VASCULAR AND INTERVENTIONAL RADIOLOGY

Role of interventional radiology in treating obstetrichaemorrhages

Raffaella Niola • Carlo Cavaliere • Lorenza Marcello • Franco Maglione • Rosaria de Ritis •

Francesco Di Pietto • Giuseppe Albano • Giuseppe Nazzaro • Fabio Sirimarco •

Carmine Mocerino • Maria Loreto • Maria Antonella Di Pasquale • Gennaro Nasti

Received: 30 December 2012 / Accepted: 13 May 2013

� Italian Society of Medical Radiology 2013

Abstract

Purpose The aim of this study was to evaluate the effi-

cacy and the safety of selective uterine artery embolisation

in patients with a high risk of haemorrhage due to obstetric

issues.

Materials and methods We retrospectively reviewed the

angiographic examinations of 63 patients (average

age ± SD, 32.6 years ± 4.8), affected by an obstetric

disease with a high risk of haemorrhage (22 cases of

ectopic pregnancy, 41 of postpartum haemorrhage) and

treated with an interventional approach. In particular, we

considered the rate of second treatment with interventional

technique or conservative or radical surgery, the incidence

of postprocedural complications, and the absorbed radia-

tion dose.

Results Immediate technical success, defined as the ces-

sation of active bleeding, was achieved in all cases. Uterine

artery embolisation was able alone to control the haemor-

rhage in 95.24 % of cases. Three patients required a second

treatment to achieve haemostasis. No peri- or postproce-

dural complications were observed. At the 12-month fol-

low-up after embolisation, 22/49 conservatively treated

patients were found to be pregnant and successfully com-

pleted their pregnancy.

Conclusions Selective uterine artery embolisation allows

for safe and complete control of haemorrhage in patients

with obstetric disease, with a very low incidence of com-

plications and preservation of fertility.

Keywords Obstetric haemorrhages � Selective

embolization � Conservative management � Postpartum

haemorrhage � Ectopic pregnancy

Introduction

Obstetric haemorrhage has a strong clinical impact because

it constitutes a major risk for the health of the woman and

the foetus and for preserving the patient’s fertility [1].

The most common causes of haemorrhaging are post-

partum haemorrhage (PPH) [2], congenital or acquired

arteriovenous malformation (the latter usually related to

uterine curettage or removal of intrauterine devices) [3],

instrumental delivery [4], or complications in the treatment

of ectopic pregnancy [5]. In obstetrics, PPH is the most

frequent cause of admissions to intensive care and is

associated with a higher mortality and morbidity rate than

other types of haemorrhage [6].

In recent years, transcatheter or percutaneous interven-

tional radiology techniques have been applied to different

pathological conditions, including disorders of the female

pelvis and obstetric and gynaecological pathology [7, 8]. In

R. Niola � L. Marcello � F. Maglione

UOSC di Radiologia Vascolare ed Interventistica AORN

Cardarelli Napoli, Naples, Italy

C. Cavaliere (&) � R. de Ritis � F. Di Pietto

Carlo Cavaliere, UOSS di RM Body AORN Cardarelli Napoli,

Via A. Cardarelli 9, 80131 Naples, Italy

e-mail: carlocavaliere1983@yahoo.it

G. Albano � G. Nazzaro � F. Sirimarco

UOSC di Ostetricia e Ginecologia AORN Cardarelli Napoli,

Naples, Italy

C. Mocerino � M. Loreto

UOSC II Servizio di Anestesia e Rianimazione AORN Cardarelli

Napoli, Naples, Italy

M. A. Di Pasquale � G. Nasti

U.O.S. Radioprotezionistica e Fisica Sanitaria AORN Cardarelli

Napoli, Naples, Italy

123

Radiol med

DOI 10.1007/s11547-013-0380-x

particular, transcatheter embolisation was first used after

bilateral ligation of the hypogastric artery [9] for the con-

trol of severe obstetric haemorrhage. This procedure is

currently considered the first choice treatment for control-

ling potentially fatal bleeding, with the aim of avoiding

hysterectomy and preserving the fertility of these patients

[10].

