CLINICAL STUDY

Usefulness of Pelvic Artery Embolization in CesareanSection Compared with Vaginal Delivery in 176

Patients

Hyun Joo Lee, MD, Gyeong Sik Jeon, MD, Man Deuk Kim, MD,Sang Heum Kim, MD, Jong Tae Lee, and Min Jeong Choi, MD

ABSTRACT

Purpose: To evaluate the efficacy and safety of transcatheter arterial embolization of the pelvic arteries for the treatment of

postpartum hemorrhage (PPH) associated with cesarean section compared with vaginal delivery.

Materials and methods: A retrospective analysis of 176 patients undergoing transcatheter arterial embolization of the pelvic

arteries for PPH from January 2006 through August 2011 was conducted at two institutions. The mean patient age was 33.9 years

(range, 24–46 years). Data including delivery details, hematology and coagulation results, embolization details, and clinical outcomes

were collected. Technical success was defined as cessation of bleeding on angiography or angiographically successful embolization of

the bleeding artery. Clinical success was defined as the obviation of repeated embolization or surgical intervention.

Results: The technical success rate was 98.8% (n ¼ 174), and the clinical success rate was 89.7% (n ¼ 158). Among 176 patients, 71

had cesarean sections, and 105 underwent normal vaginal deliveries. Of the 105 patients who underwent normal vaginal deliveries, 11

(10.5%) required repeat embolization or surgical intervention. Of the 71 patients who had cesarean sections, 7 (9.8%) required repeat

embolization or surgical intervention. The clinical success rate and complication rate were not related to the mode of delivery.

All women resumed menses after transcatheter arterial embolization, and most (n ¼ 125) described their menses as unchanged.

Subsequent spontaneous pregnancies occurred in 13 women.

Conclusions: The cesarean mode of delivery is not a predictor of poorer outcomes of transcatheter arterial embolization; however,

further study is needed to clarify this relationship.

ABBREVIATIONS

DIC = disseminated intravascular coagulation, PPH = postpartum hemorrhage, PVA = polyvinyl alcohol

Obstetric hemorrhage may occur at any point during preg-

nancy, delivery, or the puerperium and is associated with

significant maternal morbidity and death (1). Potential causes

of severe obstetric hemorrhage include uterine atony, lower

genital tract laceration, retained placenta, cervical pregnancy,

abnormal placenta, and coagulopathies. Postpartum hemo-

rrhage (PPH) can be managed conservatively with uterine

& SIR, 2013

J Vasc Interv Radiol 2013; 24:103–109

http://dx.doi.org/10.1016/j.jvir.2012.09.029

None of the authors have identified a conflict of interest.

From the Department of Radiology (H.J.L., G.S.J., S.H.K., J.T.L.), CHA Bundang

Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si,

Gyeonggi-do 463-712, Republic of Korea; Department of Radiology (M.D.K.),

Research Institute of Radiological Science, Yonsei University College of Medi-

cine, Seoul; Department of Radiology (M.J.C.), Dankook University Hospital,

Chungcheongnam-do, Republic of Korea. Received May 11, 2012; final revision

received September 17, 2012; accepted September 26, 2012. Address

correspondence to G.S.J.; E-mail: hae0820@naver.com

and vaginal packing, intravenous administration of uterotonic

drugs, and surgical repair of the genital tract laceration. If the

hemorrhage persists, surgical treatment is necessary; however,

this may be technically difficult and fail to control the

hemorrhage. Because of the abundant collateral blood flow

in the pelvis, the failure rate of vascular ligation has been

50%, and vascular ligation failure often results in hysterectomy

(2–4). These treatments also carry the risk of general

anesthesia, major emergency surgery, and the potential loss

of reproductive ability (5,6).

Brown et al (7) first described transcatheter arterial

embolization of the pelvic arteries for the control of

persistent PPH in 1979. Since then, transcatheter arterial

embolization of the pelvic arteries has been used effectively

in the management of intractable obstetric hemorrhage. It is

a less invasive technique than hysterectomy or vascular

ligation and can replace surgery in many cases (8–10).

Success rates after embolization of the pelvic arteries have

been reported to be 4 90%, with minimal complications

Lee et al ’ JVIR104 ’ Pelvic Artery Embolization for PPH

(3,7,8,11–13). Transcatheter arterial embolization is considered

an effective treatment for intractable obstetric hemorrhage.

