Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage.

ABSTRACT

OBJECTIVE: Primary postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality around the world. Most patients can be managed conservatively, but patients with intractable bleeding require more aggressive treatment. In these cases uterine artery embolisation (UAE) has proven to be a useful tool to control PPH. The reported success rate of UAE is over 90% with only minor complications. In this case series we studied the effectiveness and complications of UAE. DESIGN: Retrospective analysis of a case series. SETTING: Case series in a large peripheral hospital in the Netherlands. SAMPLE Eleven patients who were treated with UAE for intractable PPH from November 2004 to February 2008. METHODS: In this paper we review the results of all patients treated with UAE for intractable PPH in our hospital and focus on the two cases with adverse outcomes. MAIN OUTCOME MEASURES: Effectiveness, causes of failure of UAE, complications. RESULTS: Nine out of eleven patients were treated successfully with UAE. One patient needed an emergency hysterectomy for intractable bleeding. In the aftermath she developed a vesicovaginal fistula (VVF). Another patient suffered a major thrombo-embolic event of the right leg, for which she underwent embolectomies and despite fasciotomy a necrotectomy. CONCLUSIONS: UAE is a valuable tool in managing major PPH and in most cases it can replace surgery and thus prevent sacrification of the uterus. However, due to blood supply of the uterus by one of the ovarian or aberrant arteries, UAE might fail to control the bleeding. In addition, serious complications such as a thrombo-embolic event or VVF may occur. We hereby present a case of migration of an embolus from the site of re-embolisation into the femoral artery requiring immediate intervention to prevent the loss of the lower leg. This complication demonstrates that gelatine sponge particles could migrate from the internal iliac artery into the external iliac artery.