CT angiography for the management of postpartum hemorrhage refractory to conservative treatment

Abstract

Introduction

Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Computerized tomographic (CT) angiography is a useful tool to identify hemorrhage from various conditions. However, the feasibility of CT angiography for the management of PPH has not been well evaluated.

Objective

To evaluate the clinical usefulness of CT angiography in the management of PPH refractory to the conservative treatment.

Methods

This retrospective cohort study consisted of 528 consecutive patients who were transferred to our institute after delivery at 28 primary maternity hospitals for the management of PPH between 2009 and 2017. Immediate intervention such as arterial embolization and hysterectomy were performed on 278 patients. Of the remaining 250 patients, CT angiography was performed on 61 patients with hemodynamic stability but with sustained hemorrhage refractory to medical treatment. The diagnostic index was assessed using conventional angiography as the reference standard. The clinical outcome was compared between patients with and without contrast extravasation on CT angiography.

Results

(1) The prevalence of contrast extravasation was found in 61% of patients (37/61); (2) conventional angiography and arterial embolization were performed in 78% of patients (29/37) with contrast extravasation on CT angiography. Contrast extravasation was confirmed in 83% of patients (24/29) by conventional angiography; (3) among the 24 patients without contrast extravasation on CT angiography, 96% (23/24) were managed conservatively; (4) the patients with contrast extravasation on CT angiography received more packed red blood cell (PRBC) transfusion than those without that condition (7.3 ± 5.2 units vs. 3.8 ± 2.9 units, p = .009). Massive transfusion (defined as transfusion of 10 or more units of PRBC) was more common in patients with contrast extravasation than in those without (27% [10/37] vs. 0% [0/24], p = .004).

Conclusions

Conservative treatment succeeded in 96% of patients without contrast extravasation on CT angiography. CT angiography is useful to identify patients requiring intervention in the management of hemorrhage refractory to medical treatment.

Keywords:

• Postpartum hemorrhage;
• CT angiography;
• transfusion;
• arterial embolization;
• medical treatment;
• hysterectomy

Acknowledgements

The authors acknowledge the contributions of the patients, nurses, doctors, and research personnel who made the collection of data for this retrospective study possible.

Informed consent

The Institutional review board approved the retrospective review of the data and the patient informed consent was waived.

Ethical approval

All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional review board and with the 1964 Helsinki declaration.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The dataset used and analyzed during the current study are available from the corresponding author upon reasonable request.

Additional information

Funding

This work was supported by the Seoul National University Bundang Hospital Research Fund [Grant No. 02-2013-024].