| | Uterine artery embolization for postpartum hemorrhage published online 29 August 2008. A new angiographic approach for the treatment of postpartum hemorrhage has emerged over the last 30 years. Uterine arterial embolization under fluoroscopic guidance is effective but requires that experienced personnel and facilities for interventional vascular radiology are available at the hospital or close by. Interventional radiology can be used as an elective, prophylactic measure in a known or suspected case of placenta accreta for which extirpative management is planned. There are no randomized controlled trials, but several systematic reviews have reported high rates of success in hemostatic control of the pelvis. Embolization was also effective when utilized early as an adjunct in the conservative treatment of placenta accreta, leaving the entire placenta or just the adherent portion in situ as an alternative to radical management. In patients who are hemorrhaging, the initial intervention is resuscitation and stabilization. After vaginal delivery, massage, uterotonic drugs, cavity and soft tissue examination, bimanual compression, and tamponade of the uterus should be tried first. Arterial embolization can be performed before laparotomy if the woman is stable; it can also be performed during a cesarean section procedure, after compressive sutures, and if stepwise uterine devascularization fails. Introduction  Fourteen million cases of postpartum hemorrhage (PPH) occur worldwide each year, with a case-fatality rate of 1%; this is a total of 140,000 women, (one every 4 minutes).1 Severe bleeding is the single most significant global cause of maternal death, and more than half of all deaths occur within 24 hours of delivery. In addition to death, PPH can be followed by serious morbidity. Sequelae include adult respiratory distress syndrome, coagulopathy, shock, hysterectomy, and pituitary necrosis (Sheehan syndrome).2 The 2004 report of Confidential Enquiry into Maternal and Child Health (CEMACH), which is published every 3 years by the Royal College of Obstetricians and Gynaecologists, reported 17 direct deaths in the UK from hemorrhage (3 from placental abruption, 4 from placenta previa, and 10 from postpartum hemorrhage), amounting to 8.5 deaths per million maternities.3 In this triennium (2003–2005), 14 women died from hemorrhage; a rate of 0.66 per 100,000 maternities, similar to the rate for the previous triennium. Ten of the 17 women who died, i.e. almost three-fifths, received less than optimal care. In particular, there were questions concerning the most appropriate management of women with placenta percreta, a problem likely to become more prevalent because of its emerging relationship with previous caesarean section scars.4 Peripartum hysterectomy is usually carried out in the context of life-threatening obstetric hemorrhage and can therefore be regarded as a “near-miss” event for maternal mortality from hemorrhage.During the 13 months of the United Kingdom Obstetric Surveillance System (UKOSS) study5, 315 women were reported to have had a peripartum hysterectomy to control hemorrhage, a rate of 41.0 per 100,000 maternities, with a 95% confidence interval (CI) from 36.6 to 45.8 per 100,000 maternities. This suggests that more than 60 women undergo a peripartum hysterectomy for each woman who dies from hemorrhage. Of women requiring hysterectomy, 53% were reported to have uterine atony and 38% had a morbidly adherent placenta: one of placenta accreta, percreta, or increta. The management of these women was variable.5 The Scottish Confidential Audit of Severe Maternal Morbidity has identified major hemorrhage as the most common cause of severe morbidity in the pregnant population of Scotland, with a rate of 4.5 per 1000 births. The incidence of major hemorrhage seems to be rising year on year.6 In Denmark between 1995 and 2002, 152 patients had a hysterectomy due to bleeding (0.23 per 1000 deliveries). Two patients died and 16 required reoperation. There was a significantly increased incidence of peripartum hysterectomy following cesarean section compared to the incidence following vaginal delivery [P <0001, relative risk (RR) 11.1, CI 7.9–15.6].7 Postpartum hemorrhage is generally classified as primary or secondary, with primary hemorrhage occurring within the first 24 hours of delivery and secondary hemorrhage between 24 hours and 6–12 weeks postpartum. There is no single, satisfactory definition of PPH. An estimated blood loss in excess of 500mL following a vaginal birth or a loss of greater than 1000mL following cesarean birth is often used for the diagnosis, but the average volume of blood lost at delivery can approach these amounts.8 Estimates of blood loss at delivery are notoriously inaccurate, with significant underreporting being the rule.9 Major obstetric hemorrhage can be defined as an estimated blood loss of more than 2500mL, or more than five units of blood transfused, or treatment for coagulopathy. However, as a general rule, additional resources should be mobilized as soon as blood loss exceeds 1500mL.10 Table 1 identifies the symptoms related to the different degrees of blood loss in PPH.11 | | |  | Percentage blood loss (mL) | Blood pressure (mmHg) | Signs and symptoms | |
