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Abstract
Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.
Hipola JM et al., 2026·Journal of vascular surgery. Venous and lymphatic disorders·Free full text on PubMed Central
To report feasibility, safety, and clinical outcomes of direct transvaginal ultrasound (TVUS)-guided foam sclerotherapy for isolated periuterine/pericervical varices or residual venous reservoirs after prior embolization.
Prospective single-center observational cohort including consecutive women (January 2023-October 2025) meeting predefined inclusion and exclusion criteria. Procedures were performed under general anesthesia using ultrasound-guided transvaginal venous puncture with fluoroscopic confirmation. Low-nitrogen 3% polidocanol foam was injected directly into the targeted periuterine and pericervical venous plexuses until complete filling of the treated reservoirs was achieved. Primary end points were technical success and changes in the Pelvic Venous Clinical Severity Score (PVCSS) and Pelvic Varicose Vein Questionnaire (PVVQ) score at 1 month and 1 year. Normality was evaluated with the Shapiro-Wilk test, repeated-measures analysis of variance with Mauchly's test for sphericity, and Tukey's honestly significant difference for pairwise comparisons (α = 0.05). Institutional review board approval was obtained, and informed consent was required.
Twenty-three patients (mean age, 40.5 years) underwent treatment; 74% had a history of prior gonadal vein embolization and presented with persistent symptoms at inclusion, whereas 26% had no prior embolization and presented with isolated periuterine or pericervical varices without axial reflux. Technical success was 100%. The mean procedural time was 36.0 ± 12.5 minutes, and the mean fluoroscopy time was approximately 1 minute. The mean sclerosant volume was 18.5 ± 5.3 mL. Radiation exposure remained low, with a mean dose-area product of 1.945 ± 0.347 Gy cm2 and a mean absorbed dose of 72.0 ± 3.1 mGy. All patients were discharged the same day and resumed normal activities the following day. Minor vaginal bleeding occurred in 82% the day after treatment; no menstrual disturbances were reported. TVUS follow-up showed complete closure of the treated periuterine and pericervical venous plexuses, without evidence of recanalization in any patient at follow-up. The PVCSS improved from 12.91 at baseline to 7.87 (1 month) and 7.96 (1 year); the PVVQ score improved from 75.97 to 46.12 and 50.32, respectively. Overall improvement was significant (P < .001). Tukey's honestly significant difference confirmed decreases from baseline to 1 month and 1 year for both scales (PVCSS, P < .001; PVVQ, P < .003); the 1-month vs 1-year differences were not significant (PVCSS, P = .987; PVVQ, P = .094).
Direct TVUS-guided 3% polidocanol foam sclerotherapy achieved high technical success, as well as significant and durable symptom improvement at 1 year in this small, highly selected cohort, with no major complications or recanalization. The technique offers a minimally invasive, targeted option for periuterine and pericervical venous reservoirs, particularly in cases not amenable to conventional endovascular access.
Urbano J et al., 2014·Acta radiologica (Stockholm, Sweden : 1987)
Embolization is an established treatment for varicocele. Coils are most frequently used in the procedure. Liquid embolic and sclerosing agents seem to have a number of advantages over coils.
To report our experience and explain the technique of using N-2-butyl-cyanoacrylate (N2BCA) in varicocele treatment.
From January 2010 to July 2011, 42 gonadal veins in 41 consecutive patients (age range, 11-41 years; mean, 18 years) with a diagnosis of varicocele were treated with N2BCA as an embolic agent. The clinical diagnosis was confirmed by Doppler ultrasound in all patients. Institutional review board approval was obtained, and all the patients signed informed consent for this retrospective review. In all cases, a 4-F hydrophilic catheter was used to catheterize the distal portion of the gonadal vein through which N2BCA, emulsified with lipiodol, was injected.
The technical success was 100%. No complications or non-targeted embolizations were reported. Seven patients reported moderate post-embolization pain that required oral analgesic treatment for 7-10 days. After 12-month follow-up, all patients exhibited varicocele resolution in the Doppler ultrasound examination as well as relief of all previous symptoms. We have no fertility-related data for patients treated for this condition.
N2BCA as an embolic agent is a therapeutic alternative for the endovascular treatment of varicocele. This technique is uncomplicated, inexpensive, efficient, and safe.
Royo P et al., 2008·Journal of medical case reports·Free full text on PubMed Central
Postpartum ovarian vein thrombosis is an uncommon complication; incidence varies between 0.002% and 0.05%. It most often occurs during the 2-15 days following delivery.
A 22-year-old pregnant woman at term presented to hospital with uterine contractions, abdominal pain, nausea and vomiting. After delivery an ovarian vein thrombosis was diagnosed.
Low-molecular weight heparin with broad-spectrum antibiotics are the accepted therapy in non-complicated cases of postpartum ovarian vein thrombosis.
