Recurrent Postpartum Hemorrhage Research Articles

Association between uterine artery embolization for postpartum hemorrhage and second delivery on maternal and offspring outcomes: a nationwide cohort study.

What are the maternal and neonatal outcomes of second delivery in women who underwent uterine artery embolization (UAE) during their first delivery? Women who underwent UAE during their first delivery exhibited higher risks of placental problems, preterm births, and postpartum hemorrhage (PPH) in second delivery and the second offspring also showed increased risk of major congenital malformations, admission to the neonatal intensive care units (NICU), necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia. UAE is a minimally invasive procedure used as an alternative to hysterectomy for managing severe PPH. However, recent studies have raised concerns about potential obstetric complications, including recurrent PPH, placenta accreta spectrum (PAS), and fetal growth restriction in subsequent delivery following UAE. This was a nationwide retrospective cohort study using the Korean National Health Insurance Service (K-NHIS) database, covering 50 million individuals from 2004 to 2020. The cohort included 3616923 women with live births between 1 January 2005 and 31 December 2019 with follow-up data extending to 31 December 2020. The study included women who had their first live birth between 2005 and 2019, excluding those who underwent hysterectomy (without UAE = 3612389, UAE = 4534). Among them, we selected women who had single gestation secondary delivery (without UAE = 1694600, UAE = 1146). Propensity score matching was used to control for confounding factors, resulting in 11184 women without UAE and 1119 women with UAE for subsequent analysis. Women in the UAE group had significantly higher risks of PAS (odds ratio (OR) = 38.91, 95% CI = 18.61-81.34), placenta previa (OR = 6.98, 95% CI = 5.57-8.75), and preterm birth (OR = 2.23, 95% CI = 1.71-2.90) during their second delivery. The risk of recurrent PPH was also significantly higher (OR = 8.94, 95% CI = 7.19-11.12). Their second offspring were more likely to have major congenital malformations (OR = 1.62, 95% CI = 1.25-2.11) and adverse neonatal outcomes, including NICU admissions (OR = 1.83, 95% CI = 1.48-2.25). Long-term outcomes showed a higher risk of attention-deficit/hyperactivity disorder (hazard ratio = 1.64, 95% CI = 1.03-2.63) but were otherwise comparable to those in the without UAE group. Retrospective nature of the study may have introduced exposure and outcome misclassifications, despite the reliability of the K-NHIS database. Unmeasured confounders and selection bias due to only including live births could also have influenced the results. Women with a history of UAE require meticulous prenatal care and close monitoring during subsequent deliveries due to increased risks of complications. Counseling and referral to high-risk medical centers may improve outcomes. Further research is needed to understand the mechanisms of complications in both mothers and offspring at sequential delivery, as well as to refine UAE procedures. This study supported by Patient-Centered Clinical Research Coordinating Center (PACEN) funded by the Ministry of Health & Welfare, Republic of Korea (HC21C0123). This study was funded by S.-Y.O. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. N/A.

Prognosis of subsequent pregnancy in uterine necrosis after uterine artery embolization.

In an 8-year period at two medical center, 138 patients underwent uterine artery embolization, and 11 of them were diagnosed with uterine necrosis. Among them, three were successfully conceived. However, one of them developed an arteriovenous malformation after an artificial abortion, and another experienced complications, including placenta previa and placenta accreta spectrum, which resulted in early preterm delivery and recurrent postpartum hemorrhage, necessitating subtotal hysterectomy. Therefore, it is crucial to prepare for potential adverse pregnancy outcomes in subsequent pregnancies for patients with a history of uterine necrosis.

Repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage in patients who underwent UAE after a previous delivery: a multicenter study.

