|Year : 2021 | Volume
| Issue : 1 | Page : 11-16
Prophylactic interventional radiological procedures in postpartum hemorrhage: The present scenario
Savita Choudhary, Sunanda Gupta
Department of Anaesthesiology and Critical Care, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
|Date of Submission||10-Jun-2020|
|Date of Decision||05-Jul-2020|
|Date of Acceptance||17-Aug-2020|
|Date of Web Publication||22-Feb-2021|
Dr. Savita Choudhary
Department of Anaesthesiology and Critical Care, Geetanjali Medical College and Hospital, Udaipur - 313 002, Rajasthan
Source of Support: None, Conflict of Interest: None
Postpartum hemorrhage (PPH) is the leading cause of preventable maternal mortality and morbidity. Women undergoing cesarean delivery are at increased risk of PPH as compared to vaginal delivery. Improvement in obstetric care and advances in diagnostic modalities have empowered obstetricians to detect, predict, and therefore prevent catastrophic uterine bleeding. Patients at increased risk for PPH should be referred to tertiary care centers equipped with interventional radiology suite, where multidisciplinary teams are available 24 h and are prepared to deal with potential complications. This review highlights the management of PPH with special emphasis on interventional radiology procedures for the prevention of PPH. Minimally invasive interventional radiological techniques such as selective arterial embolization and arterial balloon occlusion have been effectively used to avert hysterectomy and reduce the overall incidence of blood transfusion and its associated complications while preserving reproductive functions.
Keywords: Interventional radiology, postpartum hemorrhage, prophylactic
|How to cite this article:|
Choudhary S, Gupta S. Prophylactic interventional radiological procedures in postpartum hemorrhage: The present scenario. Indian Anaesth Forum 2021;22:11-6
|How to cite this URL:|
Choudhary S, Gupta S. Prophylactic interventional radiological procedures in postpartum hemorrhage: The present scenario. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:11-6. Available from: http://www.theiaforum.org/text.asp?2021/22/1/11/309838
| Introduction|| |
Postpartum hemorrhage (PPH), a potentially preventable cause of maternal mortality and morbidity, is still a matter of concern despite significant (43.9%) worldwide decline in maternal mortality rates between 1990 and 2015. PPH accounted for 27.1% of maternal deaths. The highly vascular gravid uterus, along with increased adherence of chorionic villi to the myometrium in abnormal placental implantation or placenta accreta spectrum and placenta praevia, carries significant life-threatening risk for major blood loss during delivery and is associated with high maternal and neonatal morbidity and mortality. The incidence of placenta accreta spectrum and placenta praevia shows a rising trend following increasing rates of cesarean deliveries, increased maternal age, and use of assisted reproductive technology. The incidence of complications is increased when the abnormal placentae are diagnosed at the time of delivery, and hence, it is imperative to screen and diagnose these cases during the antenatal visit.,,
The American College of Obstetricians and Gynecologists' committee opinion recommendations (2012, 2014) have stressed on a multi-disciplinary team approach with obstetrician, anesthesiologist, maternal-foetal specialist, urologist, neonatologist, blood bank personnel, and interventional radiologist. This team approach has been shown to improve outcomes, decrease morbidity, and preserve fertility in these cases. Prophylactic radiological interventions such as arterial balloon occlusion and selective arterial embolization performed immediately before the removal of placentae have been found to be therapeutic.,
| Diagnosis of High-Risk Patients|| |
Prediction of major hemorrhage during antenatal visits can be accomplished usually by antenatal ultrasound examination and magnetic resonance imaging (MRI) in suspected cases. Women undergoing repeat cesarean section (CS) are 2.13 times more likely to develop placenta accrete spectrum (PAS) disorders. Other uterine pathologies reported to be associated with PAS disorders are surgical termination of pregnancy, dilatation, and curettage, myomectomy, endometrial resection, in vitro fertilization procedures, previous uterine artery embolization (UAE), chemotherapy and radiation, endometritis, manual removal of placenta, previous accreta, bicornuate uterus, fibroid, and adenomyosis. The most important risk factors reported in cases of PAS disorder are placenta praevia and previous CS. Patients with a history of previous CS, diagnosed with placenta praevia, should be specifically screened for PAS with diagnostic modalities such as ultrasonography (USG) and MRI.,
| Indications for Using Interventional Radiology in Postpartum Hemorrhage|| |
- PAS-placenta accreta, placenta increta, placenta percreta
- Placenta praevia
- Genital tract trauma
- Uterine atony
- Retained placenta
- Postoperative bleeding.
