Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 191e193

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Taiwanese Journal of Obstetrics & Gynecology

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Case Report

Uterine artery embolization, not cesarean section, as an option for

termination of pregnancy in placenta previa
Lingling Huang a, Reenu Awale a, Hui Tang a, ZhiShan Zeng b, FuRong Li b, Yue Chen a, *
a
Department of Obstetrics and Gynecology, The First Affiliated Hospital of GuangXi Medical University, Nanning, GuangXi, China
b
Department of Radiology, The First Affiliated Hospital of GuangXi Medical University, Nanning, GuangXi, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To summarize our experiences in the treatment of labor induction in placenta previa using
Accepted 7 April 2014 uterine artery embolization.
Case report: We retrospectively analyzed the clinical data of seven patients with placenta previa who
Keywords: underwent antepartum uterine artery embolization before vaginal delivery. After antepartum emboli-
labor induction zation, five patients with placenta previa had successful vaginal deliveries and two cases of placenta
placenta accreta
previa with accreta underwent emergency hysterectomy. Some complications were reported in this
placenta previa
experience. The follow-up study showed that most patients resumed their normal menstruation and
pregnancy
uterine artery embolization
some of them were able to conceive.
Conclusion: For the management of placenta previa, uterine artery embolization is a minimally invasive
technique that helps to avoid cesarean section. The impact on menstruation and fertility is yet to be seen.
Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All
rights reserved.

Introduction magnetic resonance imaging (MRI) or both. According to the

The placenta begins to develop after blastocyst implantation
into the endometrium. In some cases, the placenta is implanted in
the lower uterine segment close to or even covering the internal
cervix os, or invades through the endometrium and myometrium,
which causes placenta previa and placenta accreta, respectively [1],
which may lead to hemorrhage when vaginal delivery is attempted.
Arterial embolization was first described by Brown et al [2] to
control postpartum bleeding. We present our experiences with
induction of labor for placenta previa with the help of antepartum
uterine artery embolization (UAE).
Material and methods
A retrospective analysis of UAE performed for the management
of abnormal placental implantation was carried out from
November 2007 to December 2012. Abnormal placental implanta-
tion was preoperatively diagnosed using ultrasonography (USG),
* Corresponding author. Department of Obstetrics and Gynecology, The First
Affiliated Hospital of GuangXi Medical University, Number 6 Shuang Yong Road,
Nanning, 530021, GuangXi, China.
E-mail address: 2657316472@qq.com (Y. Chen).
diagnosis, all the patients were divided into two groups: placenta
previa (PP) and placenta previa with accrete (PPþPA). In the PP
group, all patients were diagnosed with total placenta previa using
USG, within gestational age 22e29 weeks. These patients chose the
vaginal route to terminate their pregnancy because of fetal death
and serious fetal malformations. In the PAþPP group, gestational
age was within 21e22 weeks, and was diagnosed as total placenta
previa with placenta accreta with the aid of USG and MRI; patients
desired to terminate the pregnancy because of persistent vaginal
bleeding. All patients gave informed consent for their management.
Ethacridine lactate (Rivanol) amniotic induction was performed
in five patients with placenta previa and in two patients with
placenta previa with accreta soon after they received antepartum
embolization. The contractile effect of ethacradine lactate is
mediated through the activation of mast cells in the myometrium
that release mediators, such as prostaglandin F2a, prostaglandin E2,
prostacyclin, and thromboxane A2 [3].
This procedure was performed using a 5-Fr Cobra catheter
(TERUMO, HangZhou, China) via a femoral artery approach.
Embolization of both uterine arteries was carried out preferentially
using pledgets of absorbable gelatin sponge (Elatine Sponge,
NanJing, China), as well as Fibre Steel Coil (Cordis Corporation). For
the PP and PPþPA groups, ethacridine lactate amniotic induction

http://dx.doi.org/10.1016/j.tjog.2014.04.028
1028-4559/Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.

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192 L. Huang et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 191e193

Table 1
Outcome after uterine artery embolization: our experience.

