Intraoperative uterine artery embolization without fetal radiation exposure in patients with placenta previa totalis: Two case reports
A 32-year-old woman, gravida 2, para 0, was admitted to Seoul National University Bundang Hospital at 35 weeks and 5 days gestational age with symptoms of vaginal bleeding in October 2011. Trans-vaginal ultrasonography revealed that the placenta completely covered the internal os. Approximately two thirds of the placenta was located in the posterior wall of the uterus and the remaining portion was located in the anterior lower segment of uterus. When the patient and her husband were counseled about the risk of hysterectomy, they strongly requested preservation of the uterus for future fertility. Therefore, a Cesarean section with prophylactic intraoperative UAE was planned. Under spinal anesthesia, a uterine incision was made transversely at the lower uterine segment. The surgeon could not avoid tearing the placenta before the female newborn weighing 2,465 g was delivered. The torn placental margins and the cut edges of the uterus were clamped by Allis forceps. During the interventional radiologist tried to insert an angiographic catheter into the right femoral artery for four minutes, the surgeon found a diffuse hemorrhage from the torn placental margin and cut edges of the uterus. At this point, the surgeon abandoned the plan of a prophylactic UAE. The surgeon removed the placenta manually and profuse hemorrhage from the placental bed sites developed. Although the implantation site was repeatedly over-sewn with 0-monofilament absorbable suture, bleeding was quite severe, thus a Cesarean hysterectomy was indicated. However, it was decided that intraoperative UAE would be attempted once more before the Cesarean hysterectomy since massive transfusion was successful. The interventional radiologist inserted an angiographic catheter into the right femoral artery and approached both uterine arteries. Embolization with gelfoam was performed under fluoroscopic guidance for bilateral enlarged tortuous uterine arteries (). Fortunately, blood flow decreased on angiography and bleeding through the vagina decreased. At this point it seemed possible to avoid a hysterectomy. The uterine wall was repaired after an additional intraoperative UAE. Estimated blood loss was 5,000 mL and massive transfusion (9 packs of RBC and 3 packs of FFP) was performed during the operation. Although bleeding decreased markedly after two attempts of intraoperative UAE, the patient was transferred to the angiography room for another attempt at UAE. Embolization of the uterine artery was performed with a coil in the angiography room () and then the patient was transferred to the intensive care unit (ICU) for close observation. While in the ICU, the patient received three more packs of RBC and six more packs of FFP as well as cryoprecipitate and platelet. The next day, her hemoglobin level was 10.2 g/dL and vital signs were stable. She was transferred to the general ward for further postoperative care. On the second day after surgery, the patient presented with a fever of 39.1℃ and after a full fever study, her antibiotic regimen was changed. The fever resolved on the fourth day and the patient was discharged from the hospital 10 days after surgery with no other complications.