Buttock necrosis after hypogastric artery embolization for postpartum hemorrhage

Introduction

Postpartum hemorrhage is a severe and important cause of morbidity and mortality in developed countries. The embolization of uterine or hypogastric arteries is a good alternative to avoid hysterectomy provided that the patient is hemodynamically stable [8]. Although it has demonstrated good results, major complications have been reported with this technique, including uterine necrosis, bladder gangrene, buttock necrosis or paraplegia [5, 6, 8].

Presentation of the case

A 31-year-old primipara with a dichorionic twin pregnancy, obtained through in vitro fertilization because of an unknown cause of primary infertility, was followed up at our institution with no complications. Following our protocol, labor was induced after 37 weeks and 6 days, after the patient’s informed consent had been obtained.

Due to favorable cervical conditions, induction was initiated with intravenous oxytocin. Intrapartum penicillin was used for the prevention of perinatal group B streptococcal disease due to a positive result in the antenatal screening. After an artificial amniotomy and 7 h of oxytocin administration, labor did not progress and a segmental hysterotomy for cesarean section was performed according to our hospital’s protocol.

Both newborns were born without complications. The placenta was extracted manually, and carbetocin was administered following our protocol. A posterior curettage of the uterine cavity was performed due to the presence of membranes, and the uterus was subsequently closed. Because of the persistence of active hemorrhage 10 min after the placental delivery and the presence of a soft consistent uterus, a uterine atonia was suspected and the postpartum hemorrhage protocol was initiated. According to our protocol, we started a pharmacologic management (including the use of one dose of 20 μg of intramuscular methylergonovine maleate, 1000 μg of rectal misoprostol and one dose of 250 μg of intramyometrial carboprost tromethamine). The abdomen was closed in the meantime. Because the hemorrhage had not ceased after 30 min of having finished the cesarean section, we placed a Bakri postpartum balloon confirmed by ultrasound in the same operating room. The hemorrhage continued for a further 30 min, and hemodynamic destabilization appeared, requiring the transfusion of a first unit of blood. As the radiologist had been alerted some time before, the medical group decided to perform a uterine artery embolization. Through left femoral access, a coil was placed and, later on, Gelfoam was injected into uterine arteries. Nevertheless, due to persistent hemorrhage, both hypogastric arteries were embolized and the hemorrhage ceased. The procedure took almost 1 h.

Review only

The patient was transferred to the intensive care unit (ICU), requiring transfusion of 5 U of blood in the following days due to an estimated blood loss of 1500 mL and a hemoglobin level that reached 6 g/dL. Six units of blood was finally transfused. No signs of coagulopathy were observed, and no vasoactive drugs were required. On the fourth day post-embolization, she started to present an eschar in the right buttock, initially treated with local cures for asepsis. After being discharged from the ICU, the patient presented pain and deterioration of the buttock lesion and necrosis was diagnosed (Figure 1). Intensive analgesia was required, and two debridements were performed by the Plastic Surgery Department 14 and 20 days after (Figure 2). The debridements were followed by a vacuum-assisted closure (VAC) therapy to promote granulation tissue formation and healing (Figure 3) after the embolization. The VAC therapy was maintained for almost 2 months, during which the patient attended regular controls and the lesion was cured. Finally, a successful skin graft was performed 3 months after the cesarean section with an acceptable result (Figure 4). In further controls, the patient reported no residual pain or dysfunction, presenting normal menstruations and a normal gynecologic ultrasound exploration.

Figure 1

Eschar lesion.

Figure 2

After both debridements.

Figure 3

Lesion after VAC treatment.

Figure 4

Residual scar lesion after graft.

Discussion

Obstetric hemorrhage is an important cause of maternal morbidity and mortality. The management of postpartum hemorrhage includes the use of uterotonic therapy (oxytocic drugs, methylergonovine, carboprost tromethamine, misoprostol), uterine massage, intrauterine balloons, uterine compression sutures such as B-Lynch, or arterial ligation, with hysterectomy being the definitive surgical solution [3]. Arterial embolization should be performed as an alternative to surgery. In any event, a multidisciplinary approach is essential in the management of a postpartum hemorrhage.

Endovascular arterial embolization was introduced in 1979 and has proven to be a highly effective technique in controlling obstetric bleeding [4].

The literature describes high clinical success rates (94.5%) with relatively low complication rates (8.7%), although some complications may have been caused by hemorrhage-related comorbidities and other contemporaneous procedures (curettage, etc.) [7]. The most common complication is low-grade fever. Rare complications include pelvic infection, groin hematoma, iliac artery perforation, transient buttock ischemia, transient foot ischemia and bladder gangrene or paraplegia [2].

Some other cases of buttock necrosis have been described [1]. The cause is believed to be a non-targeted embolization during therapeutic uterine artery embolization, most likely as a result of the reflux of embolic material from the uterine artery into the inferior gluteal artery. Another possibility is that this material could migrate through anastomotic channels between both arteries. Nevertheless, no studies have been published describing its incidence. In our case, we could not confirm or reject its presence when revising the images. Individual anatomic variants should also be considered. It is important to be as selective as possible when embolizing arteries in order to have a lower risk of ischemia in collateral territories. Uterine artery embolization should therefore be the first option. Few studies have been published on fertility and uterine artery embolization, although the material used nowadays is resorbable, hence this should not be regarded as a cause of infertility.

One critique to this case is that we should have taken into account offering uterine compression suture to this patient.

In conclusion, it is important to develop multidisciplinary algorithms with a 24-h-a-day trained interventionist radiology team to optimize the management of postpartum hemorrhage and permit the preservation of the uterus and fertility. Attendance to up-to-date courses is necessary to keep in touch with the latest advances in the management of obstetrical emergencies.