Study design
This single centre based retrospective study was conducted at Aster
Medcity Kochi, a 670 bedded NABH accredited quaternary care centre in
Kerala, India, from the period of 2015 to 2021.
All obstetric and gynecological cases in which interventional radiology
techniques were used during the period of January 2015 to December 2021
were included. None of the cases were excluded. For all elective cases,
a multidisciplinary team meeting consisting of Obstetrician and
Gynecologist, Interventional Radiologist and Anesthesiologist was
conducted prior to the procedure. Informed consent was taken from every
patient prior to the procedure.
The interventional radiology procedures were performed in ‘PHILIPS
Hybrid cath lab’ by two interventional radiologists, with one of them
having a minimum five years of experience. All patients with
arteriovenous malformations (AVM), underwent a contrast CT angiography
for assessing the feeding the vessels and draining veins. Patients with
Placenta Accreta Spectrum (PAS) disorders were subjected to a
non-contrast MRI of abdomen in the late third trimester for maximum
possible characterization of abnormal placentation. Nine women of the
PAS disorder underwent prophylactic balloon placement in bilateral
internal iliac arteries under local anesthesia. Common femoral arteries
(CFA)were used as access sites and through 6F sheath, 5mm/6mm of 40 mm
length balloons were placed in internal iliac arteries distal to common
iliac bifurcation. The sheaths and catheters were anchored to the thigh
with sutures and ‘Tegaderm’. Patients were shifted to the operation
theatre (OT) for anesthesia and surgery. The interventional radiologists
were called to the OT for inflating balloons immediately after the
delivery of baby. The balloons were kept inflated to their optimum
pressures till the placental extraction/hysterectomy was completed. Then
the balloons and sheaths were removed in the theatre and hemostasis
achieved by manual compression or using closure devices.
For uterine fibroid embolization (UFE), all patients underwent
non-contrast MRI as a baseline imaging for future comparison. Right
femoral artery access was chosen for access in all patients; in rare
circumstances, left femoral access was also taken. The anterior division
of internal iliac arteries was cannulated using 4 or 5F catheters and
microcatheter was used for selective access into the uterine artery
distal to the branches to cervix. After achieving stable position, the
arteries were embolized using PVA particles ranging from 250 to
500micron sizes without causing significant reflux of particles. Good
stasis of contrast material in the proximal uterine arteries was taken
as the endpoint and confirmed adequate embolization of arteries.
Pelvic AVM cases were rare, and often difficult to differentiate between
retained products of conception with significant vascularity in the
setting recent pregnancy with occasional coexistence. So, all patients
were extensively evaluated and followed up. Recent contrast CT angiogram
was taken to identify the feeding arteries, size of the nidus and
draining veins. Access was planned based on the CT findings. Arterial
route embolization was preferred often, however one of our cases needed
both arterial and venous route embolization.
Patients were followed up for 72 hours as in patients for any recurrence
of symptoms and complications. Continuous monitoring of vitals (heart
rate, blood pressure ,temperature, saturation ) was done. Clinical
success was defined in terms of recurrence and or need for further
surgery. Both obstetric and gynaecology cases were followed up at the
time of postsurgical review as per protocol.
Statistical analysis: No statistical analysis of data was required as it
was a single centre retrospective analysis of cases.
Results:
We had a total of 35 cases, both obstetrics and gynecological, who
underwent various interventional radiological procedures including
embolization of uterine artery, peripheral angiography and embolization,
internal iliac artery balloon placement and ovarian vein embolization
and coil insertion.
Observations have been outlined below in Table-1 and Table-2, for
gynaecologic and obstetric cases respectively.
Our case series included nine cases of placenta accreta spectrum
(PAS)disorders, four each of fibroid complicating pregnancy and
postpartum hemorrhage and the latter underwent obstetric or cesarean
hysterectomy for primary or secondary hemorrhage, two with secondary
hemorrhage following hysterectomy for gynecological indications, ten
cases of Fibroid and six cases of arteriovenous malformations (AVM). The
AVM cases included one uterine AVM and five cases of pelvic AVM. One
patient of pelvic AVM had rectal ischemia post embolisation and
underwent pelvic exenteration surgery. In another case of pelvic
congestion syndrome planned for bilateral ovarian vein embolisation,
only left side embolisation could be performed due to difficult anatomy.
We now highlight the clinical scenarios in our hospital where
interventional radiology and obstetrics and gynaecology collaborated for
the management of the patients.
Postpartum hemorrhage :
A 32 year old G3P1L1A1 at 36+ weeks gestation with 2
previous LSCS referred with MRI suggestive of Placenta previa with
accreta/increta with placenta in the left and inferior wall of uterus,
completely covering internal os. There was no evidence of extra uterine
extension of placenta, bladder infiltration or bladder tenting/ureteric
compression/hydronephrosis.
An elective Caesarean hysterectomy with classical uterine incision with
bilateral uterine artery occlusion under general anaesthesia
intraoperatively showed placenta completely covering the lower segment,
adherent-partially separated. Adnexa were normal. Hysterectomy with
placenta insitu was performed. Estimated blood loss was around 500 ml.
(Figure1).
A 37 year old referred for postpartum haemorrhage following an emergency
LSCS was taken up for laparotomy and exploration with a preoperative
emergency uterine artery embolization by interventional radiologist.
Intraoperative findings were suggestive of a longitudinal lower
posterior uterine wall rupture of 5x1 cm which was repaired. B lynch
sutures were applied for atonicity along with other measures to control
the haemorrhage. Post operative collapse in ICU led to relaparotomy with
total abdominal hysterectomy which showed Couvelaire uterus of 24 weeks
size and hemoperitoneum of 1.3-1.5 litres managed by component
replacement.