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Case 18

Severe post-partum haemorrhage treated by transcatheter embolization

Severe post partum haemorrhage

Richard Edwards

A 37-year-old female, para 1+0, developed severe post-partum haemorrhage after forceps delivery at term. Vaginal packs failed to control the bleeding and abdominal hysterectomy was performed within 24 hours. Despite surgery, bleeding continued and over 30 units of blood were transfused over the next 8 hours.

The Shock Team considered transfer to the dedicated angio unit on another site hazardous.

Findings

In order to stabilise her haemodynamic state bilateral 10m x 4cm angioplasty balloons (Cordis) were inflated across the origins of the internal iliac arteries in the maternity unit theatre using mobile fluoroscopy (Image A). The patient was then transferred within the hour to another hospital for selective embolization. The right iliac balloon was deflated first and a selective right internal iliac arteriogram was performed using a 5 F Sos Omni catheter (Angiodynamics). Active extravasation was demonstrated from a medial branch of the right obturator artery (Image B).

The bleeding right obturator artery was initially embolized with resorbable Spongostan particles and finally by several microcoils introduced via a Tracker catheter (Boston) (Image C). After haemostasis was achieved the contralateral balloon was deflated and completion arteriography demonstrated no other bleeding point (Image D). After a period of monitoring in the Intensive Care Unit, the vaginal packs were removed and her subsequent recovery was uneventful.

Diagnosis

Severe post-partum haemorrhage treated by transcatheter embolization

Discussion

Pelvic haemorrhage is a rare but potentially fatal complication of complex obstetric delivery or gynaecological surgery. The internal iliac arteries may be ligated surgically but bleeding may continue due to the rich pelvic collateral circulation. Selective embolization of the bleeding point can provide definitive treatment without compromising the pelvic circulation and should be considered at an early stage. In this case the appropriate facilities for selective embolization were not available on-site and therefore temporary balloon tamponade was performed. Ideally this should be performed with occlusion balloons (Boston, Cook) placed selectively in each internal iliac artery but distal limb ischaemia due to short term iliac occlusion should not be a major problem in young patients.

Balloon tamponade is a useful "holding measure" until definitive embolization can be performed and a sealed pack containing basic interventional equipment (balloons, catheters, guide wires etc.) should be made available in maternity theatres which do not have interventional radiology facilities available on-site.

Obstetricians and gynaecologists may not be aware of this technique (or its availability). The number of referrals will only increase by clinician education, improving critical care pathways and provision a comprehensive interventional radiology on-call service on a city-wide or regional basis.

References

A recent paper describes results in 27 patients with intractable PPH:

Pelage JP et al.
Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization.
Radiology 1998 Aug;208(2):359-62

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