To evaluate angiographic findings and outcomes of repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in patients who previously underwent UAE for PPH after a previous delivery. Among 1805 patients who underwent UAE for PPH from 2007 to 2020 at four participating hospitals, the data of 21 (1.16%) patients who underwent UAE for PPH after subsequent delivery were collected and analyzed retrospectively. The rate of placental abnormalities, causes of PPH, angiographic findings, and clinical success rate were evaluated. The technical success rates were 100% and 95.2%, and clinical success rates were 85.7% and 95.2% in association with first and second UAEs, respectively. The time intervals between first and second UAEs ranged from 15.6 to 103.3months (46.5 ± 25.0months). The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). The causes of PPH were different between first and second UAEs with borderline significance (p = 0.049); uterine atony (81.0%) and placenta accreta spectrum (57.1%) were most common in association with first and second UAEs, respectively. During second UAEs, obliterated arteries were observed in 27 uterine arteries (27/42, 64.3%) of 16 patients (16/21, 76.2%), with partial obliteration predominating over total obliteration. Collateral arteries were observed in 15 patients during second UAEs. Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE. Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). • Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE.

Recurrent postpartum hemorrhage at subsequent pregnancy in patients with prior uterine artery embolization: angiographic findings and outcomes of repeat embolization.

To evaluate angiographic findings and outcomes of uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in a subsequent pregnancy in patients with a history of prior UAE. Between March 2004 and February 2021, UAE was performed for PPH with gelatin sponge slurry in 753 patients. Among these, 13 underwent repeat UAE for recurrent PPH after subsequent delivery. The causes of PPH, angiographic findings, hemostasis, and adverse events were evaluated. The causes of recurrent PPH included retained placental tissue (n = 9) and uterine atony (n = 4). On angiography, unilateral or bilateral uterine arteries were obliterated due to prior UAE in 10 patients (76.9%). The uterine collateral vessels were embolized (anterior division of the internal iliac artery [n = 10], round ligament [n = 5], and ovarian [n = 4] artery). In the remaining three patients with recanalized or patent (not embolized at prior UAE) uterine arteries, both uterine arteries were embolized. Immediate hemostasis was achieved in nine patients (69.2%). The remaining four patients (30.8%) with obliterated uterine arteries required hysterectomy. There were three mild adverse events (pelvic pain [n = 2] and fever [n = 1]). UAE with gelatin sponge slurry frequently causes permanent uterine artery obliteration. In cases of recurrent PPH occurring in subsequent pregnancy, repeat UAE may be less likely to achieve hemostasis (69.2%). 1. UAE with gelatin sponge slurry frequently caused permanent uterine artery obliteration.2. In recurrent PPH occurring in subsequent pregnancy, the repeat UAE may be less likely to achieve hemostasis than initial UAE.

Obstetrical and Fertility Outcomes Following Transcatheter Pelvic Arterial Embolization for Postpartum Hemorrhage: A Cohort Follow-Up Study.

Objectives: Management of severe postpartum hemorrhage (PPH) includes transcatheter pelvic arterial embolization (TAE). Data regarding subsequent fertility and obstetrical outcomes is limited, as most fertility outcomes derive from TAE in uterine fibroma. The purpose of our study was to evaluate the long-term outcomes of patients undergoing TAE, particularly concerning subsequent fertility and following pregnancies. Material and methods: We included 28 patients who underwent TAE for PPH at our institution between 2009 and 2018 in a retrospective cohort study. Data were assessed by reviewing patients’ charts and by contacting the patients. Results: Ten patients had prophylactic balloon occlusion before cesarean section because of anticipated PPH, with planned hysterectomy by placenta increta/percreta. All these patients were excluded from the analysis regarding fertility. 16 (73%) patients reported having regular menstruation after TAE. In total, 11 women had no desire for subsequent pregnancy. Seven of the remaining 11 patients (63.6%) had a total of 13 spontaneous pregnancies, nine of these resulted in miscarriages. Four patients delivered a live baby (36.4%). Two of these (50%) had recurrent PPH and treatment was conservative. Of the patients with infertility (n = 4, 36.4%), two (18.1%) underwent assisted infertility treatment without success. Conclusion: Our study suggests that the fertility of patients undergoing TAE due to PPH is limited. In women who conceive, the risk for first trimester miscarriage as well as recurrent PPH seems to be increased. If this is a consequence of the underlying cause of PPH or the TAE remains unknown. Larger follow-up cohorts are needed. In the meantime, patients who desire pregnancy after TAE should be counseled accordingly.

