Please wait a minute...
Clinical and Experimental Obstetrics & Gynecology  2020, Vol. 47 Issue (4): 478-482    DOI: 10.31083/j.ceog.2020.04.5300
Original Research Previous articles | Next articles
Multidetector computed tomography to predict heavy bleeding and need for angiographic embolization in patients with postpartum hemorrhage
H.M. Kim1, 2, J.Y. Lee2, W.J. Seong1, 2, *()
1Department of Obstetrics and Gynecology, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
2Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
Download:  PDF(338KB)  ( 221 ) Full text   ( 10 )
Export:  BibTeX | EndNote (RIS)      

Purpose: This retrospective study was designed to evaluate the usefulness of multidetector computed tomography (MDCT) in the identification of heavy bleeding, as a determinant of angiographic embolization (AE) in patients with postpartum hemorrhage (PPH). Materials and Methods: Fifty-seven consecutively registered patients with PPH underwent contrast-enhanced MDCT at Kyungpook National University Hospital between January 2009 and December 2012. The characteristics of the 33 patients who showed extravasation (EV) of contrast material in MDCT (EV group) were compared with those of the 24 patients who had no EV (noEV group). AE was performed in 23 out of 57 cases, based on the decision of the treating clinician. Direct localization of the bleeding site was compared with the results of MDCT. Results: A greater proportion of the EV group required AE compared with the noEV group (64% vs. 8%). The EV group showed a greater estimated blood loss (EBL) (2,100 mL vs. 1,170 mL, p < 0.001) and was associated with the need for massive blood transfusion (6 pints vs. 3 pints, p < 0.001). Disseminated intravascular coagulation was observed more frequently in the EV group (36% vs. 8%, p = 0.027). Of the 33 patients who were managed conservatively without AE, EBL after MDCT was greater in the EV group than the noEV group (410 mL vs. 45 mL, p < 0.001). The comparison of computed tomographic and angiographic findings indicated a discordant result in only 1 case. Conclusions: Contrast-enhanced MDCT is helpful to determine which patients are candidates for AE and to reduce unnecessary angiographic intervention.

Key words:  Angiographic embolization      Estimated blood loss      Extravasation      Multidetector computed tomography      Postpartum hemorrhage     
Submitted:  15 June 2019      Accepted:  04 September 2019      Published:  15 August 2020     
*Corresponding Author(s):  W.J. Seong     E-mail:

Cite this article: 

H.M. Kim, J.Y. Lee, W.J. Seong. Multidetector computed tomography to predict heavy bleeding and need for angiographic embolization in patients with postpartum hemorrhage. Clinical and Experimental Obstetrics & Gynecology, 2020, 47(4): 478-482.

URL:     OR

Figure 1.  — (a) Contrast-enhanced computed tomographic image obtained during the portal phase demonstrating contrast extravasation in the uterine cavity (arrow). (b) There is no evidence of contrast material extravasation in the uterine cavity.

