Year : 2017 | Volume
: 7 | Issue : 2 | Page : 65--68
Interventional radiology: A disruptive innovation which is transforming management of post-partum haemorrhage
Subramanyam S Mahankali
Senior Consultant Anaesthetist, Columbia Asia Referral Hospital, Yeshwantpur, Bengaluru, Karnataka, India
Subramanyam S Mahankali
No. 28, 16th Cross, 33rd Main, 6th Phase J P Nagar, Bengaluru - 560 078, Karnataka
|How to cite this article:|
Mahankali SS. Interventional radiology: A disruptive innovation which is transforming management of post-partum haemorrhage.J Obstet Anaesth Crit Care 2017;7:65-68
|How to cite this URL:|
Mahankali SS. Interventional radiology: A disruptive innovation which is transforming management of post-partum haemorrhage. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2018 Dec 15 ];7:65-68
Available from: http://www.joacc.com/text.asp?2017/7/2/65/217778
Post-partum haemorrhage (PPH) is a leading cause of maternal mortality in the developing countries and the primary cause of nearly one-quarter of all maternal deaths globally. It is estimated that between one-quarter and one-half of preventable maternal deaths are secondary to haemorrhage. Numerous women suffer significant morbidity in the form of pituitary necrosis, renal insufficiency, coagulopathy, respiratory failure and require blood transfusions and hysterectomy because of excessive blood loss.
The precise definition of obstetric haemorrhage remains nebulous, with numerous classification systems currently in use worldwide. Traditionally, blood loss exceeding 500 mL for vaginal delivery and 1000 mL for caesarean delivery has been used in the classification of obstetric haemorrhage. However, recently, an international panel of experts in the fields of obstetrics, gynaecology, haematology and anaesthesiology proposed the following diagnostic criteria for the identification of women at an increased risk of adverse outcomes from obstetric haemorrhage:
Active bleeding >1000 mL within 24 hours following birth that continues despite the use of initial measures, including first-line uterotonic agents and uterine massage.
Although uterine atony is the most common cause of haemorrhage, genital tract trauma (uterine and cervical injury), abnormal placentation and coagulation disorders also contribute to significant morbidity and mortality. With increasing incidence of operative delivery and increasing maternal age, the incidence of PPH is set to increase. An understanding of the unique mechanisms, risk factors and clinical manifestations of these distinct causes of peri-partum bleeding is critical in the early identification and successful management of obstetric haemorrhage.
Classically, uterine massage, oxytocics, fluid replacement, uterine tamponade with gases or balloons (Bakri balloon), manual compression of the uterus, surgical repair in epithelial discontinuity, maintenance of placenta in loco and further treatment with methotrexate, or, the external uterine compression accomplished with the use of circumferential (B-Lynch) uterine sutures are some of the measures used to stop bleeding and to keep the patient alive and retain her reproductive capacity. However, more aggressive approaches such as hysterectomy and ligation of the hypogastric arteries may have to be adopted in life-threatening emergencies. Peri-partum hysterectomy is a technically challenging operation; the uterus is enlarged, exposure may be difficult, the vessels are engorged and the pregnant uterus receives a rich collateral blood supply. Mortality is more than 25 times higher in peri-partum than non-peripartum hysterectomy. After the major trauma of the haemorrhagic complication, often women have to bear the consequences of these mutilating treatments. Unfortunately, in some cases, even these measures do not result in favourable response, leading to maternal death.
Hence, the search for new technologies to attenuate the sometimes disastrous effects of haemorrhage that complicate pregnancy and delivery resulted in the development of interventional radiology (IR) for control of bleeding. Advances in IR (personnel as well as equipment) is enabling it to play increasingly important roles in the management of peri-partum haemorrhage.
According to Clayton M. Christensen, a Harvard Business School professor, a disruptive technology is a new emerging technology that unexpectedly displaces an established one.
IR has emerged as a disruptive innovation in this aspect and a welcome alternative which is very effective. It not only saves lives but also preserves the fertility of women. Success rates are over 90%, and in the most recent confidential enquiry in UK, all patients who underwent radiological embolisation survived.
IR is a minimally invasive treatment methodology using imaging modalities including fluoroscopy, ultrasound and sometimes computed tomography (CT). The IR techniques used for primary PPH include transcatheter arterial embolization (TAE) and arterial balloon occlusion.
TAE for obstetric and gynaecologic bleeding was first described in 1979 by Heaston et al. Since then, the use of IR for PPH has increased, reportedly with a high success rate (80–90%)., TAE is a method used to arrest bleeding by introducing embolic material from the catheter placed at the bleeding artery.