Incidence of postpartum hemorrhage and risk factors for recurrence in the subsequent pregnancy.

To assess incidence and risk factors for postpartum hemorrhage (PPH) and identify women at high risk of recurrence in the subsequent pregnancy. This register-based study includes data on women from the Capital Region of Denmark with two consecutive deliveries recorded in the Copenhagen Obstetric Database from 2007 to 2020. PPH, defined as a blood loss of 1000mL or more within 24h after delivery, was the primary outcome measure. We calculated incidence and recurrence rate of PPH and assessed possible risk factors at index and subsequent deliveries. We included 44,800 women with 95,673 deliveries. The overall incidence of PPH was 6.3%. Women with previous PPH had a 3.5-fold increased risk of PPH in a subsequent delivery compared to unaffected women (19.1 vs. 5.4%; OR 4.1; 95% CI 3.7-4.5). Major risk factors for recurrence were PPH in combination with blood transfusion or manual removal of placenta at the index delivery. Labor induction in subsequent pregnancy increased the risk of recurrent PPH compared to spontaneous onset (OR 1.5; 95% CI 1.2-1.9), while planned caesarean section reduced the risk, compared to planned vaginal delivery (OR 0.6; 95% CI 0.4-0.7). Previous PPH increases the risk of PPH in subsequent pregnancy 3.5-fold. The risk of recurrent PPH increases with labor induction and decreases with planned caesarean section in the subsequent pregnancy. To prevent recurrent PPH, personalized counseling based on risk factors, relevant labor history and maternal preferences is suggested.

Treatment of bleeding in a patient with immune coagulopathy (acquired haemophilia A)

Objective. We are representing the case of acquired haemophilia A and analyze the timeliness and adequacy of treatment.
 Materials and methods. The subject of the study was immune coagulopathy with a factor VIII (FVIII) inhibitor – acquired haemophilia A.
 Results and discussion. Female, 33 years old, pregnancy II, urgent delivery. There was excessive bleeding in the early postpartum period, hemostatic therapy was provided. She hospitalized three times with recurrences of uterine bleeding. Vacuum aspiration of the walls of the uterine cavity was performed twice. After the third recurrence, blood loss of 1200 ml and ineffectiveness of conservative treatment, laparotomy and extirpation of the uterus was performed. Despite intensive care, the bleeding continued, the patient was transferred to the regional clinical hospital, where she was diagnosed with DIC syndrome, stage III, severe anemia. Three relaparotomies were performed, the source of bleeding was not found, there was excessive bleeding from the operating field. The total blood loss was 24,447 ml. Intensive infusion-transfusion therapy was continued, which gave unstable hemostasis. The patient received 12,060 ml of fresh-frozen plasma (FFP), 15,130 ml of erythrocytes, 600 ml of albumin 10 %, 20 doses of cryoprecipitate (CP), 16,000 U of activated prothrombin complex (APCC), 8 mg of recombinant activated factor VII (rVIIa), 8,000 U of prothrombin complex (PC). 16.1 BU/ml of inhibitor FVIII, FVIII <1.0 %, activated partial thromboplastin time (APTT) – 146.1 s was detected on day 37. Within 30 days, blood loss was 10,608 ml; patient received 23,420 ml of FFP, 2,080 ml of erythrocytes, 17 mg of rVIIa, 19,000 U of APCC, 6000 U of PC, 61 dose of CP, 50,000 IU of FVIII. Immunosuppressive therapy (prednisolone 1-1.5 mg/kg/day) was started on day 67 and lasted for 12 months. Bleeding stopped completely 10 months after delivery, and after 14 months the inhibitor was not detected, factor levels and APTT returned to normal. Scheduled reconstructive surgery on the urinary tract was performed without the use of transfusion replacement therapy.
 Conclusions. Recurrent postpartum hemorrhage requires early diagnosis of coagulation factors inhibitors, which will ensure specific transfusion and immunosuppressive therapy, avoidance of serious consequences, including extirpation of the uterus and reduce the economic costs of treatment.