Touboul et al (14) reported 102 patients with PPH who

underwent transcatheter arterial embolization and suggested

that cesarean sections were associated with a higher failure

rate. However, controversy exists regarding whether or not

cesarean section is related to failure of embolization. Some

studies suggested that cesarean sections were not associated

with a higher failure rate in patients with PPH (15,16).

Relatively small cohorts limit the value of previous studies

concerning an association between transcatheter arterial

embolization and cesarean section. The aim of the present

study is to describe the efficacy and safety of pelvic arterial

embolization associated with cesarean section compared with

vaginal delivery.

MATERIALS AND METHODS

PatientsInstitutional review board approval was obtained from the

institutional ethical board for this retrospective study,

which included 176 patients with PPH who were treated

with transcatheter arterial embolization between January

2006 and August 2011 in two medical centers. Patients

either gave birth in our obstetrics department or were

transferred from other institutions that did not have a

vascular imaging unit.

During the study period, 16,283 women delivered in our

institution. Of 8,801 women who had cesarean sections, 42

of these patients (0.48%) received transcatheter arterial

embolization for management of PPH. Of 7,482 women

who underwent normal vaginal deliveries, 53 (0.71%)

received transcatheter arterial embolization for manage-

ment of PPH. Among the 176 women who were treated

with transcatheter arterial embolization for management of

PPH, 95 (53.9%) underwent delivery in our institutions.

There were 81 women (46%) urgently transferred from

other institutions because of continuous PPH; 52 women

were transferred after vaginal delivery, and 29 women were

transferred after cesarean section.

Clinical, biochemical, and hematologic data were col-

lected from medical records. The mean age of the patients

was 33.9 years (range, 24–46 y). In 151 patients, hemor-

rhage occurred within the first 24 hours after delivery. In

the remaining 25 patients, hemorrhage occurred 4 24

hours after delivery. Hemorrhage within the first 24 hours

after delivery was defined as early-onset PPH, and hemor-

rhage 4 24 hours after delivery was defined as late-onset

PPH. Patients received primary treatment in the obstetric

wards, including intravenous uterotonic drug administra-

tion; blood transfusions; fluid resuscitation; vaginal pack-

ing; uterine massage; vaginal, cervical, and perineal

inspection; and, when needed, tear suturing. If the treat-

ment failed and bleeding continued, the patient was

referred for angiography and transcatheter arterial

embolization.

Embolization ProcedureInterventional radiologists performed angiography and embo-

lization. Using a unilateral femoral artery approach, aortoi-

liac arteriography was performed to localize the uterine

arteries and to evaluate other sites of bleeding. Selective

study of the anterior division of the internal iliac artery or the

uterine artery was performed with a 5-F catheter (Yashiro;

Terumo, Tokyo, Japan, or RUC; Cook, Inc, Bloomington,

Indiana) to identify the bleeding vessel. Embolization was

performed using absorbable gelatin sponges (Cutanplast;

Mascia Brunelli Spa, Milan, Italy), polyvinyl alcohol

(PVA) particles (Contour; Boston Scientific, Cork, Ireland,

or PVA; PVA Foam Embolization Particles, Cook, Inc),

metallic microcoils (Tornado; Cook, Inc, or Vortx, Boston

Scientific, Cork, Ireland), and glue (Histoacryl L; Aesculap

AG, Tuttlingen, Germany) according to the physician’s

preference and angiographic findings. The endpoint of

embolization was to administer embolic agents until stasis

was evident or until the occlusion of the uterine artery was

evident angiographically. Iliac arteriography was performed

after embolization to ensure the complete occlusion of

bleeding and to identify any other potential bleeding arteries.

Data Analysis and StatisticsData were collected regarding embolic material, number of

arteries that received embolization, angiography imaging

findings, immediate and late complications, and pregnancy

after the embolization procedure. Angiography findings

were divided into two categories: findings of active bleed-

ing, such as the extravasation of contrast material or

pseudoaneurysm, and hyperemia (only increased blood flow

to the uterus). Embolic materials were also divided into two

categories: particle (gelatin sponges and PVA particles 150–

700 mm) and nonparticle (glue and metallic coils).

Immediate complications were defined as complications

that occurred within 48 hours of the embolization proce-

dure, such as postembolization syndrome, hematoma

formation, and uterine infarction. Late complications were

defined as complications that occurred 4 48 hours after

the procedure, such as alteration of menstrual quality,

sexual dysfunction, and ischemic or neurologic complica-

tions. All complications were divided into minor and major

complications according to the Society of Interventional

Radiology guidelines (17). Minor complications result in

no sequelae. They may require nominal therapy or a short

hospital stay for observation. Major complications result in

hospital admission for therapy, unplanned increases in

level of care, prolonged hospitalization, permanent adverse

sequelae, or death. Alteration of menstrual quality was

considered a late complication.

