Indications
| Indication | Mechanism | Notes |
|---|---|---|
| Primary PPH — uterine atony (70–80% of cases) | Uterine muscle failure to contract | First-line after oxytocin/uterotonics/bimanual compression fail; UAE highly effective |
| PPH — genital tract laceration refractory to surgical repair | Arterial injury | UAE if surgical access difficult or coagulopathy makes repair high-risk |
| PPH — retained placenta / placental polyp | Placental bed bleeding | UAE then manual extraction or surgical removal |
| Placenta accreta spectrum (accreta, increta, percreta) | Abnormal placentation | Pre-operative balloon placement; UAE at time of delivery; hysterectomy backup |
| Secondary PPH (>24h–6 weeks postpartum) | Subinvolution, pseudoaneurysm, retained products | UAE; may need superselective embolization of uterine artery pseudoaneurysm |
| Uterine artery pseudoaneurysm | Post-traumatic/post-operative vascular injury | Superselective coil embolization ± covered stent |
Contraindications
| Type | Contraindication |
|---|---|
| Absolute | Uncorrectable coagulopathy that precludes arterial access (correct simultaneously while proceeding) · Allergy to iodinated contrast without ability to premedicate |
| Relative | Hemodynamic instability requiring immediate surgical control (OR takes priority; IR can still be mobilized simultaneously) · Severe atherosclerosis limiting iliac access · Prior extensive pelvic surgery/radiation |
Important: Coagulopathy is never a reason to withhold UAE in life-threatening PPH — correct while proceeding.
Relevant Anatomy
The uterine arteries arise from the anterior division of the internal iliac arteries (hypogastric arteries), cross the ureter at the broad ligament ("water under the bridge"), and supply the uterus via a tortuous ascending branch. Understanding collateral supply is critical — bilateral embolization is mandatory because multiple collateral pathways can sustain uterine bleeding after unilateral treatment.
Uterine Artery Anatomy
- Origin: Anterior division of the internal iliac artery (IIA); arises near the superior vesical artery
- Course: Courses medially across the broad ligament, crosses the ureter superiorly ("water under the bridge"), then ascends tortuously along the lateral uterine wall
- "Corkscrew" morphology: Classic tortuous appearance of normal uterine artery on angiography; straightens with pregnancy/postpartum due to hypertrophy — may appear less tortuous on post-partum angiogram
- Terminal branches: Fundal, tubal, and ovarian branches at the cornua; cervicovaginal branches inferiorly
Collateral Supply — Why Bilateral UAE Is Critical
| Collateral Source | Origin | Significance |
|---|---|---|
| Ovarian arteries | Aorta (L1–L2 level) | Most important collateral; anastomose with uterine artery at cornua; if UAE fails, check aortogram for ovarian artery contribution |
| Contralateral uterine artery | Contralateral anterior IIA division | Midline anastomoses at uterine fundus; unilateral UAE alone leaves this pathway open |
| Cervicovaginal branches | Uterine artery, internal pudendal | Inferior uterine supply; may sustain bleeding from cervical lacerations |
| Internal pudendal artery | Anterior IIA division | Contributes to vaginal and cervical bleeding; consider if bilateral UAE fails |
| Inferior epigastric artery | External iliac artery | Relevant after cesarean section — may contribute to anterior abdominal wall or hysterotomy site bleeding; assess selectively in C-section patients with persistent hemorrhage |
| Broad ligament artery | Variable; uterine or ovarian artery branches | Small vessels within the broad ligament; may sustain hemorrhage when main uterine supply is controlled; consider in persistent bleeding despite bilateral UAE |
Internal Iliac Artery Divisions
- Anterior division: Uterine artery, superior vesical, inferior vesical, middle rectal, internal pudendal, obturator — all targets of concern for non-target embolization
- Posterior division: Iliolumbar, lateral sacral, superior gluteal — not typically involved in UAE
If bilateral UAE fails: Perform aortogram to assess for patent ovarian artery collateral supply. Selective catheterization of the ovarian artery (from the aorta at L1–L2) may be required for complete embolization. Internal pudendal arteries should also be assessed for vaginal/cervical bleeding contribution. After cesarean section, also assess the inferior epigastric artery (from the external iliac) — it may contribute to anterior abdominal wall or hysterotomy site hemorrhage. The broad ligament artery should be considered in persistent bleeding when all named uterine supply has been controlled.