Uterine Arteriovenous Malformation: A Rare Cause of Secondary Postpartum Hemorrhage

Ruptured uterine arteriovenous malformation (AVM) such as uterine artery pseudoaneurysm is an extremely rare cause of secondary postpartum hemorrhage (PPH), thus causing a diagnostic and therapeutic dilemma for the managing obstetricians. We describe a case of a 40-year-old lady who presented with recurrent intractable secondary PPH unresponsive to conventional treatment following an emergency lower segment cesarean section (LSCS). This was her second LSCS for a failed trial of vaginal birth after cesarean section (VBAC). Subsequently left uterine artery extravasation was identified on pelvic angiogram and selective embolization was done with successful treatment of her PPH. To date, there have been only case reports or case series available on literature due to its rarity of the diagnosis. We wish to raise awareness of this rare diagnosis in patients with risk factors as a cause of recurrent PPH not responding to medical management. We also wish to share our experience with the successful use of selective uterine artery embolization for the management of this condition which resulted in avoidance of hysterectomy and its associated morbidity. J Med Cases. 2017;8(5):152-154 doi: https://doi.org/10.14740/jmc2804w

Subsequent Pregnancy Outcomes Following Use of an Intrauterine Tamponade Balloon for Postpartum Hemorrhage (PPH) [24C

INTRODUCTION: Uterine tamponade balloons(UTB) reduce the need for invasive procedures in the setting of PPH; but subsequent pregnancy outcomes are unknown. We sought to examine subsequent pregnancy outcomes among women with PPH treated by UTB. METHODS: Retrospective cohort of women with diagnosis of PPH at a tertiary referral center, (1/2010-6/2016). Women with an EBL ≥1000 mL who required use of uterotonic medications, and who had at least one subsequent pregnancy were considered for inclusion. Cases defined as women whose PPH was treated with UTB; the woman immediate preceding and following each case were selected as controls. Simple statistics were used as appropriate. RESULTS: 8 women had a subsequent pregnancy after an index pregnancy requiring UTB, and were matched to 16 controls. During the index pregnancy, cases had lower median prepregnancy BMI (22.4 vs 33.1,p=0.01), but antenatal characteristics were otherwise similar. No difference between the intrapartum characteristics of cases and controls was noted, except that the EBL was higher for cases (2000 vs 1200 mL, p=0.004), and cases were more likely to require transfusion (88% vs 31%,p=0.027). Interpregnancy intervals were similar. In subsequent pregnancy, 75% of the UTB group had documented counseling regarding risk of recurrent PPH, compared with 31% of controls(p=0.082). PPH was similar between groups(38% vs 31%,p>0.99). No woman required UTB, hysterectomy, ICU admission, or had morbidly adherent placenta in subsequent delivery. CONCLUSION: Use of UTB for PPH does not appear to increase risk for recurrent PPH or abnormal placentation. Until larger studies can be performed, this information offers some reassurance regarding the use UTB.