Technical success was regarded as successful appropriate

catheterization or embolization of target vessels. Clinical

success was defined as the obviation of repeated emboliza-

tion or surgical intervention (17). Clinical failure of the

procedure was defined as the presence of continued bleeding

after embolization and the need for repeated embolization or

Volume 24 ’ Number 1 ’ January ’ 2013 105

surgical procedure to control hemorrhage after successful

embolization.

Statistically significant associations between subject char-

acteristics and statistical differences between women with

cesarean sections and women with normal vaginal deliveries

were evaluated with paired t tests, Pearson w2 tests, or (when

appropriate) Fisher exact tests, and clinical success rates were

evaluated. Statistical analysis was performed with SPSS

statistical software (version 18; SPSS, Inc, Chicago, Illinois).

P o .05 was considered statistically significant.

RESULTS

There were 189 embolization procedures performed in 176

patients; 71 (40.3%) patients had cesarean sections, and

105 (59.7%) patients underwent normal vaginal deliveries.

Of women, 103 were multiparous, and 73 were primipar-

ous. Table 1 lists the reasons for cesarean section.

PPH was caused by uterine atony (n¼ 102; 57.6%), cervical

or vaginal laceration (n ¼ 21; 11.9%), abnormal placentation

(including placenta accreta and percreta) (n ¼ 52;

29.5%), or placental abruption (n ¼ 1; 0.6%). Four patients

Table 1 . Reason for Cesarean Section

Reason No. Patients

Twin pregnancy 16

Previous cesarean section 17

Placenta previa 11

Cephalopelvic disproportion with

prolongation of labor

7

Induction failure 3

Breech presentation 3

Premature rupture of membrane with fetal

distress

3

Preterm labor with fetal distress at

intrauterine period 35 wk, 2 d

1

Vaginal lacerations during attempted

vaginal delivery

1

Unknown 9

Table 2 . Patient Characteristics Based on Mode of Delivery

Vagina

No. patients 105

Age (y) (mean � SD)* 33.33

Parity (no. patients)†

Primiparity 47

Multiparity 58

Onset of hemorrhage (no. patients)† o 24 h 92

4 24 h 13

Lowest hemoglobin level (g/dL) (mean � SD)* 9.17

SD ¼ standard deviation.n Paired t test.† w2 test.‡ P o .05, statistically significant.

(3.8%) with vaginal delivery and two patients (2.8%) with

cesarean section had disseminated intravascular coagulation

(DIC). One patient who underwent normal vaginal delivery

experienced hemodynamic shock. The mean (� standard

deviation) hemoglobin level of 176 patients was 8.4 g/dL �2.0. The mean number of units of whole blood transfused was

3.8 � 3.3 units (range, 2–26 units) in 151 patients.

Tables 2 and 3 summarize the patient characteristics and

embolization details based on the mode of delivery. There

were no statistically significant differences in parity, onset

of hemorrhage, lowest hemoglobin level at the time of

embolization, mean number of arteries that received embo-

lization, procedure time, angiographic findings, or embolic

materials between the cesarean section group and the

vaginal delivery group. Age was related to the mode of

delivery (P = .035). Mean age of patients with cesarean

section (34.88 y � 4.775) was significantly older than mean

age of patients with vaginal delivery (33.33 y � 4.673).

Particles such as absorbable gelatin sponges and PVA

particles were used according to the physician’s preference

in 166 patients. Only particles were used in 121 patients,

and additional glue or metallic microcoils or both were

used in 45 of 166 patients because of contrast medium

extravasation on angiogram. Metallic microcoils were used

for protection of distal flow in 6 of 166 patients. For

the remaining 10 patients, embolizations were performed

using glue or metallic microcoils or both without absorb-

able gelatin sponges or PVA particles. All 10 patients

showed contrast medium extravasation on angiogram.

Embolization of both uterine arteries was performed in

149 patients. More than one additional artery embolization

was performed in 50 patients. Table 4 shows the details of

the arteries that received embolization.

