Wednesday, April 14, 2021

Postpartum bleeding does not mean a hysterectomy

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By Alan Mozes

HealthDay reporter


WEDNESDAY, March 24, 2021 (HealthDay News) – Heavy bleeding after birth can threaten the mother’s life, and doctors sometimes turn to a hysterectomy to stop the bleeding. But a new study suggests that a less invasive and underused procedure might be a better, less drastic option.

Investigators determined that when postpartum bleeding occurs, hysterectomies – the removal of the uterus – are 60% more common than uterine artery embolization (UAE) procedures, despite the fact that “UAE is safer and has easier recovery than hysterectomySaid study author Dr. Janice Newsome, associate professor in the department of radiology and imaging at Emory University School of Medicine in Atlanta.

Speaking recently at the Society of Interventional Radiology Virtual Annual Meeting, Newsome pointed out that severe postpartum bleeding can happen quickly and is not uncommon. It affects approximately 100,000 American women each year and is the leading cause of global maternal death, she said.

The situation is complicated by the fact that in up to 20% of cases there are no obvious risk factors that would warn doctors in advance, Newsome added.

The most common intervention, she noted, is a blood transfusion. But after looking at data on nearly 10 million births in the United States between 2005 and 2017, his team concluded that hysterectomy is the second most frequently used treatment. By comparison, the UAE is an “underutilized option,” she noted.

According to the United States National Library of Medicine, a UAE involves sedation with a localized pain reliever, followed by the insertion of a thin tube (catheter) through the groin and threaded into the uterine artery. Tiny particles of gelatin are then inserted through the tube, to curb the blood supply and stem the bleeding.

Fewer patients received UAE

The Newsome team calculated that blood transfusions were given at a rate of about 116 patients per 1,000 cases of postpartum hemorrhage. Hysterectomies have been performed in approximately 20 patients per 1,000 cases. By comparison, UAE was the procedure of choice in about 13 patients per 1,000 cases of bleeding.

Continued

This has happened even though a hysterectomy is permanent, after which the patient can no longer have children. In addition, “extended hospital stays of more than 14 days were twice as likely in patients with hysterectomies”, compared to patients from the United Arab Emirates. Patients with hysterectomies are also hit with much higher hospital bills, the Newsome team noted, averaging $ 18,000 more per patient.

The study also found that hysterectomies were twice as common as the UAE in Hispanic women. They were also more frequently performed in Medicaid patients, the uninsured and those living in rural communities.

Newsome suggested that in the future, hospitals should make sure they have an interventional radiologist on hand, to strengthen their ability to deliver UAE when faced with a postpartum hemorrhagic emergency.

Results presented at medical meetings are considered preliminary until published in a peer-reviewed journal.

The study may leave questions unanswered

Dr. Eran Bornstein, vice president for obstetrics and director of fetal material medicine at Lenox Hill Hospital in New York City, argues that choosing a treatment for postpartum bleeding is much more complex than the study. seems to suggest it.

“This is important work that addresses a very important issue,” noted Bornstein, who was not part of the study. “And the results have some validity in showing that in some places in the United States there may be a problem with adequate access to interventional radiology. But I would be careful in interpreting the results.”

On the one hand, Bornstein said, it could very well be that the lower mortality and shorter hospital stay that the study linked to UAE simply meant that the UAE patients had less severe bleeding.

Another problem: “The data used in this study covers procedure codes in a large population” to calculate the frequency of treatment use. “But they don’t look at the cases in detail” and take into account all the different factors that can lead to maternal bleeding. “And not all of these conditions are treated the same,” he said.

On top of that, the study basically focuses on just two treatments, “when in truth there are a lot,” Bornstein added.

Continued

“There are pharmacological drugs: drugs to try to contract the uterus. There is manual massage, which can sometimes be effective. There is a repair of the lacerations. There are different ways to induce tamponade. [closure] in the womb. Then there are surgical techniques, with different types of stitches to compress the uterus. And then, yes, there is the embolization and the hysterectomy, ”admitted Bornstein.

“And, of course, a hysterectomy is a last result,” he said. “I’m not promoting a hysterectomy. But I don’t know of any obstetrician who would want to do a postpartum hysterectomy unless they are. The point is, embolization (UAE) is a great complementary option. But a hysterectomy can be a life-saving intervention for the most significant postpartum hemorrhages. You just can’t generalize. You need to look at each case individually. “

More information

There is more information about the UAE at Cleveland Clinic.

SOURCES: Janice Newsome, MD, associate professor, department of radiology and imaging, medical school, Emory University, Atlanta; Eran Bornstein, MD, vice president, obstetrics, and director, maternal fetal medicine, Lenox Hill Hospital, and associate professor, Zucker School of Medicine, Hofstra University / Northwell, New York City; Society of Interventional Radiology, virtual annual meeting, March 20-26, 2021

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