Uterine Arteriovenous Malformation: A Rare Cause of Secondary Postpartum Hemorrhage

Ruptured uterine arteriovenous malformation (AVM) such as uterine artery pseudoaneurysm is an extremely rare cause of secondary postpartum hemorrhage (PPH), thus causing a diagnostic and therapeutic dilemma for the managing obstetricians. We describe a case of a 40-year-old lady who presented with recurrent intractable secondary PPH unresponsive to conventional treatment following an emergency lower segment cesarean section (LSCS). This was her second LSCS for a failed trial of vaginal birth after cesarean section (VBAC). Subsequently left uterine artery extravasation was identified on pelvic angiogram and selective embolization was done with successful treatment of her PPH. To date, there have been only case reports or case series available on literature due to its rarity of the diagnosis. We wish to raise awareness of this rare diagnosis in patients with risk factors as a cause of recurrent PPH not responding to medical management. We also wish to share our experience with the successful use of selective uterine artery embolization for the management of this condition which resulted in avoidance of hysterectomy and its associated morbidity. J Med Cases. 2017;8(5):152-154 doi: https://doi.org/10.14740/jmc2804w

Risk factors for early postpartum hemorrhage (PPH) in the first vaginal delivery, and obstetrical outcomes in subsequent pregnancy

Objective: To investigate risk factors for postpartum hemorrhage (PPH) in vaginal deliveries and the influence of previous PPH on the subsequent pregnancy.Study design: A retrospective cohort study including first singleton deliveries between the years 1988 and 2012 was performed comparing deliveries with and without PPH. In addition, perinatal outcomes of the subsequent pregnancy were evaluated. Multivariable analysis was performed to control for confounders.Results: PPH complicated 0.8% of all first vaginal deliveries. Significant risk factors for PPH in vaginal delivery, using a multiple logistic regression model, were: post-term pregnancy, fertility treatments, hypertensive disorders, labor dystocia during the 2nd, and perineal tears grade 2 and 3, respectively. Previous PPH was found to be an independent risk factor for PPH in the subsequent pregnancy. Moreover, previous PPH was found to be a significant risk factor for cesarean section (CS) deliver, to complicate delivery with revision of uterus cavity, anemia, and to require blood transfusion.Conclusion: Previous PPH poses a risk for recurrent PPH in subsequent delivery and an increased risk for CS. As PPH remains one of the major causes of maternal morbidity, this study strengthens the need for a comprehensive evaluation of prior PPH as a major risk factor for PPH recurrence.

Patterns of recurrence of postpartum hemorrhage in a large population-based cohort

Although a history of postpartum hemorrhage (PPH) is a recognized risk factor for PPH in subsequent pregnancies, little is known about how the risk accumulates over multiple pregnancies, how recurrence varies by PPH subtype, and whether recurrence can be explained by chronic maternal conditions. Risks of PPH were assessed according to a history of PPH, severity, and subtype (atony, retained placenta, or lacerations) in 538,332 primiparous women whose data were included in the Swedish Medical Birth Register from 1997-2009. The role of stable maternal risk factors was evaluated in regression models that predicted probability of recurrent PPH in second and third pregnancy. Women with a history of PPH had a 3-fold increased risk of PPH in their second pregnancy compared with unaffected women (15.0% vs 5.0%, respectively). Adjustment for stable maternal risk factors did not attenuate this risk significantly (adjusted relative risk, 3.0; 95% confidence interval, 2.9-3.1). In a third pregnancy, the risk of PPH was 26.6% after 2 previously affected pregnancies, compared with 4.4% in women with no previous PPH. A history of a specific type of PPH predicted recurrence of PPH in the second pregnancy, not only of the same type but other causes as well. PPH risk is highest among women with >1 previously affected delivery and in those with a previous severe PPH. Chronic conditions that are known to be risk factors for PPH do not explain the recurrence risks. The recurrence patterns across PPH subtypes may point to shared pathologic mechanisms underlying the varying PPH causes.

Postpartum Hemorrhage Caused by Pseudoaneurysm Associated with Malformations of the Uterus

We present the first diagnosed case reported from Bahrain. The patient was 23 years old, para 1, abortion 0, had recurrent postpartum hemorrhage following cesarean section caused by a traumatic pseudoaneurysm which was treated with hysterectomy. The treatment of choice is uterine artery embolization if diagnosed early and this method is particularly helpful to preserve the reproductive function in women.

