Safety and efficacy of pelvic arterial embolization for primary postpartum hemorrhage in hemodynamically stable and hemodynamically unstable patients: Is it "time" for a paradigm change?

BACKGROUND: Pelvic artery embolization (PAE) is an effective and safe technique for treating postpartum hemorrhage (PPH) with hemodynamic stability. However, its use in hemodynamically unstable patients remains controversial.

PURPOSE: To determine the safety and efficacy of pelvic arterial embolization (PAE) according to the hemodynamic state of primary postpartum hemorrhage (PPH) patients.

METHODS: This cohort study was conducted retrospectively, using data from January 2004 to December 2021, in a resource-rich setting at a tertiary Level 1 trauma academic center. A total of 437 patients were diagnosed with PPH during the study period. Of these 437 patients, 161 with primary PPH who underwent PAE were enrolled in the study. The outcomes assessed included the clinical success rate, mortality, overall success rate, predictive factors for failed PAE, and time-dependent changes in hemodynamic parameters, such as systolic blood pressure (SBP), heart rate (HR), and shock index (SI). Propensity score (PS) matching analysis was performed to assess the influence of specific variables or conditions on the outcomes.

RESULTS: Of the 161 patients who underwent PAE for primary PPH (mean age, 32.9±4.3 [SD]), 85 were retrospectively categorized as having hemodynamic stability (mean age, 32.6±4.1 [SD]), while 76 were categorized as having hemodynamic instability (mean age, 33.3±4.4 [SD]). This study showed no significant differences in mortality between the two groups. PAE for primary PPH demonstrated a success rate of 91.9% with no significant difference in mortality rates between the groups. After PS matching, the clinical success rate was 98.3% for patients with hemodynamic stability and 83.1% for those with hemodynamic instability (p=0.004). However, there was no significant difference in the overall success rate, with 98.3% for the hemodynamic stability group and 89.8% for the hemodynamic instability group (p=0.114). Among the PS-matched population, predictive factors for the failed PAE in primary PPH were hemodynamic instability (adjusted odds ratio [aOR] 14.39, 95% CI 1.5-100; p=0.017) and bleeding during cesarian section (aOR 25.79, 95% CI 2.7-100; p=0.005). In three groups within a PS-matched population - hemodynamically stable, unstable with successful outcomes, and unstable with unsuccessful outcomes, A generalized linear mixed model (GLMM) analysis for time-dependent changes in hemodynamic parameters revealed a statistically significant difference in SBP, HR, and SI at various time points.

CONCLUSION: Pelvic arterial embolization of primary postpartum bleeding in hemodynamic instability has been identified as an alternative, safe, and effective life-saving procedure for multidisciplinary treatment in resource-rich environments even after the baseline characteristics are balanced by the PS matching, suggesting it is a primary care option.