Transcatheter arterial embolization outperforms surgery in reducing blood transfusions for postpartum vulvovaginal hematoma

Tsukasa Takahashi; Hasumi Tomita; Hirotaka Hamada; Mari Tadakawa; Noriyuki Iwama; Masatoshi Saito

doi:10.1016/j.ajog.2024.03.016

Transcatheter arterial embolization outperforms surgery in reducing blood transfusions for postpartum vulvovaginal hematoma

Am J Obstet Gynecol. 2024 Mar 20:S0002-9378(24)00445-9. doi: 10.1016/j.ajog.2024.03.016. Online ahead of print.

Authors

Tsukasa Takahashi¹, Hasumi Tomita², Hirotaka Hamada², Mari Tadakawa², Noriyuki Iwama³, Masatoshi Saito²

Affiliations

¹ Department of Obstetrics and Gynecology, Tohoku University Hospital, Sendai, Japan. Electronic address: tsukasa.takahashi.b4@tohoku.ac.jp.
² Department of Obstetrics and Gynecology, Tohoku University Hospital, Sendai, Japan.
³ Department of Obstetrics and Gynecology, Tohoku University Hospital, Sendai, Japan; Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan.

PMID: 38518850
DOI: 10.1016/j.ajog.2024.03.016

Abstract

Background: Postpartum vulvovaginal hematoma is a complication of vaginal delivery that may progress to life-threatening conditions. However, the management of hematomas, including conservative therapy, surgery, and arterial embolization, is yet to be standardized.

Objective: This study aimed to: (1) evaluate hematoma features that can be treated conservatively, and (2) determine whether surgery or transcatheter arterial embolization is superior in reducing blood transfusion.

Study design: This cross-sectional study included postpartum women transferred to Tohoku University Hospital, Japan, between January 2016 and September 2023 for postpartum vulvovaginal hematomas. Notably, all patients except 1 underwent contrast-enhanced computed tomography. The patients were classified into the following groups: (1) the conservative group who received neither surgery nor transcatheter arterial embolization and (2) the therapeutic intervention group who received surgery or transcatheter arterial embolization. The primary analysis included all patients. Variables for the choice of therapeutic intervention, including the shock index, hemoglobin concentration at arrival, hematoma size, and presence of extravasation, were assessed using a modified Poisson regression model. The secondary analysis included patients who received therapeutic intervention (ie, surgery or transcatheter arterial embolization). Variables for estimating the total amount of blood transfusion, including shock index, hemoglobin concentration at arrival, hematoma size, type of intervention, and presence of extravasation, were analyzed using multiple linear regression.

Results: Fifty-seven cases were included in this study. Patients underwent conservative treatment (n=19), surgery (n=11), or transcatheter arterial embolization (n=27). In primary analysis, only the presence of extravasation was significantly associated with the choice of therapeutic intervention (adjusted risk ratio [95% confidence interval], 5.30 [1.53-18.37]). In the secondary analysis, the choice of surgery as a therapeutic option (unstandardized coefficient [95% confidence interval], 4.64 [1.15-8.13]; reference: transcatheter arterial embolization), lower hemoglobin concentration at arrival (-2.84 [-4.71 to -0.97]; 1 g/dL increment), and larger hematoma size (3.38 [1.23-5.53]; 100 cm³ increments) were significantly associated with increased blood transfusion.

Conclusion: When a vulvovaginal hematoma does not exhibit extravasation, it can be treated conservatively regardless of size. When a therapeutic intervention is selected, transcatheter arterial embolization reduces the total amount of blood transfusion compared with surgery.

Keywords: blood transfusion; surgery; therapeutic intervention; transcatheter arterial embolization; vulvovaginal hematoma.