Abstract Postpartum hemorrhage is a serious complication in obstetrics, and it is the first cause of maternal death in China. If traditional conservative treatment is ineffective, internal iliac artery ligation or hysterectomy is performed. In recent years, the application of interventional therapy in postpartum hemorrhage has led to a breakthrough in the treatment of postpartum hemorrhage, providing a new treatment method for patients who need to preserve their reproductive function.
Keywords postpartum hemorrhage, interventional therapy, overview
Chinese Classification Number.
Postpartum hemorrhage is a common condition in obstetrics, and it is generally considered as postpartum hemorrhage when maternal blood loss exceeds 500 ml within 24 hours after delivery of the fetus. Recently, the American University of Obstetrics and Gynecology has reintroduced the definition of postpartum hemorrhage, considering that a 10% decrease in erythrocyte pressure volume at the time of delivery, postpartum, or the need for blood transfusion therapy are called postpartum hemorrhage. Traditionally, in such cases, if conservative treatment fails, bilateral internal iliac artery ligation or (sub)total hysterectomy is often performed to save life. The former requires skilled operators but has a high failure rate, especially when there is an underlying coagulation dysfunction, and may delay treatment; the latter can achieve hemostasis, but at the cost of organ loss and the resulting series of physiological and psychological changes that affect the patient’s quality of life. Therefore, there is an urgent need to find a treatment method that is both effective and can preserve the uterus. In recent years, with the improvement of interventional technology, interventional therapy has made great progress in the treatment of postpartum hemorrhage, and the progress of interventional therapy for postpartum hemorrhage is now reviewed.
1.Progress and status of interventional treatment for postpartum hemorrhage
Interventional therapy is a method to diagnose and treat the organs and tissues where the lesions are located by using ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), X-ray and other modern medical image-oriented technologies. As early as 50 years ago, foreign scholars first applied interventional therapy to surgical diseases such as hemostasis of gastrointestinal bleeding, and in the 1960s, interventional therapy was applied to treat gynecological tumors, and in 1979, Brown first successfully used interventional therapy for postpartum hemorrhage. At present, the treatment of postpartum hemorrhage by intrapelvic artery embolization technique has been widely used abroad, with a success rate of 85-95%, which is significantly higher than that of pelvic artery ligation.
In China, after the first successful application of interventional therapy for postpartum hemorrhage by Deng Jianlin in 1988, interventional therapy has been widely carried out in China. 1995, Chen Chunlin et al. successfully performed interventional therapy for patients with late postpartum hemorrhage. 1999-2002, Jiang Rongzhen treated 14 cases of refractory postpartum hemorrhage with embolization to achieve effective hemostasis, and the hemostatic effect of embolization therapy was 100%, and the cure rate was 92.8%. The hemostatic effect of embolization was 100% and the cure rate was 92.8%.
2.Theoretical foundation
2.1 Anatomical basis The female reproductive organs are mainly supplied by the bilateral internal iliac arteries and ovarian arteries, and the internal iliac artery is the terminal branch, which provides a more ideal vascular anatomical basis for the implementation of interventional therapy for postpartum hemorrhage. Interventional treatment of postpartum hemorrhage is to stop the hemorrhage quickly and completely by inserting a tube into the internal iliac artery, and then injecting an embolic agent into the diseased vessel after imaging the site of hemorrhage to block the blood flow.
2. 2 Theoretical basis of embolization treatment Arterial embolization selectively embolizes the bleeding artery, and the embolic agent not only causes platelet agglutination and fibrin deposition in the blood vessel, forming thrombus and achieving the purpose of occluding the bleeding artery, but also causes the arterial pressure in the bleeding organ-uterus to decrease significantly, slowing down the blood flow, which is conducive to thrombus formation; at the same time, due to the reduced blood supply to the uterus, the smooth muscle of the uterus The contraction of uterine smooth muscle is strengthened due to ischemia and hypoxia of fibers, which controls bleeding from the other side.
Fresh gelatin sponge embolic agent is a soluble medium-acting embolic substance, which can be absorbed 2-3 weeks after embolization, and the blood vessel is reopened. Moreover, it can only embolize to the peripheral arteries, but not the precapillary arteries and capillary beds. This can make the small pre-capillary arteries and their branches continuously occluded to achieve effective hemostasis, and also ensure the smooth circulation of the lateral branches of the pre-capillary plane to prevent the occurrence of rectal, bladder and uterine necrosis. It can achieve complete embolization in patients with normal coagulation mechanism and can be used repeatedly depending on the situation, which increases the flexibility of treatment.
