What are the indications for Interventional Radiology (IR) for postpartum hemorrhage (PPH)?

From the Guidelines

Interventional radiology (IR) for postpartum hemorrhage is indicated when medical management fails to control bleeding and the patient is hemodynamically stable enough for transport to the IR suite, with a success rate of controlling hemorrhage approaching 90% 1. The indications for IR in postpartum hemorrhage include:

• Persistent bleeding despite uterotonic medications (oxytocin, methylergonovine, carboprost, misoprostol)
• Failed tamponade techniques (Bakri balloon)
• Cases where the source of bleeding is identified as arterial in nature
• Placenta accreta spectrum disorders
• Lower genital tract lacerations with difficult surgical access
• Bleeding persists after hysterectomy The procedure typically involves selective arterial embolization of the uterine arteries or other pelvic vessels using gelfoam, coils, or particles 1. IR offers the advantage of being less invasive than surgical interventions like hysterectomy, potentially preserving fertility, and can be lifesaving in cases where surgical control is challenging 1. However, potential complications include infection, arterial dissection, non-target embolization, and rarely uterine necrosis, so patient selection is crucial 1. The American College of Radiology Appropriateness Criteria recommend that pelvic ultrasound (transabdominal and transvaginal with Doppler) is the imaging modality of choice for the initial evaluation of postpartum hemorrhage, and that contrast-enhanced CT of the abdomen and pelvis and CT angiogram of the abdomen and pelvis may be appropriate to determine if active ongoing hemorrhage is present, to localize the bleeding, and to identify the source of bleeding 1. It's also important to note that up to 12% of patients develop uterine synechiae after transarterial embolization, but the risk is less than with uterine compressive sutures or curettage, and subsequent pregnancy rate after transarterial embolization is 76%, with no increase in miscarriage or intrauterine growth restriction, but with an elevated risk of invasive placental disorders and a nearly 20% risk of postpartum hemorrhage 1.

From the FDA Drug Label

Carboprost tromethamine injection is indicated for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management. Prior treatment should include the use of intravenously administered oxytocin, manipulative techniques such as uterine massage and, unless contraindicated, intramuscular ergot preparations Studies have shown that in such cases, the use of carboprost tromethamine injection has resulted in satisfactory control of hemorrhage, although it is unclear whether or not ongoing or delayed effects of previously administered ecbolic agents have contributed to the outcome In a high proportion of cases, carboprost tromethamine injection used in this manner has resulted in the cessation of life threatening bleeding and the avoidance of emergency surgical intervention.

The indication for carboprost tromethamine (IM) in the context of postpartum hemorrhage is for the treatment of postpartum hemorrhage due to uterine atony that has not responded to conventional methods of management, including:

• Intravenously administered oxytocin
• Uterine massage
• Intramuscular ergot preparations (unless contraindicated) 2.

Key points:

• Carboprost tromethamine is used when conventional methods have failed.
• It has been shown to result in satisfactory control of hemorrhage in a high proportion of cases.
• The use of carboprost tromethamine may help avoid emergency surgical intervention.

From the Research

Indications for IR in Postpartum Hemorrhage

The following are indications for interventional radiology (IR) in the management of postpartum hemorrhage (PPH):

• Placenta accreta spectrum 3
• Placenta previa accreta 4
• Placenta previa 4
• Anticipated PPH due to abnormalities associated with hemorrhage, such as morbid placentation 5
• Unpredicted PPH, where primary management has failed 5

IR Procedures for PPH

IR procedures that can be used to manage PPH include:

• Uterine artery embolization (UAE) 4, 3, 6
• Prophylactic balloon occlusion of the common or internal iliac artery or abdominal aorta 3
• Aortic balloon occlusion catheters for the prevention of PPH 3

Effectiveness of IR in PPH

IR procedures have been shown to be effective in controlling PPH, with a high success rate of 98.7% in one study 4. Additionally, IR can reduce the need for hysterectomy and increase survival rates 4, 3.