|---|
| 10 to 15 (500 to 1000) | Normal | Palpitations, dizziness, tachycardia | | | 15 to 25 (1000 to 1500) | Slightly low | Weakness, sweating, tachycardia | | | 25 to 35 (1500 to 2000) | 70 to 80 | Restlessness, pallor, oliguria | | | 35 to 45 (200 to 3000) | 50 to 70 | Collapse, air hunger, anuria | | | | |
Risk factors A study including 154,311 deliveries compared 666 cases of PPH to controls without hemorrhage.12 Factors significantly associated with hemorrhage, in decreasing order of frequency, were: •Retained placenta: odds ratio (OR) 3.5, 95% CI 2.1–5.8. •Failure to progress during the second stage of labor: OR 3.4, 95% CI 2.4–4.7. •Placenta accreta: OR 3.3, 95% CI 1.7–6.4. •Lacerations: OR 2.4, 95% CI 2.0–2.8. •Instrumental delivery: OR 2.3, 95% CI 1.6–3.4. •Large-for-gestational age newborn, e.g. >4000g: OR 1.9, 95% CI 1.6–2.4. •Hypertensive disorders: OR 1.7, 95% CI 1.2–2.1. •Induction of labor: OR 1.4, 95% CI 1.1–1.7. •Augmentation of labor with oxytocin: OR 1.4, 95% CI 1.2–1.7. In addition to the risk factors cited above, placenta previa, history of previous PPH, obesity, high parity, Asian or Hispanic race, precipitous labor, and preeclampsia have been associated with PPH. However, only a small proportion of women with any risk factors for PPH develop the disorder, and many women without risk factors experience hemorrhage after delivery. Thus, knowledge of risk factors is not very useful clinically.12, 13, 14 When should interventional radiology be considered? The new angiographic approach to the treatment of postpartum hemorrhage has emerged over the last 30 years. In appropriate circumstances, pelvic arterial embolization provides some advantages in the management of PPH hemorrhage. In addition to providing a high technical success rate, compared to other options this angiographic approach also offers a greater likelihood of preserving fertility. The technique was first described by Brown and colleagues in 1979, and again by Pais and colleagues in 1980. To this day, the embolization technique has remained largely unchanged from these initial reports.15, 16 The procedure is performed by an interventional radiologist in the angiographic suite. Fluoroscopic guidance is used to catheterize the anterior division of internal iliac arteries with angiographic catheters, and embolization is subsequently performed (Figure 1, Figure 2). Subselective embolization of the uterine or vaginal arteries is performed whenever possible as each of these has been separately reported as the most common source of bleeding. If the exact source of bleeding cannot be identified, as sometimes occurs, empiric embolization of the anterior division of the internal iliac arteries is performed with pledgets of gelatin sponge or gelatin sponge slurry. A gelatin sponge is the agent of choice because it causes a temporary arterial occlusion with recanalization of blood flow within weeks (Figure 3). For similar reasons, bilateral embolization is often performed because bleeding can continue through transpelvic vascular supply after unilateral embolization. No prospective studies comparing unilateral and bilateral embolization are available, but bilateral embolization is typically performed.*17, 18, 19 The use of microparticles (50–1000 microns) and non-reasorbable materials has been associated with ischemia and uterine necrosis.20, 21 Practice points•Embolization is effective in PPH. •A lot of single-case studies and short series have been reported, as well as a few case-control studies and several systematic reviews. However, no randomized controlled trials have been identified. •Arterial embolization can be performed if there are no maternal hemodynamic disorders. This should take place in an interventional vascular radiology unit in hospital or at a facility close by. A senior interventional radiologist with experience in pelvic circulation should be “on call”. Recently, a good practice guidance was produced as a joint document on behalf of the Professional Standards Committee of the Royal College of Obstetricians and Gynaecologists, the Interventional Radiology Sub-Committee of the Royal College of Radiologists, and the Education Committee of the British Society of Interventional Radiology.22 The purpose of this guidance is to urge all obstetric units to consider early or prophylactic interventional radiology as an important tool in the prevention and management of PPH. Hospitals with an interventional radiology service are encouraged to draw up treatment algorithms that clearly identify the timing and place of interventional radiology in the management of PPH. This might seem predictable where there is known placenta accreta or placenta praevia (elective and prophylactic intervention). However, the majority of PPH is unpredictable and is typically secondary to atonic uterus (emergency intervention). Elective and prophylactic intervention Placental adherence abnormalities are obstetric pathologies the incidence of which has increased significantly in recent years.23 The antenatal diagnosis of placenta accreta is best made using a