Procedure Overview
The following is a high-level summary. Full catheter selection for bilateral uterine artery access, gelfoam preparation technique, balloon catheter placement for PAS, and troubleshooting for difficult anatomy are available in RadCall Pro.
Access and Setup
- Access: Unilateral CFA access with crossover for bilateral UAE; 4–5 Fr sheath
- Aortogram (optional): Survey aortic bifurcation, iliac arteries, and identify ovarian artery origins if needed
- Internal iliac catheterization: Roberts Uterine Catheter (RUC) or Cobra to select contralateral IIA via aortic crossover; repeat for ipsilateral (Waltman loop or second access)
- Uterine artery identification: Selective IIA arteriogram in AP and oblique views; uterine artery is tortuous anterior division vessel coursing medially; identify corkscrew morphology
- Superselective uterine artery catheterization: Coaxial microcatheter (2.4–2.8 Fr) into uterine artery; arteriogram to confirm territory and exclude non-target supply
Embolization
- Embolization: Gelfoam pledgets (1–2 mm) or slurry as primary embolic. Inject slowly until near-stasis. Do not use permanent agents unless specific indication (pseudoaneurysm = coils). Polyvinyl alcohol particles (PVA) 355–500 µm alternative if gelfoam not available.
- Endpoint: Near-complete stasis of uterine artery flow with preserved arterial trunk (avoid over-embolization of proximal trunk — maintains future fertility)
- Bilateral: Repeat entire process on contralateral side. Both sides must be treated.
- Check for collateral supply: If bleeding continues post bilateral UAE, check for ovarian artery contribution (selective catheterization from aorta) and internal pudendal artery
- Post-embolization arteriogram: Confirm bilateral stasis; document
Embolic Agent Selection
| Agent | Characteristics | When to Use |
|---|---|---|
| Gelfoam (gelatin sponge) — pledgets or slurry | Temporary (resorbs in 2–6 weeks); non-permanent; allows uterine recovery | Primary agent for PPH — preserves future fertility; allows uterine revascularization |
| PVA particles (355–500 µm) | Permanent; small particles | Alternative to gelfoam if unavailable; permanent occlusion — less ideal for young patients |
| Microcoils (0.018" pushable) | Permanent; precise placement | Uterine artery pseudoaneurysm; as adjunct to particles in severe atony; do NOT use as sole agent for atony |
| N-BCA (cyanoacrylate glue) | Liquid embolic; permanent; rapid occlusion | Rare; refractory cases; requires experience; risk of non-target embolization |
Complications
| Complication | Rate | Management |
|---|---|---|
| Rebleeding requiring repeat UAE or hysterectomy | 10–15% | Repeat embolization if technically feasible; surgical consultation |
| Post-embolization syndrome (fever, pelvic pain) | 50–80% | Self-limited; NSAIDs, anti-emetics; expected 3–7 days |
| Uterine necrosis / infection | 1–2% | Requires hysterectomy; rare with gelfoam; higher risk with PVA |
| Non-target embolization (bladder, bowel) | <1% | Superselective technique minimizes risk; manage per affected organ |
| Amenorrhea / ovarian failure | 1–3% | Usually temporary with gelfoam; counsel patients pre-procedure |
| Access site complications | 2–5% | Standard femoral care; pseudoaneurysm rare |
| Failed embolization requiring hysterectomy | 5–10% | Have surgical backup; IR and obstetrics coordinate continuously |
Post-Procedure Care
- Monitoring: ICU or high-acuity monitoring post-procedure; serial hemoglobin/hematocrit
- MTP continuation: Continue massive transfusion protocol (MTP) if activated — embolization does not immediately stop bleeding from coagulopathy
- Uterotonics: Uterotonic agents continue post-procedure (oxytocin infusion)
- Pain management: Uterine cramp pain — NSAIDs (ketorolac IV), PCA opioids; expected for 24–72h
- Uterine necrosis surveillance: Monitor for signs of uterine necrosis: fever >72h, escalating pelvic pain, foul discharge → CT pelvis, gynecology consult
- Fertility counseling: Pregnancy possible after UAE for PPH; conception rate 65–70%; advise 6-month interval before attempting pregnancy; MRI uterus at 3 months to assess recovery
Placenta Accreta Spectrum (PAS)
PAS represents a spectrum of abnormal placentation with increasing depth of myometrial invasion and significantly elevated hemorrhage risk at delivery. The incidence of PAS is increasing in parallel with the C-section rate.
