POST PARTUM HEMORRHAGE WHEN IR SHOULD BE INVOLVED

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1 POST PARTUM HEMORRHAGE WHEN IR SHOULD BE INVOLVED GEST 2016 New York May 5 th Hicham T. ABADA, MD Chief, Interventional Radiology Cleveland Clinic Abu Dhabi AbadaH@ClevelandClinicAbuDhabi.ae

2 Hicham Abada No relevant financial relationship reported

3 IR COULD BE INVOLVED IN 2 SITUATIONS Emergent situations: IR is consulted for an emergent embolization (PPH, vaginal delivery, C-section) Planned situations: Patient is known with placental abnormalities :multiple options are available. In both situations: Importance of having an internal care path.

4 PPH is a leading cause of M&M worldwide. Incidence Assessment of PPH could be very challenging. Inaccuracy of blood loss assessment Underestimate (up to 50%) Even if efforts have been made to help quantification of blood loss Early recognition is crucial INTRODUCTION

5 WHEN PPH IS RECOGNIZED IR is not involved at this early stage. First- line treatment: Ob-Gyn Oxyctocin Misoprostol Methylergometrine Carboprost Weeks A.T he prevention and treatment of PPH: what do we know and where do we go to next. BJOG 2015;122:

6 Second- line treatment: If uterotonic drugs fail to stop bleeding IR could be involved at this stage with uterine artery embolization. Another option: (depends on center or institution) Uterine balloon tamponade B-Lynch suture

7 ACOG bulletin in 2006: Embolization in a stable patient with persisting bleeding and for bleeding persisting after hysterectomy.

8 Identification of an algorithm for management of patients with PPH (internal care pathway) Ob-Gyn Intensivist / Anesthesiologist Interventional radiologist Conservative management fails trigger the call for UAE.

9 RESULTS 46 publications Success rate of PPH : 90.7%

10 IR INVOLVEMENT IN THE MANAGEMENT OF PLACENTA ABNORMALITIES 1.Cesarean Hysterectomy Oyelese Y et al. Obstet Gynecol 2006;107: Conservative management: Placenta left in place Kayem G et al. Obstet Gynecol 2004;104(3):531-6 IR could be involved: UAE Balloon occlusion assisted approach

11 BALLOON OCCLUSION ASSISTED APPROACH Data in the literature are limited. Case reports, mini series. No randomization, no trials. Different technical approaches. There is a heterogeneous set of management

12 BALLOON OCCLUSION ASSISTED APPROACH Abnormal placentations Placenta accreta Goal: Post delivery bleeding (average ml) 12,140 ml +/-8343 ml for Percreta Hysterectomy is not always avoided, but provide good hemodynamic conditions to perform hysterectomy

13 BALLOON OCCLUSION ASSISTED APPROACH First attempt to balloon occlusion of internal iliac arteries. 2 cases reported by Dubois et al. in 1997 Peripartum hysterectomy Balloon occlusion Embolization Reduction 1500 ml- 2000ml blood loss Am J Obstet Gynecol 1997;176:

14 Comparison of placenta accreta management with or without prophylactic balloon insertion. 5 cases prospectively (control of historical cases) Embolization of the anterior trunk. No differences re blood loss. Balloon occlusion group (1100 ml ml) Levine AB et al. Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters. J Matern Fetal Med Jul-Aug;8(4): Placenta accreta treated with UAE 5 patients Placenta accreta Placenta percreta Placenta increta No hysterectomy for hemostasis. Mitty et al. Obstetric hemorrhage: prophylactic and emergency arterial catheterization and embolotherapy. Radiology :

15 BALLOON OCCLUSION ASSISTED APPROACH 6 patients ( control 22 patients) Balloon + Embolization + C- section + Hysterectomy Balloon + Embolization+ Hysterectomy+ cystostomy+ bladder repair No significance difference in blood loss 2600 ml vs 2800 m Bodner LJ et al. Balloon assisted occlusion of the IIA in patients with placenta accreta percreta. CVIR2006:29:

16 STAGED DELIVERY APPROACH 26 patients Balloons are inserted prior delivery C section (anterior wall) Placenta is left if not detached spontaneously. No manual removal UAE (PVA, gelfoam, coils) Stepwise Approach: 4 patients C section Placenta left in place UAE Total Hysterectomy in one week Dramatic reduction is blood loss compared to a control group. Sumigama et al J Obstet Gynecol Res 33(5): Hysterectomy is performed Angstmann T et al. Am J Obstet Gynecol 2010;202:38 e1-e8

17 STAGED DELIVERY APPROACH Results:(26 pts) Blood loss Cesarean Hysterectomy 4517 ml ( ) Staged delivery 553 ml ( ) Angstmann T et al. Am J Obstet Gynecol 2010;202:38 e1-e8

18 CONSERVATIVE TREATMENT FOR PLACENTA ACCRETA: OUTCOMES FOR FERTILITY AND PREGNANCY ( ) multicenter, retrospective 131/167 patients were successfully treated with conservative treatment. Placenta left in place Management of hemorrhage: UAE, balloon, surgical( ligation, stepwise uterine devascularization ) Placenta resorption: no presence of retained placenta in US or Hysteroscopy Sentilhes et al. Human Reproduction 2010,vol 25, No11pp

19 CONCLUSION UAE for the treatment of PPH represents the standard of care as second line treatment after failure of conservative treatment in a stable patient. Further investigations are needed to better standardize the optimal management of patients with placenta accreta. Recommendation : to define a care pathway based on the local expertise of Ob-gyn and IR IR can easily fit into an algorithm for conservative treatment