WHO recommendation on the use of uterine artery embolization for the treatment of postpartum haemorrhage

WHO recommendation on the use of uterine artery embolization for the treatment of postpartum haemorrhage

 

Recommendation

If other measures have failed and if the necessary resources are available, the use of uterine artery embolization is recommended as a treatment for postpartum haemorrhage due to uterine atony.

(Weak recommendation, very-low-quality evidence)

 

Publication history

First published: September 2012

Updated: No update planned

Assessed as up-to-date: September 2012

 

Remarks

  • The GDG noted that the use of manoeuvres and other procedures requires training and that maternal discomfort and complications associated with these procedures have been reported.
  • The GDG noted that uterine artery embolization requires significant resources, in terms of the cost of the treatment, the facilities, and the training of health care workers.

 

Background

Postpartum haemorrhage (PPH) is defined as blood loss of 500ml or more within 24 hours after birth. PPH is the primary cause of nearly one-fifth of all maternal deaths globally. Most of these deaths occur during the first 24 hours after birth. The majority could be prevented through the use of prophylactic uterotonics during the third stage of labour, and by timely and appropriate management.

Uterine artery embolization involves the use of percutaneous transcatheterization, in order to complete occlude both uterine arteries with particulate emboli and ultimately reduce pelvic bleeding. 

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, based on the GRADE approach (1, 2) Outcomes used for this recommendation were the prioritized outcomes from the WHO recommendations on prevention and treatment of postpartum haemorrhage (2012).(3)

No randomised controlled trials (RCTs) have examined the use of percutaneous transcatheter arterial embolization for the treatment of PPH. Evidence from case series and case reports was evaluated. (4-26) Data on relevant outcomes and comparisons were extracted.

WHO convened a Guideline Development Group (GDG) meeting in March 2012. This group of independent experts used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences, magnitude of effect, balance of benefits versus disadvantages, resource usage, and feasibility, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • For women with postpartum haemorrhage (P), does uterine artery embolization (I) compared to placebo or no treatment (C) improve outcomes (O)?

 

Evidence summary

No RCTs have examined the use of percutaneous transcatheter arterial embolization for the treatment of PPH. However, institutions equipped with adequate radiological facilities have reported using this intervention for the treatment of PPH.

Twenty-nine case series and 24 case reports have been published (>600 women) and studies report success rates (indicating that there was no use of hysterectomy or other invasive procedures) ranging from 82 % to 100 %.

Further information on evidence supporting this recommendation are available here.

 

 

Implementation considerations

  • The successful introduction of evidence-based policies related to the prevention and management of PPH into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

 

Related links

WHO recommendations on prevention and treatment of postpartum haemorrhage (2012) - full documentand evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

 

Related resources

VIDEO: Active management of third stage of labour

Education material for teachers of midwifery. Managing postpartum haemorrhage.

 

Research implications

The GDG did not identify any research priorities related to this recommendation.

 

