Presentation about the role of Interventional Radiology and Surgical Hysterectomy in PPH presented at the FOGSI Quest 2.0

3. I AND S IN PPH
Dr. Niranjan Chavan

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

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

10. • Success rates in 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 COIL EMBOLIZATION

12. POST ILIAC ARTERY COILING

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