According to some case series [11], when used imme-

diately after bleeding onset, embolisation has an efficacy

varying between 85 and 95 %. These studies suggested 8 to

15 % of cases required a second embolisation procedure. In

other series, efficacy was between 60 and 100 %, and the

need for a second intervention was about 20 % [12]. The

greatest efficacy (100 %) with embolisation was achieved

in haemorrhages developing in abdominal and cervical

pregnancies [13].

A recent study [14] demonstrated efficacy of possible

preventive treatment with embolisation of the uterine

arteries in patients at high risk of haemorrhage, a procedure

that has the advantage of reducing both embolisation pro-

cedure time and blood loss.

The aim of this study was to evaluate the efficacy and

safety of superselective transcatheter embolisation of the

uterine arteries in patients at high risk of obstetric

haemorrhage.

Materials and methods

Patients

A retrospective review was carried out by searching our

database (Kodak Carestream PACS System v. 10.1 Sp1;

Carestream Health, Inc., Italy) for patients treated during

2009–2010 using ‘‘ectopic pregnancy’’ and ‘‘PPH’’ as key

words, and excluding those patients who were not fol-

lowed-up for at least 12 months. Of the 1,256 patients

treated with interventional procedures at our establishment

during that period, 104 were treated for a pathology shown

to be at high risk of blood loss. Of these, 41 patients were

excluded because they left the follow-up before the mini-

mum period of 12 months, and 63 patients finally proved

eligible for the analysis.

The angiographic examinations of these 63 patients (age

range, 24–41 years; average age ± SD, 32.6 years ± 4.8)

were reviewed by an interventional radiologist with

approximately 20 years of experience in the field, on a

high-resolution screen (ThinkVision 2400 L2440p; Lenovo;

USA). The haemorrhages were secondary to cervical

pregnancies in 22 cases (34.92 %) and to massive PPH in

41 cases (65.08 %) (Table 1).

Imaging techniques

Definitive diagnosis of pathology as the basis of the

haemorrhage was evaluated and characterised by means of

ultrasound (US)/colour Doppler US in 41 patients

(65.08 %) and by integration of US with magnetic reso-

nance (MR) imaging techniques in 22 cases (34.92 %).

In particular, the US/colour Doppler US was conducted

with convex transducers (2.5–5 MHz) and a dedicated US

system (GE Logiq 9 ultrasound system; General Electric,

Milan, Italy). The transabdominal approach was used in

patients with a full bladder. The transvaginal approach was

preferred in patients with abnormal insertion of the pla-

centa and with placenta praevia.

In cases of placental anomaly [15], either suspected or

confirmed on US analysis (22/63), we proceeded with

integration with MR imaging to obtain a fuller character-

isation of the placenta and to permit correct planning of the

procedure to avoid fatal haemorrhage.

MR imaging was carried out with a 1.5 Tesla scanner

(Eclipse, Picker–Marconi, Philips, Eindhoven, Nether-

lands). T2-weighted images with fast spin-echo type

sequences (RARE TR/TE, 10,000/110 ms; slice thickness,

5 mm; matrix, 256 9 256; acquisition, 1; echo train length,

Table 1 Summary of main clinical data and embolisation results

Diagnosis Embolisation

technique

Sufficient

haemostasis

Effective

dose (E)

Uterine

salvage

Complications Pregnancies

after 12 months

22 cervical pregnancy

Fixed angiography

Selective

16 PVA

5 IBC

1 Gelfoam

22 yes 4.3 mSv Yes None 10 yes

41 PPH

Mobile angiography OEC

Selective

32 PVA

6 IBC

2 Gelfoam

1 PVA ? Coils

38 yes

3 no (a second

procedure

was needed)

12 lSv 27 yes

14 Hysterectomies

None 11 yes

PPH postpartum haemorrhage, PVA polyvinyl alcohol, IBC isobutyl cyanoacrylate

Radiol med

123

140; scan time, 10 s) were obtained during breath-holding

in three planes (axial, orthogonal and sagittal). T2-weigh-

ted fast spin-echo axial images were also acquired with

suppression of fat tissue and T1-weighted signals.

