4. Professor and Unit Chief, 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
• Interventional radiology 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 artery embolization 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
8.
9. ADVANTAGES
• Distal occlusion prevents 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
13. • Normal menstruation usually 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 decrease in 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 the patient 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
LIGATION OR 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 can be 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 patients with 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
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.
We can see the occluded blood flow in the Internal Iliac artery after placement of coils.