Hemorrhage due to obstetrical and gynecological disorders can occur after severe trauma, all types of gynecological and obstetrical surgery, and germline tumors. The amount of bleeding is often very large and can lead to shock or even life-threatening if rapid and effective measures are not taken to stop the bleeding. In our department, interventional embolization (Transcatheter arterial embolization) was used to treat 21 cases of this disease, and satisfactory results were achieved. Now we report the following and discuss the relevant issues.
1.Materials and methods
1.1 General data: Among the 21 cases, there were 8 cases of late postpartum hemorrhage, 5 cases of hemorrhage at the beginning of radiotherapy for stage III cervical cancer, 1 case each of hemorrhage from erosive uterine gravida and giant rhabdomyosarcoma of the cervix, 1 case of hemorrhage from the vaginal stump after endometrial cancer, 1 case of hemorrhage after clamping for central placenta previa in midterm pregnancy, 2 cases of multiple pelvic fractures and vaginal hemorrhage caused by car accidents in young girls, and 2 cases of functional hemorrhage. The age ranged from 7 to 62 years, with an average of 35.4 years.
1.2 Methods and procedures: If the exact site of bleeding was clearly identified, a healthy arterial approach was performed; otherwise, the femoral artery approach on the easily punctured side was chosen, and the catheter (Cobra catheter 5F is sufficient) was placed in the internal and external iliac arteries or the lower segment of the abdominal aorta (at the level of the lumbar 4 vertebrae) for imaging, and in principle, both internal and external iliac arteries or further small branch angiograms such as super Selective uterine arteriography, etc., to clarify the site, extent, degree and blood supply artery of the bleeding. Then, the catheter is superselected into the blood supplying branch artery as far as possible, and the mixture of gelatin sponge particles (size about 2.0mm×2.0mm×2.0mm) and contrast agent is slowly injected into several milliliters for embolization under fluoroscopic tracking after the fluoroscopic “smoke” or contrast confirmation of the correct selection until the embolic agent in it until the embolic agent was stagnant. In three of the malignant tumors, anhydrous ethanol or silk thread segments were used as embolic material.
Ipsilateral selective or superselective contrast embolization was accomplished using an intravascular catheter into a collaterals technique. After embolization, a second imaging was performed to see if the bleeding had stopped, and if there was still bleeding, further embolization was required until the bleeding had definitely stopped. If necessary, a catheter sheath can be left in place for a short period of time to facilitate re-embolization.
2. Results
2.1 All patients in this group had successful hemostasis with one TAE treatment, including 6 cases of bilateral internal iliac artery embolization, 13 cases of bilateral uterine artery embolization, and 2 cases of embolization of one internal iliac artery and contralateral uterine artery. All patients with hemorrhage were treated with clinical transfusion of contraction, hemostatic drugs, vaginal tamponade, etc., and 15 cases had severe anemia or shock, and vaginal bleeding stopped immediately after emergency TAE. 8 cases of malignant tumors were treated with radiotherapy after TAE without recurrent bleeding, and the treatment was successfully completed.
2.2 Typical cases and efficacy evaluation
Case 1: 27-year-old patient with recurrent vaginal bleeding 20 days after cesarean section, sometimes more and sometimes less. The vaginal bleeding ceased immediately after emergency bilateral internal iliac artery angiography and embolization (see Figure 1234).
Case 2: A 23-year-old patient with irregular vaginal bleeding for 1 month with lower abdominal cramps for half a month and severe anemia was admitted to the ward and diagnosed with rhabdomyosarcoma of the uterine body and cervix after biopsy. The uterus returned to normal shape after 3 times of treatment, and surgical resection was performed (see Figure 5678 in the Appendix).
3. Discussion
Small amount of bleeding due to obstetrical and gynecological disorders can be treated by conservative methods, while for large amount and prolonged bleeding, surgical hemostasis was mostly used in the past. However, due to unfavorable factors such as excessive blood loss in shock or severe anemia, the patient can no longer tolerate larger surgery, and even if the surgery is successful, the subsequent loss of reproductive function and pathological menopause can cause serious consequences for young women. Since the application of interventional radiology in clinical practice, TAE has its unique advantages in the clinical treatment of obstetrical and gynecological bleeding disorders and can have an immediate effect.