Anaesthesia–resuscitaiton protocol

The anaesthesia–resuscitation protocol provided for a

careful anaesthesiological evaluation with history taking,

physical examination and evaluation of comorbidities and

standard preoperative tests including haemochrome, coag-

ulation profile [prothrombin time (PT), partial thrombo-

plastin time/international normalised ratio (PTT/INR),

antithrombin III (ATIII)] dimer and fibrinogen, glycaemia,

urea, creatinine, total and fractional bilirubin, transami-

nase, lactate dehydrogenase (LDH), creatine phosphoki-

nase (CPK), total protein, albumin, electrolytaemia,

urinalysis, blood group and blood type screening. This

phase was completed with the request of at least 4 units of

concentrated erythrocytes of cross-matched blood for the

operation and provision of a bed in postoperative intensive

care for intensive monitoring after the interventional

procedure.

The intervention was always performed with local

anaesthesia, whereas before the caesarean section balanced

anaesthesia was introduced using drugs such as remifen-

tanil in continuous infusion (0.05–0.25 mcg/kg/min), pro-

pofol 4–5 mg/kg on induction, cisatracurium 0.2 mg/kg

and mixtures of anaesthetic gases (O2 and sevoflurane).

Intervention protocol

Arteriography and subsequent superselective uterine artery

embolisation were performed both as elective and emer-

gent procedures, in the operating theatre with a mobile

angiograph (OEC 9800 Plus, General Electric Company,

Milan, Italy), by an expert interventional radiologist on

24-h duty. Selective angiography of the internal iliac

arteries and superselective angiography of the uterine

arteries were always done with femoral access, generally

on the right side.

Embolisation was achieved with a 5 F Cobra catheter

(William Cook Europe, Bjæverskov, Denmark) with sub-

sequent use of coaxial microcatheters (Progreat, Terumo,

Tokyo, Japan). Vessel occlusion was obtained by injecting

700–900 l polyvinyl alcohol (PVA) (Contour SE, Boston

Scientific, Natick, MA) (48/63 cases) or reabsorbable par-

ticles (Spongel, Yamanouchi, Tokyo, Japan) (3/63 cases) to

exclude the flow of blood, as shown by periprocedural

angiographic imaging. In only one case was PVA used in

combination with metal coils to occlude the blood vessels,

whereas in 11 cases, acrylic glue (isobutyl cyanoacrylate,

IBC) was used (in five cases of cervical pregnancy and in

six of re-operation for PPH after hysterectomy) (Table 1).

Where PVA was used, the choice of embolising material

was dictated by the clear hypervascularity seen at preop-

erative angiography, which permitted a durable but not

permanent treatment. Spongel was used when the angio-

graphic map was seen to allow transitory embolisation for

about 48–72 h; IBC was used when the massive bleeding

demanded definitive treatment and excluded the possibility

of preserving the therapeutic target.

In the postoperative phase, the patient was transferred to

postoperative intensive care to allow continuous monitor-

ing of vital parameters, to continue the correction of any

metabolic defects or other pathological conditions, and to

guarantee the highest level of care.

