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Pelvic arterial embolization following hysterectomy and bilateral internal iliac artery ligation for intractable primary post partum haemorrhage
Clinical Radiology (1995) 50, 710-714
Clinics in Interventional Radiology Pelvic Arterial Embolization Following Hysterectomy and Bilateral Internal Iliac Artery Ligation for Intractable Primary Post Partum Haemorrhage C. D. COLLINS and J. E. JACKSON*
Departments of Radiology, Christie Hospital NHS Trust, Wilmslow Road, Manchester, and *Royal Postgraduate Medical School, Hammersmith Hospital, London, UK A case of successful arterial embolization following hysterectomy and bilateral internal iliac artery ligation for intractable primary post partum haemorrhage is described. The selected artery was a branch of the inferior epigastric artery. Little has been written to date in the radiological literature about embolization via pelvic collateral vessels following arterial llgation. Although there is a good argument for postponing surgery until transcatheter embolization has been attempted, this case demonstrates that embolization can still be successful even when performed following surgery. Collins, C.D. & Jackson, J.E. (1995). Clinical Radiology 50, 710-714. Pelvic Arterial Embolization Following Hysterectomy and Bilateral Internal Iliac Artery Ligation for Intractable Primary Post Partum Haemorrhage
CASE REPORT
DISCUSSION
A 38-year-old patient (gravid 1, para 1) presented at 38 weeks gestation with a placental abruption. She gave birth to a still-born child. Six hours post-partum, the patient collapsed with a severe bleed per vaginam. Two subsequent laparotomies at which a hysterectomy and bilateral internal iliac artery ligation were performed failed to control the bleeding. The patient required a total of 63 units of blood in addition to coagulation replacement products and had developed disseminated intravascular coagulation and renal failure by the time of her transfer to Hammersmith hospital for emergency angiography with a view to possible embolization. Aortography was performed via the right femoral artery with a 5-F pigtail catheter. Both internal iliac arteries were ligated at their origin but both filled in their entirety via numerous collaterals including lumbar, median sacral and inferior epigastric arteries. Active contrast medium extravasation was seen from a branch of the anterior division of the right internal iliac artery (Fig. 1). Aortography performed in a left anterior oblique projection (Fig. 2) demonstrated that the pubic branch of the right inferior epigastric artery afforded the most direct approach to the branch of the right internal iliac artery from which there was contrast medium extravasation. Using the right femoral access, the right inferior epigastric artery was then catheterized with a 5-F, femoro-visceral catheter and further arteriography confirmed the communication between it and the internal iliac artery (Fig. 3). A co-axial 3-F Tracker 18 catheter (Target Therapeutics, Fremonth, CA, USA) was subsequently introduced into a wedged position in the pubic branch of the inferior epigastric artery to a point as close to the haemorrhaging internal iliac artery branch as possible. Polyvinyl alcohol (Contour, ITC) with a particle size of 150/~m 250#m was then forced through the collateral vessels into the anterior division of the right internal iliac artery and embolization of the haemorrhaging vessel was achieved. A post-embolization aortogram demonstrated a good angiographic result with occlusion of the distal branches of the right internal iliac artery and cessation of contrast medium extravasation (Fig. 4). The patient required a further laparotomy 12 h later for removal of a large pelvic haematoma. There was no evidence of active bleeding at this operation. She has since made a good recovery.
Primary post partum haemorrhage (PPH) is usually defined as bleeding from the genital tract of 600 ml or more in the first 24 h following delivery of the baby [1]. The reported incidence varies from 5 % [2] to greater than 10% [3], mainly due to difficulties in estimating the amount of blood lost. Care of the patient with PPH is directed towards rapid identification of the source and control of the bleeding before the situation becomes critical. If there is a uterine or vaginal laceration, this will require surgical repair; uterine atony is treated by ensuring the uterus is empty, 'rubbing up a contraction' and using oxytocics. If these are not successful in controlling haemorrhage, further surgery or transarterial embolization may be necessary. Traditional surgical therapy of pelvic haemorrhage consists most commonly of unilateral or bilateral internal iliac artery ligation although, in the case of PPH, hysterectomy is performed more often than ligation [4]. Surgical treatment of pelvic haemorrhage, however, is not without its difficulties. Ligation may be technically difficult or impossible [5] and removing a pelvic haematoma may destroy its tamponade effect [6]. In the largest series devoted to internal iliac artery ligation the technique was successful in eight out of nineteen cases (42%) [7]. In two further cases the procedure was unsuccessful in controlling haemorrhage [8,9]. Following analysis of the physiology of internal iliac artery ligation in the non-pregnant patient Burchell [10] concluded that this procedure reduced the pulse pressure distal to the ligation by 85%, the mean pressure by 24% and the blood flow by 48%, thereby essentially converting an arterial system into a venous one. As a result of this work he postulated that by reducing the arterial pulsation, clot forms distal to the ligation and remains in place, rather than being repeatedly removed by blood flow at arterial pressure. In pregnancy, however, the extensive collateral circulation to the distal branches
Correspondence to: Dr J.E. Jackson, Royal Postgraduate Medical School, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK. 9 1995 The Royal Collegeof Radiologists.