| Management Strategies|| |
Active management of third stage of labour is significantly the most important intervention to reduce the incidence of PPH. In majority of cases primary PPH can be managed with conservative treatment by administration of prophylactic uterotonic drugs such as syntocinon (synthetic oxytocin), carbetocin (longer-acting oxytocin derivative), methyl ergometrine (an alkaloid), carboprost (prostaglandin), misoprostol (synthetic prostaglandin E1analogue) uterine packing, bimanual compression, invasive treatment such as balloon tamponade with Sengestaken Blakemore catheter and uterine compression sutures.,, Recently, the preemptive use of Tranexamic acid has been advocated by various guidelines.,, In cases of persistent and major bleeding, arterial ligation (bilateral uterine artery or internal iliac artery), temporary bilateral vascular occlusion by intraarterial balloon, UAE or hysterectomy has been advocated. Prevention and treatment of anemia during the antenatal period are recommended in women having a high risk of postpartum bleeding to reduce associated morbidity.
| Interventional Radiological Procedures|| |
These procedures are planned in patients who have been previously diagnosed with PAS or placenta praevia by antenatal USG and MRI. These procedures can be performed under local anesthesia, under strict monitoring by the anesthesiologist. Different prophylactic approaches such as prophylactic sheath/catheter placement and transcatheter arterial embolization after delivery of the baby if needed and balloon occlusion with or without embolization postdelivery have been found useful. Advantages include the decreased duration of surgery, the overall decrease in blood loss, preservation of uterus, and a bloodless surgical field with less radiation exposure.,
Prophylactic artery balloon occlusion
The goal of intravascular balloon occlusion is to reduce postpartum blood flow to the uterus with a decrease in the severity of PPH. The most commonly used blood vessels are the internal iliac artery, anterior division of the internal iliac artery, and the uterine artery. Other uncommonly utilized sites are common iliac artery and even the infra-renal common abdominal aorta in the management of life-threatening PPH.
The procedure is performed before elective cesarean delivery in the interventional radiological suite or in a hybrid operating room, which is well equipped for cesarean delivery (which avoids problems associated with transportation of these patients) as well as for interventional radiological procedures. Prophylactic use of temporary internal iliac occlusion balloon catheter can be potentially used for emergent perioperative arterial embolization if bleeding is not controlled by only balloon inflation.,
Under ultrasound guidance, bilateral femoral arteries are accessed, followed by pulsed fluoroscopy with last image hold to guide sheath into the common trunk of internal iliac arteries and catheter into the ipsilateral internal iliac arteries. Each balloon is then inflated with approximately 1 ml of contrast and saline mixture till it conforms to the wall of arteries and volume is noted before deflation. The inflation of occlusion balloon catheter with previously recorded volume is done, timed immediately after delivery of baby to reduce uterine blood flow. The balloon inflation time (range 50–100 min) varies based on whether uterine sparing efforts are attempted, or decision of obstetric hysterectomy is made, and also on the degree of invasion by chorionic villi into adjacent pelvic structures.