Characteristics, causes and treatment of postpartum haemorrhage in first and second pregnancies

We investigated characteristics, causes and treatment of postpartum haemorrhage (PPH) in a random sample of 294 women's first and second pregnancies involving at least one PPH. Among 588 pregnancies, PPH affected 169 first pregnancies, 105 second pregnancies only and recurrent PPH affected 48 pregnancies. In 34% of PPHs, atony was the primary cause. Second pregnancy PPH involved increased pharmacological therapy, blood transfusion and median blood loss. It is important to ascertain PPH history in parous women and be prepared for PPH recurrence.

A repeat B-Lynch suture for recurrent postpartum haemorrhage in a patient with factor V Leiden mutation

Postpartum haemorrhage (PPH) is an important cause of maternal mortality, accounting for nearly one-quarter of all maternal deaths worldwide (WHO 2007). In 1997, Christopher B-Lynch introduced his ...

Fertilité et grossesses après prise en charge invasive des hémorragies du postpartum

Ligation of the internal iliac arteries and embolization of the uterine arteries are two techniques routinely used in the management of postpartum hemorrhage. The objective of this study was to examine the long-term consequences of these techniques on women's subsequent reproductive outcome and subsequent delivery morbidity. Retrospective study including women who underwent ligation and those who underwent embolization, for the treatment of postpartum hemorrhage. We analyzed resumption of menses, fertility, pregnancy and delivery outcome after each treatment. The study included 85women who underwent ligation and 90who had embolization to treat postpartum hemorrhage. No adverse event related to menses, fertility, or pregnancy outcome followed either treatment. However, the rate of recurrent hemorrhage was high: 26% after ligation and 39% after embolization. All recurrences were treated medically in the ligation group, but in the embolization group, 42% (five of 12patients) required invasive treatment and 33% (four patients) transfusions. From the perspective of subsequent menses, fertility and pregnancy outcome, both ligation and embolization are safe procedures for the management of postpartum hemorrhage. However, our results showed a high risk of recurrent postpartum hemorrhage after both treatments. Recurrences seemed more serious after the latter.

Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?

Among 23 women who underwent diagnostic hysteroscopy after triple uterine artery ligation with or without hemostatic multiple square suturing for the management of postpartum hemorrhage (PPH), five had abnormal findings. Endometritis was statistically significantly associated with abnormal diagnostic hysteroscopy findings. Twelve patients developed subsequent pregnancies, and four had abnormal obstetric outcomes: one placenta percreta, one placenta accreta, one recurrent postpartum hemorrhage, and one intrauterine growth retardation.

Impact of previous uterine artery embolization on fertility

To describe data on the effects of uterine artery embolization (UAE) on fertility. UAE is used to treat postpartum hemorrhage (PPH) and fibroids. This effective therapy is replacing surgery in many cases. One of the main goals of UAE is to preserve the uterus and therefore fertility (pregnancies, menses and ovarian reserve). Pregnancies after this technique have been described. The main complications encountered during these pregnancies are not only PPH but also miscarriages and cesarean deliveries after UAE for fibroids. Conflicting results varying from completely well tolerated to serious complications such as definitive negative effect on endometrium and ovary function have been reported. Nevertheless, the series differ in that they included women of different ages and used different material for vessel occlusion (definitive microparticles of varying sizes, temporary pledgets of gelatine sponge, etc.). We discuss the impact of these differences on uterus vascularization and fertility. UAE is an effective treatment for PPH and fibroids. Pregnancy is possible after UAE. Recurrent PPH is a serious and frequent complication. Synechia is also a potential complication. Desire of childbearing should be considered when choosing embolization or surgery and, in case of embolization, the choice of material used. Further studies on future fertility after UAE are needed as well as information on fertility after surgery.

Recurrent postpartum haemorrhage caused by endometrial carcinoma co‐existing with endometrioid carcinoma of the ovary in a full term pregnancy

Recurrent postpartum haemorrhage caused by endometrial carcinoma co‐existing with endometrioid carcinoma of the ovary in a full term pregnancy