711
PELVIC ARTERIAL EMBOLIZATION
% %
Fig. 3 - Injective with the 5-F catheter at the origin of the right inferior epigastric arteriogram. A distal branch of the right internal iliac artery is opacified from which continued contrast medium extravasation is seen. A 3-F co-axial catheter was subsequently manipulated into the pubic artery branch to the point marked (arrow).
Fig. 1 - Aortogram demonstrates proximal occlusion of both internal iliac arteries due to surgical ligation with opacification of their distal branches via collateral vessels. Contrast medium extravasation is seen in the right pelvis indicating active haemorrhage (arrow).
of the internal iliac artery may render ligation of the proximal portion ineffective in controlling pelvic haemorrhage. The first case where angiographic arterial embolization was used to control PPH was reported simulta-
neously in the radiological and obstetrical literature in 1979 [11,12]. To date, angiographic embolization has been used in the management of PPH in 35 cases. These are summarized in a paper by Duggan et al. [13]. Further examination of this literature, however, reveals that embolization has been successfully used in the management of PPH following bilateral internal iliac artery ligation in only two cases and following unilateral iliac artery ligation in one case. The access routes and embolic materials used in these three cases are summarized in Table 1. Of note, is the fact that in only one case
iI
II
"
=
"
! j ~
7 / a, ~
s
Fig. 2 Aortogram performed in a left anterior oblique projection. The pubic branch (straight arrows) arising from the right inferior epigastric artery to supply the site of active bleeding (curved arrow) is well visualised. 9 1995 The Royal College of Radiologists, Clinical Radiology, 50, 710 714.
Fig. 4 Post embolization aortogram demonstrates successful occlusion of the branch of the right internal iliac artery from which contrast medium extravasation had been seen (compare with Fig. 1).
712
CLINICAL RADIOLOGY
Table 1 - Access routes employed in pelvic arterial embolization following bilateral (n = 2) and unilateral (n = 1) internal iliac ligation Author
No. of cases
Arteries catheterized
Materials and method
Complications
1
Left medial circumflex
None
1
Rt medial circumflex Median sacral Lowest lumbar
Gelfoam - forced from wedged position Gelfoam proximal occlusion
1
Left medial circumflex Rt int iliac Lowest lumbar
Gelfoam proximal occlusion
Small bowel infarction
Bilateral
Brown [11] Heaston [12] Greenwood [14]
Transient buttock ischaemia
Unilateral
Greenwood [14]
Fig. 5 Diagram of main collateral vessels which may contribute to pelvic supply following internal iliac artery ligation. The opposite internal iliac artery (not shown) will, if patent, also contribute to the collateral supply. DCI, Deep circumflex iliac artery; IE, inferior epigastric artery; II, internal iliac artery; IL, iliolumbar artery; IMA; inferior mesenteric artery; IP, internal pudendal artery; LA, lumbar artery; LC, lateral circumflex artery; LS, lateral sacral artery; MC, medial circumflex artery; MH, middle haemorrhoidal artery; MS, median sacral artery; OA, obturator artery; PB, pubic branch of inferior epigastric artery; SG, superficial gluteal artery; SH, superior haemorrhoidal artery.
