Intern Seminar
By Intern 許碩修、李世瑜
Date: 2006/08/28
Case
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23 y/o lady
No systemic diseases
Chief complaint: active vaginal bleeding after
D&C for one day
Present Illness
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This lady found she was pregnant and went
to the Ob/Gyn clinic this Feb
Thereafter, massive vaginal bleeding without
abdomianl pain attacked
She went to the clinic again and signs of
abortion and cervical pregnancy was told
Some medication was given but poor
compliance due to chest tightness
Present Illness
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Vaginal bleeding still noted, and D&C was
performed on 4/13 (estimated gestational age:
9 weeks)
Massive bleeding after the operation and
cervix was packed and compressed
She was transferred to our hospital for
bleeding control
Past History
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DM (-), HTN (-)
Asthma (+) in the childhood
G5P2AA2E1
Operation History:
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Appendectomy 5 years ago
C/S due to prolonged labor last year
D&C twice
Physical Findings
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Vital signs: T/P/R: 36.5/82/22, BP: 108/60
Tenderness over lower abdomen, no
rebounding pain
Pelvic examination
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Fresh blood noted after removing the vaginal
gauzes
Management
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Active vaginal bleeding after D&C
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Suspected cervical pregnancy or pre-C/S scar
pregnancy
Emergent operation
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Foley balloon compression
PGF2α injection
Cervix suture
Course of Admission
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Elevated HCG was noted, so MTX was given
on 4/18
Foley was removed without active bleeding
MBD on 4/20
OPD Follow-up
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Active bleeding was noted occasionally, and
abdominal pain with frequent dizziness
MTX was given for the second time due to
poor HCG decline on 4/25
Severe bleeding and one fainting episode
noted so she came to our ER on 6/27
Angiography
TAE
Following Angiography
OPD Follow-up
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Several episodes of massive bleeding still
noted
DOE, dizziness and intermittent abdominal
pain was complained
Blood transfusion was given and then
admitted on 7/31
MRI
Following Sonography
ER
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Acute onset of active bleeding from vagina on
8/9 evening
Palpitation, general weakness and dry mouth
also noted
Emergent TAE was arranged
Emergent Angiography
Course of Admission
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Transamine, Marvelone were given
Another episode of massive bleeding on 8/12
and emergent hemostasis was performed
(Bosmin packing + Transamine)
MBD with stable situation
Following Sonography
Discussion:
Post-partum hemorrhage
Post-partum hemorrhage
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Definition:
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blood loss >500 mL after vaginal birth
blood loss >1000 mL after cesarean delivery
incidence : approximately 3 percent of births
Classified to primary VS. secondary
post-partum hemorrhage
Secondary post-partum hemorrhage
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excessive uterine bleeding occurring between
24 hours and 6 weeks postpartum
Incidence rate: 0.5~1.3%
History of PPH: sevenfold
History of manual removal of retained
placenta: fourfold
British journal of Obstetrics and Gynaecology
September 2001. Vol. 108 pp. 927-930
Secondary post-partum hemorrhage
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Pathogenesis: uterine atony secondary to
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retained products of conception
(D&C, suction curettage)
infection
exact cause unknown
Etiology
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Uterine problems
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Uterine, cervical, or vaginal lacerations (occur 1/8
deliveries)
Uterine atony (occurs 1/20 deliveries)
Uterine inversion
Uterine rupture
Coagulopathy
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Dilutional coagulopathy (eg, from abruptio placentae,
placenta previa)
Consumptive coagulopathy (eg, from abruptio placentae,
sepsis,)
Etiology
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Hysterotomy
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Dehiscence of a hysterotomy scar
Lateral extension of a hysterotomy incision into
the uterine vessels
Poor hemostasis of a hysterotomy incision
Retained placenta or placenta accreta
Clinical future
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lightheadedness
vertigo
syncope
hypotension
tachycardia
Oliguria
Hypovolemic shock
Sequential steps in managing PPH
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Uterine massage
Uterotonic drugs (ex: oxytocin, methergine,
hemabate)
Inspect vaginal and cervix for laceration,
repair as necessary
Transarterial embolization
Sequential steps in managing PPH
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Laparotomy
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Ligation of bleeding site
Uterine artery ligation
B-lynch stitch
Hysterectomy
Suturing and tacking of deep pelvic bleeders
Pelvic packing
Intervention radiology in managing PPH
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hemodynamically stable
single bleeding vessel or proximal part of
multiple small vessels could be identified
Consider before laparotomy
if not succeed or patient unstable, consider
laparotomy
If coagulopathy, corrected first
Intervention radiology in managing PPH
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Diagnostic angiography performed:
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look for bleeding sites
abnormal vascular findings (ex: extravasation,
abnormal arteriovenous communication,
pseudoaneurysm, spasm, or truncation)
Gelfoam is the preferred agent
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the duration of occlusion is temporary (two to six
weeks)
sufficient to reduce hemorrhage
Intervention radiology in managing PPH
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Success rate: 90~95%
Patient retained reproductive capacity
Complication: uncommon in young
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Inadvertent embolization of adjacent vessels
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Bladder and rectal wall necrosis (cystic a.)
Neurological injury and muscle pain (sciatic a.)
