In his December editorial (“Massive obstetric hemorrhage: High- and low-tech tools”), Dr. Robert L. Barbieri pointed out that high- and low-tech approaches are often complementary.
I would expect any woman known to have an invasive placenta, as mentioned in the editorial, to be delivered at a facility equipped for high-risk situations, and that such a facility would have fully equipped interventional radiology services.
One method Dr. Barbieri described, prophylactic placement of internal iliac artery occlusion balloons, has proven safe and effective. It is important to inflate the balloons as early as possible (as soon as the baby is delivered) to forestall hemorrhage, rather than wait until hemorrhage begins.
As for the tamponading intrauterine balloon, I think it is a wonderful idea. We have learned from managing esophageal and gastric varices that balloon tamponade can be excellent for acute control of bleeding, but usually not for definitive control.
Embolization is more effective than surgical ligation of the internal iliac or uterine arteries at controlling postpartum and postsurgical hemorrhage. And because ligation without control of bleeding precludes effective embolotherapy, I encourage balloon tamponade followed by embolotherapy at the earliest opportunity.
Dr. Barbieri also posed the question, “Should all obstetric services have access to the high-technology interventional radiology procedures?” The Letters page subsequently reflected some views that filled me with sadness for the patient population for whom we all care: the assertion that newly introduced technologies are unproven and overly expensive, and the concern that IR in every hospital might mean that “our hysterectomies disappear into their intervention rooms.”
An IR suite costs about as much as an OR to install, but is almost always a source of profit to a hospital. OR services are often a source of operating loss.
It is unreasonable to fear that gynecologists will no longer perform hysterectomies in the presence of an IR service. Depending on who you read, 30% to 70% of hysterectomies are done for causes other than fibroids; these patients are not candidates for embolization. Even with fibroid disease, there are more than enough patients for both gynecologists and interventional radiologists. Current published data show that 20% to 25% of women having uterine artery embolization will go on to have another procedure (hysterectomy, myomectomy, or repeat uterine artery embolization) within 5 years. Most have hysterectomies. This rate is no higher than the rate of subsequent procedures for fibroids after myomectomy, and far below the rate of recurrent procedures after endometrial ablation.
I want to emphasize the importance of ObGyns and interventional radiologists viewing one another as colleagues rather than competitors. If I decide that a patient would be better served by surgery, I refer her—even set up an appointment with the surgeon. If I thought uterine artery embolization were an obsolete procedure, I would stop doing it and direct patients to a better procedure—if it existed. That is part of my oath as a physician: to place patients’ health and safety interests above my own professional or economic interest.
Robert L. Worthington-Kirsch, MD
Image Guided Surgery/Interventional Radiology
Dr. Worthington-Kirsch receives grant/research support from Terumo Interventional Systems, is a consultant to BioSphere Medical, and is a speaker for both companies.