Frequently reported complications are at puncture sites such as hematoma, pseudoaneurysm, femoral artery dissection, and fetal bradycardia. Rare complications reported with the procedure are acute limb ischemia, sciatic nerve ischemia, embolism to lower limbs, and distal reperfusion injuries. In view of these complications, fetal monitoring and; monitoring of distal pulsation is required until sheath removal.,,
Selective artery embolization
Selective artery embolization is considered a safe and effective primary modality in predicted PPH. Bilateral UAE should be done to prevent further risk of bleeding from collateral branches, and in cases where the uterine artery could not be accessed or the patient is hemodynamically unstable, then anterior divisions of bilateral internal iliac arteries should be embolized., Ease of bleed detection, faster control of bleed, ability to assess results, and a repeatable procedure in the same or other collateral vessels with lesser incidence of rebleeding; are some of the advantages associated with this method. This procedure can also be used when hysterectomy is planned after a few weeks of cesarean delivery in cases of placenta percreta to minimize bleeding during this period. Before attempting surgical arterial ligation, embolization should be done in many situations as ligation may hamper the radiological technique. Higher success rates of embolization 70%–90% with good clinical outcomes have been reported.,,, Disseminated intravascular coagulopathy has been reported to be a statistically significant predictive factor of failure to achieve hemostasis.,
The ultrasound-guided arterial access is achieved by the right femoral approach, under digital subtraction angiography/fluoroscopy guidance. A catheter over the wire is introduced into each internal iliac artery, which reveals the anatomy of uterine arteries with the identification of the active site of bleed. The prophylactic placement of the catheter is done before starting the surgery in suspected high-risk patients for major bleeding based on ultrasound findings. Preventive UAE is performed in the time period between fetal delivery and placenta removal, as embolization before delivery can decrease uterine blood flow and compromise fetal well-being. Time for embolization is a variable factor; depending on the experience of interventional radiologist team, anatomical variations, and site or number of bleeding vessels.
The material commonly used for embolization is an inexpensive absorbable gelatin sponge piece that achieves faster delivery at the site with rapid embolization, and it is usually reabsorbed in 10 days. Another material used for embolization is N-butyl cyanoacrylate, which is preferred in patients with active bleeding, hemodynamicaly unstable patients and in cases of failed/repeat embolization with gelatin sponge.,,
Complications reported with this intervention are fever, vessel perforation, abscess, transient buttock ischemia, lower extremities ischemia, rectal wall, and uterine necrosis.,,
| What Does the Literature Say?|| |
Prophylactic intraoperative UAE has been found to relatively safe and effective for reducing PPH among patients with placenta accrete, but in patients with placenta increta or percreta potential benefits could be lower. Thus, women with placenta increta or percreta were found to have more chances of requiring postpartum hysterectomy as compared to placenta accrete. Success rates aimed at preserving the uterus range from 70% to 97%,,,, whereas other authors have failed to show this benefit.,,, A beneficial reduction in the total blood transfusions required was observed in the interventional radiology (IR) group,,, ranging from 0 to 8U versus 2–13U in non-IR group, while other authors have not found any such benefits.,, Similarly, Izbizky et al., in their retrospective study on 95 patients, have also found a clinical success rate of 86% in averting hysterectomy, though 14% of patients received large-volume blood transfusions.
Some studies have been able to show that IR may decrease blood loss without much affecting hysterectomy incidences.,, Picel et al. found a median blood loss of 2 L (range, 1.5–2.5 L) in the balloon placement group versus 2.5 L (range, 2–4 L) in the control group (P = 0.002). Patients in the IR group were transfused a median of 2 U (range, 0–5 U) of packed red blood cells versus 5 U (range, 2–8 U) in patients in the non-IR group (P = 0.002). In the balloon placement group, 34% had large volume blood loss >2500 mL versus 61% in the control group (P = 0.001), and 21% required blood transfusion >6 U versus 44% in the control group (P = 0.002). Eight complications (9%) were attributed to occlusion balloon placement.
Yu et al. found no significant differences between the occlusion and the control groups regarding the median intraoperative blood loss (1451 [1024–2388] mL vs. 1454 [888–2300] mL; P = 0.945), the median length of surgery (49 [30–62] min vs. 37 [30–51] min; P = 0.204), or the need for blood transfusion during operation (57.9% vs. 50.0%; P = 0.621). They did not encounter any complications related to procedures.