Table 2 - Advantages of early radiological approach prior to surgical intervention 1 Higher likelihood of controlling haemorrhage 2 Easier selective catheterization and embolization of haemorrhaging internal iliac artery branch vessel 3 Lesser risk of target organ ischaemia/infarction (bladder, bowel, uterus) 4 Prevention of hysterectomy and subsequent preservation of childbearing capabilities
was the use of a wedged catheter position commented upon, none used the pubic branch of the inferior epigastric artery and none used polyvinyl alcohol as embolic material. Complications recorded included transient buttock ischaemia and small bowel infarction. Our patient did not develop any complications as a result of this procedure. The principal vessels which may contribute to the continued filling of the internal iliac artery after its proximal surgical ligation are shown in Fig. 5 and prior knowledge of these is important if embolization is to be successful in cases of continuing pelvic haemorrhage. Pubic or obturator branches arising from the proximal inferior epigastric artery are potential collateral vessels which are not mentioned in previous reports of pelvic embolization. A pubic artery is a constant branch of the inferior epigastric artery which anastomoses with the pubic branch of the obturator artery. In 20% to 30% of individuals this branch will be large and will replace the obturator artery, a normal variant which is present on the left side in this patient (Figs 1 & 2). In this case a pubic branch afforded the most direct access to the haemorrhaging vessel and allowed successful embolization. A wedged catheter position allowed particulate embolic material to be forced through this collateral circulation into the internal iliac artery without reflux into the femoral artery. Even though our approach was successful in obtaining haemostasis, and represented a life-saving procedure for this patient, angiography and embolization would have been easier to perform without prior surgery. This would have allowed direct catheterization of the internal iliac artery, identification of the haemorrhaging vessel and specific vessel embolization. Bleeding sites are often impossible to localize at surgery but are usually easily identified an angiography. Furthermore, the radiological approach may prevent the need for hysterectomy thus preserving childbearing capabilities. Other potential benefits of a radiological approach are listed in Table 2.
CONCLUSION The present report serves as a reminder that vascular embolization can be a life saving technique in controlling 9 1995 The Royal College of Radiologists; Clinical Radiology, 50, 710-714.
PELVIC ARTERIAL EMBOLIZATION
life threatening PPH even following bilateral internal iliac artery ligation.
713
small arteries in the pelvis without the risk of producing widespread tissue ischaemia and possible infarction.
REFERENCES 1 Beischer NA, Mackay EV. Obstetrics and the newborn, 2nd ed. Eastbourne: Balliere Tindall, 1986:360-375. 2 Halt MH, Halliwell R, Carr-Hitl R. Concomitant and repeated happenings of complications of the third stage of labour. British Journal of Obstetrics and Gynaecology 1985;86:633-636. 3 Gilbert L, Porter W, Brown V. Post partum haemorrhage - a continuing problem. British Journal of Obstetrics and Gynaecology 1987;94:67-71. 4 Shingawa S. Extraperitoneal ligation of the internal iliac arteries as a life and uterus saving procedure for uncontrollable post partum haemorrhage. American Journal of Obstetrics and Gynaecology 1964;88:130-134. 5 Seavers R, Lynch J, Ballard R et aL Hypogastric artery ligation for uncontrollable haemorrhage in acute pelvic trauma. Surgery 1964;58:516-518. 6 Ravdin IS, Ellison EH. Hypogastric artery ligation in acute trauma. An editorial. Surgery 1964;58:601. 7 Clark SL, Phelan JP, Yeh SY et al. Hypogastric artery ligation for obstetric haemorrhage. Obstetrics and Gynaecology 1985;66:353356. 8 Bruce SL, Paul RH, VanDorsten JP. Control of post partum uterine atony by intramyometrial prostglandin. Obstetrics and Gynaecology 1982;59:47S-50S. 9 Fahmy K. Internal iliac artery ligation and its efficiency in controlling pelvic haemorrhage. International Surgery 1969; 59:244-250. 10 Burchell RC. Physiology of internal iliac artery ligation. Journal o f Obstetrics and Gynaecology of the British Commonwealth 1968;75:642-651. 11 Brown BJ, Heaston DK, Poulson AM et al. Uncontrollable post partum bleeding: A new approach to haemostasis through angiographic arterial embolization. Obstetrics and Gynaecology 1979;54:361-364. 12 Heaston DK, Mineau DE, Brown BJ et al."Transcatheter arterial embolization for control of persistent massive puerperal haemorrhage after bilateral surgical hypogastric artery ligation. American Journal of Roentgenology 1979;133:152-154. 13 Duggan PM, Jamieson MG, Wallie WJ. Intractable postpartum haemorrhage managed by angiographic embolization: Case report and review of the literature. Australian and New Zealand Journal o f Obstetrics and Gynaecology 1991;31:229 234. 14 Greenwood LH, Glickman MG, Schwartz PE et al. Obstetric and non malignant gynaecological bleeding: treatment with angiographic embolization. Radiology 1987;164:155-159.