3.Indications and contraindications
3.1 Indications The procedure can be considered for postpartum hemorrhage due to various causes that have not been treated with systematic non-surgical treatment, including: postpartum hemorrhage due to weak uterine contraction, postpartum hemorrhage due to placental implantation, severe soft birth tear, postpartum hemorrhage due to coagulation dysfunction; postpartum hemorrhage of up to 1000 ml that still has a tendency to bleed after aggressive non-surgical treatment; late postpartum hemorrhage with one bleed of up to 500ml, who still have bleeding tendency after active non-surgical treatment.
3.2 Contraindications Severe abnormalities of coagulation mechanism; patients with DIC combined with bleeding from other organs; severe dysfunction of heart, liver, kidney and vital organs; allergy to chronic contrast agents; patients with extremely unstable vital signs who should not be moved.
4.Method
In patients in shock, puncture of the strongest pulsating point of the femoral artery at the midpoint of the inguinal ligament on one side is performed under local anesthesia while the patient is in anti-shock. Femoral artery cannulation is completed with the Seldinger technique. A pelvic angiogram was performed, followed by bilateral internal iliac and uterine artery angiograms to show the site of bleeding and the uterine artery on the bleeding side, and the area of massive contrast spillage was the site of bleeding. A catheter is quickly inserted into the anterior trunk of the internal iliac artery on the bleeding side, and internal iliac artery embolization (IIAE) or uterine artery embolization (UAE) is performed, both of which are transcatheter arterial embolization (TAE). Both are part of transcatheter arterial embolization (TAE). After fixing the catheter and injecting gelatin sponge pellets or gelatin sponge strips with antibiotics or gelatin sponge spring coils into the artery until the bleeding is confirmed to have stopped, digital subtraction imaging (DSA) imaging is performed to confirm that the bleeding has been successfully stopped, without over-embolization. The same method is used to embolize the contralateral side.
Because of the obvious bilateral nature of the uterine supply, embolization of only one uterine artery or the anterior trunk of the internal iliac artery will result in embolization failure. Clinical findings suggest that intraoperative refractory postpartum hemorrhage occurs preferably with internal iliac artery ligation and hysterectomy. In contrast, internal iliac artery embolization is preferred for intractable postpartum hemorrhage occurring postoperatively or after normal delivery. For recurrent hemorrhage, re-embolization is still available.
5.Efficacy evaluation
Interventional treatment of postpartum hemorrhage or late postpartum hemorrhage is effective. The success rate of arterial embolization has been reported to be 97%. The main advantage of this form of treatment is that it eliminates some unnecessary exploratory procedures, specifies the site of bleeding, is effective, preserves the uterus and fertility, and avoids open surgery, anesthetic complications, and concerns about future quality of life. Even if embolization fails, radiographic localization helps the surgeon to perform better and more direct arterial ligation during cesarean section.Ledee et al. concluded that interventional treatment of uterine bleeding due to retained placenta (implantation) is ineffective and hysterectomy is appropriate . However, the success rate of interventional treatment for postpartum hemorrhage caused by abnormal placenta has been reported to be 62-71%. Chen Chunlin et al. reported 18 patients with severe postpartum hemorrhage who had failed conservative treatment, and the hemostasis was successful after TAE treatment, with a hemostasis time of 3-10mim, mean time (6±4) min, and an operation time of 30-50 min, mean (39±5) min; at a follow-up of 4 to 68 months, all 18 patients resumed regular menstruation without serious complications, and ovulation was normal on self-test. One of the patients had delivered again and the mother and baby were healthy.
Pelage et al. reported that 35 patients with severe refractory postpartum hemorrhage (25 with primary postpartum hemorrhage and 10 with late postpartum hemorrhage) had immediate cessation of hemorrhage and no further bleeding after embolization therapy. Goldszmidt et al. used uterine artery interventional embolization successfully in patients with amniotic fluid embolism in combination with severe postpartum hemorrhage, DIC and concomitant respiratory or circulatory dysfunction. Some authors suggest that embolization is easier to develop if the patient is relatively hemodynamically stable. In patients with vaginal delivery, cesarean section, or postoperative bleeding, arterial ligation can still be used if embolization fails. Because the bleeding vessels are limited at this time, it is easier to do. However, embolization after arterial ligation, especially after internal iliac artery ligation, will be particularly difficult or impossible because cannulation cannot be performed. Zhong Jie and Wang C.M. retrospectively analyzed and compared the treatment results of 6 cases of internal iliac artery embolization and 5 cases of internal iliac artery ligation, and the results showed that both methods were effective in treating refractory postpartum hemorrhage, with internal iliac artery embolization having more definite efficacy and being rapid and safe, preserving the uterus and its physiological functions.