An obstetric hemorrhage may occur before or after delivery, but more than 80% of cases occur postpartum. Worldwide, a massive obstetric hemorrhage, resulting from the failure of normal obstetrical, surgical and/or systemic hemostasis, is responsible for 25% of the estimated 358,000 maternal deaths each year. Most women will not have identifiable risk factors. Nonetheless, primary prevention of a postpartum hemorrhage (PPH) begins with an assessment of identifiable risk factors. Women identified as being at high risk of a PPH should be delivered in a center with access to adequately trained staff and an onsite blood bank. A critical feature of a massive hemorrhage in obstetrics is the development of disseminated intravascular coagulation (DIC), which, in contrast to DIC that develops with hemorrhage from surgery or trauma, is frequently an early feature. Data from clinical trials to guide management of transfusion in PPH are lacking. There are likely to be similarities in the management of transfusion in severe PPH to that of major bleeding in other clinical situations, but the pathophysiological processes that contribute to a massive PPH may necessitate different transfusion strategies such as the ratio of red blood cells to plasma components, in particular fibrinogen. Caution should be exercised when considering the appropriate place for recombinant activated factor VII (rFVIIa) in the management of a major PPH. An early hysterectomy is recommended for severe bleeding as a result of placenta accreta or uterine rupture. However, in women with uterine atony who have ongoing bleeding in spite of an adequate transfusion, it may be reasonable to consider a trial of rFVIIa before a hysterectomy.
Jauniaux E et al., 2019·American Journal of Obstetrics and Gynecology·Free to read
The objective of this study was to evaluate the prevalence of placenta accreta spectrum in general population studies and the main maternal outcomes at delivery. We searched PubMed, Google Scholar, clinicalTrials.gov, and MEDLINE between 1982 and 2018. Articles that provided data on the number of cases of placenta accreta spectrum per pregnancies, births, or deliveries in a defined population were used. STUDY APPRAISAL Study characteristics were evaluated by 2 independent reviewers who used a predesigned protocol. Primary outcomes were the prevalence of placenta accreta spectrum and clinical diagnostic data at birth; the pathologic criteria were used to confirm the diagnosis. Secondary outcomes included cases that required transfusion, incidence of peripartum hysterectomy, and maternal mortality rates. Heterogeneity between studies was analyzed with the Cochran's Q-test and the I2 statistics. Of the 98 full-text studies that were identified, 29 articles met the defined criteria and included 22 retrospective and 7 prospective studies comprising 7001 cases of placenta accreta spectrum of 5,719,992 births. Prevalence rates ranged from 0.01-1.1% with an overall pooled prevalence of 0.17% (95% confidence interval, 0.14-0.19). Only 10 studies provided detailed histopathologic data. The pool prevalence for the adherent vs the invasive grades was 0.5 (95% confidence interval, 0.3-0.36) and 0.3 (95% confidence interval, 0.2-0.4) per 1000 births, respectively. The pooled incidence for peripartum hysterectomy was 52.2% (95% confidence interval, 38.3-66.4; I2=99.8%) and 46.9% (95 % confidence interval, 34-59.9; I2=98.8%) for hemorrhage that required transfusion. The pooled estimate of maternal death was 0.05% (95% confidence interval, 0.06-0.69; I2=73%). We found large amounts of heterogeneity between studies for all parameters and further quantification was limited because of methodologic inconsistencies between studies with regards to clinical criteria that were used for the diagnosis of the condition at birth and the histopathologic confirmation of the diagnosis and differential diagnosis between adherent and invasive accreta placentation. This meta-analysis indicated wide variation between studies for the prevalence rate of placenta accreta spectrum and for the different grades of accreta placentation that highlighted the need for consistency in definitions that are used to describe placenta accreta spectrum at birth and in the reporting of this increasing common obstetric complication.
The aim of the present study was to assess the efficacy of endoscopic repair for secondary infertility caused by post-cesarean scar defect (PCSD). Our investigation focused on the validity of new diagnostic criteria and selection methods. MATERIAL AND The subjects were 22 women with secondary infertility due to PCSD with retention of bloody fluid in the uterine cavity. Women with a residual myometrial thickness of ≥ 2.5 mm and an anteflexed or straight uterus underwent hysteroscopic surgery, while all others underwent laparoscopic repair. Hysteroscopic surgery involved resection and coagulation of scarred areas, whereas laparoscopic surgery involved removal of scarred areas combined with hysteroscopy, followed by resuturing. Fourteen of the 22 women (63.6%) who were followed up for ≥ 1 year after surgery achieved pregnancy. Pregnancies occurred in all four women (100%) who underwent hysteroscopic surgery and in 10 of the 18 women (55.6%) who underwent laparoscopic surgery. Three out of four women who underwent hysteroscopic surgery had term deliveries. Among the women who underwent laparoscopic surgery, five had term deliveries. No cases of uterine rupture were experienced, and the delivery method was cesarean section in all cases. We propose that infertility associated with PCSD, cesarean scar syndrome, is caused by the retention of bloody fluid in the uterine cavity and scarring. Endoscopic treatment, such as hysteroscopy or laparoscopy, was effective for cesarean scar syndrome.
Birth and Delivery › Birth Outcomes › Postpartum Hemorrhage · Diagnostics › Tubal and Uterine Imaging › Hysteroscopy
Alberto Alonso-Burgos, Ignacio Díaz-Lorenzo, Laura Muñoz-Saá, Guillermo Gallardo, Teresa Castellanos, Regina Cárdenas, Luis Chiva de Agustín
A Alonso-Burgos, I Díaz-Lorenzo, L Muñoz-Saá, G Gallardo, T Castellanos, R Cárdenas, L Agustín
PMID 38349501 38349501 DOI 10.1186/s42155-024-00429-7 10.1186/s42155-024-00429-7 Alonso-Burgos et al. 2024, Alonso-Burgos 2024