European Radiology

, Volume 28, Issue 11, pp 4800–4809 | Cite as

Postpartum haemorrhage due to genital tract injury after vaginal delivery: safety and efficacy of transcatheter arterial embolisation

  • Sang Min Lee
  • Ji Hoon ShinEmail author
  • Jong Joon Shim
  • Ki Woong Yoon
  • Young Jong Cho
  • Jong Woo Kim
  • Heung Kyu Ko



To evaluate the safety and efficacy of transcatheter arterial embolisation (TAE) managing postpartum haemorrhage associated with genital tract injury (PPH-GTI) and to determine the factors associated with clinical outcomes.


From 2002 to 2017, a retrospective analysis was performed in 60 patients (mean 31.5 years) undergoing TAE for PPH-GTI. Information regarding clinical data, angiography and embolisation details, and clinical outcomes was obtained. Univariate analyses were performed to determine the factors related to clinical outcomes.


Technical and clinical success was achieved in 98% and 88%, respectively. Bleeding foci were observed on angiography in 56 patients (93%). The major bleeding artery was the vaginal artery (32%, 24/74), followed by the uterine artery (cervicovaginal branch) (n = 18), internal pudendal artery (n = 13), cervical artery (n = 9), inferior mesenteric artery (n = 4) and external pudendal artery (n = 3). Embolic agents were gelatin sponge particles (n = 23), gelatin sponge with permanent embolic agents (microcoils, n-butyl cyanoacrylate) (n = 34) and permanent embolic agents only (n = 3). In seven patients, bleeding control failed and was managed by repeat TAE (n = 5) or surgery (n = 2) and with eventual bleeding control in all of these patients. Univariate analysis showed that paravaginal haematoma, massive transfusion and long hospital stay were related to clinical failure. During the mean follow-up period of 33.1 months, regular menstruation resumed in 95.2% (40/42) and 14 of them became pregnant.


TAE is safe and effective for treating PPH-GTI. Massive transfusion, paravaginal haematoma and long hospital stay were related to the failure of bleeding control.

Key Points

• PPH-GTI had a high detection rate of active bleeding foci on angiography.

• Besides vaginal artery, inferior mesenteric and external pudendal arteries were notable bleeding foci.

• Permanent embolic agents were used more than only gelatin sponge particles.

• Paravaginal haematoma and massive transfusion were related to clinical failure.

• TAE for PPH-GTI was safe and effective with preservation of menstrual cycles.


Postpartum haemorrhage Genitalia, female Wounds and injuries Delivery, obstetric Radiology, interventional 



Inferior mesenteric artery


n-butyl cyanoacrylate


Postpartum haemorrhage associated with genital tract injury


Transcatheter arterial embolisation



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Moon Gyu Lee.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the institutional review board.

Ethical approval

Institutional review board approval was obtained.


