Uterine artery embolization for PPH Prof David Baud, MD PhD Switzerland Uterine artery embolization for PPH

Maternal death

Prevention Be aware of risk factors Treat anaemia antenatally Active management of the 3rd stage Prophylactic oxytocics = reduce risk of PPH by 60% (oxytocin or ergometrine) Causes: 4T Tone 70% Trauma 20% Tissue 10% Thrombin 1%

Medical Surgical / invasive

B-Lynch / Ut. Art. ligation Uterine artery embolisation Gelatin sponge, Gelfoam, alcohol particles, microparticles

Short term complications after UAE for PPH

Vascular injuries 1-2%

Other complications Vascular injuries Endometritis Distant necrosis Limb Intestine Buttock Fistula Ovaries => failure? Uterine necrosis

Uterine necrosis

Long term complications after UAE for PPH

Return to normal in 81% of patients Menstrual cycle Return to normal in 81% of patients

Pregnancies after UAE 38 studies with long F/U = 1072 patients 23% had subsequent pregnancies Among 499 patients who were asked whether they were attempting pregnancy, 35% answer YES - 76% were able to conceive - delay to conceive = 4-12 months - uterine synechiae as cause of infertility - Normal birth weight - more placenta accreta (20%) - 20% recurence PPH

Our own study

Method Retrospective study All patients treated with embolization for PPH 2003 – 2013 Outcomes: Gynaecological symptoms Future fertility Obstetrical outcomes Psychological impact

Inclusion

Matching 1:3 Maternal age Ethnicity Year of delivery Parity Mode of delivery Birth weight Gestational age

MORE TIME TO GET PREGNANT

NO MAJOR DIFFERENCE IN GYNECOLOGICAL & SEXUAL OUTCOME

NO ADVERSE PREGNANCY OUTCOMES EXCEPT MORE CESAREAN & PPH

Conclusion After embolization for PPH: SIMILAR menstrual cycle SIMILAR sexual function SIMILAR fertility, but... Subsequent pregnancies: Time to achieve a new pregnancy is longer after UAE Fear to get pregnant might be a major factor SIMILAR obstetrical complications, except for recurrence of PPH and cesaerian

Mini-International Neuropsychiatric Interview 1 Have you ever been consistently depressed or down, most of the day, nearly every day? 2 Have you been much less interested in most things or much less able to enjoy the things you used to enjoy most of the time? 3 After the birth of the baby have you been much less interested in most things? 4 Was your appetite decreased or increased nearly every day? If unclear, did your weight decrease or increase without trying intentionally? 5 Did you have trouble sleeping nearly every night (difficulty falling asleep, waking up in the middle of the night, waking early in the morning) or sleeping excessively? 6 Did you talk or move more slowly than normal or were you fidgety, restless or having trouble sitting still almost every day? 7 Did you feel tired or without energy almost every day? 8 Did you feel worthless? 9 Did you feel guilty? 10 Did you have difficulty concentrating or making decisions?

MINI - maternal

Post-traumatic stress disorder Walters JT, Bisson JI, Shepherd JP. Predicting post-traumatic stress disorder: validation of the Trauma Screening Questionnaire in victims of assault. Psychol Med. 2007 Jan;37(1):143-50. Epub 2006 Sep 7

TSQ maternal

TSQ Paternal ? ?

MINI Paternal

TSQ Paternal

Conclusions Preserved fertility after embolization Good pregnancy outcomes after embolization, except recurrent PPH & CS!! Do not underestimate Post-Traumatic Stress !!! Also partner

THANKS Francoise Damnon Karine Lepigeon Dominique Bertaud Mathilde Morisod Maude Bernasconi