Invited Commentary by Dr J. Mclvor, Consultant Radiologist, Hammersmith and Chafing Cross Hospitals, London This is an interesting paper describing a relatively new technique, which seems to have been life saving in this patient. The background is well reviewed and it was interesting to learn that arterial ligation has a success rate of less than 50% in severe obstetric haemorrhage. The paper underlines the role of angiography in managing this condition but it should be borne in mind that the degree of technical expertise required for super selective catheterization using a coaxial system is not widely available. The account of the physiological changes produced by ligating the internal iliac arteries is fascinating and the diagram of the potential collateral arterial pathways in the pelvis is really excellent. This report illustrates how a co-axial system using 3-F catheters is a major technical advance which has made it possible to selectively catheterize and embolize 9 1995 The Royal Collegeof Radiologists, ClinicalRadiology, 50, 710-714.
Invited Commentary by Dr R. Forman, Senior Lecturer and Consultant in Obstetrics and Gynaecology, Guy's and St Thomas' Hospitals Trust, London Major post partum haemorrhage (PPH) is a significant obstetric emergency. As in the case illustrated in this report, PPH is a frequent sequel ofantepartum haemorrhage due to placental abruption. Obstetric haemorrhage accounted for 22 of the 145 maternal deaths described in the report on Confidential Enquiries into Maternal Deaths between 1988 and 1990 [1]. This was double the incidence in the previous triennium and highlighted the need for greater awareness of the potential catastrophic consequences of this obstetric complication. The authors of the Confidential Enquiries report stressed the need for written protocols on every labour ward to manage major PPH. Delay in undertaking surgery is a significant factor associated with mortality. In the light of these comments, is there a place for pelvic arterial embolization in the management of primary PPH and should, as the authors of this paper suggest, embolization be performed before surgery? PPH can be due to uterine atony, which accounts for over 80% of cases, trauma to the uterus, or its vascular supply, or vaginal lacerations. The latter are easily amenable to surgical repair. Atonic uterus is managed initially by oxytocics, the removal of any retained placental tissue if present, followed if necessary by intramyometrial administration of prostaglandin. If the uterus remains atonic surgery would be considered at this stage. Uterine trauma, suggested by bleeding in the absence of a vaginal or cervical laceration with a well contracted uterus is also usually treated surgically. Either hysterectomy or ligation of the initial iliac arteries can be performed as surgical management of an atonic uterus. The latter will not cause the uterus to contract but, as explained in this paper, will reduce arterial pulse pressure distal to the site of occlusion allowing clotting to occur. Clark et al. reported that internal iliac artery ligation was only successful in controlling haemorrhage from the uterine atony in six of 15 cases [2]. Hysterectomy of a term gravid uterus is a difficult procedure associated with significant risks, including damage to ureters and bladder as well as secondary haemorrhage. While surgery carries high operative morbidity, failure to perform surgery may be responsible for maternal death. If radiologists can steer a middle course in this therapeutic minefield, it should be welcomed by obstetricians and patients alike. From a practical point of view if pelvic arterial emboiization is to be offered as the treatment of first choice should medical therapy be unsuccessful it is imperative that a 24h emergency service must be available. The number of cases performed to date is limited and only a few centres will be able to amass experience. PPH resulting in hypovolaemia occurs in 0.5% of deliveries. Perhaps 10% of these would currently be treated surgically. An average obstetric unit delivering 2000-3000 women per year would only have one or two cases per year suitable for pelvic arterial embolization. Whereas the case reported here was transferred to a centre of excellence for the technique to be performed, this would
714
CLINICAL RADIOLOGY
probably not be feasible for a patient haemorrhaging from an atonic uterus. It remains to be seen whether a suitable infrastructure can be created at a local level so that pelvic arterial embolization can be made more widely available to women experiencing this potentially catastrophic obstetric complication.
REFERENCES
1 Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1988-90. London: HMSO, 34-42. 2 Clark SL, Phelan, JP, Yeh SY et al. Hypogastric artery ligation for obstetric haemorrhage. Obstetrics and Gynecology 1985;66: 353-6.
