Postpartum Hemorrhage — Uterine Artery Embolization

1

Indications & Contraindications

Etiologies of PPH, refractory hemorrhage criteria, patient selection

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Indications

Postpartum hemorrhage refractory to uterotonics (oxytocin, methylergonovine / methergine, carboprost / hemabate) and uterine massage / tamponade (Bakri balloon)
Massive PPH: defined as >1000 mL blood loss after delivery or any amount causing hemodynamic instability
Primary PPH (within 24 h of delivery) or secondary PPH (>24 h post-delivery)
Patient desire for future fertility — embolization as alternative to emergent hysterectomy

Contraindications

Hemodynamic instability requiring emergent surgical intervention — patient too unstable for angiographic procedure; proceed to hysterectomy
Anaphylaxis to iodinated contrast (relative — CO₂ angiography may be used for uterine source)
No absolute contraindications to embolization of PPH per literature
Relative: unmanaged severe coagulopathy / DIC (known predictor of clinical failure)

Etiologies — The 4 Ts of PPH

Etiology	Examples	Frequency
Tone	Uterine atony — macrosomia, polyhydramnios, prolonged labor, general anesthesia	Most common
Tissue	Retained products of conception, abnormal placentation (accreta spectrum)	Common
Trauma	Cervical / vaginal laceration, uterine rupture, uterine inversion	Moderate
Thrombin	DIC, coagulopathy (pre-existing or acquired), amniotic fluid embolism	Less common

2

Pre-Procedure Planning

Resuscitation, labs, OB coordination, imaging

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Resuscitation & Labs

Massive transfusion protocol (MTP) — likely already activated; confirm with blood bank
Type & screen / crossmatch (usually already done); if transfusion needed before crossmatch, use type-specific uncrossmatched blood
Coag panel: PT/INR, fibrinogen, platelets — assess for DIC (DIC is a predictor of embolization failure)
CBC, BMP (creatinine for contrast), blood gas analysis
Hemodynamic stabilization: IV fluids wide open, pressors if needed, secure IV access ×2 (consider central line placement by IR)

Coordination & Imaging

OB consultation: obtain obstetric history — mode of delivery (vaginal vs C-section), suspected bleeding source, prior interventions (uterotonics, Bakri balloon, O’Leary stitch, IIA ligation)
Patient desire for future fertility — confirm directly or via OB team
CTA pelvis if patient stable — identifies extravasation site, variant anatomy, ovarian collaterals
Do NOT delay for CTA if patient is hemodynamically unstable — proceed directly to angiography
Foley catheter placement (may already be in place)

MTP activated / blood products available. pRBCs, FFP, platelets, cryoprecipitate at bedside or in transit.

Coag panel reviewed. Fibrinogen, INR, platelets assessed for DIC. Correct coagulopathy as able.

OB history obtained. Delivery mode, suspected etiology, prior surgical maneuvers (ligation, packing, Bakri).

Hemodynamics assessed. If stable enough for angiography, proceed. If crashing, discuss hysterectomy vs IR with OB.

Consent obtained (or emergent implied consent). Key risks: continued bleeding, uterine necrosis (rare), infection, loss of fertility (rare with Gelfoam).

Foley catheter in place. Secure IV access ×2 confirmed. Anesthesia team notified / at bedside.

3

Relevant Anatomy

Uterine artery origin, postpartum vascular changes, collateral supply

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Uterine Artery

Arises from the anterior division of the internal iliac artery (IIA)
Post-delivery: uterus dramatically enlarged with hypertrophied, tortuous uterine arteries — may extend well cephalad above the umbilicus
Postpartum UA is typically large and easy to catheterize, but also prone to spasm
Cervicovaginal branch — arises early from UA; can be a source of hemorrhage from cervical / vaginal laceration
Other anterior division branches: superior vesical, middle rectal, inferior rectal, vaginal, internal pudendal arteries