3.1 Relevant blood supply characteristics: The blood supply of the pelvic organs is mainly supplied by the internal iliac artery, and most obstetric and gynecological bleeding is from the branches of the internal iliac artery. The branches of the internal iliac artery can be divided into two categories: one is the iliolumbar artery, the lateral sacral artery, the superior gluteal artery, the inferior gluteal artery, the obturator artery and the internal pubic artery, which are distributed to the pelvic wall, perineum and buttocks; the other is the dirty branch of the uterine artery (the uterine artery is a branch of the anterior trunk of the internal iliac artery) and the umbilical artery, the superior bladder artery, the inferior bladder artery and the inferior rectal artery, which are distributed to the pelvic organs. Among them, the rectum has branches from the inferior mesenteric artery, the ovarian artery branches from the abdominal aorta, and the left ovarian artery may branch from the renal artery [1]. Because the anastomotic branches of the pelvic organs are abundant, any or all branches of the internal iliac artery can be embolized and no ischemic necrosis usually occurs after embolization, so there are no major risks and complications.
3.2 Indications and contraindications of TAE
3.2.1 Indications: Traumatic pelvic hemorrhage. Hemorrhage caused by malignant pelvic tumors (such as cervical cancer, uterine sarcoma, erosive staphyloma, choriocarcinoma, etc.), which temporarily cannot be treated by surgery or radiotherapy. Patients with benign tumors (uterine fibroids, uterine adenomyosis, etc.) who wish to be treated conservatively for various reasons. Postpartum hemorrhage and late hemorrhage after cesarean section, unhealthy uterine bleeding and unexplained uterine hemorrhage. Pelvic surgery (e.g. after total hysterectomy or vaginal haemorrhage);
3.2.2 Contraindications: There is no absolute contraindication. As long as the trauma does not prevent the femoral artery puncture angiography and there is no contraindication to general angiography, interventional embolization is feasible to stop bleeding.
3.3 Angiographic performance
Selective angiography can detect arterial capillary bleeding with a bleeding rate greater than or equal to 0.5 ml/min. With the application of new generation DSA equipment, the accuracy of detecting the source of bleeding is greatly improved by applying carbon dioxide as the contrast agent.
In typical hemorrhage, extravasation and aggregation of contrast agent is seen in the arterial phase, sometimes forming a typical blood pool or blood lake. On sequential imaging, extravasation becomes more pronounced, with indistinct margins and a process in which the contrast agent density changes from less to more and from low to high to low.
In the case of bleeding caused by malignant tumor, in addition to the vascular thickening, twisting, tumor staining, A-V-F (arteriovenous fistula) and so on, we can also see the extravasation of contrast agent beyond the tumor staining area, which stays for a longer period of time, and the tumor staining disappears, but the contrast agent outside still stays, resulting in the formation of “filling defect” area in the tumor area.
3.4 Embolic agents and their principles of use: The main embolic agents are gelatin sponge (cut into thin strips or 2.0mm×2.0mm×2.0mm particles according to the situation), stainless steel ring or detachable balloon, sometimes combined with silk thread and anhydrous ethanol, etc.
Principle of use: For small branches of the internal iliac artery and peripheral vessels with bleeding or bleeding, gelatin sponge granules are generally used because they can reach the surrounding branches. For hemorrhage in large branches of the internal iliac artery vessels, stainless steel rings or detachable balloon embolization is used. Diffuse hemorrhage can be started with gelatin sea sponge granules (2mm×2mm×2mm or so) or with stainless steel rings. Malignant tumor can be embolized with silk thread segment and anhydrous ethanol.
3.5 Main complications: ischemic necrosis of the embolized organ, which can be followed by pelvic organ infection, thrombophlebitis and other rare complications. Ischemic necrosis of the distal limb caused by misembolization can be basically avoided by strictly standardized operation. A few may present with hip pain.
3.6 Efficacy evaluation: In TAE treatment, the embolic material effectively reduces the arterial pressure and blood flow of the bleeding artery, which facilitates the rapid formation of intravascular thrombus and achieves hemostasis. For bleeding caused by non-neoplastic lesions, the gelatin sponge can be absorbed in 2-3 weeks and the vessel can be recanalized without causing serious ischemic necrosis of the organ. For malignant tumors, the blood supply is blocked due to the permanent embolism of the threads and the occlusion of blood vessels caused by the protein coagulation property of anhydrous alcohol, which can cause ischemic necrosis of the tumor in addition to hemostasis.
Therefore, as long as the operation is carefully, gently and skillfully, avoiding serious complications caused by misembolization of important organs, and the postoperative treatment is closely observed, the interventional embolization method for treating various difficult hemorrhages in obstetrics and gynecology is a method with exact and rapid efficacy, high success rate, few complications, less patient pain, low cost, and the ability to preserve the uterus in patients with postpartum and post-induction hemorrhage, which has good clinical application value.
Figure I, bleeding, before treatment
Figure 2 After treatment