Technical success was achieved in 174 of 176 patients

(98.8%). In one patient, catheterization of the left uterine

artery was unsuccessful and resulted in contrast medium

extravasation owing to its small diameter and the acute

angle of its origin. However, in this patient, successful

embolization of the left internal iliac artery and right

uterine artery was achieved, and bleeding eventually

stopped with conservative treatment without complications.

l Delivery Cesarean Section P Value

71

� 4.673 34.88 � 4.775 .035‡

.251

26

45

59 .421

12

� 1.928 8.76 � 2.079 .173

Table 3 . Details of Pelvic Artery Embolization Based on Mode of Delivery

Vaginal Delivery Cesarean Section P Value

Mean no. embolized arteries* 2.31 2.44 .267

No. embolized arteries

1 7 5

2 64 41

3 28 16

4 6 6

5 0 3

Angiographic findings† .06

Extravasation/pseudoaneurysm 45 45

Hyperemia 60 26

Embolic material (patient number)† .379

Particle‡ (121) 68 53

Nonparticle§(10) 4 6

Combined (45) 23 22

Procedure time (min) (mean � SD)* 71.39 � 28.062 70.45 � 36.032 .881

SD ¼ standard deviation.n Paired t test.† w2 test.‡ Absorbable gelatin sponge or polyvinyl alcohol, or both, without metallic microcoils or glue.§ Metallic microcoils or glue, or both, without absorbable gelatin sponge or polyvinyl alcohol.

Table 4 . Embolized Arteries and Number of Patients

Embolized Arteries No. Patients

Both uterine arteries 99

Both uterine arteries and one round ligament

artery

18

Both uterine arteries and one ovarian artery 14

Both uterine arteries and both round ligament

arteries

3

Both uterine arteries and both IIAs 3

Both uterine arteries and one IIA 3

Both uterine arteries, one round ligament artery,

and one ovarian artery

3

Both uterine arteries and both ovarian arteries 2

Both uterine arteries, both round ligament

arteries, and one ovarian artery

1

Both uterine arteries, both IIAs, and one round

ligament artery

1

Both uterine arteries, one IIA, and one round

ligament artery

1

Both uterine arteries and one middle rectal

artery

1

One ovarian artery 6

One IIA 6

One IIA and one uterine artery 5

One IIA and both round ligament arteries 1

Both IIAs 4

Both IIAs and one uterine artery 2

Both IIAs and one inferior epigastric artery 1

Both IIAs, both ovarian arteries, and one round

ligament artery

1

Both IIAs and both round ligament arteries 1

IIA ¼ internal iliac artery.

Lee et al ’ JVIR106 ’ Pelvic Artery Embolization for PPH

Hemostasis was achieved in 158 patients, resulting in

89.7% clinical success. In 12 patients (6 after cesarean

section and 6 after vaginal delivery), repeat embolization

was required. Eight patients with repeat intervention

showed recanalization, and one patient had collateral

vessels. The remaining three patients demonstrated com-

bined recanalization and collaterals. After the successful

embolization of bilateral uterine arteries, continuous

hemorrhage was observed in 1 of the 12 patients. A third

embolization was performed within 24 hours in this

patient. Abnormal staining of the uterus from the right

ovarian artery and the right round ligament artery was

observed on digital subtraction angiography. Selective

catheterization of the right ovarian artery was unsuccessful

because of its small size and the acute angle of its origin;

however, embolization of the right round ligament

artery was successful. With conservative treatment, the

bleeding stopped. This patient was regarded as a technical

failure.

Five patients who had vaginal deliveries underwent hyster-

ectomies, including one patient who underwent repeat

embolization because of persistent bleeding after transcatheter

arterial embolization. Only one patient with a cesarean section

had a surgical ligation (Table 5). After surgical intervention,

the vaginal bleeding stopped in all of these patients.

Two patients who underwent normal vaginal delivery

eventually died. The first patient was a 36-year-old primi-

gravida who had PPH secondary to uterine atony. Her initial

hemoglobin level was 2.5 g/dL. She received 12 units of

whole blood. After successful embolization of the bilateral

uterine arteries, a repeat embolization was performed because

of continued bleeding and hemodynamic instability. Although

bleeding stopped after repeat embolization, severe multiorgan

Volume 24 ’ Number 1 ’ January ’ 2013 107

failure had already occurred, and the patient died 20 hours

after the first embolization.

The second patient was a 34-year-old multigravida who

had delivered vaginally in another institution and had PPH

secondary to uterine atony. She had DIC. Her hemodynamic

status remained stable after transcatheter arterial emboliza-

tion. However, her mental status changed, and she entered a

stupor. At this point, computed tomography of the brain

showed a cerebral hemorrhage with intraventricular bleeding,

although gynecologic bleeding had stopped by then. After 15

days in the intensive care unit, the patient died.

