DOI: 10.1111/j.1471-0528.2009.02138.
x
www.blackwellpublishing.com/bjog
Complications and failure of uterine artery
embolisation for intractable postpartum haemorrhage
Sir,
We read with interest the article by MS Maassen et al.1 We
recently managed a case of postpartum haemorrhage
(PPH) as a result of multiple fibroids with uterine artery
embolisation (UAE) and would like to highlight delayed
complications.
Our participant was a 35-year-old primiparous black
African with known multiple fibroids. She had an elective
caesarean section at 38 weeks because of a transverse lie
due to a large anterior cervical fibroid measuring 13 ·
12 · 10 cm. The baby was delivered through a classical
uterine incision and the cervical fibroid had to be enucle-
ated to facilitate uterine closure. A brace suture was inserted
as the usual measures to manage an atonic uterus failed to
control bleeding. This seemed effective initially, but because
of the signs of continued bleeding and significant loss into a
pelvic drain, she underwent a successful UAE with gel foam,
7 hours postoperatively. She had a blood transfusion and
replacement with fresh plasma, cryoprecipitate and platelets
as preoperative haemoglobin was only 10 g/dl. She made a
slow postoperative recovery complicated by nausea and
pain, which was managed conservatively.
She was discharged on the 8th postoperative day, but
unfortunately re-admitted 48 hours later with severe
abdominal pain, nausea and diarrhoea. Examination
revealed a distended, tense and tender abdomen and an Ini-
tial impression of fibroid degeneration was made. A CT
scan was performed 48 hours later as she did not respond
to intravenous antibiotics and analgesia. This revealed a
multilocular pelvic abscess for which she underwent a
laparatomy. A copious amount of peritoneal fluid and
purulent discharge was noted on opening the abdomen with
the bladder and distended bowels loops adherent to the
dehisced uterine incision. In view of the findings, a difficult
hysterectomy was performed during which the bladder was
inadvertently opened and repaired. The bowel was inspected
thoroughly by surgeons and a peritoneal lavage was carried
out. Proteus mirabilis was isolated from the peritoneal aspi-
ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
Correspondence
rate and she was commenced on Tazocin. The postoperative
period was stormy with recalcitrant pain and abdominal
distension. A repeat CT scan was performed 5 days postop-
eratively to exclude any bowel pathology.
Histology of the uterus revealed active chronic inflam-
mation, necrosis and subinvolution with necrotic and hya-
linised leiomyomata. These histological findings were also
reported by Cottier et al.2 following UAE.
She was discharged 10 days following the hysterectomy,
but sadly readmitted 9 weeks after the caesarean section
with acute abdominal pain and vomiting. A diagnosis of
bowel obstruction was made, which did not improve with
conservative management. As a result, she underwent a lap-
arotomy and division of bowel adhesions. She made a good
recovery and was recently discharged home to be reviewed
in a few weeks. j
References
1 Maassen MS, Lambers MDA, Tutein Nolthenius RP, van der Valk PHM,
Elgersma OE. Complications and Failure of Uterine Artery Embolisation
for Intractable Postpartum Haemorrhage. Dordrecht, the Netherlands:
Department of Obstetrics and Gynaecology, Department of Surgery
and Department of Radiology, Albert Schweitzer Hospital, 2009
2 Cottier JP, Fignon A, Tranquart F, Herbreteau D. Uterine necrosis after
arterial embolization for postpartum hemorrhage. [Case Reports.
Journal Article]. Obstet Gynecol. 2002;100 (5 Pt 2):1074–7.
N Katakam,a S Vitthala,b S Sassonc & A Williamsa
a
Royal Bolton Hospital, Bolton, UK
b
St Mary’s Hospital, Manchester, UK
c
Stepping Hill Hospital, Stockport, UK
Accepted 27 January 2009.
DOI: 10.1111/j.1471-0528.2009.02138.x
The place of subtotal/supracervical hysterectomy
in current practice
Sir,
From Professor Garry’s commentary in the December 2008
issue of the BJOG, it seems that the advantages laparo-
863