In conclusion, the results of a large number of clinical studies have shown that internal iliac artery ligation, hysterectomy and transcatheter arterial embolization are three treatment methods with comparable effects, but internal iliac artery embolization has the best effect because it has short operation time, quick recovery, little trauma, rapid and complete hemostasis, repeatability, little adverse effects, preservation of reproductive function, and is easily accepted by women of childbearing age, which is worth promoting.
6.Complications and side effects
Interventional treatment has obvious efficacy, but at the same time there are certain side effects and complications. Chen Chunlin et al. reported 12 cases of hip pain, 11 cases of fever, and 6 cases of mild weakness and numbness of the lower limbs in 14 patients treated with UAE. Cottier et al. reported a case of a 29-year-old woman with a twin pregnancy who had severe postpartum hemorrhage after vaginal delivery at 37 weeks of gestation. Pathological examination revealed massive localized ischemic necrosis of the myometrium. Other common side effects include bleeding, vascular injury, catheter dissection, thrombosis, abdominal pain, local skin necrosis, misembolism, nerve damage, and iodine allergy.
Whether there is any effect on ovarian function is a common concern at present. Patients with postpartum hemorrhage are mostly young women whose ovaries are highly sensitive to X-rays. Some studies have shown that interventional treatment has some damage to the ovaries, the extent of which depends on the patient’s anatomy, the interventional equipment, the level of interventional technique and the duration of interventional treatment. Immediate or long-term damage can occur when the irradiation received by the ovaries is 200-300 cGY, and >400 cGY leads to irreversible damage to the ovaries. Therefore, if the vascular anatomy of the pelvis is clear and the interventional technique is of a certain level, the radiation dose of interventional treatment is relatively safe if the interventional time is controlled within a certain period of time. wolanske et al. reported a case of a 39-year-old patient in whom embolic agent entered the ovarian artery through the arterial traffic between the uterine artery and the ovarian artery during uterine artery embolization, resulting in a 6-month return visit of the patient symptoms such as emotional instability and irritability. The authors concluded that UAE has an effect on the ovaries and can lead to premature menopause, and Goldbery [19] and others concluded that UAE leads to a decrease in ovarian blood flow and thus affects ovarian function. Recently, American obstetricians and gynecologists followed 28 patients treated with pelvic embolization for postpartum hemorrhage from 1977 to 2002 with a mean follow-up time of 11.7 ± 6.9 years. The findings showed that six patients had separate successful pregnancies and deliveries in the years following embolization. The majority of scholarly studies concluded that postpartum hemorrhage interventions have no effect or a mild, transient and reversible effect, if any, on ovarian function. However, the long-term effects need to be confirmed by further studies and follow-up of more cases.
7. Prospects
In recent years, surgical techniques have tended to be minimally invasive, i.e., minimizing medically induced trauma in order to obtain the desired treatment. Compared with surgical techniques, the greatest advantage of interventional therapy is that it is less invasive, less painful for patients, less dangerous, faster recovery, reliable and can preserve fertility. With the popularization of various new knowledge and techniques, we should pay more attention to the use of minimally invasive techniques to treat postpartum hemorrhage, and even expect preventive applications for patients with potential bleeding tendencies. With the increase of cesarean section rate, the incidence of postpartum hemorrhage has a tendency to rise, so interventional treatment will certainly gain great development.
Interventional treatment of postpartum hemorrhage has achieved promising results in clinical practice, but there are still some difficulties in making it a routine clinical treatment. Most of the available clinical data are recent observations, and most of them are small samples, which lack systematic and comparability. Therefore, we cannot be blindly optimistic about its long-term efficacy, and we need systematic long-term follow-up with large samples to prove the effectiveness and feasibility of this treatment method. Interventional therapy is an interdisciplinary treatment that requires certain skills and expertise to be carried out effectively and to minimize adverse effects and complications, so that interventional therapy can play a greater role in the treatment of postpartum hemorrhage and improve the prognosis of patients with postpartum hemorrhage.