Uterine Artery Embolization for Postpartum Hemorrhage

Background and indications

Uterine artery embolization (UAE) for postpartum hemorrhage (PPH) is a life-saving emergency intervention to control massive uterine bleeding resistant to medical measures (uterotonics: oxytocin, sulprostone) and intrauterine tamponade (Bakri balloon). Severe PPH complicates 1-3% of deliveries and remains the leading cause of maternal mortality worldwide.

Embolization is indicated for PPH refractory to medical treatment, regardless of etiology (uterine atony, placenta accreta, cervical tear, coagulopathy). It is an alternative to surgical uterine artery ligation and hemostatic hysterectomy.

Pre-procedure assessment

In emergency, diagnosis is clinical (massive postpartum bleeding). CT angiography may be performed if hemodynamic status allows. Resuscitation (massive transfusion, coagulopathy correction) proceeds in parallel.

Procedure

Under local anesthesia (or general anesthesia if patient condition requires), a catheter is introduced through the femoral artery. Under fluoroscopic guidance, both uterine arteries are selectively catheterized and embolized bilaterally with resorbable gelatin particles (Gelfoam). Resorbable gelatin is specifically used to allow uterine artery recanalization in 2-4 weeks, preserving fertility. The procedure takes 30-60 minutes.

Results and scientific evidence

Embolization offers 85-95% success rate (bleeding cessation and uterus preservation). It avoids hysterectomy in the vast majority of cases. Fertility is preserved, with 70-80% subsequent pregnancy rate in women desiring future pregnancy. CNGOF and RCOG guidelines include UAE in the severe PPH management algorithm.

Risks and complications

Pelvic pain (30-50%, transient), fever (10-20%), partial uterine ischemia (< 2%), uterine necrosis (< 0.5%, exceptional), transient amenorrhea (5-10%, recovery in 1-3 months). Asherman syndrome (uterine synechiae) is rare (< 2%).

Recovery

2-5 day hospitalization depending on context (post-PPH monitoring, anemia correction). Gynecological follow-up at 6 weeks.

Practical information

The procedure is performed as an emergency inpatient procedure. It is performed by an interventional radiologist, in coordination with the obstetrician, anesthetist, and intensivist. 24/7 availability of an interventional radiologist is essential in level III maternity units.