Feng et al. and Dai et al. demonstrated that prophylactic balloon occlusion of the internal iliac arteries was associated with a shortened postoperative hospital stay (P = 0.033) and (P = 0.029), respectively; while Mei et al. failed to show this benefit.
Shahin and Pang in a meta-analysis of 69 studies (1811 patients) observed that IR group was associated with less blood loss than no endovascular intervention (P < 0.001) and among them the lowest blood loss was in a subset, who were subjected to PBOAA (P < 0.001). It was associated with a lower rate of hysterectomy (P = 0.030) and lower blood loss (P < 0.001) than other modalities. The endovascular intervention did not result in an increased duration of hospital stay or operative time and proved to be effective in controlling hemorrhage in abnormal placentation deliveries.
Thus, varying success rates could be attributed to a variable degree of placental invasion, variation in the targeted vessel, and the technique utilized for IR procedures among the studies reviewed in the literature.
Heterogeneous case reporting makes it difficult to identify the incidence of complications directly attributable to IR techniques. Embolization related maternal complications have been reported by some authors, which include: transient paresthesia and decreased temperature of the lower limb, uterine necrosis, peritonitis, and endometritis. Maternal complications attributed to catheter placement have also been noted by some authors, like lower extremity arterial thrombosis, hematoma-related pain in the right leg., Fetal bradycardia necessitating emergency CS has also been reported.,
Interventional radiological procedures such as arterial occlusion and embolization are thus, used as uterine preservation techniques in major obstetric hemorrhage thus avoiding major surgery/obstetric hysterectomy and its complications such as massive blood transfusion, coagulopathy, urinary tract injury and hemodynamic instability along with early recovery and shorter hospital stay.
Meta-analysis and observational studies have been conducted to evaluate the efficacy and impact of prophylactic interventional radiological procedures in suspected high-risk patients for PPH, to compare blood loss, incidence of hysterectomy, fetal, and maternal outcomes. Other studies have also focused on the length of stay and radiation exposure. Most of these studies have reported high success rates in uterine preservation, total blood loss, and volume of blood transfusion [Table 1].
| Anaesthetic Consideration|| |
A contingency plan for the management of PAS spectrum disorders, including 24 h interdisciplinary team, adequate blood bank support in a tertiary care center should be ensured. Pregnant women should be properly counseled, and their apprehensions regarding exposure to radiology should be adequately allayed. Limiting fluoroscopy time, using lead shields to cover the abdomen and ultrasound guidance during procedures are some measures which can protect the women and her baby. Adequate measures should be in place to safely transport patients between IR suite, ward and operation theatres to avoid the risk of sheath displacement with subsequent hemorrhage and supine hypotension. If there is a previous history of allergy, asthma, bronchospasm, hypotension, extra precautions need to be taken as such procedures are relatively contraindicated.,
The choice of anesthesia is epidural/combined spinal epidural or local anesthesia. The epidural catheter can be placed before the occlusion catheter or arterial sheath insertion to avoid displacement of the arterial sheath and also to avoid complications following anticoagulants. Interventional procedures can also be done under local anesthesia in cooperative patients, followed by general anesthesia for cesarean delivery., A significant conversion rate from neuraxial to general anesthesia has also been reported.,,
| Conclusion|| |
Early diagnosis and timely radiological intervention along with multidisciplinary approach may play a significant role in decreasing the incidence of hysterectomy, hemorrhage, and related morbidities, especially women who desire to preserve fertility. The value of prophylactic placement of balloon catheter or embolization in PPH is still not universally accepted, mainly owing to the emergent situations with economic considerations, risk of complications, in addition to limited access to IR and scarcity of well-trained personnel. IR may be considered as a useful adjunct therapy in carefully selected patients with clear indication and strict vigilance for complications; to ensure the best possible outcomes. These IR techniques and hybrid operative suites along with strategic institutional protocols should be available to deal with catastrophic obstetric haemorrhage.
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Conflicts of interest
There are no conflicts of interest.
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