Collateral Supply & Key Variants

Ovarian artery — arises from aorta; provides significant collateral supply to gravid/postpartum uterus; must check if bleeding persists after bilateral UAE
Round ligament artery — arises from inferior epigastric / external iliac artery; can supply vaginal and uterine arteries
Bilateral embolization almost always required — rich cross-pelvic collateralization means unilateral embolization is rarely sufficient for diffuse uterine bleeding / atony
Adjust imaging field of view: postpartum uterine arteries extend much more cephalad than typical pelvic arteriography

Angiographic Views

Contralateral anterior oblique (CAO, ~30 degrees) best shows the IIA origin. Steep ipsilateral oblique (30–45 degrees) differentiates anterior and posterior divisions and isolates the uterine artery. Use a fast filming rate (4–6 frames/sec) with injection rates of 7–10 mL/s for 2–4 seconds for pelvic arteriography. Road mapping or fluoro-fade technology is very helpful for rapid vessel selection in the setting of shock physiology.

4

Technique

Access, catheterization, embolic selection, endpoints

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1

Arterial Access

Right common femoral artery (CFA) access preferred. Ultrasound-guided micropuncture technique. Place 4–5 Fr vascular sheath. Sheath attached to heparinized pressurized saline or transduced for continuous pressure monitoring. Transradial access is an alternative — advantages include hemostasis assurance in coagulopathy, favorable catheter angle, and ability to maintain lithotomy position for OB access.

2

Pelvic Arteriography (Optional)

Flush aortogram at operator discretion with 4–5 Fr pigtail or Omniflush catheter positioned 2–3 cm above the aortic bifurcation. AP and 30–45 degree oblique projections. Fast filming rate 4–6 fps. May be reserved for troubleshooting or end-of-case assessment; not always needed if CTA was obtained pre-procedure.

3

Contralateral IIA Selection

Traverse the aortic bifurcation with a 5 Fr Cobra or Roberts Uterine Catheter (RUC). Select the contralateral internal iliac artery. Obtain IIA angiogram with ipsilateral oblique (30–45 degrees) to separate anterior and posterior divisions. Identify uterine artery origin from anterior division.

4

Selective Uterine Artery Catheterization

Postpartum uterine arteries are typically hypertrophied and may be catheterized with the base catheter alone (microcatheter not always necessary). However, microcatheter (0.027″ ID or Hi-Flo) preferred to reduce vasospasm risk. Avoid deep catheterization — position in proximal-to-mid uterine artery. Confirm position angiographically. Avoid intra-arterial nitroglycerin (hypotensive side effects in hemorrhaging patient).

▶ Round ligament artery — collateral supply to uterus

Round ligament artery opacified as collateral supply during PPH embolization

Round ligament artery (anastomosis of uterine and ovarian circulations) — identify and include in embolization map to avoid incomplete control.

5

Embolization

Embolic of choice: Gelfoam pledgets / thick slurry (PREFERRED — temporary occlusion over 2–4 weeks, allows uterine recovery and preserves future fertility). Gelfoam slurry: cut sponge into cubes, place in 10 mL syringe, connect via 3-way stopcock to another syringe with 50/50 contrast-saline, rapidly agitate until “floating clouds” consistency. If Gelfoam insufficient: PVA particles 500–700 µm as second-line agent. Avoid particles <500 µm (associated with uterine infarction). Goal is NOT complete ischemic infarction — aim for sluggish forward flow / 3–5 beat stasis in the uterine artery.

▶ Ovarian artery collateral — persistent PPH supply

Ovarian artery providing collateral supply during PPH embolization after bilateral uterine artery occlusion

Ovarian artery collateral opacification after bilateral uterine artery occlusion — always assess for non-uterine supply in refractory PPH.

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Ipsilateral IIA — Waltman Loop to Cross to Right Side

After embolizing the contralateral uterine artery, the Cobra/RUC must be reformed without sheath exchange. The Waltman loop is the standard technique:

Retract catheter to the distal aorta above the bifurcation, tip facing cephalad.
Advance the catheter with gentle clockwise torque — the tip buckles against the opposite aortic wall, forming a reverse-curve loop in the aortic lumen.
Continue advancing until the loop is stable and the tip points caudally toward the right iliac.
Pull back slowly — traction in reverse-curve configuration paradoxically advances the tip into the ipsilateral IIA. Use fluoroscopy to monitor tip position.
Confirm with contrast injection. If the catheter keeps slipping, advance a stiff wire deep into the right external iliac first to anchor, then advance the catheter over it.