Follow-up data were available for only 148 patients of

the 175 patients who survived the hospitalization. During

the follow-up period (mean, 22.4 mo; range, 2–58 mo), 13

women had spontaneous pregnancies; 4 delivered via

cesarean section, and 9 had vaginal delivery. Eleven births

occurred at term, and two births occurred preterm, at 34

weeks and 36 weeks; all 13 births were without complica-

tions. One case of abortion was observed in each group;

however, the reasons for the abortions were not recorded.

There were immediate complications related to postembo-

lization syndrome, including transient fever, mild leukocyto-

sis, and abdominal pain in 13 patients. All of these patients

did well with conservative treatment. Three of the 13 patients

also complained of hematoma formation at the arterial

puncture site. After transcatheter arterial embolization, 23

patients experienced altered menstrual quality. Five patients

described heavier menses, and 17 patients described lighter

Table 5 . Number of Patients Treated with InterventionalProcedures after Clinical Failure of Initial Embolization

Vaginal

Delivery

Cesarean

Section

Repeat embolization 6 6

Secondary to recanalization

of embolized artery

4 4

Collateral flow 1 0

Combined 1 2

Surgical procedure 5 1

Hysterectomy 5 0

Vascular ligation 0 1

Total no. patients 11 7

Table 6 . Clinical Effectiveness and Safety of Transcatheter Arterial E

Vaginal Delivery

(No. Patients)

Immediate complication* 9

Postembolization syndrome 9

Hematoma formation 2

Late complication* 13

Overall complication* 22

Clinical failure 11

Clinical success rate (%) 89.5

n w2 test.

menses. One patient complained of dysmenorrhea. All of

these complications were graded as minor. There were no

uterine infarctions, ischemic injuries, or neurologic complica-

tions. Embolization was not related to any major complica-

tions. One woman complained of axillary sweating, which did

not appear to be related to the transcatheter arterial emboliza-

tion procedure. There were no statistically significant differ-

ences in immediate, late, or overall complication rates or the

clinical success rates between the two groups. Table 6 shows

the clinical effectiveness and safety of transcatheter arterial

embolization.

DISCUSSION

Overall, the rate of cesarean sections has increased

from o 7% in the 1970s to 4 25% since 2000 (18,19).

The increase in the cesarean section rate is multifactorial,

and reasons include improved surgical techniques reducing

postoperative risk, repeat cesarean sections, and increased

maternal age (20,21). Transcatheter arterial embolization

has been proposed as a second-line therapeutic option

when initial medical treatment fails to stop bleeding in

patients with PPH. The incidence of transcatheter arterial

embolization in patients with PPH who have cesarean

sections is increasing. Our study shows the correlation

between patient age and mode of delivery. Mean age of

patients with cesarean section was significantly older than

age of patients with vaginal delivery; however, the mean

difference in age between the two groups was o 2 years.

In the present study, patients with cesarean sections had a

tendency toward active bleeding being detected on digital

subtraction angiography. However, there was no statistically

significant association between the angiographic findings and

the mode of delivery (P = .06). The rates of active contrast

medium extravasation reported in the literature range from

30%–100% (22–24); however, the negative findings on

angiography do not exclude bleeding. In addition, contrast

medium extravasation is not a whole marker of severe

hemorrhage. Angiography can detect contrast medium extra-

vasation with a threshold flow rate of 1–2 mL/min (25). If the

arterial bleeding is slow or intermittent or occurs in a patient

with an atonic uterus, angiography often fails to demonstrate

mbolization

Cesarean Section

(No. Patients) P Value

4 .564

4

1

10 .769

14 .927

7

90.1 .396

Lee et al ’ JVIR108 ’ Pelvic Artery Embolization for PPH

active bleeding. Even when contrast medium extravasation

and other direct signs of a bleeding source are not seen on

pelvic arteriography, bilateral embolization of the uterine

arteries can result in bleeding cessation (26).

The clinical success rate of transcatheter arterial embo-

lization in the present study was 89.7% and was not related

to the mode of delivery. The effectiveness of transcatheter

arterial embolization in managing intractable PPH and in

avoiding emergency pelvic surgery has been clearly

demonstrated previously. These studies describe high

clinical success rates with relatively low complication

rates. Reported rates of the immediate cessation of hemor-

rhage range from 87%–100% (7,13,27,28). After successful

embolization, there is typically a rapid improvement in

hemodynamic stability and a correction of clotting abnorm-

alities, with a decreased need for further transfusion.