two-stage diagnostic algorithm that includes ultrasound screening for patients at high risk for placenta accreta and magnetic resonance imaging (MRI) for inconclusive ultrasound features. In a recent report of 453 women with placenta previa, the sensitivity/specificity of ultrasound was 0.77/0.96 and of MRI was 0.88/1.0 for the diagnosis of placenta accreta.24 Miller and colleagues quantified the amount of blood loss during cesarean hysterectomy associated with placenta accreta in a group of 62 patients.25 Estimated blood loss exceeded 2000mL in 41 patients, 5000mL in 9 patients, 10,000mL in 4 patients, and 20,000mL in 2 patients. Practice points•Women with a placenta previa and a prior cesarean section are at high risk for placenta accreta. If there is imaging evidence of pathological adherence of the placenta, delivery should be planned in an appropriate setting with adequate resources (II-2B).26 •Interventional radiology can be used as an elective and prophylactic measure where there is a known or suspected case of placenta accreta, such as placenta previa on a previous caesarean section scar, or placenta accreta diagnosed by scan/color Doppler or MRI. Temporary occlusion of both internal iliac arteries with angioplasty balloons or compliant occlusion balloons can be done after initial catheterization via the femoral approach. This portion of the procedure is performed in the angiographic suite before delivery and the balloons are left deflated. Then, while the patient is in the operating room, the balloons are inflated to occlude the blood flow once the fetus is born. Embolization with a suitable embolic material (such as an absorbable gelatine preparation) can be performed via the balloon catheters if bleeding continues despite inflation.*27, 28 At the author's tertiary care center (C. Argerich. Htal, Buenos Aires, Argentina), we performed a multidisciplinary study that included 50 consecutive patients. They presented a presumptive diagnosis of placental adherence abnormalities both clinically and by means of complementary methods (ultrasonography, Doppler velocimetry, and MNR).The kind of surgery was determined intraoperatively. Hemostatic control of the pelvis was obtained by prophylactic transcatheter embolization of the uterine arteries in 20 cases, infrarenal aortic clamping in another 20, and stepwise ligatures in the remaining 10. No previous randomization was performed; instead, the hemostatic method was chosen depending on technical availability, and on the clinical and surgical circumstances. Neither higher morbidity rates nor maternal deaths occurred despite the hemostatic control used. We were able to preserve the uterus in 7 patients with small focal accretas.29 A review by Greenberg et al of the vascular and obstetrical literature reveals divergent recommendations for the use of balloon catheters in patients with abnormal placentation.30 No guidance from rigorous prospective evidence is available, and thus Greenberg and colleagues offer recommendations for the cautious use of this modality. They report a case of a 27-year-old woman with placenta percreta with preemptive bilateral internal iliac artery balloons in whom iliac artery thrombosis and acute limb ischemia developed 7hours after cesarean hysterectomy.30 Dubois et al described the successful prophylaxis of two patients with placenta percreta using 8.5-mm occluding balloon catheters placed in the anterior divisions of both internal iliac arteries.27 They inflated the catheters only after the cesarean section and subsequently performed transcatheter Gelfoam (Pfizer, New York City, USA) embolization. There was no control group in this study and embolization was performed regardless of the response to balloon occlusion. Dubois et al reported that the technique significantly reduced intraoperative blood loss.27 Recently, Bodner et al reported another cohort study of six patients who received temporary balloon occlusion of the bilateral internal iliac arteries (anterior divisions), followed by transcatheter embolization.31 All arterial sheaths and catheters were connected to saline flushes and were removed immediately after operation. A comparison group of 22 patients with similar pathology underwent cesarean hysterectomy without endovascular intervention and no difference in blood loss was found (2.8 L catheter group vs. 2.6 L control group, P=.4), nor was there a need for blood transfusion. All but one patient treated with balloon occlusion required hysterectomy. No catheter-related complications were reported.31 Prophylactic intravascular balloon catheters did not benefit women in a case-control study of 69 subjects who had cesarean hysterectomy performed for placenta accreta; 19 subjects had balloon catheters plus hysterectomy and 50 subjects had hysterectomy alone. No significant differences were noted in estimated blood loss (P=.79), transfused blood products (P=.60), operative time (P=.85), and postoperative days in hospital (P=.85). Three of the 19 subjects who received balloon catheters (15.8%) had complications from catheter placement; two required stent placement and/or arterial bypass.32 Practice points•Interventional