Arch Gynecol Obstet DOI 10.1007/s00404-014-3310-9
Case Report
Uterine necrosis and lumbosacral‑plexopathy following pelvic vessel embolization for postpartum haemorrhage: report of two cases and review of literature Minakshi Rohilla · Purnima Singh · Jaswinder Kaur · G. R. V. Prasad · Vanita Jain · Anupam Lal
Received: 9 March 2014 / Accepted: 2 June 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract We are reporting two cases of uterine necrosis and lumbosacral-plexopathy in patients, who underwent pelvic vessel embolization (PVE) following postpartum hemorrhage. Embolization was performed with gelfoam slurry, polyvinyl alcohol (PVA) particles and coil in one patient and with gelfoam slurry only, in second patient. Both patients had lower limbsweakness and had persistent fever in the postembolization period. Nerve conduction study in both were suggestive of common peroneal and tibial neuropathy. Anultrasonography and computed tomography of abdomen and pelvis revealed bulky uterus with no identifiable endometrium and multiple air foci in subendometrial regionsuggestive of uterine necrosis, confirmed later by histology of expelled uterine mass. Lumbosacral ischemia resulting in paraparesis and uterine necrosis presenting aslongstanding fever after embolization are extremely rare but overwhelming complications of embolization. Only 19 cases of uterine necrosis and 1 mm) to prevent prolonged obliteration of the distal vascular bed downstream from the uterine arteries. Ultrasound was the first-line diagnostic tool for uterine necrosis, with CT scan or MRI confirming the diagnosis. Guidelines recommend using absorbable gelatin particles, avoiding PVA particles and small-sized gelatin sponge particles. A diagnosis of uterine necrosis may be suggested by pelvic pain associated with fever and requires pelvic CT scan or MRI to confirm. We were also planning for hysterectomy in both cases as both had persistent high grade temperature that was not responding to higher antibiotics but meanwhile both of them expelled necrotic uterus and became afebrile afterwards. Spinal cord or lumbosacral ischemia that results in paraplegia or paraparesis after embolization is another extremely rare but devastating complication. It is uncommon because, the plexus has rich blood supply. It is supplied by superior gluteal artery and other branches of posterior division of internal iliac artery. Al Thunyan et al. [8] reported a case of bilateral extensive gluteal skin and muscle necrosis with concurrent severe lumbosacral plexopathy after bilateral internal iliac artery embolization for PPH. Hare and Holand [9] described three cases of ischaemic nerve injury and local skin damage after internal iliac embolisation by gelfoam powder for pelvic disease. Management of ischemic lumbosacral-plexopathy needs analgesics and physiotherapy. Both patients in our report managed the same way and recovered.
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Arch Gynecol Obstet
Recently occlusion balloon catheters have been suggested to prevent reflux of an embolic agent injected through the catheter tip beyond the balloon [10]. The simultaneous occurrence of uterine necrosis and lumbosacral-plexopathy, described for the first time in our patients points towards development of ischemia involving both anterior and posterior division of internal iliac artery. Presence of severe shock at the time of embolization in both the patient, repeat embolization in one of the patients, concomitant use of permanent embolizing material, lack of standardized size of the gel foam particles used as slurry and a non-selective embolization of internal iliac artery probably contributed to the development of these coexisting complications. In conclusion, PVE is a safe and effective procedure with relatively uncommon complications of uterine necrosis and lumbosacral plexopathy. Several factors, however, can predict the outcome of such grave complications. After PVE it is expected that a woman would return to normal menses with preservation of future fertility and achieve successful uneventful pregnancies [11]. Arterial embolization should be an integral part in the emergency management of obstetric hemorrhage in tertiary care hospitals.The life saving benefits of PVE will, however, still outweigh even the severest complications like uterine necrosis and lumbosacral-plexopathy. Conflict of interest We declare that we have no conflict of interest.
References 1. Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ (1979) Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization. Obstet Gynecol 54:361–365 2. Likeman RK (1992) The boldest procedure possible for checking the bleeding. Aust NZ J Obstet Gynaecol 32:256–262 3. Das BN, Biswas AK (1998) Ligation of internal iliac arteries in pelvic haemorrhage. J Obstet Gynaecol Res 24:251–254 4. Picone AL, Green RM, Ricotta JR et al (1986) Spinal cord ischemia following operations on the abdominal aorta. J Vasc Surg 3:95–103 5. Vendantham S (1997) Goodwin SC, Buckley PJ, Mc Lucas B, Mohr G. Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 176:938–948 6. Porcu G, Roger V, Jacquier A et al (2005) Uterus and bladder necrosis after uterine artery embolisation for postpartum haemorrhage. BJOG 112:122–123 7. Poujade O, Ceccaldi PF, Davitian C, Amate P, Chatel P, Khater C, Aflak N, Vilgrain V, Luton D (2013) Uterine necrosis following pelvic arterial embolization for post-partum hemorrhage: review of the literature. Eur J Obstet Gynecol Reprod Biol 170:309–314 8. Al-Thunyan A, Al-MeshalO, Al-Hussainan H, Al-Qahtani MH, El-Sayed AA, Al-Qattan MM (2012) Buttock necrosis and paraplegia after bilateral internal iliac artery embolization for postpartum hemorrhage. Obstet Gynecol 120(2 pt 2):468–470
Arch Gynecol Obstet 9. Hare WSC, Holland CJ (1983) Paresis following internal iliac artery embolisation. Radiology 146:47–51 10. 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):e1–e4
11. Dilauro MD, Dason S, Athreya S (2012) Prophylactic bal loon occlusion of internal iliac arteries in women with placenta accreta: literature review and analysis. Clin Radiol 67(6):515– 520 Epub 2012 Jan 2