9 1995 The Royal College of Radiologists, Clinical Radiology, 50, 710-714.
Clinics in Interventional Radiology Pelvic Arterial Embolization Following Hysterectomy and Bilateral Internal Iliac Artery Ligation for Intractable Primary Post Partum Haemorrhage C. D. COLLINS and J. E. JACKSON*
Departments of Radiology, Christie Hospital NHS Trust, Wilmslow Road, Manchester, and *Royal Postgraduate Medical School, Hammersmith Hospital, London, UK A case of successful arterial embolization following hysterectomy and bilateral internal iliac artery ligation for intractable primary post partum haemorrhage is described. The selected artery was a branch of the inferior epigastric artery. Little has been written to date in the radiological literature about embolization via pelvic collateral vessels following arterial llgation. Although there is a good argument for postponing surgery until transcatheter embolization has been attempted, this case demonstrates that embolization can still be successful even when performed following surgery. Collins, C.D. & Jackson, J.E. (1995). Clinical Radiology 50, 710-714. Pelvic Arterial Embolization Following Hysterectomy and Bilateral Internal Iliac Artery Ligation for Intractable Primary Post Partum Haemorrhage
CASE REPORT
DISCUSSION
A 38-year-old patient (gravid 1, para 1) presented at 38 weeks gestation with a placental abruption. She gave birth to a still-born child. Six hours post-partum, the patient collapsed with a severe bleed per vaginam. Two subsequent laparotomies at which a hysterectomy and bilateral internal iliac artery ligation were performed failed to control the bleeding. The patient required a total of 63 units of blood in addition to coagulation replacement products and had developed disseminated intravascular coagulation and renal failure by the time of her transfer to Hammersmith hospital for emergency angiography with a view to possible embolization. Aortography was performed via the right femoral artery with a 5-F pigtail catheter. Both internal iliac arteries were ligated at their origin but both filled in their entirety via numerous collaterals including lumbar, median sacral and inferior epigastric arteries. Active contrast medium extravasation was seen from a branch of the anterior division of the right internal iliac artery (Fig. 1). Aortography performed in a left anterior oblique projection (Fig. 2) demonstrated that the pubic branch of the right inferior epigastric artery afforded the most direct approach to the branch of the right internal iliac artery from which there was contrast medium extravasation. Using the right femoral access, the right inferior epigastric artery was then catheterized with a 5-F, femoro-visceral catheter and further arteriography confirmed the communication between it and the internal iliac artery (Fig. 3). A co-axial 3-F Tracker 18 catheter (Target Therapeutics, Fremonth, CA, USA) was subsequently introduced into a wedged position in the pubic branch of the inferior epigastric artery to a point as close to the haemorrhaging internal iliac artery branch as possible. Polyvinyl alcohol (Contour, ITC) with a particle size of 150/~m 250#m was then forced through the collateral vessels into the anterior division of the right internal iliac artery and embolization of the haemorrhaging vessel was achieved. A post-embolization aortogram demonstrated a good angiographic result with occlusion of the distal branches of the right internal iliac artery and cessation of contrast medium extravasation (Fig. 4). The patient required a further laparotomy 12 h later for removal of a large pelvic haematoma. There was no evidence of active bleeding at this operation. She has since made a good recovery.
Primary post partum haemorrhage (PPH) is usually defined as bleeding from the genital tract of 600 ml or more in the first 24 h following delivery of the baby [1]. The reported incidence varies from 5 % [2] to greater than 10% [3], mainly due to difficulties in estimating the amount of blood lost. Care of the patient with PPH is directed towards rapid identification of the source and control of the bleeding before the situation becomes critical. If there is a uterine or vaginal laceration, this will require surgical repair; uterine atony is treated by ensuring the uterus is empty, 'rubbing up a contraction' and using oxytocics. If these are not successful in controlling haemorrhage, further surgery or transarterial embolization may be necessary. Traditional surgical therapy of pelvic haemorrhage consists most commonly of unilateral or bilateral internal iliac artery ligation although, in the case of PPH, hysterectomy is performed more often than ligation [4]. Surgical treatment of pelvic haemorrhage, however, is not without its difficulties. Ligation may be technically difficult or impossible [5] and removing a pelvic haematoma may destroy its tamponade effect [6]. In the largest series devoted to internal iliac artery ligation the technique was successful in eight out of nineteen cases (42%) [7]. In two further cases the procedure was unsuccessful in controlling haemorrhage [8,9]. Following analysis of the physiology of internal iliac artery ligation in the non-pregnant patient Burchell [10] concluded that this procedure reduced the pulse pressure distal to the ligation by 85%, the mean pressure by 24% and the blood flow by 48%, thereby essentially converting an arterial system into a venous one. As a result of this work he postulated that by reducing the arterial pulsation, clot forms distal to the ligation and remains in place, rather than being repeatedly removed by blood flow at arterial pressure. In pregnancy, however, the extensive collateral circulation to the distal branches
Correspondence to: Dr J.E. Jackson, Royal Postgraduate Medical School, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK. 9 1995 The Royal Collegeof Radiologists.