PAS Spectrum Classification
| Type | Invasion Depth | Frequency |
|---|---|---|
| Accreta | Superficial myometrial invasion (no decidua) | ~75% of PAS |
| Increta | Deep myometrial invasion | ~18% of PAS |
| Percreta | Through serosa ± adjacent organ invasion (bladder, bowel) | ~7% of PAS; highest hemorrhage risk |
Pre-operative Planning for PAS
- MRI for depth of invasion assessment: Determines extent of myometrial and extra-uterine involvement; guides surgical and IR planning
- Multidisciplinary team: Maternal-fetal medicine (MFM), urology, colorectal surgery, IR, blood bank — all must be coordinated before planned delivery
- Prophylactic balloon placement: Bilateral internal iliac artery or uterine artery balloons placed in IR suite under fluoroscopy before going to OR; inflation at time of uterine incision/delivery to reduce blood loss; UAE performed through same sheaths after balloon deflation
- Evidence for prophylactic balloons: Mixed evidence on blood loss reduction; major centers use routinely for percreta given potential for catastrophic hemorrhage
- FIGO 2019 classification: Provides standardized clinical and histological grading for PAS diagnosis and management algorithm
PAS coordination: For any patient with suspected percreta on imaging, IR should be involved in pre-delivery planning, regardless of whether hemorrhage ultimately occurs. Pre-placed sheaths allow immediate UAE without additional access time in a hemorrhaging patient.
Evidence Summary
- ACOG/SMFM: UAE recommended as first-line for PPH after failed medical/surgical management; success rate 85–95% for uterine preservation
- Sentilhes et al (2016, Radiology): Systematic review; UAE technical success 90.7%; clinical success 73.7%; fertility preserved in 72.9% of subsequent pregnancies
- Two large systematic reviews demonstrate UAE for PPH safe with maintained fertility; complication rates acceptable vs. hysterectomy
- For PAS: Multidisciplinary management with planned UAE reduces need for emergency hysterectomy; major referral centers report substantially lower hysterectomy rates with structured IR involvement
References
- Sentilhes L, et al. Fertility and pregnancy outcomes following pelvic arterial embolization for postpartum haemorrhage: a cohort study and systematic review. Eur Radiol. 2016;26(10):3349–3360.
- Soyer P, et al. Uterine artery embolization for postpartum hemorrhage: long-term follow-up clinical and angiographic results. Diagn Interv Imaging. 2015;96(4):361–367.
- Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168–e186.
- Collins SL, et al. FIGO Classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet. 2019;145(1):20–35.
- ACOG Committee Opinion No. 764: Medically Indicated Late-Preterm and Early-Term Deliveries. Obstet Gynecol. 2019;133(2):e151–e155.
- Matula V, et al. Fertility after transcatheter uterine artery embolization for postpartum hemorrhage — systematic review and meta-analysis. Am J Obstet Gynecol. 2022;226(2):180–192.
- d'Archambeau O, et al. Prophylactic uterine artery embolization in patients with placenta accreta spectrum. J Vasc Interv Radiol. 2023;34(3):405–412.
Full technique in RadCall Pro
Complete catheter selection for bilateral uterine artery access, gelfoam preparation and injection technique, balloon catheter placement protocol for placenta accreta spectrum, and troubleshooting for difficult anatomy in RadCall Pro.
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