Evaluation of treatment outcome

In evaluating the diagnostic–therapeutic outcome of

selective embolisation, we considered the following fac-

tors: (1) immediate technical success, defined as the

capacity to identify the afferent vessel, block the blood

flow to the uterus and confirm this by periprocedural

angiography; (2) procedural success, defined as permanent

haemostasis with no further bleeding episodes that would

necessitate further intervention; (3) the need for further

intervention using transcatheter embolisation; (4) the need

for further conservative surgery, with multiple ligatures, or

radical surgery with hysterectomy; (5) the preservation of

the uterus and its adnexa, defined as the maintenance of the

viability of the organ until discharge or for 30 days of

follow-up; (6) detection of early complications (non-target

embolisation, haematoma to the arterial access, transient

fever, severe postembolisation syndrome) or late compli-

cations (uterine necrosis) after the interventional radio-

logical procedures through clinical-ultrasound assessment

at 1 and 6 months; (7) time spent in postoperative intensive

care; and (8) the onset and outcome of pregnancies arising

in patients previously treated with superselective emboli-

sation of the uterine arteries and preservation of the uterus,

by means of clinical and imaging assessment at 12 months

after the procedure.

Finally, for the purposes of radiation protection and

optimisation of the interventional procedure, an a posteriori

analysis was carried out on the dosimetric data (dose area

product—DAP) expressed in mG cm2, which was auto-

matically recorded by the angiographic instruments at the

end of the procedure; the average value of DAP, evaluated

separately for 41 patients with cervical pregnancy and 22

patients with PPH was then correlated with (NRPB-W4)

Effective dose E (mSv). All the procedures were performed

with continuous fluoroscopy, using predominantly standard

fields without magnification 12–31 cm, in PA.

Radiol med

123

Results

Superselective embolisation of the uterine arteries was cho-

sen in all cases with complete exclusion of blood flow from

the lesion. A single superselective embolisation of the uterine

arteries was sufficient to prevent haemorrhage in 95.24 % of

cases. In particular, the interventional procedure proved

efficient as the sole approach in the majority of cases treated,

with no need to resort to a second intervention. In all cases of

ectopic pregnancy and in 38/41 of PPH, embolisation was

adequate to prevent the risk of haemorrhage (Figs. 1, 2). In

3/63 cases (4.76 %) treated with superselective embolisation

of the uterine arteries, relapse of bleeding was observed and

necessitated re-operation within 24 h (Fig. 3). In particular,

there were three cases of PPH previously treated with PVA

which required re-operation; in two of these patients also the

cervical–vaginal branches (PVA) were embolised and in one

case of massive haemorrhage also the hypogastric artery

(Spongel). Finally, in 14 cases treated for massive PPH, it was

impossible to perform conservative treatment and hysterec-

tomy was necessary to control the haemorrhage and achieve

haemodynamic stability (Table 1).

The entire interventional procedure was conducted

while limiting as much as possible the dose of ionising

Fig. 1 Case of cervical ectopic

pregnancy in a 40-year-old

woman treated with uterine

artery embolisation with

isobutyl cyanoacrylate (IBC). In

a, b the ultrasonography scans

show the anomalous cervical

implant with a magnification of

the gestational sac. In c, d,

selective catheterisation of the

left uterine artery and its

embolisation with acrylic glue

(IBC). In e, f selective

catheterisation of the right

uterine artery and its

embolisation with IBC

Radiol med

123

radiation absorbed by the patient and particularly by the

uterus, with the aim of avoiding iatrogenic damage that

could have compromised the fertility and thus the quality

of life of these patients. In particular, average values of E

of 4.3 mSv for the patients treated for cervical pregnancy

(n = 22; Fig. 2) and 12 lSv for those treated for PPH

(n = 41; Fig. 3) were recorded (Table 1).

Immediately after the operation, all patients were

transferred to postoperative intensive care for anaesthesi-

ological monitoring. After this, they returned to the

obstetrics unit for the following 24–48 h.

At clinical-imaging follow-up at 1 and 6 months, no

adverse reactions correlated to the embolisation procedure

were observed. At the 12-month follow-up examination

Fig. 2 Case of placenta praevia

in a 34-year-old woman treated

with uterine artery embolisation

with polyvinyl alcohol (PVA).

