title: Three-dimensional computerized tomographic angiography for diagnosis and management of intractable postpartum hemorrhage.
abstract: OBJECTIVE
  To report our experience on the value of dynamic three-dimensional computerized tomographic (CT) angiography for immediate diagnosis and management of intractable postpartum hemorrhage (PPH).
  
  
  METHODS
  Retrospective study of all cases of PPH examined by three-dimensional CT angiography between January 2007 and August 2013 in a single center. In each case, emergency dynamic CT was taken at the early arterial, late arterial and venous phases to identify the extravasated contrast agent that represents active hemorrhage. Images for three-dimensional CT angiography were reconstituted from multiplanar CT images. Based on these findings, management procedures were individually determined and those outcomes were compared with angiographic, surgical and clinical findings.
  
  
  RESULTS
  Twenty-nine cases with primary PPH and 19 cases with secondary PPH were examined. In primary PPH, extravasation in the early arterial phase was noted in 12 cases. Those included vulvovaginal hematoma (n=4), invasive placenta (n=2), retained placenta (n=2), uterine atony (n=1), retroperitoneal hematoma (n=1), retrovesical hematoma (n=1) and rectus sheath hematoma after cesarean section (n=1). Of these, ten cases were treated by transcatheter arterial embolization (TAE) of the offending vessels with or without additional therapies. In secondary PPH, extravasation was identified in 14 cases. Those included invasive placenta (n=8), uterine artery pseudoaneurysm (n=3), uterine arteriovenous fistula (n=2), and subinvolution of placenta bed (n=1), which were treated by TAE of the offending vessels with or without additional therapies. Successful hemostasis with fertility preservation was achieved in all cases. Complications were not identified except for a case of placenta increta that developed secondary amenorrhea after TAE of both uterine arteries. In subsequent gestation after TAE of both uterine arteries, normal vaginal delivery (n=4), uncomplicated cesarean delivery (n=3), cesarean delivery followed by recurrent arteriovenous fistula (n=1) and spontaneous miscarriage followed by recurrent invasive placenta (n=1) were identified.
  
  
  CONCLUSIONS
  This case series emphasizes that three-dimensional CT angiography has significant diagnostic value when the appropriate procedure for management of PPH was immediately determined to avoid potential maternal morbidity and mortality.
authors.affiliation: Department of Obstetrics & Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan. Electronic address: gyendoscopy@gmail.com.
authors.forename: Akihiro
authors.initials: A
authors.lastname: Takeda
authors.affiliation: Department of Diagnostic Radiology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.
authors.forename: Wataru
authors.initials: W
authors.lastname: Koike
authors.affiliation: Department of Obstetrics & Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.
authors.forename: Sanae
authors.initials: S
authors.lastname: Imoto
authors.affiliation: Department of Obstetrics & Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.
authors.forename: Hiromi
authors.initials: H
authors.lastname: Nakamura
mesh_terms: D000328:Adult; D000792:Angiography / Q000379:methods; D004621:Embolization, Therapeutic / Q000379:methods; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000175:diagnosis; D005260:Female; D006801:Humans; D006473:Postpartum Hemorrhage / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D011247:Pregnancy; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000379:methods
keywords: Computerized tomographic angiography; Diagnostic imaging; Postpartum hemorrhage; Transcatheter arterial embolization