711
PELVIC ARTERIAL EMBOLIZATION
% %
Fig. 3 - Injective with the 5-F catheter at the origin of the right inferior epigastric arteriogram. A distal branch of the right internal iliac artery is opacified from which continued contrast medium extravasation is seen. A 3-F co-axial catheter was subsequently manipulated into the pubic artery branch to the point marked (arrow).
Fig. 1 - Aortogram demonstrates proximal occlusion of both internal iliac arteries due to surgical ligation with opacification of their distal branches via collateral vessels. Contrast medium extravasation is seen in the right pelvis indicating active haemorrhage (arrow).
of the internal iliac artery may render ligation of the proximal portion ineffective in controlling pelvic haemorrhage. The first case where angiographic arterial embolization was used to control PPH was reported simulta-
neously in the radiological and obstetrical literature in 1979 [11,12]. To date, angiographic embolization has been used in the management of PPH in 35 cases. These are summarized in a paper by Duggan et al. [13]. Further examination of this literature, however, reveals that embolization has been successfully used in the management of PPH following bilateral internal iliac artery ligation in only two cases and following unilateral iliac artery ligation in one case. The access routes and embolic materials used in these three cases are summarized in Table 1. Of note, is the fact that in only one case
iI
II
"
=
"
! j ~
7 / a, ~
s
Fig. 2 Aortogram performed in a left anterior oblique projection. The pubic branch (straight arrows) arising from the right inferior epigastric artery to supply the site of active bleeding (curved arrow) is well visualised. 9 1995 The Royal College of Radiologists, Clinical Radiology, 50, 710 714.
Fig. 4 Post embolization aortogram demonstrates successful occlusion of the branch of the right internal iliac artery from which contrast medium extravasation had been seen (compare with Fig. 1).
712
CLINICAL RADIOLOGY
Table 1 - Access routes employed in pelvic arterial embolization following bilateral (n = 2) and unilateral (n = 1) internal iliac ligation Author
No. of cases
Arteries catheterized
Materials and method
Complications
1
Left medial circumflex
None
1
Rt medial circumflex Median sacral Lowest lumbar
Gelfoam - forced from wedged position Gelfoam proximal occlusion
1
Left medial circumflex Rt int iliac Lowest lumbar
Gelfoam proximal occlusion
Small bowel infarction
Bilateral
Brown [11] Heaston [12] Greenwood [14]
Transient buttock ischaemia
Unilateral
Greenwood [14]
Fig. 5 Diagram of main collateral vessels which may contribute to pelvic supply following internal iliac artery ligation. The opposite internal iliac artery (not shown) will, if patent, also contribute to the collateral supply. DCI, Deep circumflex iliac artery; IE, inferior epigastric artery; II, internal iliac artery; IL, iliolumbar artery; IMA; inferior mesenteric artery; IP, internal pudendal artery; LA, lumbar artery; LC, lateral circumflex artery; LS, lateral sacral artery; MC, medial circumflex artery; MH, middle haemorrhoidal artery; MS, median sacral artery; OA, obturator artery; PB, pubic branch of inferior epigastric artery; SG, superficial gluteal artery; SH, superior haemorrhoidal artery.
