Jpn J Intervent Radiol Vol.24 No.2 2009

State of the Art
Interventional Radiology for Major Obstetric Hemorrhage

1. Management of Major Obstetric Hemorrhage

Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences
Hisashi Masuyama, Tomonori Segawa, Yuji Hiramatsu

 Major obstetric hemorrhage remains one of the major causes of maternal mortality and morbidity. This review summarizes the management of obstetric hemorrhage and highlights recent advances and developments. The most common etiologies of hemorrhage are abruptio placenta, placenta previa/accreta, uterine rupture in the antepartum period and retained placenta/placenta polyp, uterine atony, uterine inversion and genital tract trauma in the postpartum period. Appropriate surgical and/or pharmacological treatments should be combined for each hemorrhagic condition. If previous measures have failed, interventional radiology (IVR) is the main option to reduce blood loss. Recently, prophylactic temporary balloon occlusion has been tried to determine whether it has some roles in the management of patients with placenta previa/accreta.  Recombinant activated factor Ⅶ may also be considered for obstetric hemorrhage. Hysterectomy must be considered when all other interventions have failed. Although there are no randomized controlled trials, recent systematic reviews demonstrated high success rates of IVR in hemostatic control in the pelvis. Further analysis is required to clarify the role of IVR in the management of obstetric hemorrhage.

Key words

  • Obstetric hemorrhage
  • Maternal mortality
  • Interventional radiology


2. Anatomical Variation of the Pelvic Artery, and the Procedure, Safety and Possible Complications of Uterine Arterial Embolization for Obstetrical Hemorrhage

Department of Radiology, Shiga University of Medical Science
Shuzo Kanasaki, Akira Furukawa, Makoto Wakamiya, Tomohiro Hirose
Toyohiko Tanaka, Norihisa Nitta, Kiyoshi Murata

 Uterine artery embolization (UAE) has been widely accepted as a safe and effective treatment for uterine fibroids. UAE is also recently performed for obstetric hemorrhage refractory to conservative treatment as an alternative to surgical treatments such as bilateral internal iliac artery ligature and hysterectomy. UAE is less-invasive and acceptable in patients with poor general condition, and excellent results of this treatment have been recently reported.
 In the procedure of UAE, a catheter must be inserted into the uterine artery for selective embolization ; however, vascular anatomy of the pelvis is relatively complex and a large number of variations exist. Knowledge of the precise anatomy of the branching patterns of the pelvic arteries and the variations is essential for a safe and effective treatment. Preoperative assessment of vascular anatomy by CTA or MRA is helpful for UAE in the treatment of uterine fibroids, although this may not be possible in emergent patients with obstetric hemorrhage.
 In this article, anatomy of the pelvic arteries and the variations are demonstrated with illustrations. The procedure, safety and efficiency of UAE in the treatment of obstetric hemorrhage are explained with possible complications.

Key words

  • Obstetric hemorrhage
  • Uterine artery embolization
  • Internal iliac artery


3. Emergent Selective Arterial Embolization in the Management of Intractable Obstetric Hemorrhage

Department of Radiology, Okayama University Medical School
Kentaro Shibamoto, Hidefumi Mimura, Takao Hiraki, Hideo Gobara, Susumu Kanazawa

 Obstetric hemorrhage is one of the main causes of maternal mortality. Emergent selective arterial embolization is an effective and safe means to control intractable obstetric hemorrhage. Gelatin sponge is the embolic material most frequently used in cases of emergent embolization with a potential for recanalization a few weeks later. In cases of pseudoaneurysms or profound contrast medium extravasation, metallic coils or glue are often needed to achieve complete devascularization.
 In this article we describe the indication, methods, and outcomes regarding hemorrhage control of selective arterial embolization, procedural complications, and postprocedural fertility in emergent selective arterial embolization for management of intractable obstetric hemorrhage.

Key words

  • Arterial embolization
  • Obstetric hemorrhage
  • Gelatin sponge


4. Transarterial Embolization Using NBCA-Lipiodol for Life-threatening Obstetric and Gynecologic Hemorrhage

Department of Radiology, St.Marianna University School of Medicine
Misako Yoshimatsu, Kenji Takizawa, Yukihisa Ogawa, Kunihiro Yagihashi
Masakatsu Funakubo, Yoshiko Kurihara, Yasuo Nakajima

 The success rate of hemostasis of transarterial embolization (TAE) using gelatine sponge particles (GS) for obstetric and gynecologic hemorrhage ranges from 75% to 96%. GS can cause vascular occlusion by mechanical obstruction followed by thrombosis and inflammatory reaction of the vessel wall. However, the vessel lumen embolized by GS embolic agent is possibly recanalized especially in cases with coagulopathy associated with DIC. N-butyl-2-cyanoacrylate (NBCA) polymerized by contact with +Na is a liquified permanent embolic material that immediately blocks serious hemorrhage even when complicated with coagulopathy. Since May 2005, we started TAE using a mixture of NBCA diluted with Lipiodol for such a serious hemorrhage complicated with DIC and/or pseudoaneurysms. There are just only a few reports on embolotherapy using NBCA for obstetric and gynecologic hemorrhage. The authors will introduce the procedure of the NBCA embolization, and mention embolization necessity of NBCA based on their experience.

