Olivier Morel

Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization

The purpose of this retrospective study was to evaluate the role of transcatheter arterial embolization in the management of severe postpartum haemorrhage due to a ruptured pseudoaneurysm and to analyse the clinical symptoms that may suggest a pseudoaneurysm as a cause of postpartum haemorrhage. A retrospective search of our database disclosed seven women with severe postpartum haemorrhage in whom angiography revealed the presence of a uterine or vaginal artery pseudoaneurysm and who were treated using transcatheter arterial embolization. Clinical files were reviewed for possible clinical findings that could suggest pseudoaneurysm as a cause of bleeding. Angiography revealed extravasation of contrast material in five out of seven patients. Transcatheter arterial embolization allowed to control the bleeding in all patients and subsequently achieve vaginal suture in four patients with vaginal laceration. No complications related to transcatheter arterial embolization were noted. Only two patients had uterine atony, and inefficiency of sulprostone was observed in all patients. Transcatheter arterial embolization is an effective and secure technique for the treatment of severe postpartum haemorrhage due to uterine or vaginal artery pseudoaneurysm. Ineffectiveness of suprostone and absence of uterine atony should raise the possibility of a ruptured pseudoaneurysm.

Value of pelvic embolization in the management of severe postpartum hemorrhage due to placenta accreta, increta or percreta.

OBJECTIVES To evaluate the role, efficacy and safety of pelvic embolization in the management of severe postpartum hemorrhage in women with placenta accreta, increta or percreta. METHODS The clinical files and angiographic examinations of 12 consecutive women with placenta accreta (n=4), increta (n=2) or percreta (n=6) who were treated with pelvic embolization because of severe primary (n=10) or secondary (n=2) postpartum hemorrhage were reviewed. Before embolization, four women had complete placental conservation, four had partial placental conservation, three had an extirpative approach and one had hysterectomy after failed partial conservative approach. RESULTS In 10 women, pelvic embolization was successful and stopped the bleeding, after one (n=7) or two sessions (n=3). Emergency hysterectomy was needed in two women with persistent bleeding after embolization, both with placenta percreta and bladder involvement first treated by extirpation. One case of regressive hematoma at the puncture site was the single complication of embolization. CONCLUSIONS In women with severe postpartum hemorrhage due to placenta accreta, increta or percreta, pelvic embolization is effective for stopping the bleeding in most cases, thus allowing uterine conservation and future fertility. Further studies, however, should be done to evaluate the potential of pelvic embolization in women with placenta percreta with bladder involvement.

Postpartum hemorrhage: guidelines for clinical practice from the French ă College of Gynaecologists and Obstetricians (CNGOF) in collaboration ă with the French Society of Anesthesiology and Intensive Care (SFAR)

Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patients hemodynamic condition so allows (professional consensus).

Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP)

*The Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, UK; †The Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK; ‡Department of Obstetrics and Division of Experimental Obstetrics, Study Group Perinatal Programming, Charité Campus Virchow, Berlin, Germany; §Department of Obstetrics and Gynecology, General Faculty Hospital, Charles University, Prague, Czech Republic; ¶Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; **Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, Nancy, France; ††Fetomaternal Medical Center, Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; ‡‡Prenatal Zürich, Zürich, Switzerland; §§Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; ¶¶University of Liège, CHR de la Citadelle, Liège, Belgium *Correspondence. (e-mail: sally.collins@obs-gyn.ox.ac.uk)

Statins and Pregnancy

Cardiovascular diseases are the leading cause of mortality in industrialized countries. Treatment with statins is effective in primary prevention in patients at high cardiovascular risk. Statins are inhibitors of hydroxymethylglutarylcoenzyme A (HMG-CoA) reductase and are classed as lipid-lowering drugs. In 2010, atorvastatin was the biggest-selling drug in the world (

Conservative management of a Cesarean scar ectopic pregnancy: a case report.

US10.73 billion). Increases in the average age of pregnant women and in the prevalence of morbid obesity have inevitably led to exposure to statins in certain women during the first trimester of pregnancy. The teratogenic risk attendant upon use of statins is unclear because the available data are contradictory, but statins remain contraindicated in pregnant women.The benefits of statins in prevention of cardiovascular risk may not be solely due to their cholesterol-lowering effects: the so-called pleiotropic effects of vascular protection lead some experts to posit a potential benefit in the management of preeclampsia.In this review we evaluate the theoretical benefits and supposed risks of statins in pregnant women. After a brief overview of the pharmacodynamic properties of statins, we address the question of the teratogenic risk of statins, and then detail the rationale for the therapeutic potential of statins in preeclampsia.

Laparoscopic sentinel node biopsy in cervical cancer using a combined detection: 5-years experience.