Table 2 - Advantages of early radiological approach prior to surgical intervention 1 Higher likelihood of controlling haemorrhage 2 Easier selective catheterization and embolization of haemorrhaging internal iliac artery branch vessel 3 Lesser risk of target organ ischaemia/infarction (bladder, bowel, uterus) 4 Prevention of hysterectomy and subsequent preservation of childbearing capabilities
was the use of a wedged catheter position commented upon, none used the pubic branch of the inferior epigastric artery and none used polyvinyl alcohol as embolic material. Complications recorded included transient buttock ischaemia and small bowel infarction. Our patient did not develop any complications as a result of this procedure. The principal vessels which may contribute to the continued filling of the internal iliac artery after its proximal surgical ligation are shown in Fig. 5 and prior knowledge of these is important if embolization is to be successful in cases of continuing pelvic haemorrhage. Pubic or obturator branches arising from the proximal inferior epigastric artery are potential collateral vessels which are not mentioned in previous reports of pelvic embolization. A pubic artery is a constant branch of the inferior epigastric artery which anastomoses with the pubic branch of the obturator artery. In 20% to 30% of individuals this branch will be large and will replace the obturator artery, a normal variant which is present on the left side in this patient (Figs 1 & 2). In this case a pubic branch afforded the most direct access to the haemorrhaging vessel and allowed successful embolization. A wedged catheter position allowed particulate embolic material to be forced through this collateral circulation into the internal iliac artery without reflux into the femoral artery. Even though our approach was successful in obtaining haemostasis, and represented a life-saving procedure for this patient, angiography and embolization would have been easier to perform without prior surgery. This would have allowed direct catheterization of the internal iliac artery, identification of the haemorrhaging vessel and specific vessel embolization. Bleeding sites are often impossible to localize at surgery but are usually easily identified an angiography. Furthermore, the radiological approach may prevent the need for hysterectomy thus preserving childbearing capabilities. Other potential benefits of a radiological approach are listed in Table 2.
CONCLUSION The present report serves as a reminder that vascular embolization can be a life saving technique in controlling 9 1995 The Royal College of Radiologists; Clinical Radiology, 50, 710-714.
PELVIC ARTERIAL EMBOLIZATION
life threatening PPH even following bilateral internal iliac artery ligation.
713
small arteries in the pelvis without the risk of producing widespread tissue ischaemia and possible infarction.
REFERENCES 1 Beischer NA, Mackay EV. Obstetrics and the newborn, 2nd ed. Eastbourne: Balliere Tindall, 1986:360-375. 2 Halt MH, Halliwell R, Carr-Hitl R. Concomitant and repeated happenings of complications of the third stage of labour. British Journal of Obstetrics and Gynaecology 1985;86:633-636. 3 Gilbert L, Porter W, Brown V. Post partum haemorrhage - a continuing problem. British Journal of Obstetrics and Gynaecology 1987;94:67-71. 4 Shingawa S. Extraperitoneal ligation of the internal iliac arteries as a life and uterus saving procedure for uncontrollable post partum haemorrhage. American Journal of Obstetrics and Gynaecology 1964;88:130-134. 5 Seavers R, Lynch J, Ballard R et aL Hypogastric artery ligation for uncontrollable haemorrhage in acute pelvic trauma. Surgery 1964;58:516-518. 6 Ravdin IS, Ellison EH. Hypogastric artery ligation in acute trauma. An editorial. Surgery 1964;58:601. 7 Clark SL, Phelan JP, Yeh SY et al. Hypogastric artery ligation for obstetric haemorrhage. Obstetrics and Gynaecology 1985;66:353356. 8 Bruce SL, Paul RH, VanDorsten JP. Control of post partum uterine atony by intramyometrial prostglandin. Obstetrics and Gynaecology 1982;59:47S-50S. 9 Fahmy K. Internal iliac artery ligation and its efficiency in controlling pelvic haemorrhage. International Surgery 1969; 59:244-250. 10 Burchell RC. Physiology of internal iliac artery ligation. Journal o f Obstetrics and Gynaecology of the British Commonwealth 1968;75:642-651. 11 Brown BJ, Heaston DK, Poulson AM et al. Uncontrollable post partum bleeding: A new approach to haemostasis through angiographic arterial embolization. Obstetrics and Gynaecology 1979;54:361-364. 12 Heaston DK, Mineau DE, Brown BJ et al."Transcatheter arterial embolization for control of persistent massive puerperal haemorrhage after bilateral surgical hypogastric artery ligation. American Journal of Roentgenology 1979;133:152-154. 13 Duggan PM, Jamieson MG, Wallie WJ. Intractable postpartum haemorrhage managed by angiographic embolization: Case report and review of the literature. Australian and New Zealand Journal o f Obstetrics and Gynaecology 1991;31:229 234. 14 Greenwood LH, Glickman MG, Schwartz PE et al. Obstetric and non malignant gynaecological bleeding: treatment with angiographic embolization. Radiology 1987;164:155-159.
