Embolisation in the Therapy of Post-Partum Haemorrhage in a Patient with a Massive Myoma

Study background: The world prevalence of post-partum haemorrhage is approx. 10.5% of pregnancies, and it is the leading mortality cause among young women, accounting for approx. 25% of fatalities. Post-partum haemorrhage is defined as over 500 ml blood loss from genitals, occurring within the first 24 hours post partum. The presented case is an example of efficacy of the embolisation procedure in the management of post-partum haemorrhage. A 29-y.o. female patient was referred to the hospital in her third pregnancy. Because of the presence of a massive myoma the patient was qualified for delivery by Caesarean section. The child was delivered. The uterine muscle was sutured. Haemostasis control no signs of active bleeding. Three hours after the Caesarean section a massive postpartum haemorrhage developed. Oxytocin and Methylergometrin were administered intravenously, and Mizoprostol per rectum. The bleeding from the uterine cavity was still massive, and a decision was made on embolisation of uterine arteries. Methods: The procedure was performed with access via the right femoral artery, under local anaesthesia. A selective injection of a contrast medium to the left uterine artery was performed, which allowed visualisation of the uterine vascular bed with the myoma, as well as of the site of the active, massive bleeding. First the left uterine artery was embolised with particles, in order to close the vascular bed of the myoma. Then, a part of the vessel supplying the uterine muscle with the bleeding site, was closed with Spongostan gel. Results: Control angiography indicated a correctly closed left uterine artery, with no filling of the uterine vascular bed. No other sites of bleeding were detected. Conclusion: The selective embolisation of vessels in course of a postpartum haemorrhage in that case was a safe, minimally invasive and highly effective therapeutic method, that ensures an option of further pregnancies. Page 2 of 4 Citation: Pyra K, Woźniak S, Światłowski Ł, Czuczwar P, Sojka M, et al. (2016) Embolisation in the Therapy of Post-Partum Haemorrhage in a Patient with a Massive Myoma. Gynecol Obstet (Sunnyvale) 6: 349. doi:10.4172/2161-0932.1000349 Volume 6 • Issue 1 • 1000349 Gynecol Obstet (Sunnyvale) ISSN: 2161-0932 Gynecology, an open access journal and clotting disorders (Thrombin). The most common cause is the postpartum uterine atony (70% of cases) [9]. All those causes may occur both during a natural labour and the Caesarean section [11]. The treatment of PPH requires an interdisciplinary approach. In majority of cases, postpartum haemorrhages may be stopped with techniques increasing the uterine contraction activity. These include: massage of the uterus, administration of prostaglandin E2 analogues, oxytocin, ergometrin. Those are the first-line drugs. They were introduced for treatment of uterine atony already in the 19th century. In those women who still bleed after the first-line treatment, further lines should be applied [12]. Initially, haemostatics should be used. They are: transexamic acid and recombined active factor VII (rFVIIa) [13]. was referred to the hospital in her third pregnancy 39 weeks and 3 days for elective Caesarean section because of a large uterine myoma. At admission the patient was examined and a good general condition was confirmed: RR –131/78 mm Hg, HR – 98 bpm, Hb – 12.1 mg/dL. The patient felt normal foetal movements, FHR -154 bpm. The uterine muscle reacted with contractions to palpation; the cervix was closed and approx. 2 cm long. The speculum examination revealed a minor adenous ectopy on the vaginal part of the cervix, current Pap test negative acc. to the Bethesda 2001 classification. Non-stress cardiotocography was normal. Ultrasound examination – a single, viable foetus, cephalic longitudinal lie, normal anatomy, estimated weight of the foetus 3600g. AFI – 5.6. Within the anterior wall of the isthmus of the uterus an uterine myoma, dimensions 132.9×74.3 mm (FIGO – 6, subserosal <50% intramural) was visualized (Figure 1). Because of the presence of a massive myoma in the area of the uterine isthmus the patient was qualified for delivery by Caesarean section. The procedure was performed using the Misgav-Ladach method. A female child was delivered, body weight of 3450 g, APGAR score -10 points. After cutting the umbilical cord, 1 ampoule of Carbetocin – 100 mg was administered intravenously. The uterine muscle was sutured with the double-layer continuous suture. Haemostasis control no signs of active bleeding. Three hours after the Caesarean section a massive postpartum haemorrhage developed an estimated blood loss of approx. 1000 ml, Hb – 7.9 mg/dL. 10 IU Oxytocin and 200 mg Methylergometrin were administered intravenously, and 3 tablets (a 0.2 mg) of Mizoprostol per rectum. Despite the achievement of a normal uterine muscular tonus, the bleeding from the uterine cavity was still massive, and a decision was made on embolisation of uterine arteries.