Use of small embolic particles (polyvinyl alcohol
particle)
Not encountered with gelfoam pledget
Best Practice & Research Clinical Obstetrics and
Gynaecology Vol. 15 No.4. pp. 557-561 2001.
UAE :an effective Treatment for
intractable obstetric haemorrhage
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Material and methods
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10 women : PPH (n=7) post-abortion
haemorrhage with placenta accreta (n=3)
From October 1999 to February 2003
Mean age : 30.2 years old
Clinical Radiology(2004) 59, 96–101
UAE :an effectiveTreatment for intractable
obstetric haemorrhage
Clinical Radiology(2004) 59, 96–101
UAE :an effective Treatment for
intractable obstetric haemorrhage
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After UAE, the vaginal bleeding resolved in
all eight patients
further surgical intervention was not needed.
No complication related to the embolization
was encountered.
three of them gave birth to full-term babies
Clinical Radiology(2004) 59, 96–101
UAE :an effective Treatment for
intractable obstetric haemorrhage
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Heaston et al. reported the first case using
TAE for control of persistent PPH in1979.
Pros:
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preservation of the fertility
decreased incidence of rebleeding from collaterals
due to more distal occlusion than with surgical
ligation
visualize, catheterize and occlude collateral
vessels contributing to bleeding.
Clinical Radiology(2004) 59, 96–101
UAE :an effective Treatment for
intractable obstetric haemorrhage
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UAE by the coaxial method is a safe and
effective method
should be the first choice when interventional
radiologists are available
Clinical Radiology(2004) 59, 96–101
Arteriovenous malformation of the uterus
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rare, but life-threatening
described as a cirsoid aneurysm, arteriovenous
aneurysm, arteriovenous fistula, and cavernous
hemangioma
congenital AVMs (50%) : high-flow malformation
acquired AVMs
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after uterine instrumentation (eg, curettage)
associated with disorders ( ex gestational trophoblastic
disease, endometrial adenocarcinoma, or maternal
diethylstilbestrol exposure)
Arteriovenous malformation of the uterus
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Diagnosis:
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Noninvasive : color Doppler ultrasound
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hypoechoic, tortuous spaces in the myometrium,
demonstrating a low impedance and high velocity flow
Can not differential high or low flow velocity
Invasive: gold standard
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Catheter angiography
Differential high flow and low flow velocity
Eur Radiol (2006) 16: 299–306
AUVM: radiological and clinical outcome
after transcatheter embolotherapy
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retrospective study
17 patients (mean age: 29.7 years) from
January 2000 and January 2004
Embolization
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decision to embolize one or both uterine arteries
based on the US findings
Depending on the vascular anatomic findings,
microcatheter needed or not
embolization with polyvinyl alcohol microparticles
or trisacryl gelatin microparticles without coil
Eur Radiol (2006) 16: 299–306
AUVM: radiological and clinical outcome
after transcatheter embolotherapy
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After embolization short or inter-term follow-up
Duplex US followed 1 day after embolization
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disappearance of the hypervascular area in p’t
one p’t some small hypervascular areas in the
embolized AUVM
revascularization (2 weeks)
failure
hysterectomy (path: choriocarcinoma)
Others 1 day and 1 month follow-up were within
normal limits
Eur Radiol (2006) 16: 299–306
AUVM: radiological and clinical outcome
after transcatheter embolotherapy
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Clinical follow-up
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no other bleeding recurrence, and in all p’ts
Six women became pregnant, and all delivered a
healthy, term baby (mean time: 15.6 months)
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2/6 accepted bilateral uterine a. embolization
4/6 accepted unilateral left-sided embolization
post-embolization pelvic pain in two p’ts
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Subside after oral medication
Eur Radiol (2006) 16: 299–306
AUVM: radiological and clinical outcome
after transcatheter embolotherapy
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embolizing one or both uterine a. depending
on the US findings is a very effective and
durable treatment option especially low-flow
AUVM
using microparticles (PVA and trisacryl gelatin)
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In low-flow UVM, no direct AVF and no risk of
pulmonary embolism
In high-flow UVM, fistula between arterioles and
venules, not complicated by pulmonary embolism
Eur Radiol (2006) 16: 299–306
AUVM: radiological and clinical outcome
after transcatheter embolotherapy
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low-flow AUVM can be successfully treated
by TAE
Pivotal role of US in the pre-interventional
decision
There is still a potential to become pregnant
after a uni- or even bilateral uterine artery
embolization.
Eur Radiol (2006) 16: 299–306
Referrence
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Up to date: causes and treatment of postpartum hemorrhage
Secondary post-partum hemorrhage: incidence, morbidity and
current management British journal of Obstetrics and
Gynaecology September 2001. Vol. 108 pp. 927-930
Arterial embolization for hemorrhage in obstetric patient Best
Practice & Research Clinical Obstetrics and Gynaecology Vol. 15
No.4. pp. 557-561 2001
Uterine artery embolization : an effective treatment for intractable
obstetric haemorrhage ClinicalRadiology(2004) 59, 96–101
Acquired uterine vascular malformations : radiological and
clinical outcome after transcatheter embolotherapy
EurRadiol(2006)16:299–306
Thanks for your attention !!