References

  1. WHO Handbook for Guideline Development (second edition). Geneva: World Health Organization; 2014.
  2. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-6. Epub 2011/01/05. doi: 10.1016/j.jclinepi.2010.07.015. PubMed PMID: 21208779.
  3. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization, 2012.
  4. Horng HC, Hu WM, Tseng HS, Chang WH, Chao KC, Yang MJ. Uterine arterial embolization in the management of severe post-partum hemorrhage: a successful rescue method to avoid peripartum hysterectomy. J Chin Med Assoc. Jun;74(6):255-8.
  5. Sheikh L, Najmi N, Khalid U, Saleem T. Evaluation of compliance and outcomes of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in Pakistan. BMC Pregnancy Childbirth.11:28.
  6. Chen YT, Xu LF, Sun HL, Li HQ, Hu RM, Tan QY. Clinical efficacy and safety of uterine artery chemoembolization in abnormal placental implantation complicated with postpartum hemorrhage. Zhonghua Fu Chan Ke Za Zhi. Apr;45(4):273-7.
  7. Sidhu HK, Prasad G, Jain V, Kalra J, Gupta V, Khandelwal N. Pelvic artery embolization in the management of obstetric hemorrhage. Acta Obstet Gynecol Scand. Aug;89(8):1096-9.
  8. Ganguli S, Stecker MS, Pyne D, Baum RA, Fan CM. Uterine artery embolization in the treatment of postpartum uterine hemorrhage. J Vasc Interv Radiol. Feb;22(2):169-76.
  9. Lee JS, Shepherd SM. Endovascular treatment of postpartum hemorrhage. Clin Obstet Gynecol. Mar;53(1):209-18.
  10. Sentilhes L, Gromez A, Marpeau L. Fertility after pelvic arterial embolization, stepwise uterine devascularization, hypogastric artery ligation, and B-Lynch suture to control postpartum hemorrhage. Int J Gynaecol Obstet. Mar;108(3):249.
  11. Zwart JJ, Dijk PD, van Roosmalen J. Peripartum hysterectomy and arterial embolization for major obstetric hemorrhage: a 2-year nationwide cohort study in the Netherlands. Am J Obstet Gynecol. Feb;202(2):150 e1-7.
  12. Kirby JM, Kachura JR, Rajan DK, Sniderman KW, Simons ME, Windrim RC, et al. Arterial embolization for primary postpartum hemorrhage. J Vasc Interv Radiol. 2009 Aug;20(8):1036-45.
  13. Uchil D. Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. BJOG. 2009 Aug;116(9):1275; author reply 6.
  14. Wi JY, Kim HC, Chung JW, Jun JK, Jae HJ, Park JH. Importance of angiographic visualization of round ligament arteries in women evaluated for intractable vaginal bleeding after uterine artery embolization. J Vasc Interv Radiol. 2009 Aug;20(8):1031-5.
  15. Wang MQ, Liu FY, Duan F, Wang ZJ, Song P, Song L. Ovarian artery embolization supplementing hypogastric-uterine artery embolization for control of severe postpartum hemorrhage: report of eight cases. J Vasc Interv Radiol. 2009 Jul;20(7):971-6.
  16. Guasch E, Alsina E, Diez J, Ruiz R, Gilsanz F. Postpartum hemorrhage: an observational study of 21,726 deliveries in 28 months. Rev Esp Anestesiol Reanim. 2009 Mar;56(3):139-46.
  17. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage. Obstet Gynecol. 2009 May;113(5):992-9.
  18. Shah M, Wright JD. Surgical intervention in the management of postpartum hemorrhage. Semin Perinatol. 2009 Apr;33(2):109-15.
  19. Touboul C, Badiou W, Saada J, Pelage JP, Payen D, Vicaut E, et al. Efficacy of selective arterial embolisation for the treatment of life-threatening post-partum haemorrhage in a large population. PLoS One. 2008;3(11):e3819.
  20. Irion O, Terraz S, Boulvain M, Boehlen F, Becker CD. Postpartum hemmorhage: prevention and treatment by arterial embolization and activated recombinant factor VII. Rev Med Suisse. 2008 Oct 22;4(176):2269-70, 72, 74-5.
  21. Ratnam LA, Gibson M, Sandhu C, Torrie P, Chandraharan E, Belli AM. Transcatheter pelvic arterial embolisation for control of obstetric and gynaecological haemorrhage. J Obstet Gynaecol. 2008 Aug;28(6):573-9.
  22. Winograd RH. Uterine artery embolization for postpartum hemorrhage. Best Pract Res Clin Obstet Gynaecol. 2008 Dec;22(6):1119-32.
  23. Pelage JP, Limot O. Current indications for uterine artery embolization to treat postpartum hemorrhage. Gynecol Obstet Fertil. 2008 Jul-Aug;36(7-8):714-20.
  24. Uchiyama D, Koganemaru M, Abe T, Hori D, Hayabuchi N. Arterial catheterization and embolization for management of emergent or anticipated massive obstetrical hemorrhage. Radiat Med. 2008 May;26(4):188-97.
  25. Moore M, Morales JP, Sabharwal T, Oteng-Ntim E, O'Sullivan G. Selective arterial embolisation: a first line measure for obstetric haemorrhage? Int J Obstet Anesth. 2008 Jan;17(1):70-3.
  26. Eisele G, Simonelli D, Galli E, Alvarado A, Malvino E, Martinez M. Angiographic findings and results of uterine artery embolization in severe postpartum hemorrhage: arteriography and embolization of postpartum hemorrhage. Rev argent radiol. 2007;71(4):395-400.

 

Citation: WHO Reproductive Health Library. WHO recommendation on the use of uterine artery embolization for the treatment of postpartum haemorrhage (September 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.