1. 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

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

3. 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

4. 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

5. 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

6. 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

8. 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

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

11. 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

13. Angiography

14. TAE

15. Following Angiography

17. 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

18. MRI

20. Following Sonography

21. ER Acute onset of active bleeding from vagina on 8/9 evening
Palpitation, general weakness and dry mouth also noted
Emergent TAE was arranged

22. Emergent Angiography

23. 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

24. Following Sonography

25. Discussion: Post-partum hemorrhage

26. 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

27. 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 Vol. 108 pp

28. Secondary post-partum hemorrhage
Pathogenesis: uterine atony secondary to
retained products of conception
(D&C, suction curettage)
infection
exact cause unknown

29. 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,)

30. 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

31. Clinical future lightheadedness vertigo syncope hypotension
tachycardia
Oliguria
Hypovolemic shock

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

33. 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

34. 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

35. 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

36. 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

37. 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

38. UAE :an effectiveTreatment for intractable obstetric haemorrhage
Clinical Radiology(2004) 59, 96–101

39. 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

40. 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

41. 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

42. 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)

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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 Vol. 108 pp
Arterial embolization for hemorrhage in obstetric patient Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 15 No.4. pp
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

50. Thanks for your attention !!