Table 1  — Maternal and obstetrical characteristics.
EV (n = 33) noEV (n = 24) p value
Age, years, median (range) 34 (19-38) 31 (22-43) NS
Primiparity, n (%) 15 (45) 13 (54) NS
GAD, days, median (range) 273 (180-290) 274 (225-287) NS
Birth weight, g, median (range) 3410 (870-4120) 3150 (2420-3800) NS
Cesarean section, n (%) 14 (42) 9 (38) NS
Multiple pregnancy, n (%) 2 (5.8) 1 (4.1) NS
AE, n (%) 21 (64) 2 (8) < 0.001
Hysterectomy 1 0 NS
Table 2  — Parameters indicative of estimated blood loss.
EV (n = 33) noEV (n = 24) p value
EBL, mL, median (range) 2100 (870-6500) 1170 (700-2420) < 0.001
Transfusion, pints, median (range) 6 (2-32) 3 (2-9) 0.001
Pre-CT Hb, g/dL, median (range) 8.9 (4.5-12.5) 9.2 (5.3-12.2) NS
Post-CT Hb, g/dL, median (range) 8.2 (4.8-10.1) 9.0 (7.4-13.1) 0.008
Platelets, 10e3/uL, median (range) 137 (39-279) 166 (60-347) 0.024
Fibrinogen, mg/dL, median (range) 96 (14-347) 220 (25-449) 0.032
DIC, n (%) 12 (36%) 2 (8%) 0.027
[1] Ledee N., Ville Y., Musset D., Mercier F., Frydman R., Fernandez H.: “Management in intractable obstetric haemorrhage: an audit study on 61 cases”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2001, 94, 189.
doi: 10.1016/s0301-2115(00)00349-3 pmid: 11165724
[2] Kim T.H., Lee H.H., Kim J.M., Ryu A.L., Chung S.H., Seok Lee W.: “Uterine artery embolization for primary postpartum hemorrhage”. Iran J. Reprod. Med., 2013, 11, 511.
[3] Zwart J.J., Dijk P.D., van Roosmalen J.: “Peripartum hysterectomy and arterial embolization for major obstetric hemorrhage: a 2-year nationwide cohort study in the Netherlands”. Am. J. Obstet. Gynecol., 2010, 202, 150.e1.
doi: 10.1016/j.ajog.2009.09.003
[4] Cho G.J., Kim L.Y., Hong H.R., Lee C.E., Hong S.C., Oh M.J., et al.: “Trends in the rates of peripartum hysterectomy and uterine artery embolization”. PLoS One, 2013, 8, e60512.
doi: 10.1371/journal.pone.0060512 pmid: 23565254
[5] Poujade O., Ceccaldi P.F., Davitian C., Amate P., Chatel P., Khater C., et al.: “Uterine necrosis following pelvic arterial embolization for post-partum hemorrhage: review of the literature”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2013, 170, 309.
doi: 10.1016/j.ejogrb.2013.07.016 pmid: 23932304
[6] Cheong J.Y., Kong T.W., Son J.H., Won J.H., Yang J.I., Kim H.S: “Outcome of pelvic arterial embolization for postpartum hemorrhag.: A retrospective review of 117 cases”. Obstet. Gynecol. Sci., 2014, 57, 17.
doi: 10.5468/ogs.2014.57.1.17 pmid: 24596814
[7] Desille H., Ouldamer L., Bleuzen A., Arbion F., Herbreteau D., Marret H.: “Novel use of contrast-enhanced sonography in the diagnosis of central uterine necrosis following embolization for postpartum hemorrhage”. J. Ultras. Med., 2013, 32, 1869.
[8] Chitrit Y., Zafy S., Pelage J.P., Ledref O., Khoury R., Caubel P.: “Amenorrhea due to partial uterine necrosis after uterine artery embolization for control of refractory postpartum hemorrhage”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2006, 127, 140.
doi: 10.1016/j.ejogrb.2004.01.047 pmid: 16024157
[9] Kawamura Y., Kondoh E., Hamanishi J., Kawasaki K., Fujita K., Ueda A., et al.: “Treatment decision-making for post-partum hemorrhage using dynamic contrast-enhanced computed tomography”. J. Obstet. Gynaecol. Res., 2014, 40, 67.
doi: 10.1111/jog.12123 pmid: 23937115
[10] McLintock C., James A.H.: “Obstetric hemorrhage”. J. Thromb. Haemost., 2011, 9, 1441.
doi: 10.1111/j.1538-7836.2011.04398.x pmid: 21668737
[11] Sierra A., Burrel M., Sebastia C., Radosevic A., Barrufet M., Albela S., et al.: “Utility of multidetector CT in severe postpartum hemorrhage”. Radiographics, 2012, 32, 1463.
doi: 10.1148/rg.325115113
[12] Lee N.K., Kim S., Lee J.W., Sol Y.L., Kim C.W., Hyun Sung K., et al.: “Postpartum hemorrhage: Clinical and radiologic aspects”. Eur. J. Radiol., 2010, 74, 50.
doi: 10.1016/j.ejrad.2009.04.062