Temporary balloon occlusion of the artery is usually introduced in a situation of deteriorating haemodynamic status or to obtain haemodynamic stability in an emergency situation. Temporary arterial balloon occlusion can stop bleeding simply by inflation of the balloon catheter at a site proximal to the bleeding point. In PPH, the occlusion level can be at the infrarenal abdominal aorta, bilateral common iliac artery or internal iliac artery – the more proximal the occlusion, the more effective it will be because it will eliminate blood flow from collateral pathways. The infrarenal position in the abdominal aorta is chosen to occlude blood flow from the ovarian artery, which is one of the major collateral pathways.
The Royal College of Obstetrics and Gynaecology recommends the use of IR in elective cases of placenta praevia and placenta accreta, as well as in emergency cases. With recent studies indicating good fertility outcomes following conservative surgical or radiological treatment of PPH, it has been proposed that a second (or even a third) uterine sparing procedure be performed in case of a failed first procedure before considering hysterectomy in a haemodynamically stable patient. Hysterectomy should represent the last resort in the management of PPH owing to uterine cause when all other options of management have been exhausted.
Prompt recognition and diagnosis is essential for the successful management of primary PPH. The presentation of PPH is often dramatic, although bleeding may be slower and seemingly less noteworthy; this, however, may ultimately result in critical blood loss and shock. The major factor in the adverse outcomes associated with primary PPH is a delay in initiating appropriate management. An important aspect influencing the outcomes of primary PPH is decision making. Although it is the obstetrician who will likely take the call on the what approach to take in a particular case, the anaesthesiologist can play a crucial role to decide the course to take at a critical point. Decision to pursue a particular line of management has to be made by the team after comprehensively assessing the situation and of all of the necessary and available treatment measures.
The order of priority in the choice of treatment measures should be modified depending on the cause of PPH, available human resources, accessibility of the operating suite or angiographic suite and the patient's vital signs. The first-line treatment for PPH includes removal of the causative factor(s), especially surgically correctable injuries such as uterine rupture, inversion, genital tract lacerations, blood transfusions, administration of uterotonic drugs such as oxytocin and prostaglandin analogs in conjunction with external massage of the uterus and uterine compression. The timing of the decision to shift to a more intensive, invasive and aggressive treatment should be appropriate and not subject to delay.
Interventional radiologist has to be involved early at the time when abnormal bleeding is observed, regardless of the severity of PPH, because IR is a useful and important measure for any type of pathogenesis or situation. Surgery should be the priority for traumatic bleeding, including uterine rupture, inversion and genital tract lacerations. Nevertheless, in such situations, IR can be helpful if introduced promptly before any surgical intervention for achieving a safer and more comfortable operation by reducing the bleeding speed and improving haemodynamic status. If there is massive bleeding from the placenta praevia, it is ideal to introduce IR immediately in the operating room. Emergency introduction of arterial balloon occlusion can recover and maintain haemodynamic stability during hysterectomy or TAE. Atonic bleeding is the most frequent bleeding pathogenesis among primary PPH. IR for atonic bleeding has been shown to have high technical and clinical success rates of nearly 100%.
For IR to be performed in the emergency situation, access to imaging is desirable either in the obstetric unit or in an adjacent special procedures unit in the radiology department or Cathlabs. If an institution has poor medical resources, an early decision must be made to arrange transfer of the patient to an advanced treatment hospital without delay.
In these situations, access to the anterior division of the internal iliac arteries is obtained via a femoral artery approach. In most cases, bilateral uterine arteries or the anterior division of internal iliac arteries are the first choices for embolisation, even without extravasation observed, because of the high possibility of bleeding from these arteries or their branches. However, other bleeding arteries may have to be evaluated in particular occasions. Different embolic materials are used depending on the type of treatment: temporary embolotherapy (pledgets of absorbable gelatine sponge or nonbovine sponge, etc.), and definitive vascular occlusion (microparticles of several sizes, coils, etc.).
In the early years of IR management, after identifying the uterine vessels by angiography, they were obstructed by non-resorbable microparticles of various sizes. These small particles can enter the endometrial arteries causing ischaemia with risk of amenorrhoea, synechia or even ovarian failure if they pass into the utero-ovarian anastomoses. Recently non-resorbable material composed of microspheres (Embospheres) greater than 500 mm are being used to better preserve endometrial and ovarian vascularisation.
To minimise the complications (thrombus, ischaemia and necrosis), embolisation should be performed as selectively as possible. The occlusion of the distal uterine artery bed is, however, temporary and it will re-canalise. Successful pregnancies have been reported after internal iliac embolisation.
