1. Minimally-Invasive Management of Post-Caesarian Section Bleeding by Interventional Radiology Michael S. Stecker, MD, FSIR Raj Pyne, MD Chieh-Min Fan, MD

2. Caesarian Sections C-section is a surgical procedure that allows delivery of a baby through an incision in the mother’s abdomen In general, used when there is danger either to the mother or the fetus: –Labor is not progressing –Problem with bloodflow reaching the baby –Problem with positioning or large baby –Placental abnormalities –Health of the mother –Twins or triplets

4. How Common Are C-Sections in the U.S.? 1.2 million C-sections performed in the U.S. alone in 2004 Approximately 1 out of every 3 deliveries is now a C-section Current rate is a 40% increase over a decade ago

5. Percentage of C-Sections in the U.S. (National Center for Heath Statistics)

6. Complications of C-Sections Serious bleeding during or after the procedure and/or damage to the blood vessels Infection or abscess formation Organ damage to the reproductive organs or to the bladder Damage to the intestines, including perforation (a hole in its lining) Nerve damage Rupture of the uterus at a scar site

7. Bleeding After Delivery Potentially life-threatening complication of childbirth Can occur either after C-section or after vaginal delivery At least 1 in 20 women bleed excessively after childbirth Most are treated successfully with supportive measures such as medication and transfusion 10% have a hysterectomy or other major surgical procedure to save their lives

8. Reasons for Bleeding After C-Section Uterine atony (failure of uterine contraction) Retained products of conception (placental tissue) Placental abnormalities: - Placenta acreta (into uterine muscle) - Placenta increta (through uterine muscle) - Placenta percreta (into adjacent organs) Laceration of blood vessels

9. Treatment Options for Bleeding Supportive management: –Careful observation –Transfusion –Hydration –Medications that make the uterus contract Balloon tamponade in the uterine cavity Manual compression of uterus Procedure to take out the remnant parts of placenta Hysterectomy Embolization by Interventional Radiology

10. Why Does This Matter To Women Undergoing A C-Section? Most patients (and even some referring doctors) may not understand what embolization by Interventional Radiology is and how it is performed It is readily available at many hospitals and provides a minimally-invasive option for treatment Embolization is a relatively safe procedure that can not only save a woman’s uterus but also can save a mother’s life if she has life-threatening bleeding

11. How Is Embolization By Interventional Radiology Performed? Embolization is a well-established technique that has been used for over 20 years A small incision is made in the groin A small tube called a catheter is guided up through the leg artery and into the artery that feeds the uterus Moving X-ray images are used to visualize the catheter as it is placed and X-ray contrast is injected to see the vessels Tiny particles (the size of grains of sand) or little metal coils are used to occlude the site of bleeding

12. Uterine Blood Supply

13. Bleeding Image reprinted with permission by David Klemm

14. Embolization materials

15. Before Embolization

31. After Coil Embolization

48. Before Gelfoam EmbolizationAfter Gelfoam Embolization

49. Purpose of Our Study Identify all women who came to Interventional Radiology for severe bleeding after C-section Review techniques used to control bleeding in these patients Look at clinical course after embolization Examine safety and efficacy of this treatment option

50. Results of Our Study 13 women over past 3 years came to IR from the obstetrics service for serious post C-section bleeding 5 of 13 had active bleeding seen on angiography and were treated 8 of 13 had no findings of active bleeding, but were empirically treated anyway All women did well with no recurrence of bleeding Pseudoaneurysm (a specific type of bleeding) was seen in 2 patients; both had delayed presentation at 2 weeks, the other 11 presented immediately

51. Conclusions from Our Study Endovascular embolization is a safe and effective minimally-invasive method of treating emergent bleeding after C-section Women tended to have quick recoveries, short hospital stays, and no recurrence of bleeding in our sample Embolization preserves the uterus and potentially allows for future childbearing compared to hysterectomy

52. References and Resources Society of Interventional Radiology www.sir.org World Health Organization National Center for Health Statistics Special thanks to David Klemm for use of his copyrighted image