radiology as an elective and prophylactic measure for hemostatic control of the pelvis is an option if the woman is hemodynamically stable and personnel and facilities are available. Ideally, this technique should be subject to prospective, randomized analysis. •If used, intense vascular surveillance is mandatory, and catheters and sheaths should be removed at first opportunity. Timmermans et al reviewed all the articles on conservative management of abnormally invasive placentation published between 1985 and 2006.34 Over the past 20 years, 48 reports have described outcomes of 60 women who were treated conservatively for abnormally invasive placentation. In 12 reported cases, selective arterial embolization was utilized as an adjunct in the conservative management of abnormally invasive placentation. This approach was successful in one-quarter of these cases; in the other three-quarters, significant vaginal bleeding or disseminated intravascular coagulation (DIC) developed.33 In a retrospective study, Bretelle et al reviewed 50 cases of placenta accreta diagnosed between 1993 and 2003.35 Two treatments were available for placenta accreta management: a conservative approach (i.e. placenta “not removed from uterus”) and a standard surgical treatment that consisted of either a surgical non-conservative approach with a primary total hysterectomy or resection and extraction of the placenta (extirpative approach). Of the 50 cases, 24 patients (48%) were managed by the standard approach and 26 patients (52%) underwent conservative treatment. The overall rate of hysterectomy in the placenta accreta population was 58%; in the population treated conservatively this rate was reduced to 19.3%. Nevertheless, conservative treatment failed in five cases and resulted in hysterectomy. Two of the five cases were directly related to complications of the embolization procedure.34 Sergent et al searched – in English and French – the electronic sources PubMed, MEDLINE.35 For uterine atony, the success rate of arterial embolization and uterine artery ligations is close to 100%.With placenta accreta, the accreta portion of the placenta can be left in place and arterial embolization or vascular ligations can be done. Nevertheless, the main cause of failure with conservative treatments is placenta accreta.35 Kayem et al retrospectively reviewed the medical records of 33 patients diagnosed with placenta accreta.36 Two consecutive periods, A and B, were compared. During period A (January 1993 to June 1997), the written protocol called for the systematic manual removal of the placenta, to leave the uterine cavity empty. In period B (July 1997 to December 2002), they changed the policy by leaving the placenta in situ. Comparison of the two periods shows fewer cases of hysterectomy, transfusion, and DIC during period B than during period A. The hysterectomy rate decreased between 1993 and 2002, although the number of cases of placenta accreta was higher during period B. One uterine artery embolization and one hypogastric artery ligation were performed during period A, and one hypogastric artery ligation and one uterine artery embolization during period B (P=.43).36 A recent report by the same group, added 18 patients receiving a conservative approach, as this appears to be a safe alternative to radical management.37 Ornan et al performed a chart review and telephone interviews of 28 consecutive patients who underwent pelvic embolization for PPH between the years 1977 and 2002 to study the effect on fertility and menses.38 The average time to follow-up was 11.7 years. Six patients reported a total of six uncomplicated pregnancies and deliveries in the years after their embolization. Of the remaining patients interviewed, none made subsequent attempts to become pregnant. Stancato-Pasik et al reported the long-term effects (follow-up range 1–6 years) of selective embolotherapy on menses and subsequent pregnancy in 12 women treated for both antepartum and PPH.40 Normal menses resumed in all but one, and all three patients who desired a subsequent child were able to conceive and deliver full-term, healthy infants.39 Pelage et al evaluated 35 patients treated with uterine artery embolization for PPH, and normal menses resumed in all women but two, who underwent hysterectomy.40 One woman became pregnant during the 4-year follow-up period, but the outcome was not stated. Another study by the same group evaluated 14 women treated with embolization for secondary PPH, and, again, normal menses resumed in all women.41 However, there have been reports suggesting problems associated with subsequent pregnancies in women treated with pelvic embolization for PPH. Cordonnier et al reported fetal growth retardation in a case in which a patient conceived 17 months after being embolized for PPH with gelatin sponge pledgets.42 Practice points•The primary idea of conservative management is to leave the entire placenta or just the part that is adherent to the myometrium in situ to preserve the uterus. •Conservative management should be considered only in highly selected cases in whom blood loss is minimal and there is desire for fertility preservation. Whether