• retrospective

• diagnostic or prognostic study

• performed at one institution


  1. 1.
    Oyelese Y, Ananth CV (2010) Postpartum hemorrhage: epidemiology, risk factors, and causes. Clin Obstet Gynecol 53:147–156CrossRefGoogle Scholar
  2. 2.
    Salomon LJ, deTayrac R, Castaigne-Meary V et al (2003) Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum Reprod 18:849–852CrossRefGoogle Scholar
  3. 3.
    Lee HY, Shin JH, Kim J et al (2012) Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution. Radiology 264:903–909CrossRefGoogle Scholar
  4. 4.
    Fahmy K, el-Gazar A, Sammour M, Nosair M, Salem A (1991) Postpartum colposcopy of the cervix: injury and healing. Int J Gynaecol Obstet 34:133–137CrossRefGoogle Scholar
  5. 5.
    Fargeaudou Y, Soyer P, Morel O et al (2009) Severe primary postpartum hemorrhage due to genital tract laceration after operative vaginal delivery: successful treatment with transcatheter arterial embolization. Eur Radiol 19:2197–2203CrossRefGoogle Scholar
  6. 6.
    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 177:145–149CrossRefGoogle Scholar
  7. 7.
    Yamashita Y, Takahashi M, Ito M, Okamura H (1991) Transcatheter arterial embolization in the management of postpartum hemorrhage due to genital tract injury. Obstet Gynecol 77:160–163PubMedGoogle Scholar
  8. 8.
    Touboul C, Badiou W, Saada J et al (2008) Efficacy of selective arterial embolisation for the treatment of life-threatening post-partum haemorrhage in a large population. PLoS One 3:e3819CrossRefGoogle Scholar
  9. 9.
    Al Mamun MA, MAAM K, Alles N et al (2013) Gelatin hydrogel carrier with the W9-peptide elicits synergistic effects on BMP-2-induced bone regeneration. J Oral Biosci 55:217–223CrossRefGoogle Scholar
  10. 10.
    Shlansky-Goldberg R, Cope C (2001) A new twist on the Waltman loop for uterine fibroid embolization. J Vasc Interv Radiol 12:997–1000CrossRefGoogle Scholar
  11. 11.
    Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ (2015) Births: final data for 2013. Natl Vital Stat Rep 64:1–65PubMedGoogle Scholar
  12. 12.
    Parikh R, Brotzman S, Anasti JN (2007) Cervical lacerations: some surprising facts. Am J Obstet Gynecol 196:e17–e18CrossRefGoogle Scholar
  13. 13.
    Shah M, Wright JD (2009) Surgical intervention in the management of postpartum hemorrhage. Semin Perinatol 33:109–115CrossRefGoogle Scholar
  14. 14.
    Park HS, Shin JH, Yoon HK et al (2014) Transcatheter arterial embolization for secondary postpartum hemorrhage: outcome in 52 patients at a single tertiary referral center. J Vasc Interv Radiol 25:1751–1757CrossRefGoogle Scholar
  15. 15.
    Pelage JP, Le Dref O, Mateo J et al (1998) Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 208:359–362CrossRefGoogle Scholar
  16. 16.
    Pelage JP, Soyer P, Repiquet D et al (1999) Secondary postpartum hemorrhage: treatment with selective arterial embolization. Radiology 212:385–389CrossRefGoogle Scholar
  17. 17.
    Soyer P, Fargeaudou Y, Morel O, Boudiaf M, Le Dref O, Rymer R (2008) Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization. Eur Radiol 18:1181–1187CrossRefGoogle Scholar
  18. 18.
    Dohan A, Soyer P, Subhani A et al (2013) Postpartum hemorrhage resulting from pelvic pseudoaneurysm: a retrospective analysis of 588 consecutive cases treated by arterial embolization. Cardiovasc Intervent Radiol 36:1247–1255CrossRefGoogle Scholar
  19. 19.
    Kim CH, Jeon GS, Lee SJ, Kang SH (2016) Embolization of the inferior mesenteric artery for post-partum hemorrhage with a vaginal laceration: a case with unusual collateral supply. J Obstet Gynaecol Res 42:1878–1880CrossRefGoogle Scholar
  20. 20.
    Shin SM, Yi KW, Chung HH (2015) Postpartum uterine bleeding from the inferior mesenteric artery: case report and review of the literature. Gynecol Obstet Investig 80:60–63CrossRefGoogle Scholar
  21. 21.
    Kim CH, Lee SJ, Jeon GS, Kang SH, Kim HC (2016) Embolization of inferior mesenteric artery for intractable intrapelvic and vaginal bleeding after hysterectomy. J Minim Invasive Gynecol 23:1191–1194CrossRefGoogle Scholar
  22. 22.
    Pelage JP, Le Dref O, Soyer P et al (1999) Arterial anatomy of the female genital tract: variations and relevance to transcatheter embolization of the uterus. AJR Am J Roentgenol 172:989–994CrossRefGoogle Scholar
  23. 23.
    Yamashita Y, Harada M, Yamamoto H et al (1994) Transcatheter arterial embolization of obstetric and gynaecological bleeding: efficacy and clinical outcome. Br J Radiol 67:530–534CrossRefGoogle Scholar
  24. 24.
    Kanematsu M, Watanabe H, Kondo H et al (2011) Postpartum hemorrhage in coagulopathic patients: preliminary experience with uterine arterial embolization with n-butyl cyanoacrylate. J Vasc Interv Radiol 22:1773–1776CrossRefGoogle Scholar
  25. 25.
    Park KJ, Shin JH, Yoon HK, Gwon DI, Ko GY, Sung KB (2015) Postpartum hemorrhage from extravasation or pseudoaneurysm: efficacy of transcatheter arterial embolization using n-butyl cyanoacrylate and comparison with gelatin sponge particle. J Vasc Interv Radiol 26:154–161CrossRefGoogle Scholar
  26. 26.
    Kim GM, Yoon CJ, Seong NJ, Kang SG, Kim YJ (2013) Postpartum haemorrhage from ruptured pseudoaneurysm: efficacy of transcatheter arterial embolisation using N-butyl-2-cyanoacrylate. Eur Radiol 23:2344–2349CrossRefGoogle Scholar
  27. 27.
    Sierra A, Burrel M, Sebastia C et al (2012) Utility of multidetector CT in severe postpartum hemorrhage. Radiographics 32:1463–1481CrossRefGoogle Scholar
  28. 28.
    Poujade O, Zappa M, Letendre I, Ceccaldi PF, Vilgrain V, Luton D (2012) Predictive factors for failure of pelvic arterial embolization for postpartum hemorrhage. Int J Gynaecol Obstet 117:119–123CrossRefGoogle Scholar
  29. 29.
    Doumouchtsis SK, Nikolopoulos K, Talaulikar V, Krishna A, Arulkumaran S (2014) Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG 121:382–388CrossRefGoogle Scholar
  30. 30.
    Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L (2010) Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage. BJOG 117:84–93CrossRefGoogle Scholar
  31. 31.
    Lee HJ, Jeon GS, Kim MD, Kim SH, Lee JT, Choi MJ (2013) Usefulness of pelvic artery embolization in cesarean section compared with vaginal delivery in 176 patients. J Vasc Interv Radiol 24:103–109CrossRefGoogle Scholar
  32. 32.
    Fiori O, Deux JF, Kambale JC, Uzan S, Bougdhene F, Berkane N (2009) Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility. Am J Obstet Gynecol 200:384.e381–384.e384CrossRefGoogle Scholar
  33. 33.
    Gaia G, Chabrot P, Cassagnes L et al (2009) Menses recovery and fertility after artery embolization for PPH: a single-center retrospective observational study. Eur Radiol 19:481–487CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Sang Min Lee
    • 1
  • Ji Hoon Shin
    • 1
    Email author
  • Jong Joon Shim
    • 1
  • Ki Woong Yoon
    • 1
  • Young Jong Cho
    • 1
  • Jong Woo Kim
    • 1
  • Heung Kyu Ko
    • 1
  1. 1.Department of Radiology and Research Institute of Radiology, Asan Medical CenterUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulKorea

Personalised recommendations