By Intern 許碩修、李世瑜 Date: 2006/08/28 Intern Seminar By Intern 許碩修、李世瑜 Date: 2006/08/28

Case 23 y/o lady No systemic diseases Chief complaint: active vaginal bleeding after D&C for one day

Present Illness 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 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 DM (-), HTN (-) Asthma (+) in the childhood G5P2AA2E1 Operation History: Appendectomy 5 years ago C/S due to prolonged labor last year D&C twice

Physical Findings Vital signs: T/P/R: 36.5/82/22, BP: 108/60 Tenderness over lower abdomen, no rebounding pain Pelvic examination Fresh blood noted after removing the vaginal gauzes

Management Active vaginal bleeding after D&C Emergent operation Suspected cervical pregnancy or pre-C/S scar pregnancy Emergent operation Foley balloon compression PGF2α injection Cervix suture

Course of Admission Elevated HCG was noted, so MTX was given on 4/18 Foley was removed without active bleeding MBD on 4/20

OPD Follow-up 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 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 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 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 Definition: 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 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 Pathogenesis: uterine atony secondary to retained products of conception (D&C, suction curettage) infection exact cause unknown

Etiology Uterine problems Coagulopathy Uterine, cervical, or vaginal lacerations (occur 1/8 deliveries) Uterine atony (occurs 1/20 deliveries) Uterine inversion Uterine rupture Coagulopathy Dilutional coagulopathy (eg, from abruptio placentae, placenta previa) Consumptive coagulopathy (eg, from abruptio placentae, sepsis,)

Etiology Hysterotomy Retained placenta or placenta accreta 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 lightheadedness vertigo syncope hypotension tachycardia Oliguria Hypovolemic shock

Sequential steps in managing PPH Uterine massage Uterotonic drugs (ex: oxytocin, methergine, hemabate) Inspect vaginal and cervix for laceration, repair as necessary Transarterial embolization

Sequential steps in managing PPH Laparotomy 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 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 Diagnostic angiography performed: look for bleeding sites abnormal vascular findings (ex: extravasation, abnormal arteriovenous communication, pseudoaneurysm, spasm, or truncation) Gelfoam is the preferred agent the duration of occlusion is temporary (two to six weeks) sufficient to reduce hemorrhage

Intervention radiology in managing PPH Success rate: 90~95% Patient retained reproductive capacity Complication: uncommon in young Inadvertent embolization of adjacent vessels 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 Material and methods 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 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 Heaston et al. reported the first case using TAE for control of persistent PPH in1979. Pros: 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 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 rare, but life-threatening described as a cirsoid aneurysm, arteriovenous aneurysm, arteriovenous fistula, and cavernous hemangioma congenital AVMs (50%) : high-flow malformation acquired AVMs after uterine instrumentation (eg, curettage) associated with disorders ( ex gestational trophoblastic disease, endometrial adenocarcinoma, or maternal diethylstilbestrol exposure)

Arteriovenous malformation of the uterus Diagnosis: Noninvasive : color Doppler ultrasound 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 Catheter angiography Differential high flow and low flow velocity Eur Radiol (2006) 16: 299–306

AUVM: radiological and clinical outcome after transcatheter embolotherapy retrospective study 17 patients (mean age: 29.7 years) from January 2000 and January 2004 Embolization 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 After embolization short or inter-term follow-up Duplex US followed 1 day after embolization 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 Clinical follow-up 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) 2/6 accepted bilateral uterine a. embolization 4/6 accepted unilateral left-sided embolization post-embolization pelvic pain in two p’ts Subside after oral medication Eur Radiol (2006) 16: 299–306

AUVM: radiological and clinical outcome after transcatheter embolotherapy 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) 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 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 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 !!