adjuvant methotrexate or selective arterial embolization is beneficial is uncertain. •Pelvic arterial embolization with gelatin sponge pledgets is safe, effective, and has no long-term negative effects on menstruation or fertility. Emergency intervention Resuscitation and stabilization are the initial focus of intervention in patients who are hemorrhaging: •Get help: Every hospital should have a major obstetric hemorrhage protocol. •Monitor the patient: ECG, non-invasive blood pressure, pulse oximetry, and hourly urine volumes are mandatory. •Initiate resuscitation:•Oxygen: 10 liters per minute. •Intravenous access: two 14-G cannulae. •Fluid: ensure fluids are warm and use high-pressure infusing devices if appropriate. •Crystalloid: up to 2 liters. •Colloid (not dextrans): up to 1.5 liters.43 •Recent experience has shown that, as the initial response to massive obstetric hemorrhage, we should consider infusing fresh-frozen plasma (FFP) at a ratio of 1:1 or 1:2 with transfusion of units of red blood cells (RBCs).44 As the case progresses, administer blood products to achieve specific targets: Patients with PPH after vaginal delivery should have any lacerations repaired and the uterus massaged. Ensure that there are no retained products or clots within the uterus and that the bladder is empty. Atony should be treated medically with uterotonic drugs: oxytocin (10–40 U via intravenous infusion); then methergine (0.2mg intramuscularly every 2–4 hours) if not hypertensive, and then carboprost (250μg intramuscularly every 15–90 minutes, as needed, to a total dose of 2mg) if no asthma. Misoprostol (800–1000μg rectally) can be given to women with hypertension or asthma, and to those who fail other therapies (Box 1).45 Box1 Sequential steps in managing bleeding from uterine atony After vaginal birth•Uterine massage •Uterotonic drugs •Inspect the vagina and cervix for lacerations •Ensure that there are no retained products or clots within the uterus •Bimanual uterine compression •Uterine tamponade •Arterial embolization if the woman is hemodynamically stable and personnel and facilities are available If treatment fails or during the cesarean section procedure•Compressive uterine sutures •Stepwise uterine devascularization •Hysterectomy or arterial embolization if the woman is hemodynamically stable and personnel and facilities are available •Temporary clamping of the abdominal aorta •Pelvic packing •Recombinant activated factor VIIa in non-responders Uterine tamponade (gauze packing, Foley, Sengstaken--Blakemore tube, Bakri balloon) should be considered if medical therapy and bimanual uterine compression fail, and prior to or in conjunction with preparations for surgery.46, 47, 48, 49 Arterial embolization can be performed before laparotomy if the woman is hemodynamically stable, if facilities for interventional vascular radiology are available at the hospital, and if an interventional radiologist with experience in pelvic circulation is “on call”. For persistent uterine atony, the success rate of emergency arterial embolization varies from 70 to 100%.50, 51, 52, 53, 54 If medical management fails, surgical approaches that are quick, relatively easy, and effective should be tried first. If the patient is stable and bimanual compression of the uterus successfully arrests the bleeding, then compression sutures might be of value. Various modifications have been reported to the original B-Lynch suture technique. The easy application of such sutures is a major advantage, and fertility is preserved. The obvious disadvantages are the need for laparotomy.55, 56, 57 When utilizing these measures, the surgeon should be cognizant of the amount of blood loss and the stability of the patient, and should perform hysterectomy rather than resort to temporizing measures if the patient's cardiovascular status is unstable or if it appears that the anesthesiologist will not be able to keep up with the patient's fluid needs. However, there is generally time for progressive, step-wise devascularization, whereby uterine, tubal branches of the ovarian and finally internal iliac arteries are ligated.58 Significant coagulopathy should be corrected quickly by replacing plasma components; and RBC should be transfused to maintain tissue oxygenation.59, 60, 61 A new large case series describes the use of recombinant activated factor VII (rFVIIa) for the treatment and secondary prophylaxis of severe primary postpartum hemorrhage.62 A recent American College of Obstetricians and Gynecologists (ACOG) practice bulletin suggests that tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony, and that procedures such as uterine artery ligation or B-Lynch suture can be used to obviate the need for hysterectomy.8 Arterial embolization might be suitable in patients with stable vital signs and persistent bleeding, especially if the rate of loss is not excessive. Furthermore, it is suggested that if hysterectomy is performed for uterine atony, there should be documentation of other therapy attempts.8 In the UK, recent reports recommended that obstetricians must consider all available interventions to stop hemorrhage, including B-Lynch suture, embolization of