In a, b the longitudinal and

coronal T2-weighted magnetic

resonance (MR) images show

the abnormal placentation

without significant signs of

percretism. In c, d selective

catheterisation of the left uterine

artery and its embolisation with

PVA. In e, f selective

catheterisation of the right

uterine artery and its

embolisation with PVA

Radiol med

123

Fig. 3 Case of placenta praevia

in a 31-year-old woman treated

first with uterine artery PVA

embolisation, and then with

coils. In a, b the axial and

coronal T2-weighted MR

images show the abnormal

placentation with suspected

percretism. In c uterine

compression with hands. In d, e,

selective catheterisation of the

left uterine artery and its

embolisation with PVA. In

f selective catheterisation of the

right uterine artery and its

embolisation with PVA. In g, h,

the second treatment performed

with catheterisation of the left

hypogastric artery (early and

late time point, respectively): no

signs of haemorrhage were

shown. In i, catheterisation of

the right hypogastric artery with

evidence of haemorrhage from

the uterine artery previously

treated with PVA. In

l embolisation with coils

Radiol med

123

22/49 (44.9 %) patients treated with superselective em-

bolisation of the uterine arteries and preservation of the

uterus were found to be pregnant and carried their preg-

nancy to term (Table 1). In the remaining patients, ovula-

tion proceeded regularly from the ovaries after the

embolisation procedure, as shown by routine ultrasound

and from case-history records.

Discussion

In this study, we retrospectively reviewed the angio-

graphic examinations performed from 2009 to 2010 on 63

patients affected by obstetric conditions with a high risk

of bleeding and treated with an interventional approach as

a first-line strategy. The approach used consisted of

accessing only the right or left femoral artery with su-

perselective catheterisation of the uterine arteries, caesar-

ean section, and embolisation. Using this approach,

immediate technical success was obtained in all cases,

with total cessation of the blood flow, as shown by peri-

procedural angiography, and limitation of the dose of

ionising radiation to which the patients were exposed.

These results are consistent with those reported in the

literature, although therapeutic success in treating the

specific causes of obstetric haemorrhaging has often been

evaluated on small patient series. Frates et al. [5], for

example, published the largest study on the conservative

treatment of cervical ectopic pregnancy, with only four

cases successfully treated using arterial embolisation of

branches of the uterine and transverse cervical arteries

using Gelfoam. In this study, the 22 cervical ectopic

pregnancies were treated with immediate technical success

using embolisation with PVA, Gelfoam or IBC, with no

need for a second embolisation for haemostatic control

and without encountering any complications at clinical-

imaging follow-up at 1, 6, and 12 months.

Recently, Delotte et al. [16] reported results regarding

the efficacy of pelvic arterial embolisation in the control of

PPH. The authors reported an overall success rate for

control of haemostasis of 92 %, despite the need for seven

hysterectomies, and there were four deaths postembolisa-

tion. Other authors [14], conversely, have compared the

efficacy of preventive embolisation treatment with the

classic posthaemorrhagic treatment, finding equivalent

success rates for the two groups, but with a significant

reduction in the time for embolisation and in the blood loss

for the group receiving preventive treatment. In our series,

an overall success rate of 100 % for the manoeuvre for the

prevention of haemorrhage was found in 41 patients treated

for PPH, with an immediate technical success rate solely

for arterial embolisation of 92.68 % (38/41). It is also

necessary to consider the different causes of PPH [17] that

may also benefit, with varying success rates, from super-

selective embolisation of the uterine arteries. In particular,

even if the overall success rate for interventional treatment

of PPH is between 85 and 95 % [11], this percentage

diminishes in those cases where the PPH is due to placental

anomalies, with a range that varies from 20 to 100 % [18].

At this time, it is not yet clear what determines this wide

range of results; nevertheless, it may be correlated to the

time and the intensity of the forces used to remove the

placenta, as well as to patient’s condition at the time of the

intervention. In this regard, it is interesting to note that in

the 14 cases in which hysterectomy was necessary, the PPH

in 13 of these was due to placenta previa percreta. In

patients with placental anomalies, where magnetic reso-

nance (MR) imaging led to a suspicion of percretism [19,

20], later confirmed at surgery, hysterectomy was done

immediately, without waiting for the afterbirth, to limit

further possible sources of bleeding.