Invited Commentary by Dr J. Mclvor, Consultant Radiologist, Hammersmith and Chafing Cross Hospitals, London This is an interesting paper describing a relatively new technique, which seems to have been life saving in this patient. The background is well reviewed and it was interesting to learn that arterial ligation has a success rate of less than 50% in severe obstetric haemorrhage. The paper underlines the role of angiography in managing this condition but it should be borne in mind that the degree of technical expertise required for super selective catheterization using a coaxial system is not widely available. The account of the physiological changes produced by ligating the internal iliac arteries is fascinating and the diagram of the potential collateral arterial pathways in the pelvis is really excellent. This report illustrates how a co-axial system using 3-F catheters is a major technical advance which has made it possible to selectively catheterize and embolize 9 1995 The Royal Collegeof Radiologists, ClinicalRadiology, 50, 710-714.
Invited Commentary by Dr R. Forman, Senior Lecturer and Consultant in Obstetrics and Gynaecology, Guy's and St Thomas' Hospitals Trust, London Major post partum haemorrhage (PPH) is a significant obstetric emergency. As in the case illustrated in this report, PPH is a frequent sequel ofantepartum haemorrhage due to placental abruption. Obstetric haemorrhage accounted for 22 of the 145 maternal deaths described in the report on Confidential Enquiries into Maternal Deaths between 1988 and 1990 [1]. This was double the incidence in the previous triennium and highlighted the need for greater awareness of the potential catastrophic consequences of this obstetric complication. The authors of the Confidential Enquiries report stressed the need for written protocols on every labour ward to manage major PPH. Delay in undertaking surgery is a significant factor associated with mortality. In the light of these comments, is there a place for pelvic arterial embolization in the management of primary PPH and should, as the authors of this paper suggest, embolization be performed before surgery? PPH can be due to uterine atony, which accounts for over 80% of cases, trauma to the uterus, or its vascular supply, or vaginal lacerations. The latter are easily amenable to surgical repair. Atonic uterus is managed initially by oxytocics, the removal of any retained placental tissue if present, followed if necessary by intramyometrial administration of prostaglandin. If the uterus remains atonic surgery would be considered at this stage. Uterine trauma, suggested by bleeding in the absence of a vaginal or cervical laceration with a well contracted uterus is also usually treated surgically. Either hysterectomy or ligation of the initial iliac arteries can be performed as surgical management of an atonic uterus. The latter will not cause the uterus to contract but, as explained in this paper, will reduce arterial pulse pressure distal to the site of occlusion allowing clotting to occur. Clark et al. reported that internal iliac artery ligation was only successful in controlling haemorrhage from the uterine atony in six of 15 cases [2]. Hysterectomy of a term gravid uterus is a difficult procedure associated with significant risks, including damage to ureters and bladder as well as secondary haemorrhage. While surgery carries high operative morbidity, failure to perform surgery may be responsible for maternal death. If radiologists can steer a middle course in this therapeutic minefield, it should be welcomed by obstetricians and patients alike. From a practical point of view if pelvic arterial emboiization is to be offered as the treatment of first choice should medical therapy be unsuccessful it is imperative that a 24h emergency service must be available. The number of cases performed to date is limited and only a few centres will be able to amass experience. PPH resulting in hypovolaemia occurs in 0.5% of deliveries. Perhaps 10% of these would currently be treated surgically. An average obstetric unit delivering 2000-3000 women per year would only have one or two cases per year suitable for pelvic arterial embolization. Whereas the case reported here was transferred to a centre of excellence for the technique to be performed, this would
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probably not be feasible for a patient haemorrhaging from an atonic uterus. It remains to be seen whether a suitable infrastructure can be created at a local level so that pelvic arterial embolization can be made more widely available to women experiencing this potentially catastrophic obstetric complication.
REFERENCES
1 Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1988-90. London: HMSO, 34-42. 2 Clark SL, Phelan, JP, Yeh SY et al. Hypogastric artery ligation for obstetric haemorrhage. Obstetrics and Gynecology 1985;66: 353-6.
9 1995 The Royal College of Radiologists, Clinical Radiology, 50, 710-714.