Elective and prophylactic intervention
IR can also be used as a prophylactic measure where there is a known or suspected case of placenta accrete, placenta praevia on previous caesarean section scar, or placenta accrete diagnosed by scan/colour Doppler or magnetic resonance imaging. In elective cases, the procedure begins by inserting sheaths into the femoral arteries, and a balloon into each of the internal iliac arteries prior to delivery. This can be done under local anaesthesia to reduce exposure of the foetus. Once in place, caesarean section proceeds as normal. The balloons are inflated immediately after delivery. If there is no major bleeding, they are deflated in turn, but can be re-inflated immediately should bleeding recur. Embolisation can be performed via balloon catheters if bleeding continues despite inflation. Even if hysterectomy is still required, blood loss, blood transfusion and numbers of admissions to intensive care units can be reduced. The surgical field will not be bloodless (because of the collateral blood supply of the uterus) but it will be much drier than in cases where no balloons are used. If this facility is not available locally, it might be prudent to arrange transfer to a hospital where it is available electively.
IR for obstetrics is not universally available. Data on the availability of facility and expertise is limited. In India, numerous institutes and large tertiary referral hospitals have started to establish such services. A survey in the United Kingdom by Webster et al. revealed that only 31% of responding units had experience of IR in the management of obstetric haemorrhage and only 29% of units had 24 h availability of a specialised vascular radiologist.
Few maternity hospitals have a permanent IR department and most obstetric centers have no radiological equipment. If necessary, or when managing a patient in an emergency situation, it may be complicated to remove a severely ill patient to a radiology department of the hospital. It is even worse if an external team has to be called upon. It is assumed that at least 2 hours are necessary to have this group ready to intervene. This huge time gap may be fatal for the patient. Maternity hospitals are advised to have protocols for IR techniques for both internal actions or in association with large facilities that provide equipment and specialized staff. Therefore, it is very important to make decisions in advance in cases expected to evolve to massive haemorrhage.
In situations where there is no facility for radiological intervention, an early recourse to hysterectomy may be warranted after failure of brace sutures, internal iliac ligation or tamponade in the presence of significant ongoing bleeding.
Although there are no unified recommendations for the management of PPH, unique standardised guidelines must be made at each institution and regional level which follows a logical course of action. Such guidelines can have a positive impact on the reduction of the number and severity of PPH cases.
Literature on the anaesthetic management of obstetric patients in the IR suite is available but limited. However, the available literature describing IR procedures is largely written by radiologists, with little attention paid to anaesthetic considerations. Extreme care is required while transporting the parturient between the IR suite and the obstetric theatre, especially if facilities of hybrid OR do not exist; this is pertinent to Indian scenario.
In elective placenta praevia cases, the choice of the anaesthetic is at the discretion of the anaesthetist but there is increasing evidence to support the safety of regional anaesthesia. If regional anaesthesia is used, consideration should be given to a combined spinal/epidural technique to allow time for surgery. As general anaesthesia may be necessary, the patient should be fully prepared for conversion. For placenta accreta cases, although some centres advocate the use of regional anaesthesia, general anaesthesia may allow more control.
In emergencies, haemodynamic instability and concerns over coagulopathy make general anaesthesia the technique of choice. Nevertheless, if a working epidural is in place then cautious top-ups may be appropriate. Senior anaesthesiologists should be involved early in all cases. Rapid restoration of intravascular volume is generally initiated with the use of warmed, non-dextrose-containing crystalloid, including lactated Ringer solution and normal saline. Although crystalloid can restore intravascular volume, RBCs are needed to ensure adequate oxygen-carrying capacity of blood and avoid acidosis. There is currently no consensus on the optimal pathway for resuscitation of massive bleeding in the obstetric patient. Given the unique changes in the coagulation and fibrinolytic systems accompanying pregnancy, most obstetric-specific massive transfusion protocols suggest resuscitation with the early administration of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate and platelets. In the setting of haemorrhage unresponsive to blood component therapy, consideration should be given to pro-haemostatic and anti-fibrinolytic agents. Furthermore, the use of cell salvage techniques offers the ability to recycle blood lost from the surgical field, potentially minimizing heterologous transfusion and associated complications.
A high-dependency setting is appropriate for at least half of those with a major obstetric haemorrhage. The majority who do require intensive care do so only for mechanical ventilation and usually for less than 48 hours.
All maternity units and hospitals should have in place protocols that include the use of IR in the management of obstetric cases where PPH is likely. In addition, hospitals must have clear strategies for the management of unpredicted PPH. In hospitals with an IR service, treatment algorithms must be drawn up which clearly identify the timing and place of IR in the management of PPH. Where IR services are not available locally or where there is no continuous on-call IR service, hospitals should ensure that there is an agreed formal arrangement for the provision of these services either with a larger centre nearby or through formation of a network with surrounding hospitals. Anaesthesiologists should be involved early and a team decision should be made to decide and formulate the best plan for a particular patient to improve the outcome.
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