Patient types Case no. Mode of delivery Hysterectomy (Y/N) Placenta expelled Complications Menses Subsequent pregnancy (Y/N)

Placenta previa 1 VD N SE Normal Y

2 VD N SE Normal
3 VD N SE Normal
4 VD N MRP þ UC Femoral artery thrombosis Normal Y
5 VD N SE Normal Y (abortion)
Placenta previa and accreta 6 VD Y Infection
7 CS Y Infection

CS ¼ cesarean section; MRP ¼ manual removal of placenta; N ¼ no; SE ¼ spontaneously expelled; UC ¼ uterine curettage; VD ¼ vaginal delivery; Y ¼ yes.

was performed after antepartum embolization. For the PPþPA
group, methotrexate was injected into the uterine arteries before
blocking the vessels with gelatin sponge. We confirmed all the
patient's vital signs were stable and that coagulation profiles were
normal before embolization.
Results
All the placenta previa cases, who received antepartum embo-
lization and ethacridine lactate amniotic induction, had successful
vaginal deliveries without excessive blood loss (Cases 1e5; Table 1).
In the PPþPA group, one case of placenta accreta with previa (Case
6) also had vaginal delivery but with retained placenta. Case 7
underwent cesarean section because of uncontrolled bleeding
during labor. Eventually, Cases 6 and 7 underwent emergency
hysterectomy because of massive hemorrhage (total blood
loss > 5 L in each case): one occurred at the time of placenta
expulsion (1 month after delivery), and the other during labor.
Placenta increta and percreta were diagnosed intraoperatively and
a pathological examination on the hysterectomy specimens in both
cases was performed. In Case 7, the placenta had invaded the
bladder wall and partial cystectomy was performed, however, MRI
did not disclose this finding before surgery.
Severe complications of UAE were reported in a few cases. One
case in the PP group had femoral artery thrombosis due to long
duration of catheterization. However, after thrombectomy and
thrombolysis, the patient had a good outcome (Case 4; Table 1).
Infection was a complication in patients with retained placenta.
During subsequent clinical follow up by the obstetrician (from 3
months to 4 years), no midterm complications were reported.
During the follow-up study, we were able to contact the five
patients with placenta previa. All five reported normal postpartum
menstruation without any change in menstrual cycle and men-
strual flow. Three patients conceived after their deliveries; among
them, two patients had uneventful pregnancies and one asked for
an abortion.
With regard to the two cases of placenta previa with accreta,
conservative management was unsuccessful, even though sup-
ported with adjuvant therapy, methotrexate, which acts by
inducing placental necrosis and expediting placenta involution
[7e10]. During the operation, we found that the placenta had
already invaded the uterine wall, leading to placenta percreta. The
reason for this may be the invasion of the uterine wall and posterior
bladder wall by the placenta, and perfusion from the bladder artery.
In this situation, UAE is not sufficient to block the blood supply
completely to the placenta. Another possible reason may be due to
continuous vascularization after embolization. Sherer et al [8] re-
ported multiple bilateral UAE in patients with placenta previa
percreta and the successful conservative management confirms
this point.
Although UAE is effective for control of hemorrhage caused by
placenta previa, a serious complication has been reported, namely,
femoral artery thrombosis. We consider that the skilled technique
described in the present study might be a measure to reduce this
complication [11]. Infection was reported in our study, which can be
controlled by prophylactic broad-spectrum antibiotic therapy.
With regard to the effect of embolization on the menstrual cycle,
we showed that patients resumed their normal menstruation after
1e3 months, which was similar to the study of Descargues et al
[12]. UAE provokes obliteration and reduction in uterine perfusion,
thus, it is possible that uterine hypovascularization can induce
some pregnancy complications later. In our study, there was the
limitation of subsequent pregnancy after UAE, but it does not
confirm that it was because of uterine hypovascularization that
there was limitation of subsequent pregnancy. Randomized trials
would be desirable to quell any future controversy [13].
In conclusion, the advantages of UAE in the management of
placenta previa have been established. Our study indicates that a
woman who undergoes arterial embolization can resume her
normal menstruation and reproduction. As long as long-term ef-
fects are concerned, more cases need to be studied.
Conflicts of interest

Discussion The authors have no conflicts of interest relevant to this article.

Medical termination of midtrimester pregnancy with placenta

previa has been reported [4]. Reviewing these articles, most termi-
nations were carried out in the early second trimester, and there are
no reports regarding third trimester termination. Pelvic arterial
embolization to control obstetric hemorrhage was reported in suc-
cession [5,6]. Therefore, in this study, we performed UAE in the pa-
tients with complete placenta previa following ethacridine lactate
amniotic induction. UAE blocks the main blood supply of the placenta,
hence reducing bleeding when vessels rupture during uterine con-
tractions. From the outcome in our study, we concluded that UAE is an
effective method to avoid cesarean section and hemorrhage in pa-
tients with placenta previa who need pregnancy termination.
Acknowledgments
The authors thank Gowreesunkur Purvarshi Devi for her assis-
tance in writing the article in English.
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