Minimally-Invasive Management of Post-Caesarian Section Bleeding

by Interventional Radiology

Michael S. Stecker, MD, FSIR

Raj Pyne, MD

Chieh-Min Fan, MD

Caesarian Sections

• C-section is a surgical procedure that allows delivery of a baby through an incision in the mother’s abdomen

• In general, used when there is danger either to the mother or the fetus:– Labor is not progressing– Problem with bloodflow reaching the baby– Problem with positioning or large baby– Placental abnormalities– Health of the mother– Twins or triplets

How Common Are C-Sections in the U.S.?

• 1.2 million C-sections performed in the U.S. alone in 2004

• Approximately 1 out of every 3 deliveries is now a C-section

• Current rate is a 40% increase over a decade ago

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5

10

15

20

25

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35

1965 1970 1980 1990 2002 2006

% of All Deliveries

Percentage of C-Sections in the U.S.(National Center for Heath Statistics)

Complications of C-Sections

• Serious bleeding during or after the procedure and/or damage to the blood vessels

• Infection or abscess formation• Organ damage to the reproductive organs or to

the bladder• Damage to the intestines, including perforation

(a hole in its lining)• Nerve damage • Rupture of the uterus at a scar site

Bleeding After Delivery

• Potentially life-threatening complication of childbirth

• Can occur either after C-section or after vaginal delivery

• At least 1 in 20 women bleed excessively after childbirth

• Most are treated successfully with supportive measures such as medication and transfusion

• 10% have a hysterectomy or other major surgical procedure to save their lives

Reasons for Bleeding After C-Section

• Uterine atony (failure of uterine contraction)• Retained products of conception (placental

tissue)• Placental abnormalities:

- Placenta acreta (into uterine muscle)

- Placenta increta (through uterine muscle)

- Placenta percreta (into adjacent organs)• Laceration of blood vessels

Treatment Options for Bleeding

• Supportive management:– Careful observation– Transfusion– Hydration– Medications that make the uterus contract

• Balloon tamponade in the uterine cavity• Manual compression of uterus• Procedure to take out the remnant parts of placenta• Hysterectomy• Embolization by Interventional Radiology

Why Does This Matter To Women Undergoing A C-Section?

• Most patients (and even some referring doctors) may not understand what embolization by Interventional Radiology is and how it is performed

• It is readily available at many hospitals and provides a minimally-invasive option for treatment

• Embolization is a relatively safe procedure that can not only save a woman’s uterus but also can save a mother’s life if she has life-threatening bleeding

How Is Embolization By Interventional Radiology Performed?

• Embolization is a well-established technique that has been used for over 20 years

• A small incision is made in the groin• A small tube called a catheter is guided up through the

leg artery and into the artery that feeds the uterus• Moving X-ray images are used to visualize the catheter

as it is placed and X-ray contrast is injected to see the vessels

• Tiny particles (the size of grains of sand) or little metal coils are used to occlude the site of bleeding

Uterine Blood Supply

Bleeding

Image reprinted with permission by David Klemm

Embolization materials

Before Embolization

After Coil Embolization

Before Gelfoam Embolization After Gelfoam Embolization

Purpose of Our Study

• Identify all women who came to Interventional Radiology for severe bleeding after C-section

• Review techniques used to control bleeding in these patients

• Look at clinical course after embolization• Examine safety and efficacy of this treatment

option

Results of Our Study

• 13 women over past 3 years came to IR from the obstetrics service for serious post C-section bleeding

• 5 of 13 had active bleeding seen on angiography and were treated

• 8 of 13 had no findings of active bleeding, but were empirically treated anyway

• All women did well with no recurrence of bleeding• Pseudoaneurysm (a specific type of bleeding) was

seen in 2 patients; both had delayed presentation at 2 weeks, the other 11 presented immediately

Conclusions from Our Study

• Endovascular embolization is a safe and effective minimally-invasive method of treating emergent bleeding after C-section

• Women tended to have quick recoveries, short hospital stays, and no recurrence of bleeding in our sample

• Embolization preserves the uterus and potentially allows for future childbearing compared to hysterectomy

References and Resources

• Society of Interventional Radiology www.sir.org• World Health Organization• National Center for Health Statistics

• Special thanks to David Klemm for use of his copyrighted image