

 

Presentation

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Internal Iliac Artery
Internal Iliac Artery
Internal Iliac Artery
 

Anatomy

Beware

  • The cervicovaginal branch arises from the transverse segment of the UA and supplies blood to cervix and vagina
  • A persistent sciatic artery, which can cause ischemic damage of the lower limb

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Primary

Secondary

  • Atony (most common, 70–80%)
  • Genital tract laceration
  • Retained placenta
  • Coagulopathy
  • Uterine rupture

  • Retained placenta (most common)
  • UA injury
  • Uterine AVM
  • Uterine sub involution
  • Coagulopathy
  • Genital tract laceration

Higher incidence of UA pseudoaneurysm and contrast extravasation in secondary PPH

 

Indications

  • Blood loss > 500 mL within 24 hours after vaginal delivery
  • Blood loss > 1000 mL after cesarean delivery
  • Blood loss accompanied by hypovolemia within 24 hours after birth
  • Hemorrhage from 24 hours after birth to 12 weeks

 

Pre procedural

  • In secondary PPH a CTA is indicated
  • ICU bed

 

Materials

Essentials

  • Stiff Terumo
  • 7F sheaths
  • RIM catheter
  • Python balloons
  • 0.018" catheters (Progreat)
  • 0.018" coils

Non-Essentials

 

Positioning the patient

  • Supine

 

The procedure in steps

Pre-procedureel

  • TOP
  • Patient supine
  • Clean with chloorhexidine
  • Sterile covers
Toegang
  • Infiltrate with Lidocaine and Bupivacaine
  • Ultrasound guided puncture of both AFC's.
  • Placement of 25 cm long 7F sheaths
Occlusie van de AII bdz.
  • Up-and-over with RIM catheter
  • Selective catheterisation of the IIA's
  • Python balloon placement proximal in the IIA
  • Inflation on both sides
  • Check the occlusion with an injection through the sheath
  • Write down the volume in de balloon
  • Clinical evaluation
  • If hemodynamically stable leave the ballons inflated
  • Fixate with sutures and tape

  • In case of persistant hemodynamical instability search for other cause(s)
Afronden.
  • Transport to ICU
  • SOP

Other causes

  • Ovarian
  • Round ligament
  • Obturator
  • External pudendal from femoral
  • Deep circumflex
  • Superior rectal
  • Median sacral
  • Iliolumbar

 

Tips and tricks

  • Aortography is needed to identify other potential bleeders, such as ovarian arteries, in patients with persistent or recurrent bleeding after embolization of bilateral UAs and IIAs.

 

Complications

  • The rebleeding rate after TAE has been reported to range from 5.2% to 13.5%, despite its technical success

 

Post-op

  • Intensive care
  • Balloon deflation after 12-24 hours

 

Report

 

Literature

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