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For release Tuesday, March 28

UTERUS-SPARING PROCEDURE CAN SAVE LIVES, PRESERVE FERTILITY AFTER POSTPARTUM BLEEDING

SAN DIEGO -- Worries about labor pains and the baby's health dominate pregnant women's concerns, yet 1 in 20 will bleed excessively after giving birth and 1 in 200 will be told they must undergo emergency hysterectomy, or risk bleeding to death. But now there's a new twist to a proven non- surgical, uterus-sparing alternative that stops the bleeding in its tracks.

An interventional radiologist inflates a balloon in the uterine artery (balloon occlusion) to immediately stop the bleeding, then temporarily plugs up the artery (embolization) that is the source of the hemorrhage. Research on the procedure is being presented at the 25th Annual Scientific Meeting of the Society of Cardiovascular & Interventional Radiology (SCVIR).

"I get Christmas cards from some of my patients, many of whom plan to have more children and are thrilled that they were able to avoid a hysterectomy," said Mahmood K. Razavi, M.D., assistant professor of radiology, division of cardiovascular and interventional radiology, Stanford University Medical Center, Stanford, Calif. "With this procedure, even women with very brisk bleeding can be helped. Women should discuss the procedure with their doctors before delivery so there is awareness of this option."

Postpartum hemorrhage can occur after vaginal birth or Cesarean section. At least 1 in 20 women bleed excessively after childbirth, and although most are treated successfully with conservative measures such as medication, about 10 percent have a hysterectomy or another major surgical procedure to save their lives. Embolization is not always offered because many obstetricians are unaware of the option.

To perform the procedure, the interventional radiologist makes a tiny incision in the patient's groin and guides a catheter, or small tube, to the uterine artery using a moving X-ray (fluoroscopy) to monitor progress. A tiny balloon is inflated in the uterine artery to stop the bleeding immediately. Microscopic plastic particles the size of grains of sand then are released into the catheter, where they travel to the uterine artery to temporarily obstruct it and stop the bleeding. Embolization to stop postpartum bleeding has been performed successfully for 20 years, while using a balloon to stop the bleeding more quickly is a new step.

In the Stanford study, 9 of 11 women (82 percent) avoided hysterectomy. Of those women whose bleeding was stopped and who avoided hysterectomy, 7 (64 percent) had balloon therapy followed by embolization and 2 (18 percent) had the balloon therapy alone. Hysterectomy was performed on 2 patients (18 percent) who did not have balloons placed, and whose bleeding continued despite embolization.

Published research on hundreds of patients who have been treated with embolization demonstrates the technique is more than 80 percent effective in stopping postpartum hemorrhage and preserving the uterus. Adding balloon occlusion to the technique stops the bleeding even more quickly, increasing the likelihood of sparing the uterus.

Postpartum bleeding typically is caused by one of several factors, including: a uterus that becomes limp after delivery; placenta previa, in which the placenta covers the cervix; and placenta accreta, in which the placenta grows into the uterine muscle. Some conditions can be diagnosed well before delivery, and an interventional radiologist can be on call to perform the procedure. In the Stanford study, the 4 patients with placenta problems had balloons placed before C-section was performed, which prevented excessive bleeding and saved them from having hysterectomies.

An advantage to the interventional procedure is reduced loss of blood. The more blood lost, the higher the risk of complications, lengthy hospital stays and transfusion. The patient also is prone to complications, such as continuation of bleeding and infection. In the 2 patients who had balloons placed before C-section and whose uteri were saved, blood loss averaged 2,000 cc (about half the blood in the human body), vs. an average of 3,000 cc blood loss (about three- quarters of the blood in the human body) for the others in whom the procedure was successful and 4,200 cc (total volume of blood in the human body) for the patients who proceeded to hysterectomy. Lost blood is replaced by transfused blood and fluids given intravenously.

"Typically, hysterectomy in the setting of post partum bleeding is said to be the second bloodiest procedure after cardiac surgery, so I'm sure the blood loss is far less with embolization," said Dr. Razavi.

Besides hysterectomy, another surgical procedure is sometimes used to treat postpartum bleeding. Surgical ligation involves tying off the blood vessels; however, half of the time it doesn't stop the bleeding permanently, according to Dr. Razavi.

"Embolization is a straight-forward technique that preserves fertility and is performed by interventional radiologists regularly," said Dr. Razavi. "There's no reason this can't be done in any hospital where an interventional radiologist is present, which today is in most U.S. hospitals."

Interventional radiologists use embolization to treat a variety of other conditions and diseases. For instance, it is used in the delivery of chemotherapy directly to tumors and is performed to shrink fibroid tumors in the uterus.

Co-authors of a paper on the topic being presented by Dr. Razavi are: E. Hansch, M.D.; D.Y. Sze, M.D., Ph.D.; C.P. Semba, M.D.; M.D. Dake, M.D.; and V. Chitkara, M.D.

An estimated 5,000 people are attending the Annual Scientific Meeting in San Diego, Calif., of SCVIR, a professional society based in Fairfax, Va., for physicians who specialize in minimally invasive interventional procedures.

An interventional radiologist is a physician who has special training to diagnose and treat illness using miniature tools and imaging guidance. Typically, the interventional radiologist performs procedures through a very small nick in the skin, about the size of a pencil tip. Interventional radiology treatments are generally easier for the patient than surgery because they involve no surgical incisions, less pain and shorter hospital stays.

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Editor's note: Study numbers are current as of March 15, and may change.