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Interventional Radiology and Hysterectomy in PPH
Dr. Niranjan Chavan presents a comprehensive overview of managing postpartum hemorrhage (PPH) through various methods including uterine artery embolization (UAE) which boasts a high success rate of 90-95%. The document emphasizes the advantages of UAE over surgical options like hysterectomy, highlighting its minimally invasive nature and ability to maintain fertility. It concludes that individualized treatment approaches are critical for optimal outcomes, particularly in complex cases involving conditions like placenta accreta.
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Interventional Radiology and Hysterectomy in PPH
- 3. I AND SIN PPH Dr. Niranjan Chavan
- 4. Professor and UnitChief, L.T.M.M.C & L.T.M.G.H, Sion Hospital Joint Treasurer, FOGSI (2021-2024) Vice President, MOGS (2021-2022) Member Oncology Committee, SAFOG (2020-2021) (2021-2023) Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses Editor-in-Chief, FEMAS, JGOG & TOA Journal 56 publications in International and National Journals with 90 Citations National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2022) Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16) Member, Oncology Committee AOFOG (2013-2015) Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at L.T.M.G.H (2010-16) Member, Managing Committee IAGE (2013-17), (2018-20) Editorial Board, European Journal of Gynaec. Oncology (Italy) Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS) at LTMGH (2018-19) DR. NIRANJAN CHAVAN MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP, DIPLOMA IN ENDOSCOPY (USA)
- 5. HEMOSTASIS FOR PPH •H - Help and hands on uterus • E - Etiology, Ensure blood, Ecbolics • M - Massage Compression • O - Oxytocics • S - Shift OT/Transport - Aortic pressure NASG • T - Tamponade • A - Apply compression sutures B lynch and others • S - Systemic pelvic devascularization • I - Interventional Radiology • S - Subtotal/ Total Hysterectomy
- 6. INTERVENTIONAL RADIOLOGY • Interventionalradiology is a subspecialty which provides • minimally invasive diagnosis and /or treatment using imaging (ultrasound, CT, or fluoroscopy) to target the intervention and show the results of the intervention.
- 7. • Uterine arteryembolization is a minimally invasive alternative • Performed under conscious sedation Technique • Common femoral artery access • Pelvic aortogram • Selective angiography of internal iliac arteries • Gel-foam embolization of uterine arteries +/- others
- 9. ADVANTAGES • Distal occlusionprevents arterial reconstitution from collaterals • Temporary occlusive effect(usually 10-30 days) • Rapid (similar to trauma) • Available at all times • Procedure time usually less than one hour
- 10. • Success ratesin controlling PPH (hysterectomy avoided): • Greenwood (1987): 8/8 • Gilbert (1992): 10/10 • Mitty (1993): 17/18 • Yamashita (1994): 15/15 • Merland (1996): 15/16 • Pelage (1998): 34/35 • Deux (2001): 24/25 • Borgatta (2001): 10/11 • Chung (2003): 31/33 • Tourne (2003): 11/12 • Mee Kristine Aas-Eng (2016) : 28/32 • Overall success rate of 90-95%
- 11. UTERINE ARTERY COILEMBOLIZATION
- 12. POST ILIAC ARTERYCOILING
- 13. • Normal menstruationusually resumes in 3-6 months • Complications are uncommon(3-7%) and much lower than laparotomy • Post-embolization syndrome: Fever, Abdominal Pain & Leukocytosis • Access site hematoma • Infection • Rare ischemic complications(bladder or uterine necrosis, nerve paresis) • Increases incidence of Placenta Accreta Syndrome and PPH is noted in future pregnancies.
- 14. • A decreasein the incidence of postpartum hysterectomy since introduction of UAE for PPH was observed. • UAE resulted in clinical success in 28/34 patients (82 %). None were re-embolized. • High recurrence rate of PPH after previous UAE was observed.
- 15. According to thepatient background‐matched analysis based on the presence of prior PPH, • women with prior UAE were associated with higher rates of PAS and PPH • Not associated with higher rates of hysterectomy, placenta previa, FGR or PTB, compared with those who did not undergo prior UAE. March 2021
- 16. ADVANTAGES OVER SURGICAL LIGATIONOR HYSTERECTOMY • Less invasive/morbid • Unanticipated (non-uterine) bleeding sources can be identified and treated • Immediate angiographic confirmation of success • No adverse impact on subsequent arterial ligation if necessary • Embolization can be successful even after all surgical options have failed, however, it is more technically difficult to be performed.
- 17. • Embolotherapy canbe a first-line treatment for PPH refractory to local measures • Surgical options are always available for embolization failures • Close collaboration between obstetrics and IR should result in a low rate of hysterectomy or Exsanguination in patients with PPH
- 18. SUBTOTAL/ TOTAL HYSTERECTOMY •Hysterectomy is a definitive treatment of uterine bleeding • Regardless of the etiology of postpartum haemorrhage (PPH), continued blood loss can lead to severe coagulopathy due to massive loss of coagulation factors • Severe hypovolemia, tissue hypoxia, hypothermia, electrolyte abnormalities, and acidosis can result, which further compromise the patient's status
- 19. • In patientswith placenta accreta spectrum or uterine rupture, • early resort to hysterectomy may be the least morbid approach for controlling haemorrhage • It may prevent deaths and morbidity caused by delays while ineffective fertility-preserving procedures are attempted.
- 20. • In contrast,uterine atony can usually be controlled by uterotonic drugs alone or in combination with fertility-preserving procedures (e.g., uterine compression sutures, uterine artery/utero-ovarian artery ligation, arterial embolization, intrauterine balloon tamponade) • However, if fertility-preserving procedures do not reduce the bleeding to a manageable level, then there is no choice but to proceed with hysterectomy.
- 21. TAKE HOME MESSAGE •Individualization of cases and choice of therapy is required for the best outcome • Post-partum haemorrhage can be effectively and safely controlled by UAE, with success rates of 90-95% - • Fertility maintained • Low radiation dose • Fast and readily available • Balloon occlusion or UAE can be considered for patients with invasive placenta to reduce blood loss • Anecdotal effectiveness • Subtotal/Total Hysterectomy may be required in case of failure of IR therapy and as a last resort
Editor's Notes
- #16 A 34yr old multiparous female referred to us un view of primary atonic PPH underwent Bilateral Internal Iliac Coil Embolization. We can see Platinum coils placed in the Internal Iliac artery which causes foreign body reaction leading to permanent occlusion of Internal Iliac. Colateral circulation develops over long term. Procedure was uneventful and patient was discharged in D4 of procedure afte stabilization.
- #17 We can see the occluded blood flow in the Internal Iliac artery after placement of coils.