Teaching Case

21-year-old woman, delivered a healthy baby by spontaneous vaginal delivery, two hours later, she suffered from severe bleeding.

21-year-old woman, gravid 2, para 1, delivered a healthy baby by spontaneous vaginal delivery. She denied any medical problem during pregnancy. Two hours after delivery, she suffered from severe bleeding. Uterotonic drugs were administered and then a vaginal pack was placed, but these measures failed and anaesthetists were not able to stabilise the hypovolemic shock with continuous blood transfusions and vasoactive-drugs. Despite transfusion of 6 units of blood, the patient remained haemodynamically unstable and Gynaecologists alert us. A pelvic angiography and selective arteriography of both uterine arteries was performed to identify the potential sites of bleeding. The arteriography showed a uterine heterogeneous hypervascularisation. We performed a bilateral selective embolisation of uterine arteries with absorbable gelatine sponge. Post-embolisation angiography confirmed that the occlusion of the vessels was complete and the arterial embolisation was clinically successful. After only one day in the intensive care unit, the patient recovered blood pressure and heart rate and once back on the ward she became stable and conscious, and she was discharged after four days.

The management of obstetric haemorrhage remains one of the significant challenges to clinical practitioners of obstetrics today. Excessive blood loss is considered to be greater than 500 ml by completion of the third stage of a vaginal delivery or 1000 ml after cesarean section.
Haemorrhage either before, during or after delivery represents a major preventable cause of morbidity and death [1,2].

The first measure to take is to maintain vital signs of patient.
Obstetric haemorrhage is often:
o Sudden
o Unexpected
o May be associated with coagulopathy
Important points:
o Early recognition
o Early treatment

In many cases, the haemorrhage can be managed by correction of hypovolemic shock and abnormal coagulation with the used of blood or blood products, management of uterine atony with pharmacologic measures (uterotonics drugs) and other treatment for uterine atony (e.g. use of fundal abdominal massage, with uterine cavity exploration). Vaginal packing, surgical repair of genital tract lacerations, and curettage for retained placental fragments may control bleeding. When bleeding fails to respond to such measures, surgical procedures may be effective. Haemostatic hysterectomy is typically offered as a last-resort treatment, but it is associated with a high rate of morbidity and mortality, and the loss of fertility [3].
Arterial embolisation to treat postpartum haemorrhage was fist reported in 1979 [4] and there are now several series reporting technical success and good clinical outcomes, selective transcatheter arterial embolisation of the uterine arteries has become an effective method for the control of postpartum haemorrhage [5,6]. Uterine atony is the most common cause of primary postpartum haemorrhage; other aetiologies include lower genital lacerations, coagulopathy, retained placental fragments, placental abruption, invasive placenta, uterine rupture and uterine inversion [7]. In a study of 102 patients with obstetric bleeding, it found that the presence of an atonic uterus was associated with an 89 % clinical success rate in haemorrhagic control, whereas embolisation after caesarean section delivery had 48 % failure rate [6].
If a bleeding point is identified, the superselective catheterisation and embolization of appropiate artery is indicated. In these cases the embolisation in performed with permanent material: particles or coils placement to occlude the vessel injured (7)
In this patient the decision to perform embolisation was made on the basis of active continuing haemorrhage despite appropriate medical and obstetric management. The best embolic agent to use when treating post-partum haemorrhage is debated, and depends to some extent on the angiographic findings, but Gelfoam slurry has been shown to be successful in controlling bleeding in uterus atonic cases, without compromising uteroovarian or cervicovaginal collateral vessels. To achieve this jelly like consistency is important, because it is a stable preparation witch prevents obstruction of the catheter (see Fig. 7). The embolic effect is temporary, lasting 10-30 days, reducing flow long enough to stop haemorrhage while decreasing the risk of ischemia [8]. Complications related to embolic agent is infrequent, and most are reported in patients who have undergone embolisation with use of small particles (9,10].

In conclusion, embolotherapy is an effective method of controlling the postpartum haemorrhage that avoids the morbidity associated with pelvic surgery and preserves fertility in women.