Repeat selective right uterine artery catheterization with microcatheter past the cervicovaginal branch. Bilateral embolization is mandatory in diffuse atony — unilateral embolization has significantly higher failure rate in PPH.

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Completion Angiography & Closure

Post-embolization pelvic arteriogram to confirm bilateral uterine artery stasis and absence of ongoing extravasation. If persistent bleeding: investigate ovarian artery supply (aortogram), cervicovaginal branches, internal pudendal artery. Remove catheters. Femoral closure device or manual compression. Transfer to ICU for monitoring.

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5

Angiographic Landmarks

Key identification points on IIA angiogram

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Uterine Artery Identification

IIA angiogram in steep ipsilateral oblique (30–45 degrees) separates anterior and posterior divisions
Uterine artery originates from the anterior division — typically the dominant vessel in postpartum patients
Postpartum UA is markedly hypertrophied and tortuous with prominent spiral artery branches
Road mapping / fluoro-fade essential for rapid selection, especially in shock physiology where vessels may appear “clamped down”

Key Findings

Extravasation — frank contrast blush beyond the vessel lumen; indicates active arterial hemorrhage
Pseudoaneurysm — contained contrast collection that persists and washes out with the arterial phase
Enlarged postpartum vessels — uterine arteries extend well above the pelvis; widen field of view
Posterior division landmark: identify superior gluteal artery origin — catheter tip must be positioned beyond this to prevent nontarget embolization of the gluteal supply

6

Troubleshooting

Intraoperative problems and solutions

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Critical

DIC Limiting Embolization Efficacy

DIC is a known predictor of embolization failure. Gelfoam and coils rely on in-situ thrombogenesis for vessel occlusion. Aggressively correct coagulopathy with cryoprecipitate (fibrinogen goal >150), FFP, and platelets. Consider n-BCA glue as embolic agent in coagulopathic patients — does not rely on the coagulation cascade for vessel occlusion. Coordinate ongoing resuscitation with anesthesia team throughout the case.

Persistent Bleeding After Bilateral UAE

Continued Hemorrhage Despite Bilateral Uterine Artery Embolization

Check for ovarian artery supply — hypertrophied ovarian arteries from the aorta can provide extensive blood supply to the postpartum uterus. Perform nonselective aortography to identify collaterals. Investigate cervicovaginal branches, internal pudendal artery, obturator artery, and round ligament artery (from inferior epigastric / external iliac). Remove vaginal or uterine packing temporarily to unmask angiographic abnormality. If anterior division embolization of IIA may be required when uterine artery cannot be selectively catheterized.

Vasospasm

Uterine Artery Spasm During Catheterization

Uterine arteries are prone to spasm. Use microcatheter for selection to minimize trauma. Avoid deep catheterization. Catheter-related vasospasm alone is unlikely to provide durable hemostasis — attempt to break or cross the spasm and proceed with distal embolization. If unable to cross: less selective anterior division embolization is an acceptable alternative. Avoid intra-arterial nitroglycerin in hemorrhaging patients (hypotensive side effects).

Critical

Hemodynamic Instability During Procedure

Patient may decompensate on the table. Ensure anesthesia team is at bedside managing resuscitation. Consider placing central venous catheter (IJ triple lumen) for volume resuscitation. If patient cannot be stabilized: embolize the entire anterior division of the IIA (faster, broader hemostasis) rather than attempting selective UA catheterization. Communicate continuously with OB — hysterectomy may become necessary if embolization cannot achieve hemostasis in a timely manner.

Prior Vessel Ligation

O’Leary Stitch or IIA Ligation by OB Team

Obtain detailed operative history from OB. Suspect ligation when usually apparent uterine or IIA arteries are not visualized. In a published series, 9 of 11 ligated IIAs demonstrated residual angiographic flow — crossing the ligated vessel remains viable. Empiric anterior division embolization can control collateral flow around a ligated uterine artery. Prior ligation has not been shown to impact embolization success rates.

