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Abstract

  1. Top of page
  2. Abstract
  3. Case report 1
  4. Case report 2
  5. Discussion
  6. References

Haemorrhage from pelvic veins during obstetric and gynaecological surgery is a major cause of morbidity and mortality. In a recent commentary entitled The Seven Surgeons of King's: a fable by Aesop1, surgeons from different specialties used techniques peculiar to their own practice to treat a woman with intractable haemorrhage. Could transcatheter arterial embolisation be the ‘eighth surgeon’? We describe two cases where embolisation was used to control bleeding when local surgical measures had failed and discuss the use of embolisation in obstetrics and gynaecology.


Case report 1

  1. Top of page
  2. Abstract
  3. Case report 1
  4. Case report 2
  5. Discussion
  6. References

A 35 year old woman underwent a Burch colposuspension. During the operation, after the sutures for the colposuspension had been placed, bleeding was seen to come from the right side of the pelvis. The sutures on the right side of the colposuspension were removed to investigate the bleeding. Attempts at controlling the bleeding with further sutures were unsuccessful and after two hours the pelvis was packed and the advice of an interventional radiologist was sought. Emergency balloon tamponade of both internal iliac arteries was carried out, and the woman was transferred to the angiography suite, still under general anaesthesia. Selective bilateral internal iliac arteriography showed there was extravasation of dye from the anterior division of the right internal iliac artery (Fig. 1). Gelfoam pledgets were injected until haemostasis was confirmed radiologically (Fig. 2) and then a metallic coil inserted. She was then transferred for 36 hours to the intensive care unit. Before extubation the following day the pelvic packs were removed. Her recovery was complicated by parasthesia and lack of power in her right leg, which has gradually improved. Nerve conduction studies suggested that this was neuropraxia and a full recovery is likely.

image

Figure 1. Extravasation of dye from the anterior division of the internal iliac artery.

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Figure 2. Injection of gelfoam pledgets until haemostasis confirmed radiologically.

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Case report 2

  1. Top of page
  2. Abstract
  3. Case report 1
  4. Case report 2
  5. Discussion
  6. References

A 34 year primigravid woman was admitted to our hospital at 26 weeks of gestation with increasingly severe abdominal pain. Investigations, including magnetic resonance imaging, showed a mass measuring 12 cm in diameter in the rectovaginal pouch. While undergoing evaluation of this mass she collapsed with sign of intra-abdominal haemorrhage. A laparotomy was performed when the peritoneal cavity was found to be full of blood. A classical caesarean section was carried out, a little boy weighing 1.06 kg being born. Only after the delivery was it possible to ascertain that the origin of the bleeding was spontaneous rupture of a left ovarian cyst. The cyst was impacted in the pelvis and bound to the side wall by adhesions. Attempts to remove the cyst provoked free bleeding. We consulted the interventional radiologist who successfully occluded both iliac arteries with balloon catheters. Angiography showed that the bleeding area was supplied by both internal iliac arteries which were successfully embolised by gelfoam. Post-operatively, there was evidence of continued intra-abdominal haemorrhage, but this was not severe and did not require active treatment. Her baby progressed well.

Discussion

  1. Top of page
  2. Abstract
  3. Case report 1
  4. Case report 2
  5. Discussion
  6. References

Diagnostic angiography to identify the site of acute haemorrhage was first described in the 1960s2, and the introduction of several percutaneous methods of controlling of bleeding first used in the 1970s. These included intra-arterial vasoconstrictors3, the Wholey balloon occlusion catheter4 and transcatheter embolisation5. In recent years transcatheter embolisation has been shown to be a highly effective technique for controlling bleeding from the pelvis.

In both our cases haemorrhage was so severe that it was not possible to identify clearly the site of the bleeding; this was possible only with arteriography. Furthermore in the second case, the extensive collateral circulation in pregnancy made successful surgical control of haemostasis unlikely.

The standard treatment of sustained pelvic haemorrhage is ligation of the internal iliac arteries. The justification for this treatment is the haemodynamic studies carried out by Burchell6, who showed that bilateral ligation of the internal iliac arteries reduced pelvic blood flow by 49% and the pulse pressure beyond the ligation by 85%, thus promoting haemostasis. However, the reported success of this treatment is 40% to 100%7–11, with a poor result in haemorrhage due to an atonic uterus8,10. These observations may be explained by radiologic evidence showing that there is rapid reconstitution of blood flow through the distal internal iliac artery after proximal ligation12.

In the setting of massive pelvic haemorrhage, visualisation of the pelvic floor and the iliac vessels can often be difficult13. In our two cases continuing haemorrhage distorted the anatomy and made visualisation of the pelvis difficult, making identification of the source of the bleeding impossible. The main advantage of embolisation is that it allows easy identification of the source of the bleeding. It also allows more distal occlusion than with surgical ligation, as well as occlusion of collateral vessels contributing to the bleeding. Even when the bleeding vessel cannot be identified, either surgically or angiographically, successful control of bleeding has been seen with embolisation of the internal iliac artery12. Angiographic embolisation like any other technique has its limitations. It is important to realise that it may not be always effective in controlling haemorrhage14. In addition, not all maternity units will have facilities for arterial embolisation.

Nevertheless, we believe that arterial embolisation should be the first-line treatment of postpartum and gynaecological haemorrhage refractory to local or conservative treatment, since failed surgical arterial ligation can render later embolisation difficult or impossible15, with the result that hysterectomy is the only treatment.

References

  1. Top of page
  2. Abstract
  3. Case report 1
  4. Case report 2
  5. Discussion
  6. References