Key words

  • Obstetoric and gynecologic hemorrhage
  • Postpartum hemorrhage
  • Transcatheter arterial embolization
  • N-butyl-2-cyanoacrylate(NBCA)


5. Caesarean Section under Balloon Occlusion of the Bilateral Internal Iliac Arteries in Patients with High Risk Pregnancy

Department of Diagnostic Imaging and Interventional Radiology, Maternal and Fetal Medicine1),
Tokyo Women’s Medical University Yachiyo Medical Center
Joe Toda, Tomo Kimura, Asuka Tsuchiya, Masato Sakai1), Naoki Masaoka1)
Department of Radiology, Koshigaya Hospital, Dokkyo University School of Medicine
Mamoru Iimuro

 Placenta accera / percreta are one of the most serious causes of massive hemorrhage. Temporary balloon occlusion of bilateral internal iliac arteries was performed in five patients including placenta accera/ percreta to prevent hemorrhage during caesarean section. No significant bleeding was seen in any of the five patients. Caesarean section under balloon occlusion of the internal iliac artery in patients with high risk pregnancy is a feasible prophylactic procedure for reducing such hemorrhage.

Key words

  • Balloon occlusion
  • Internal iliac artery
  • High risk pregnancy
  • Placenta accreta


6. Japanese Society of Interventional Radiology Clinical Practice Guidelines :Development of Evidence-based Guidelines for Interventional Radiology in Postpartum Hemorrhage

Department of Radiology, Iwate Medical University
Miyuki Sone
Department of Radiology, St. Marianna University
Yasuo Nakajima

Clinical Practice Guidelines Committee and Task Force for the Postpartum Hemorrhage
Yasukazu Shioyama1, Masakatsu Tsurusaki2, Takao Hiraki3, Susumu Kanazawa3
Misako Yoshimatsu4, Hideo Kayama5, Satoko Kakita6, Reiko Woodhams6
Hiroshi Nishimaki6, Yukunori Korogi7, Yasuo Goto8, Yoshiaki Narimatsu9
Dokkyo Medical University1, National Cancer Center2, Okayama University Medical School3, St. Marianna University4
International Goodwill Hospital5, Kitasato University6, University of Occupational and Environmental Health7
Sendai Shakai Hoken Hospital8, Kawasaki City Kawasaki Hospital9

 In 2008, the Japanese Society of Interventional Radiology (JSIR) launched a project to develop the clinical practice guidelines in interventional radiology. Guidelines for blood access intervention, embolization for the bleeding caused by trauma, and interventional management of postpartum hemorrhage are currently under development. These guidelines will be written to provide the procedural recommendations to complement the preexisting disease-oriented guidelines. Evidence-based methodology will be used to construct the guidelines. This paper illustrates a summary of the early phase in developing guidelines for interventional radiology for postpartum hemorrhage.

Key words

  • Obstetric hemorrhage
  • Guidelines
  • EBM


Original Article

Right Adrenal Vein Sampling Technique : Predictive Significance of the Nephrogramy

Department of Radiology, Graduate School of Medical Science, University of the Ryukyus
Masaki Gibo, Shinobu Unten, Akira Yogi, Sadayuki Murayama
Department of Radiology, Hart-Life Hospital
Makoto Takara

Adrenal vein sampling is an important procedure for the diagnosis of primary aldosteronism, but catheter insertion into the right adrenal vein is particularly difficult. At the start of the procedure, we inject 40 to 50 mL of contrast medium to visualize the nephrogram of the right kidney and determine whether there is an index to predict the level of the right adrenal vein. Of 24 consecutive patients who underwent adrenal vein sampling in our institutions, there were 22 technical successes. We measured the distance between the upper end of the right nephrogram and the right adrenal vein as the basis of height of vertebra for 1, and distance an average of both was 0.6 body of vertebra. In all patients, right adrenal vein position entering the inferior vena cava is higher than the upper end of the right nephrogram. This knowledge is useful for the right adrenal vein sampling technique.

Key words

  • Adrenal venous sampling
  • Primary aldosteronism
  • Catheter technique

Technical Note

Initial Experience of a Novel Cone-beam CT Guided Percutaneous Drainage for Abscesses in the Trunk

Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine
Hiroki Higashihara, Keigo Osuga, Noboru Maeda, Kaname Tomoda, Hironobu Nakamura
Department of Radiology, Suita Municipal Hospital
Koji Mikami
Department of Radiology, Kangnam St. Mary’s Hospital , The Catholic University of Korea
Ho Jong Chun
Department of Diagnostic Radiology, National Cardiovascular Center
Tetsuro Nakazawa

We report the initial clinical experience with a realtime needle navigation using cone-beam CT(CBCT)guided targeting system or XperGuide(Philips Medical Systems). Six patients with abscess in the trunk underwent percutaneous drainage using XperGuide. In each patient, CBCT was performed to plan the needle path on a 3D-workstation, and the virtual needle path was shown on the live fluoroscopy overlapped with the CBCT image. The needle was positioned in the target circle under the “bull’s eye view” to define the needle direction, and then, advanced until it reached the target under the “progress view” to monitor the needle depth. After confirming the needle tip position by CBCT again, a drainage tube was placed under X-ray fluoroscopy. The procedures were successful in all six patients without complications. Fluoroscopy time during the total procedure ranged from 1 minute to 2 minutes 26 seconds. XperGuide is a feasible needle navigation system and useful for percutaneous drainage procedures.

Key words

  • Cone-beam CT
  • Needle guidance
  • Drainage