7

Complications

Expected sequelae and serious adverse events

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Common / Expected

Post-embolization syndrome — pelvic pain, low-grade fever, nausea; self-limited; manage with analgesics and antipyretics
Access site hematoma — especially in coagulopathic patients; more common with femoral vs radial approach
Rebleeding / re-embolization (~5–10%) — may require repeat angiography; CTA useful for workup of rebleeding

Serious Complications

Uterine necrosis (rare with Gelfoam) — associated with smaller particles (<500 µm) and simultaneous ovarian + uterine artery embolization; requires hysterectomy
Infection / endometritis / abscess — low incidence; prophylactic antibiotics recommended
Asherman syndrome (intrauterine adhesions) — rare; may affect future fertility
Ovarian failure / amenorrhea — extremely rare with Gelfoam; more concerning with permanent embolic agents or if ovarian arteries embolized
Nontarget embolization — reflux into posterior division (superior gluteal artery); meticulous catheter positioning beyond posterior division origin is critical

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Pearls & Pitfalls

High-yield tips for PPH embolization

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Gelfoam is the embolic of choice. Temporary occlusion (2–4 weeks) is sufficient to stop acute hemorrhage while preserving uterine recovery and future fertility. Reserve permanent embolics (PVA 500–700 µm) for cases where Gelfoam is insufficient.

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Technical success rate >95%. Clinical success rates range from 80–90% with predictors of failure including DIC, large-volume transfusion (>10 U pRBCs), and C-section delivery.

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Fertility is preserved in the vast majority. Multiple studies confirm successful conception and term delivery after UAE for PPH. Emphasize this when counseling patients and OB teams as alternative to hysterectomy.

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TIME IS LIFE. Do not delay for CTA if the patient is hemodynamically unstable. Proceed directly to angiography. Use the access and equipment you are most comfortable with in an emergency.

✦

Always check ovarian artery supply if bleeding continues after bilateral UAE. Hypertrophied ovarian arteries from the aorta are a common cause of persistent hemorrhage.

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Do NOT use particles <500 µm. Smaller particle size is associated with uterine infarction and ovarian insufficiency. The goal is hemorrhage control, not tissue infarction.

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Avoid intra-arterial nitroglycerin in the hemorrhaging patient. Hypotensive side effects can worsen hemodynamic instability. Use sparingly or not at all, unlike fibroid embolization.

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DIC dramatically reduces embolization efficacy. Embolic agents that rely on thrombogenesis (Gelfoam, coils) may fail. Correct coagulopathy aggressively; consider n-BCA glue if coagulopathy is refractory.

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References & Resources

Primary sources and related procedures

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Key Outcomes

Technical success: approaching 100% in most modern series
Clinical success: ~89% per meta-analysis (Sathe et al. 2016)
Fertility preservation: multiple retrospective studies confirm successful conception and delivery post-UAE for PPH

Primary References

Pelage JP, Le Dref O, Jacob D, et al. Selective arterial embolization of the uterine arteries in the management of intractable post-partum hemorrhage. Acta Obstet Gynecol Scand. 1999;78(8):698–703.
Soncini E, Pelicelli A, Larini P, Marcato C, Monaco D, Grignaffini A. Uterine artery embolization in the treatment and prevention of postpartum hemorrhage. Int J Gynaecol Obstet. 2007;96(3):181–185.
Newsome J, Martin JG, Bercu Z, Shah J, Shekhani H, Peters G. Postpartum hemorrhage. Tech Vasc Interv Radiol. 2017;20(4):266–273.
Brown M, Hong M Jr, Lindquist J. Uterine artery embolization for primary postpartum hemorrhage. Tech Vasc Interv Radiol. 2021;24(4):100727.
Heaston DK, Mineau DE, Brown BJ, et al. Transcatheter arterial embolization for control of persistent massive puerperal hemorrhage after bilateral surgical hypogastric artery ligation. AJR Am J Roentgenol. 1979;133(1):152–154.
Lee HY, Shin JH, Kim J, et al. Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution. Radiology. 2012;264(3):903–909.