In three cases of PPH, positioning of an intrauterine

balloon was combined with the embolisation, and in one of

these cases the technique of compressive uterine suture,

using the method of B-Lynch [21] was used to render the

haemostasis even more efficient. In one case of uncon-

trollable PPH after spontaneous birth with episiotomy,

embolisation of the uterine arteries and the cervical–vagi-

nal branches with PVA was performed after application of

vaginal tampons and abdominal packing. Upon removal of

these after 48 h, an aorto-iliac angiogram was obtained to

verify the loss of further vascular branches.

Regarding a second embolisation or subsequent surgery

for the control of haemostasis, in 4.76 % of cases (3/63),

the embolisation of several vascular branches had to be

combined with the primary embolisation treatment, and in

22.22 % (14/63), surgical treatment with hysterectomy was

required. These data are consistent with the literature [16,

22, 23], in which, especially for PHH control and resolu-

tion of the underlying pathology, hysterectomy must be

combined with arterial embolisation. Analysis of the

interventional procedure in these two types of patients has

shown that therapeutic efficiency is certainly lower in PPH

compared with ectopic pregnancy. The different results of

the embolisation treatment in our series may be due to the

percentage of placental anomalies included in the PPH,

which, as analysed previously, respond significantly less

well to interventional treatment, often requiring the inte-

gration of a second treatment with hysterectomy. Retro-

spective analysis of the effective dose of radiation

delivered to patients treated with the interventional

approach has shown slightly higher doses for patients

undergoing embolisation for ectopic pregnancy compared

to those treated for PPH, obtaining in both cases an

effective haemostatic control with limited exposure to

ionising radiation.

Radiol med

123

Early and late complications linked to the interventional

procedure include fever, vascular perforations, ischaemia

of the lower limbs, and necrosis of the uterus or of the

walls of the bladder or rectum. In our study, at 1- and

6-month follow-up, no complications related to the inter-

ventional procedure were observed. This information is in

keeping with the low complication rate (about 3 %)

reported in some other studies [22], and correlates with the

nature of the embolising agent chosen [24].

With respect to hysterectomy, considered the standard

treatment for the control of both PPH and obstetric

haemorrhages in general, embolisation has proved efficient

in guaranteeing and preserving the fertility of the patient

treated with superselective embolisation of the uterine

arteries and preservation of the uterus [25–27]. Some

studies [10], for example, have reported preservation of the

uterus in 95 % of cases of PPH treated with embolisation

and the return of menstrual flow in all patients, with a

pregnancy rate of 20 % in these patients. Other studies [28]

have reported a return of menstrual flow in 100 % of

patients with a subsequent pregnancy rate of 29.4 %. In our

study, we found a pregnancy rate of 34.92 % in patients

treated, with the return of normal ovulation and menstru-

ation in the remaining cases. The increased pregnancy rate

in our study compared with the current literature [10, 25,

28] can presumably be ascribed to the greater safety of the

preventive treatment compared to the standard approach

that results in reduced operating times and a lower blood

loss [14], as well as reduced length of stay in postoperative

intensive care (about 24–48 h). Only one case of amenor-

rhoea due to hypothalamic hypogonadism after embolisa-

tion with Gelfoam was reported in the literature [29],

which may be resolved with the aid of hormone

stimulation.