IntroductionCesarean scar pregnancy is the rarest kind of ectopic pregnancy. The immediate prognosis depends on the risks associated with uterine rupture and massive bleeding.Case presentationA 32-year-old woman (gravida 2, para 1) presented with massive vaginal bleeding. A Cesarean scar pregnancy was diagnosed. She was treated by local methotrexate injection, followed by uterine artery embolization. Recurrence of bleeding necessitated two repeat embolizations. Hysteroscopy four months later revealed the presence of a uterine defect within the Cesarean section scar.ConclusionCesarean scar pregnancy should be diagnosed and treated as soon as possible to prevent severe complications and spare fertility.

Vascularization of the placenta and the sub-placental myometrium: feasibility and reproducibility of a three-dimensional power Doppler ultrasound quantification technique. A pilot study.

BackgroundTo evaluate the feasibility after 5 years experience of a laparoscopic sentinel node (SN) procedure with combined radioisotopic and patent blue labeling in patients with cervical cancer.MethodsSixty-seven patients (median age 48.9 years) with cervical cancer underwent a laparoscopic SN procedure using an endoscopic gamma probe, after both radioactive and patent blue injections. After the procedure, all the patients underwent complete laparoscopic pelvic/para-aortic lymphadenectomy.ResultsAt least one SN was identified in 57 patients (85.1%). According to the Stage, the SN identification rate was 91.2% in early-stage cervical cancer and 78.5% in locally advanced cervical cancer. The mean number of SN was 2.3 per patient (range 1–5). A total of 129 SNs were removed. Lymph node metastasis involvement was identified in the 20 SNs (15.5%) from 14 patients (24.6%). Nine of the 14 patients had at least one macrometastases, three patients presented micrometastases in H&S, and two patients presented isolated single cells. Six patients presented a pelvic non-SN involvement including two patients whose SNs were uninvolved. The false-negative SNs rate was 12.5% (two patients out of 16). Both patients have locally advanced cervical cancer.ConclusionThis study confirms that laparoscopic SN detection with a combination of radiocolloid and patent blue is accurate in patients with early cervical cancer to assess pelvic lymph node status.

Congenital diaphragmatic hernia: does gestational age at diagnosis matter when evaluating morbidity and mortality?

Objective. To assess the feasibility of placental and myometrial vascularization quantification using 3D power Doppler ultrasonography. Methods. 3D standardized acquisition was performed in the mid part of the utero-placental unit, once, in 38 patients undergoing normal pregnancies between 15 and 39 weeks. Vascularization parameters (VI, FI, and VFI) of placentae and myometrium were measured. Intra and inter-observer, as well as inter-acquisition reproducibility were evaluated. Results. Intra-class Correlation Coefficient of vascularization measurements were at least 0.94 for intra-observer, 0.92 for inter-observer, and 0.56 for inter-acquisition reproducibility. There was no significant difference for placental measurements for VI, FI and VFI between the second trimester and the third trimester pregnancies. Concerning the myometrium, we observed no significant difference between second and third trimester for FI. However, VI (28.090 vs. 19.374) and VFI (17.691 vs. 11.336) was significantly lower in the third trimester (p < 0.01). Conclusion. 3D quantification of placental and myometrial vascular parameters is feasible with a high intra and inter-observer reproducibility. Evaluating a potential myometrial vascular impairment appears to be as relevant as studying the placenta alone and might be of great clinical interest. We believe that this technique should therefore be evaluated in clinical observational studies.

Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: Preliminary experience

OBJECTIVE The objective of the investigation was to study the relationship between gestational age at diagnosis and mortality and morbidity in fetuses with an isolated congenital diaphragmatic hernia. STUDY DESIGN Between January 2008 and November 2013, 377 live births with isolated congenital diaphragmatic hernia diagnosed antenatally at a known gestational age were recorded in the database of the French National Center for Rare Diseases. The primary outcome studied was mortality estimated at 28 days and at 6 months. The secondary outcome was morbidity evaluated by pulmonary arterial hypertension at 48 hours, oxygen therapy dependence at 28 days, oral disorders, enteral feeding, and prosthetic patch repair. Analyses were adjusted for the main factors of congenital diaphragmatic hernia severity (side of the hernia, thoracic herniation of the liver, gestational age at birth, lung-to-head ratio, and prenatal treatment by tracheal occlusion. RESULTS Mortality rates at 28 days decreased significantly (P < .001) when gestational age at diagnosis increased: 61.1%, 39.2%, and 10.4% for a diagnosis in the first, second, and third trimester, respectively. Adjusted odds ratios were 3.12 [95% confidence interval, 1.86-5.25] and 0.35 [95% confidence interval, 0.18-0.66] for a diagnosis in the first and third trimesters, respectively, compared with a diagnosis in the second trimester. Similarly, morbidity decreased significantly when gestational age at diagnosis increased, and the trend remained significant after adjustment for the main factors of congenital diaphragmatic hernia severity (P < .001). CONCLUSION Gestational age at diagnosis is an independent predictor of postnatal prognosis for children presenting an isolated congenital diaphragmatic hernia and should be taken into account when estimating postnatal morbidity and mortality.