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Case Report
Uterine necrosis and lumbosacral‑plexopathy following pelvic vessel embolization for postpartum haemorrhage: report of two cases and review of literature Minakshi Rohilla · Purnima Singh · Jaswinder Kaur · G. R. V. Prasad · Vanita Jain · Anupam Lal
Received: 9 March 2014 / Accepted: 2 June 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract We are reporting two cases of uterine necrosis and lumbosacral-plexopathy in patients, who underwent pelvic vessel embolization (PVE) following postpartum hemorrhage. Embolization was performed with gelfoam slurry, polyvinyl alcohol (PVA) particles and coil in one patient and with gelfoam slurry only, in second patient. Both patients had lower limbsweakness and had persistent fever in the postembolization period. Nerve conduction study in both were suggestive of common peroneal and tibial neuropathy. Anultrasonography and computed tomography of abdomen and pelvis revealed bulky uterus with no identifiable endometrium and multiple air foci in subendometrial regionsuggestive of uterine necrosis, confirmed later by histology of expelled uterine mass. Lumbosacral ischemia resulting in paraparesis and uterine necrosis presenting aslongstanding fever after embolization are extremely rare but overwhelming complications of embolization. Only 19 cases of uterine necrosis and 1 mm) to prevent prolonged obliteration of the distal vascular bed downstream from the uterine arteries. Ultrasound was the first-line diagnostic tool for uterine necrosis, with CT scan or MRI confirming the diagnosis. Guidelines recommend using absorbable gelatin particles, avoiding PVA particles and small-sized gelatin sponge particles. A diagnosis of uterine necrosis may be suggested by pelvic pain associated with fever and requires pelvic CT scan or MRI to confirm. We were also planning for hysterectomy in both cases as both had persistent high grade temperature that was not responding to higher antibiotics but meanwhile both of them expelled necrotic uterus and became afebrile afterwards. Spinal cord or lumbosacral ischemia that results in paraplegia or paraparesis after embolization is another extremely rare but devastating complication. It is uncommon because, the plexus has rich blood supply. It is supplied by superior gluteal artery and other branches of posterior division of internal iliac artery. Al Thunyan et al. [8] reported a case of bilateral extensive gluteal skin and muscle necrosis with concurrent severe lumbosacral plexopathy after bilateral internal iliac artery embolization for PPH. Hare and Holand [9] described three cases of ischaemic nerve injury and local skin damage after internal iliac embolisation by gelfoam powder for pelvic disease. Management of ischemic lumbosacral-plexopathy needs analgesics and physiotherapy. Both patients in our report managed the same way and recovered.
13
Arch Gynecol Obstet
Recently occlusion balloon catheters have been suggested to prevent reflux of an embolic agent injected through the catheter tip beyond the balloon [10]. The simultaneous occurrence of uterine necrosis and lumbosacral-plexopathy, described for the first time in our patients points towards development of ischemia involving both anterior and posterior division of internal iliac artery. Presence of severe shock at the time of embolization in both the patient, repeat embolization in one of the patients, concomitant use of permanent embolizing material, lack of standardized size of the gel foam particles used as slurry and a non-selective embolization of internal iliac artery probably contributed to the development of these coexisting complications. In conclusion, PVE is a safe and effective procedure with relatively uncommon complications of uterine necrosis and lumbosacral plexopathy. Several factors, however, can predict the outcome of such grave complications. After PVE it is expected that a woman would return to normal menses with preservation of future fertility and achieve successful uneventful pregnancies [11]. Arterial embolization should be an integral part in the emergency management of obstetric hemorrhage in tertiary care hospitals.The life saving benefits of PVE will, however, still outweigh even the severest complications like uterine necrosis and lumbosacral-plexopathy. Conflict of interest We declare that we have no conflict of interest.
References 1. Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ (1979) Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization. Obstet Gynecol 54:361–365 2. Likeman RK (1992) The boldest procedure possible for checking the bleeding. Aust NZ J Obstet Gynaecol 32:256–262 3. Das BN, Biswas AK (1998) Ligation of internal iliac arteries in pelvic haemorrhage. J Obstet Gynaecol Res 24:251–254 4. Picone AL, Green RM, Ricotta JR et al (1986) Spinal cord ischemia following operations on the abdominal aorta. J Vasc Surg 3:95–103 5. Vendantham S (1997) Goodwin SC, Buckley PJ, Mc Lucas B, Mohr G. Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 176:938–948 6. Porcu G, Roger V, Jacquier A et al (2005) Uterus and bladder necrosis after uterine artery embolisation for postpartum haemorrhage. BJOG 112:122–123 7. Poujade O, Ceccaldi PF, Davitian C, Amate P, Chatel P, Khater C, Aflak N, Vilgrain V, Luton D (2013) Uterine necrosis following pelvic arterial embolization for post-partum hemorrhage: review of the literature. Eur J Obstet Gynecol Reprod Biol 170:309–314 8. Al-Thunyan A, Al-MeshalO, Al-Hussainan H, Al-Qahtani MH, El-Sayed AA, Al-Qattan MM (2012) Buttock necrosis and paraplegia after bilateral internal iliac artery embolization for postpartum hemorrhage. Obstet Gynecol 120(2 pt 2):468–470
Arch Gynecol Obstet 9. Hare WSC, Holland CJ (1983) Paresis following internal iliac artery embolisation. Radiology 146:47–51 10. 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):e1–e4
11. Dilauro MD, Dason S, Athreya S (2012) Prophylactic bal loon occlusion of internal iliac arteries in women with placenta accreta: literature review and analysis. Clin Radiol 67(6):515– 520 Epub 2012 Jan 2
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