uterine arteries, or radical surgery. In addition, recommendations have been made that all hospitals with delivery units should aim to provide an emergency interventional radiology service as these have the potential to save lives of patients with catastrophic PPH.3, 63 Doumouchtsis et al performed a systematic review to identify all studies evaluating the success rates of treatment of major PPH by uterine balloon tamponade, uterine compression sutures, pelvic devascularization, and arterial embolization.64 As the search identified no randomized controlled trials, they shifted their focus to observational studies (396 publications) and, after exclusions, 46 studies were included in the systematic review. The cumulative outcomes showed success rates of 90.7% (95% CI 85.7–94.0) for arterial embolization, 84.0% (95% CI 77.5–88.8) for balloon tamponade, 91.7% (95% CI 84.9–95.5) for uterine compression sutures, and 84.6% (81.2–87.5) for iliac artery ligation or uterine devascularization (P=.06). At present, there is no evidence to suggest that any one method is better for the management of severe PPH.64 Summary An increasing amount of evidence supports the use of interventional radiology, which can be used electively in cases of placenta previa/accreta in which large blood loss is anticipated or in the emergency situation, typically secondary to atonic uterus. Although a lot of single-case studies and short series have been reported, as well as some case-control studies and several systematic reviews, no randomized controlled trials have been identified. There are difficulties with the transfer of unstable patients and not all centers have access to an interventional radiology unit or a senior radiologist. Interventional radiology as an elective and prophylactic measure for hemostatic control of the pelvis is an option if hysterectomy is planned. Ideally, it should be subject to prospective, randomized analysis. If used, intense vascular surveillance is mandatory and catheters and sheaths should be removed at the first opportunity. The primary idea of conservative management is to leave the entire placenta or just the part that is adherent to the myometrium in situ to preserve the uterus. Conservative management should be considered only in highly selective cases when blood loss is minimal and there is desire for fertility preservation. It is not clear whether adjuvant methotrexate or selective arterial embolization is beneficial. Occlusion of the distal uterine artery bed with absorbable gelatine preparations lasts for about 4 weeks, whereupon it recanalizes, thus preserving fertility and reproductive potential if conservative treatment is possible. Resuscitation and stabilization are the initial focus of intervention in patients who are hemorrhaging after a vaginal birth. If temporizing measures are ineffective, arterial embolization can be performed before laparotomy if the woman is hemodynamically stable and facilities for interventional vascular radiology are available or close by. If failure of management occurs during cesarean section, compressive sutures, and stepwise devascularization, which are quick, relatively easy, and effective, should be tried first. For persistent uterine atony, the success rate of emergency arterial embolization varies from 70–100%. Research agenda•Elective and prophylactic embolization should ideally be submitted to prospective, randomized analysis. •Research is needed into how to minimize vascular complications. •More experience with early embolization for conservative approach in placenta accreta is necessary. •The timing and place of emergency embolization after vaginal delivery and cesarean section requires investigation. Acknowledgements Thanks to Dr B.R. Löwenstein for his contribution in the preparation of the paper. References *1. 1.WHO . Maternal mortality in 2000. Estimates developed by WHO, UNICEF, and UNFPA. Geneva: Department of Reproductive Health and Research, World Health Organization; 2004;. 2. 2AbouZahr C. Global burden of maternal death and disability. Br Med Bull. 2003;67:1–11. MEDLINE |
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*22. 22. Royal College of Obstetricians and Gynaecologists (RCOG) . The role of emergency and elective interventional radiology in postpartum haemorrhage. www.rcog.org.uk/good practicejune 2007;. 23. 23Wu S, Kocherginski M, Hibbard J. Abnormal placentation:twenty-yearanalysis. Am J Obst Gynecol. 2005;192:1458–1461. 24. 24Warshak CR, Eskander R, Hull AD, et al. Accuracy of ultrasnonography and magnetic resonancy imaging in the diagnosis of placenta accreta. Obstet Gynecol. 2006;108:573–581. MEDLINE 25. 25Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placentaaccreta. Am J Obstet Gynecol. 1997;177(1):210–214. Abstract | Full Text |
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26. 26Diagnosis and Management of Placenta Previa SOGC Clinical Practice Guideline No. 189, March 2007. *27. 27.Dubois J, Garel L, Grignon A, et al. Placenta percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses. Am J Obstet Gynecol. 1997;176(3):723–726. Abstract | Full Text |
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