Even though the small series is a limitation of our study,

easy access to dedicated instruments in the operating the-

atre, team work and professional expertise accounted for

the high rate of immediate success found in our study. In

the assessment of long-term outcomes following the

interventional approach to pathologies at high risk of

bleeding, such as ectopic pregnancy and PPH, conflicting

results continue to be reported with regard the recurrence

rate after subsequent pregnancies [10, 28, 30]. This rela-

tively new question is probably the product of the high

success rate of the interventional procedure in these

pathologies which allows the conservative treatment of

patients who would otherwise be subjected to hysterec-

tomy. However, the lack, for clinical reasons, of a real

control group treated only with hysterectomy and followed

in parallel to the embolising treatment, certainly represents

the main limitation of this study. A longer follow-up period

would perhaps have permitted clarification of this aspect

and will certainly be the subject of further studies.

Future prospects for study are thus analysis of this

treatment on a greater number of patients and over a longer

follow-up period. Furthermore, given the excellent safety

and effectiveness demonstrated by this type of treatment

and the low exposure to ionising radiation during the

interventional procedure, a pilot study will soon be begun

on the possibility of performing the embolisation in the

immediate ante-partum period with a view to further

reducing the risks of massive haemorrhaging for this type

of patient.

Conclusions

The percutaneous method in the prevention/treatment of

obstetric haemorrhage is currently an example of the

integration of imaging and clinical methods, and it proves

extremely useful in reducing the rate, although still high, of

mortality linked to postpartum haemorrhage. The high

success rate, the low morbidity, and the possibility of

preserving reproductive function have rendered this

approach the technique of choice for the control of haem-

orrhage in patients otherwise destined for hysterectomy.

Superselective embolisation of the uterine arteries thus

permits prompt and safe control of haemostasis in patients

with obstetric haemorrhage, resulting in an extremely low

incidence of complications and guaranteeing the possibility

of further pregnancies.

Conflict of interest Raffaella Niola, Carlo Cavaliere, Lorenza

Marcello, Franco Maglione, Rosaria de Ritis, Francesco Di Pietto,

Giuseppe Albano, Giuseppe Nazzaro, Fabio Sirimarco, Carmine

Mocerino, Maria Loreto, Maria Antonella Di Pasquale, Gennaro Nasti

declare that they have no conflict of interest related to the publication

of this article.

References

1. Walfish M, Neuman A, Wlody D (2009) Maternal haemorrhage.

Br J Anaesth 103:i47–i56

2. Subtil D, Somme A, Ardiet E et al (2004) Postpartum hemor-

rhage: frequency, consequences in terms of health status, and risk

factors before delivery. J Gynecol Obstet Biol Reprod (Paris)

33:4S9–4S16

3. Castillo MS, Borge MA, Pierce KL (2007) Embolization of a

traumatic uterine arteriovenous malformation. Semin Interv

Radiol 24:296–299

4. Sheiner E, Sarid L, Levy A et al (2005) Obstetric risk factors and

outcome of pregnancies complicated with early postpartum

hemorrhage: a population-based study. J Matern Fetal Neonatal

Med 18:149–154

5. Frates MC, Benson CB, Boubilet PM et al (1994) Cervical

ectopic pregnancy: results of conservative treatment. Radiology

191:773–775

6. Pinto A, Niola R, Brunese L et al (2012) Postpartum hemorrhage:

what every radiologist needs to know. Curr Probl Diagn Radiol

41:102–110

Radiol med

123

7. Velling TE, Brennan FJ, Hall LD et al (2000) Role of the

interventional radiologist in treating obstetric–gynecologic

pathology. AJR Am J Roentgenol 175:1273–1278

8. Thabet A, Kalva SP, Liu B et al (2012) Interventional radiology

in pregnancy complications: indications, technique, and methods

for minimizing radiation exposure. Radiographics 32:255–274

9. Hansch E, Chitkara U, Mc Alpine J et al (1999) Pelvic arterial

embolization for control of obstetric hemorrhage: a five-year

experience. Am J Obstet Gynecol 180:1454–1460

10. Eriksson LG, Mulic-Lutvica A, Jangland L et al (2007) Massive

postpartum hemorrhage treated with transcatheter arterial embo-

lization: technical aspects and long-term effects of fertility and

menstrual cycle. Acta Radiol 48:635–642

11. Mayer DC, Smith KA (2009) Antepartum and postpartum hem-

orrhage. In: Chestnut DH, Polley LS, Tsen LC, Wong CA (eds)

