Success rate and long-term effects of embolization of pelvic arteries for the treatment of postpartum hemorrhage

Introduction:

Postpartum hemorrhage (PPH) is the leading cause of peripartum maternal mortality and accounts for 25% of all maternal deaths worldwide. The most common causes of PPH are uterine atony, retained placenta or morbidly adherent placenta. Treatment of PPH depends on the etiology and includes administration of uterotonic drugs and curettage if retained placental tissue is suspected. In severe refractory PPH, hysterectomy has been the ultima ratio for many decades. In the last years the interventional embolization of the pelvic arteries (PAE) has become a valid alternative. Besides being a highly effective minimal-invasive method, PAE avoids hysterectomy with consecutively reduced morbidity and mortality. However, data concerning the long-term effects of PAE on fertility and menstrual cycle is scarce.

Methods:

In this single-center study all women who underwent a PEA between January 2012 and 2016 in the University Hospital of Zürich were included. Descriptive characteristics of the study population, clinical course during PPH, and effectiveness of PAE -defined as cessation of bleeding- were analyzed retrospectively. Furthermore, all the patients were contacted and asked to complete a questionnaire to obtain a long-term follow up regarding pattern of menstruation and fertility after embolization.

Results:

Twenty patients with PAE were included. Success rate of PAE was reported in 95% of the patients, only one patient underwent a further PAE. No patient needed a hysterectomy or any other surgical intervention. The reason for PPH differed according to the mode of delivery. After spontaneous delivery, the main reason of PPH was retained placenta (83%), while after cesarean section, this was uterine atony in most cases (66%). Twelve patients answered the follow-up questionnaire. Most of them reported a regular pattern of menstruation with shorter duration (72%) and lower or similar intensity (62%) than before PAE. Dysmenorrhea decreased in 90% of the patients. Four patients were planning a new pregnancy, of those only one had become pregnant without assisted reproductive technology in the previous pregnancy. This patient became pregnant spontaneously as well after PAE.

Discussion:

Our study confirms the effectiveness of PAE in PPH. This additional method obviates severe surgical interventions and thus reduces morbidity. The success of PAE seems to not depend on the primary cause of PPH. Furthermore, PAE might increase patient's quality of life due to short convalescence and no side effects on menstrual pattern in the long-term follow up. Our results may encourage the promptly decision to perform PAE in the management of severe PPH.