anterior division of the internal iliac artery versus the superselective embolisation of the uterine artery for PPH. All patients in our series had severe PPH.3 This ...
Correspondence
Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage
Author’s Reply Sir, We thank Dr Uchil1 for his response. The studies reporting on the use of arterial embolisation for the management of major postpartum haemorrhage (PPH) have generally a poor methodological quality. The number of cases reported is low, very often lower than in our series, leaving room for reporting bias.2 Dr Uchil1 raises the issue of selective embolisation of the anterior division of the internal iliac artery versus the superselective embolisation of the uterine artery for PPH. All patients in our series had severe PPH.3 This resulted in a situation where the embolisation procedure had to be performed within a limited time frame on patients who were haemodynamically challenged. Further, the procedure was often performed in an (non-angiographic suite) operating room under suboptimal circumstances. Our first goal was always to selectively place the catheter in the left and right uterine artery. As many interventional radiologists who perform elective uterine artery embolisations for fibroids will acknowledge, superselective placement of a catheter in the uterine artery can be troublesome and timeconsuming because of the often acute angle of the vessel at the origin of the uterine artery or vessel spasm.4 We agree that superselective embolisation is preferable in order to minimize the risk of collateral damage. However, because of the circumstances, the anterior division of the internal iliac artery was embolised in most cases. A recent review confirms that this is common practice in the majority of reported studies.2 The last issue raised by Dr Uchill1 concerned the accidental arterial embolisation that has never been noted. This may be true. However, accidental arterial embolisation does occur, either with bronchial artery embolisation resulting in stroke,5 or with renal artery embolisation resulting in ischaemic legs and feet, as well as with uterine artery embolisation.2 However, spill in the pelvic vessels is often asymptomatic and probably therefore not noted. If noted, it is often not reported because of positive publication bias.6 On the other hand, spill from the internal iliac artery to the external iliac artery in our case was not directly caused by the injection of the embolising agent, but was due to a very high velocity injection of contrast agent in the internal iliac artery at the final post-embolisation angiogram. j
References 1 Uchil D. Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. BJOG 2009;116:1275.
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2 Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv 2007;62:540–7. 3 Gu¨lmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2007;3:CD000494. 4 Pelage JP, Le Dref O, Mateo J, Soyer P, Jacob D, Kardache M, et al. Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 1998;208:359– 62. 5 FitzGerald DB, Suran EL, Sargent J. Posterior circulation infarct after bronchial artery embolization and coiling. Neurology 2005;65:1312. 6 Dwan K, Altman DG, Arnaiz JA, Bloom J, Chan AW, Cronin E, et al. Systematic review of the empirical evidence of study publication bias and outcome reporting bias. PLoS ONE 2008;3:e3081.
OE Elgersma,a PHM van der Valk,a MS Maassenb & MDA Lambersb a
Department of Radiology Department of Obstetrics and Gynaecology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
b
Accepted 16 March 2009. DOI: 10.1111/j.1471-0528.2009.02206.x
Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage
Sir, We read with interest the study by Maassen et al.1 concerning uterine artery embolisation (UAE) for postpartum haemorrhage (PPH) and have several comments to make about this work. First, we were surprised to learn that in the Netherlands, PPH is defined by a blood loss in excess of 1000 ml, whatever the method of delivery, whereas the usual threshold for vaginal delivery is 500 ml. Current recommendations2 concerning UAE were respected in this study (usage after failure of uterotonics and after transfusion of packed red cells and platelets), but the delay in the diagnosis, because of the excessively high threshold, may have been the main cause of the failure of the treatment for PPH. Moreover, concerning the technique for embolisation, we would like to underline the need to create an angiographic map of the vascular bed before the intervention for occlusion. Eventhough it may be difficult to establish such a map because of vasospasm induced by the haemodynamic state, it does allow detection of the zone responsible for the bleeding as well as anastomoses notably utero-ovarian that may exist. It is then possible to obturate these anastomoses proximally, using microcoils, even before UAE to maintain ovarian function.
ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
Correspondence
Moreover, several cases of uterine necrosis secondary to UAE have been reported,3 and this despite the use of resorbable material. In the present study, the vesico-vaginal fistula, secondary to the vesical necrosis, is a further example to confirm sometimes irreversible occlusion caused by the gelatin particles. The size of the particles and the degree of selectivity in the site of embolisation seem to play a major role in the genesis of ischaemic necrosis. The smaller the particles, the more distal the embolisation and the lower the risk of recurrence of bleeding, at the price, however, of a greater risk of ischaemia (impossibility to develop collateral circulation). In contrast, the bigger the particles, the more proximal the embolisation and the lower the risk of ischaemia. The risk of recurrent haemorrhage, however, is greater because of the development of collaterals. Maassen et al.1 also reported the risk of gelatin particles migrating to the femoral artery in the case of iterative interventions. Thus, it seems irresponsible to continue to perform re-embolisations, sometimes sacrificing the two ovarian arteries in the process, in patients who will be able to preserve the uterus, but at the price of definitive menopause. In cases of severe PPH, Touboul et al.4 confirmed the interest of UAE in uterine atony in vaginal delivery. In contrast, the efficacy seems to be less certain in cases of haemodynamic instability or for cesarean section. They propose a clinical trial to clarify the interest of UAE in comparison with surgery (ligature of the hypogastric arteries or hysterectomy) in this life-threatening situation. Uterine artery embolisation has certainly become an essential tool in the management of PPH. However, we must advise his reasoned use in second-line treatment, by avoiding re-embolisations, as its efficacity compared with surgery has not yet been clearly established in cases of extremely severe PPH. j
References 1 Maassen MS, Lambers MD, Tutein Nolthenius RP, van d V, Elgersma OE. Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. BJOG 2009;116:55– 61. 2 Pelage JP, Limot O. Current indications for uterine artery embolization to treat postpartum hemorrhage. Gynecol Obstet Fertil 2008;36:714– 20. 3 Coulange L, Butori N, Loffroy R, Filipuzzi L, Cercueil JP, Douvier S, et al. Uterine necrosis following selective embolization for postpartum hemorrhage using absorbable material. Acta Obstet Gynecol Scand 2009;88:238–40. 4 Touboul C, Badiou W, Saada J, Pelage JP, Payen D, Vicaut E, et al. Efficacy of selective arterial embolisation for the treatment of lifethreatening post-partum haemorrhage in a large population. PLoS ONE 2008;3:e3819.
H Tixier,a R Loffroy,b B Guiu,b L Coulange,a N Butori,b JP Cercueil,b S Douvier,a D Krauseb & P Sagota,c a
Department of Gynecology and Obstetrics Department of Diagnostic and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, Dijon cedex, France c INSERM EA 4184, Epide´miologie des Populations, IFR Sante´-STIC, Faculty of Medicine, Dijon, France b
Accepted 7 February 2009. DOI: 10.1111/j.1471-0528.2009.02207.x
Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage
Author’s Reply Sir, We thank Dr Tixier1 for his comments. The definition of postpartum haemorrhage (PPH) is arbitrary.2 Our policy of conservative management proved to be adequate in over 97% of our patients with intractable postpartum haemorrhage. If an endovascular procedure had been performed in all patients with PPH, the number of endovascular procedures would have increased 40-fold. Severe PPH makes endovascular procedures more difficult because the patient becomes haemodynamically unstable. Because haemostasis has to be achieved quickly, often one does not have enough time to place the catheter superselectively in the uterine artery. If correct placement was not achieved within minutes, the anterior division of the internal iliac artery was embolised instead. A recent review of PPH shows that this approach was adopted in 75% of the series reported.3 Although we did not mention it in our paper, angiographic maps were always obtained with selective contrast agent injection in the internal iliac artery prior to embolisation. We agree that the size of the particles is of importance. Small particles (250 lm) can cause ischaemic damage to the ovaries.4 One of the main reasons for using larger particles (700 lm) for uterine artery embolisation of fibroids is that it keeps ovarian function intact.5 If time was not an issue, one could selectively embolise all the utero-ovarian anastomoses using microcatheters and microcoils as suggested by Tixier et al.1 However, using gelatine foam, the particle size is difficult to control, although no irreversible ovarian damage has been reported after uterine artery embolisation even if gelfoam particles do penetrate into the ovaries.6 It is therefore not likely that the use of gelfoam will definitely result in a menopause as suggested by Tixier et al.1; likewise, we doubt that proximal embolisation with coils of one ovarian artery would alter this outcome. j
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