Obstetric anesthesia principles and practice, 4th edn. Elsevier

Mosby, Missouri, pp 811–836

12. Shim JY, Yoon HK, Won HS et al (2006) Angiographic embo-

lization for obstetrical haemorrhage and follow-up outcome of

fertility. Acta Obstet Gynecol Scand 85:815–820

13. Badawy SZ, Etman A, Singh M et al (2001) Uterine artery

embolization: the role in obstetrics and gynecology. Clin Imaging

25:288–295

14. Diop AN, Chabrot P, Bertrand A et al (2010) Placenta accreta:

management with uterine artery embolization in 17 cases. J Vasc

Interv Radiol 21:644–648

15. Baughman WC, Corteville JE, Shah RR (2008) Placenta accreta:

spectrum of US and MR imaging findings. Radiographics

28:1905–1916

16. Delotte J, Novellas S, Koh C (2009) Obstetrical prognosis and

pregnancy outcome following pelvic arterial embolisation for

post-partum hemorrhage. Eur J Obstet Gynecol Reprod Biol

145:129–132

17. Devine PC (2009) Obstetric haemorrhage. Semin Perinatol

33:76–80

18. Josephs SC (2008) Obstetric and gynecologic emergencies: a

review of indications and interventional techniques. Semin Interv

Radiol 25:337–346

19. Elsayes KM, Trout AT, Friedkin AM et al (2009) Imaging of the

placenta: a multimodality pictorial review. Radiographics

29:1371–1391

20. Derman AY, Nikac V, Haberman S et al (2011) MRI of placenta

accreta: a new imaging perspective. AJR Am J Roentgenol

197:1514–1521

21. Malibary AM (2004) Modified B-Lynch technique for the control

of massive postpartum haemorrhage. An alternative to hysterec-

tomy. Saudi Med J 25:1999–2000

22. Vegas G, Illescas T, Munoz M et al (2006) Selective pelvic

arterial embolization in the management of obstetric hemorrhage.

Eur J Obstet Gynecol Reprod Biol 127:68–72

23. Chauleur C, Fanget C, Tourne G et al (2008) Serious primary

post-partum hemorrhage, arterial embolization and future fertil-

ity: a retrospective study of 46 cases. Hum Reprod 23:1553–1559

24. Cottier JP, Fignon A, Tranquart F (2002) Uterine necrosis after

arterial embolization for postpartum hemorrhage. Obstet Gynecol

100:1074–1077

25. Salomon LJ, deTayrac R, Castaigne-Meary V et al (2003) Fer-

tility and pregnancy outcome following pelvic arterial emboli-

zation for sever post-partum haemorrhage. A cohort study. Hum

Reprod 18:849–852

26. Soncini E, Pelicelli A, Larini P et al (2007) Uterine artery

embolization in the treatment and prevention of postpartum

hemorrhage. Int J Gynaecol Obstet 96:181–185

27. Okazaki M, Higashihara H, Koganemaru F et al (2011) Uterine

artery embolization for emergent management of postpartum

hemorrhage associated with placenta accreta. Acta Radiol

52:638–642

28. Sentilhes L, Gromez A, Clavier E et al (2010) Fertility and

pregnancy following pelvic arterial embolisation for postpartum

haemorrhage. BJOG 117:84–93

29. Chung JW, Jeong HJ, Joh JH et al (2003) Percutaneous trans-

catheter angiographic embolization in the management of

obstetric hemorrhage. J Reprod Med 48:268–276

30. Canonico S, Arduini M, Epicoco G et al (2013) Placenta previa

percreta: a case report of successful management via conservative

surgery. Case Rep Obstet Gynecol 2013:702067. doi:10.1155/

2013/702067

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