Arterial embolization for postpartum haemorrhage: let's stay cautious

L.J. Salomon and H. Fernandez

Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, 157 rue de la Porte-de-Trivaux, 92141 Clamart cedex, France

Email: herve.fernandez{at}abc.ap-hop-paris.fr

Sir,

We read with interest the paper by Descargues et al. (2004)Go, reporting their experience in the follow-up of patients with a history of arterial embolization for the control of postpartum haemorrhage. We would like to make a few comments.

The authors studied 27 patients who underwent successful postpartum embolization for life-threatening obstetric haemorrhage. It is detrimental to the study that they do not report any evidence of the severity of the haemorrhage such as the use of prostaglandin analogues, or the need for blood transfusion and fresh frozen plasma in any of the cases. Moreover, although it can be assumed that a pelvic angiogram was performed for each patient, it is unclear how it was taken into account during the procedure as they reported a symmetric and successful uterine artery embolization in all the cases. Finally they achieved the feat of contacting directly 25 of the 27 patients but they do not mention the exact follow-up period.

We also regret that the authors did not update their literature review with our results (Salomon et al., 2003Go), since Descargues et al. confirm our previous data regarding the fact that arterial embolization is a safe and efficient life-saving procedure for postpartum haemorrhage. In the same fashion, they show again that women who undergo arterial embolization can expect a return of normal menses with no adverse effects.

Our main concern is their conclusion that, conversely to our report, patients should be able to look forward to a normal pregnancy. Surprisingly, they do not report a case of postpartum haemorrhage at subsequent deliveries. In fact, obstetricians are aware that the risk of recurrence of post-partum haemorrhage is high. Furthermore uterine embolization might be causal in some of these recurrences. In our study, we reported a high risk of recurrence and speculated that the uterus might be damaged by an unknown mechanism allowing defective decidual development. In fact, we reported excessively adherent placentas needing manual removal and hysterectomy in two cases because of placenta accreta. Although not highlighted by Descargues et al., the 30% miscarriage rate they report at subsequent pregnancies might suggest such uterine damage.

Embolization for fibroids and postpartum haemorrhage cannot be directly compared but the issue of the high risk of postpartum haemorrhage has already been raised following fibroid embolization (Goldberg et al., 2002Go). Recently, the American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice (2004)Go stated that uterine artery embolization for the treatment of fibroids should be considered investigational or relatively contraindicated in women wishing to retain fertility.

In our experience of 21 pregnancies following hypogastric artery ligation, the main alternate procedure, we did not observe either adverse effects or severe recurrence of post-partum haemorrhage (Nizard et al., 2003Go). It is obvious that the small number of patients in our studies renders speculative any conclusions drawn. Animal studies might provide insight into the effects of embolization on uterine tissues. Large randomized trials comparing this technique with other therapies will ultimately be necessary. Therefore, we believe that albeit conservative treatments are emergency procedures, obstetricians should remain cautious when recommending embolization in patients with postpartum haemorrhage until this procedure can definitely be proved to be safe for subsequent pregnancies.

References

American College of Obstetricians and Gynecologists (2004) ACOG Committee Opinion. Uterine artery embolization. Obstet Gynecol 103, 403–404.[Free Full Text]

Descargues G, Mauger Tinlot F, Douvrin F, Clavier E, Lemoine JP and Marpeau L (2004) Menses, fertility and pregnancy after arterial embolization for the control of postpartum haemorrhage. Hum Reprod 19, 339–343.[Abstract/Free Full Text]

Goldberg J, Pereira L and Berghella V (2002) Pregnancy after uterine artery embolization. Obstet Gynecol 100, 869–872.[Abstract/Free Full Text]

Nizard J, Barrinque L, Frydman R and Fernandez H (2003) Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum haemorrhage. Hum Reprod 18, 844–848.[Abstract/Free Full Text]

Salomon LJ, De Tayrac R, Castaigne-Meary V, Audibert F, Musset D, Ciorascu R, Frydman R and Fernandez H (2003) Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum Reprod 18, 849–852.[Abstract/Free Full Text]

Submitted on March 4, 2004; accepted on April 11, 2004.





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