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Practice Clinical updates

Diagnosis and management of postpartum haemorrhage

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3875 (Published 27 September 2017) Cite this as: BMJ 2017;358:j3875
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A visual summary of suggested approaches for the management of primary and secondary postpartum haemorrahage

Rapid Response:

Re: Diagnosis and management of postpartum haemorrhage

Dear Sir,

I was disappointed by the lack of reference to Interventional Radiology (IR) in the above clinical update by Edwin Chandraharan and Archana Krishna BMJ 2017; 358: j3875 Published 27 Sep 2017. IR plays a major role in the prevention and treatment of post partum haemorrhage (PPH) and the need for early involvement of interventional radiology in the management of patients with PPH is stressed in the Royal college of obstetricians and gynaecologists good practice guidelines (1-19). Uterine artery embolisation should be mentioned in the “What you need to know” panel and the need for early involvement of IR described explicitly in the text. This review fails to recognise that IR is a specialty in its own right.

I would draw your attention to multiple publications (1-13) describing the benefit of IR techniques in PPH and a health care commission report (14) which highlights the potential of IR to save lives.
Arterial balloon occlusion and embolisation performed by an interventional radiologist in an IR suite can prevent major blood loss acutely reducing the need for blood transfusion and hysterectomy. The technique involves percutaneous femoral artery access with incisions of 1-2mm and using X-ray guidance to access either the anterior division of the internal iliac artery or more selectively the uterine artery to prevent or arrest acute haemorrhage. A variety of different embolic agents can be used including gelfoam, glue, coils and particles. A similar technique is also commonly used as part of a prophylactic strategy in abnormal placentation.

It is crucial that your readers are made aware of the potential benefit of early involvement of interventional radiology in the management of a patient with PPH and not denied potentially life saving treatments.

Dr R Uberoi
President of the British Society of Interventional Radiologists
Royal College of Radiologists
Lincoln Inn Fields
London.
Raman.uberoi@ouh.nhs.uk

1. Heaston DK, Mineau DE, Brown BJ et al (1979) Transcatheter arterial embolization for control of persistent massive puerperal hemorrhage after bilateral surgical hypogastric artery ligation AJR Am J Roentgenol 133:152–154
2. Pelage JP, Le Dref O, Mateo J et al (1998) Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 208:359–362
3. Deux JF, Bazot M, Le Blanche AF et al (2001) Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage? AJR Am J Roentgenol 177:145–149
4. Ratnam LA, Gibson M, Sandhu C et al (2008) Transcatheter pelvic arterial embolisation for control of obstetric and gynaecological haemorrhage. J Obstet Gynaecol 28:573–579
5. Boulleret C, Chahid D, Gallot D et al (2004) Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases. Cardiovasc Intervent Radiol 27:334–348
6. Ojala K, Perala J, Kariniemi J et al (2005) Arterial embolization and prophylactic catheterization for the treatment of severe obstetric hemorrhage. Acta Obstet Gynecol Scand 84:1075–1080
7. Tsang ML, Wong WC, Kun KY et al (2004) Arterial embolisation in intractable primary post-partum haemorrhage: case series. Hong Kong Med J 10:301–306
8. Tourne G, Colleta F, Seffert P et al (2003) Place of embolization of the uterine arteries in the managementof post-partum haemorrhage:a study of 12 cases. Eur J Obstet Gynecol Reprod Biol110:29–34
9. Tixier H, Loffroy R, Guiu B et al (2009) Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. BJOG 116:55–61
10. Deux JF, Bazot M, Le Blanche AF, Tassart M, Khalil A, Berkane N, Uzan S, Boudghe`ne F (2001) Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage ? AJR Am J Roentgenol 177:145–149
11. Soyer P etal, Transcatheter Arterial Embolization for Postpartum Hemorrhage: Indications, Technique, Results, and Complications CVIR Feb 2015 Oct;38(5):1068-81
12. Multidisciplinary approach to manage antenatally suspected placenta percreta: updated algorithm and patient outcomes.Lee PS, Kempner S, Miller M, Dominguez J, Grotegut C, Ehrisman J, Previs R, Havrilesky LJ, Broadwater G, Ellestad SC, Secord AA. Gynecol Oncol Res Pract. 2017 Aug 22;4:11.
13. Endovascular management of massive post-partum haemorrhage in abnormal placental implantation deliveries. Rebonato A, Mosca S, Fischer M, Gerli S, Orgera G, Graziosi L, Maiettini D, Di Renzo GC, Epicoco G, Krokidis M, Rossi M, Scialpi M. Eur Radiol. 2016 Jun;26(6):1620-30.
14. Investigation into 10 maternal deaths at, or following delivery at, Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005. Health care Commission
15. Royal College of Obstetricians and Gynaecologists (2007) The role of emergency and elective interventional radiology in postpartum hemorrhage. Royal College of Obstetricians and Gynaecologists Good Practice Guideline No. 6. Royal College of Obstetricians and Gynaecologists, London. Available at: http://www.rcog.org.uk/ womens-health/clinical-guidance/role-emergency-and-electiveinterventional- radiology-postpartum-haem.
16. Royal College of Obstetricians and Gynaecologists 2011; Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia - .Royal College of Obstetricians and Gynaecologists Good Practice Guideline No. 27. Royal College of Obstetricians and Gynaecologists https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_27.pdf
17. Royal College of Obstetricians and Gynaecologists (2016)Prevention and management of post partum haemorrhage .Royal College of Obstetricians and Gynaecologists Good Practice Guideline No. 52. Royal College of Obstetricians and Gynaecologists, London. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/

Competing interests: No competing interests

09 October 2017
Raman Uberoi
Doctor
President of the Bristish Society of Radiologists
Royal College of Radiologists, Lincoln Inn fields, London