Touboul et al (14) studied 102 patients with PPH who had

undergone transcatheter arterial embolization and found

relatively high failure rates (47.6% in patients who had

cesarean section deliveries). However, the percentage of

patients who had cesarean section deliveries was small

(20.5%). In contrast, Kirby et al (29) studied 43 patients

with PPH who had undergone transcatheter arterial

embolization and found no statistically significant difference

in outcome based on the mode of fetal delivery. In Kirby’s

study (29), the percentage of patients with cesarean section

was larger (48%) than in Touboul’s study (14). Lee et al (16)

studied 251 patients and found that the mode of delivery was

not independently related to the clinical failure of transcatheter

arterial embolization in multivariate analysis. In Lee’s study

(16), the percentage of patients who had cesarean section

deliveries was 43.8%. Similar to the studies of Kirby et al (29)

and Lee et al (16), in the present study, no statistically

significant difference in the clinical success rates of patients

with normal vaginal deliveries and patients with cesarean

section deliveries was found. It was found that a relatively high

percentage of patients had cesarean section deliveries (40.3%)

compared with the study of Touboul et al (14). In Touboul’s

study (14), nearly half of the patients (45%) were in shock, and

59.8% had DIC. However, in the current study, only one

patient had hemodynamic shock, and six patients had DIC.

When transcatheter arterial embolization is performed by

experienced interventional radiologists, complication rates

are low, with the overall complication rate 6%–9% (26–

28). The most frequent complications are self-limited mild

fever, leukocytosis, and abdominal pain after embolization.

These results reported in the literature are very similar to

the results found in the present study. Ischemic or

neurologic complications are rare; however, they may

occur if small embolic particles are used or if there is an

interruption of collateral supply because of previous

surgical ligation of the internal iliac artery (8,9,30). A

more recent report described ischemia after embolization

using absorbable gelatin sponge pledgets and PVA parti-

cles 150–250 mm (13). Although the incidence of these

serious complications is low, the use of small absorbable

and nonabsorbable particles should probably be avoided. In

the present study, particles 150–250 mm were used in only

two patients. In 13 patients, embolization of both internal

iliac arteries was performed; however, none of the patients

complained of ischemic or neurologic symptoms.

Signs of ovarian failure have been reported in previous

studies of women undergoing transcatheter arterial emboliza-

tion for fibroids (31,32). Nontarget embolization of the

ovarian arteries via uteroovarian collateral circulation could

induce ischemic injury to the ovary and subsequent alteration

of the follicular contingent (33). However, Tropeano et al

(34) found that uterine artery embolization in reproductive-

age women did not have short-term or medium-term effects

on ovarian reserve as assessed by hormonal and ultrasound

parameters. Salomon et al (35) suggested that ovarian

function was not impaired by transcatheter arterial

embolization for PPH based on self-reported unchanged

menstruation. The present study shows results similar to the

results found in these reports. However, no other measure of

ovarian function was recorded, and no information on

contraception or on desire for pregnancy was available.

One case of fetal growth restriction was reported in the

literature after transcatheter arterial embolization for PPH

(36). The authors suggested that embolization could damage

endometrial or myometrial areas, leading to placental dys-

function. However, Fiori et al (37) reported 20 pregnancies in

13 women among 46 patients undergoing transcatheter arterial

embolization for severe PPH. They reported a 60% rate of

vaginal delivery of healthy infants with normal weight for

gestational age. In addition, color flow Doppler images were

found for all these pregnancies, suggesting good quality of the

uteroplacental exchanges.

The present report has some limitations. First, as with

other published series, the value of the present findings is

limited by the retrospective nature of the study. Second, no

data were collected about the rate of women with no desire

for pregnancy or the rate of women who have attempted to

become pregnant. The exact influence of embolization on

fertility was not evaluated.

In conclusion, the present study, involving a larger sample

size, showed that the use of transcatheter arterial embolization

is a safe and effective method to control obstetric hemorrhage,

with minor risks of complications, regardless of the mode of

delivery. The present study calls into question whether the

cesarean mode of delivery is a predictor of poorer outcomes

after embolization. Further study is needed to understand more

thoroughly whether mode of delivery is a predictor of success

of embolization in treating patients with PPH.

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