[13] Thachil J., Toh C.H.: “Disseminated intravascular coagulation in obstetric disorders and its acute haematological management”. Blood Rev., 2009, 23, 167.
doi: 10.1016/j.blre.2009.04.002
[14] Tew K., Davies R.P., Jadun C.K., Kew J.: “MDCT of acute lower gastrointestinal bleeding”. Am. J. Roentgenol., 2004, 182, 427.
doi: 10.2214/ajr.182.2.1820427
[15] Lee N.K., Kim S., Kim C.W., Lee J.W., Jeon U.B., Suh D.S.: “Identification of bleeding sites in patients with postpartum hemorrhage: MDCT compared with angiography”. Am. J. Roentgenol., 2010, 194, 383.
doi: 10.2214/AJR.09.3073
[16] Kuhle W.G., Sheiman R.G.: “Detection of active colonic hemorrhage with use of helical CT: Findings in a swine model. Radiology, 2003, 228, 743.
doi: 10.1148/radiol.2283020756 pmid: 12954894
[17] Chen J.K., Johnson P.T., Fishman E.K.: “Diagnosis of clinically unsuspected posttraumatic arteriovenous fistulas of the pelvis using CT angiography”. Am. J. Roentgenol., 2007, 188, W269.
doi: 10.2214/AJR.05.1230
[18] Takeda A., Koyama K., Mori M., Sakai K., Mitsui T., Nakamura H.: “Diagnostic computed tomographic angiography and therapeutic emergency transcatheter arterial embolization for management of postoperative hemorrhage after gynecologic laparoscopic surgery”. J. Minim. Invas. Gynecol., 2008, 15, 332.
doi: 10.1016/j.jmig.2008.02.010
[19] Shanmuganathan K., Mirvis S.E., Sover E.R.: “Value of contrast-enhanced CT in detecting active hemorrhage in patients with blunt abdominal or pelvic trauma”. Am. J. Roentgenol., 1993, 161, 65.
doi: 10.2214/ajr.161.1.8517323
[20] Roy-Choudhury S.H., Gallacher D.J., Pilmer J., Rankin S., Fowler G, Steers J., et al.: “Relative threshold of detection of active arterial bleeding: In vitro comparison of MDCT and digital subtraction angiography”. Am. J. Roentgenol., 2007, 189, W238.
doi: 10.2214/AJR.07.2290
[1] K. Tamura, H. Takahashi, S. Uchida, M. Ogoyama, R. Usui, S. Matsubara. Intrauterine balloon failure: unrecognized placenta accreta spectrum disorders[J]. Clinical and Experimental Obstetrics & Gynecology, 2020, 47(3): 405-408.
[2] K. Lee, S. Lee, H. N. Lee, H. Lim, I. J. Kim, I. Y. Park, M. J. Kim. Uterine necrosis following selective embolization for postpartum hemorrhage: report of four cases and review of literature[J]. Clinical and Experimental Obstetrics & Gynecology, 2019, 46(6): 1020-1025.
[3] Ichiro Miwa, Masahiro Shinagawa, Terumi Miwa, Keiko Ootani, Masakatsu Sase, Yasuhiko Nakamura. Severe postpartum hemorrhage with placental abruption managed by the uterine sandwich: a case report[J]. Clinical and Experimental Obstetrics & Gynecology, 2019, 46(2): 289-290.
[4] D.H. Im, J.M. Byun, H.S. Jung, D.H. Jeong, B.J. Min, Y.N. Kim, E.J. Jung, K.B. Lee, M.S. Sung, K.T. Kim. The utility of Doppler ultrasonography in diagnosis of delayed postpartum hemorrhage: a case report[J]. Clinical and Experimental Obstetrics & Gynecology, 2018, 45(6): 946-948.
[5] H. Kyozuka, K. Takiguchi, A. Owada, Y. Endo, M. Kojima, S. Suzuki, K. Fujimori. Two cases of placenta accreta with conservative management[J]. Clinical and Experimental Obstetrics & Gynecology, 2018, 45(2): 283-286.
[6] S. Matsubara, H. Takahashi. Cesarean scar pregnancy and uterine artery pseudoaneurysm: preceding or coexisting?[J]. Clinical and Experimental Obstetrics & Gynecology, 2018, 45(1): 72-74.
[7] M. Wang, C. Zhu, Z. Wang. A successful pregnant outcome in patient with Sheehan syndrome: a case report[J]. Clinical and Experimental Obstetrics & Gynecology, 2017, 44(6): 944-945.
[8] H.G. Kim, Y.J. Na, Y.J. Song, J. Yang, O.H. Choi. Bilateral rupture of the renal pelvis as a complication of placental abruption in multiparous female[J]. Clinical and Experimental Obstetrics & Gynecology, 2017, 44(4): 613-615.
[9] T.H. Kim, H.H. Lee, J.M. Kim. Efficacy of computed tomography for the diagnosis of postpartum hemorrhage[J]. Clinical and Experimental Obstetrics & Gynecology, 2017, 44(2): 244-246.
No Suggested Reading articles found!