Primary vaginal gestational trophoblastic neoplasia treated with uterine angiographic embolization and Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, and Vincristine: Philippines’ first reported case / Philippine Journal of Obstetrics and Gynecology

@#Gestational trophoblastic neoplasia (GTN) in itself is an uncommon condition, much so is primary extrauterine GTN. The incidence of GTN in the Philippines is at 22.4/40,000 pregnancies. However, no report has been made for primary extrauterine GTN. Only two cases of primary vaginal choriocarcinoma are reported in literature. This is a case of a 26 year old G1P0 (0010) who came in for profuse vaginal bleeding. Serum beta‑human chorionic gonadotropin (β‑hCG) was elevated and ultrasound showed hypervascular vaginal mass and an empty uterus. A primary vaginal GTN was considered and the patient was treated with etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMACO) regimen. During the course of chemotherapy, there was a note of profuse vaginal bleeding which was controlled by angiographic uterine artery embolization. A normal β‑hCG level was achieved after six cycles of EMACO. The patient was able to have three successful pregnancy outcomes thereafter. Primary vaginal GTN is a rare condition that requires a high index of suspicion. In a nulliparous patient complicated with profuse vaginal bleeding, angiographic embolization is an effective fertility‑sparing procedure that can manage the said complication.

Primary vaginal gestational trophoblastic neoplasia treated with uterine angiographic embolization and chemotherapy / Philippine Journal of Obstetrics and Gynecology

@#Gestational trophoblastic neoplasia (GTN) in itself is an uncommon condition, much so is a primary extrauterine GTN. The incidence of GTN in the Philippines is at 22.4/40,000 pregnancies. However, no report has been made for primary extrauterine GTN. Only two cases of primary vaginal choriocarcinoma are reported in the literature. This is a case of a 26‑year‑old gravida 1 para 0 (0010) who came in for profuse vaginal bleeding. Serum beta‑human chorionic gonadotropin (β‑hCG) was elevated and ultrasound showed a hypervascular vaginal mass and an empty uterus. A primary vaginal GTN was considered, and the patient was treated with etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMACO) regimen. During the course of chemotherapy, there was a note of profuse vaginal bleeding, which was controlled by angiographic uterine artery embolization. A normal β‑hCG level was achieved after six cycles of EMACO. The patient was able to have three successful pregnancy outcomes thereafter. Primary vaginal GTN is a rare condition that requires a high index of suspicion. In a nulliparous patient complicated with profuse vaginal bleeding, angiographic embolization is an effective fertility‑sparing procedure that can manage the said complication.

A Case of Dieulafoy's Lesion with Pseudoaneurysm in the Sigmoid Colon / 대한소화기내시경학회지

Dieulafoy's lesions are characterized by a single large tortuous arteriole in the submucosa, and this arteriole does not undergo normal branching. These lesions are an uncommon cause of massive, sometimes fatal gastrointestinal bleeding; this had been reported to be the cause of 0.3~1.5% of the cases of major gastrointestinal bleeding. The lesions mainly occur in the proximal stomach, but they may occur in all parts of the gastrointestinal tract, including the small bowel, colon and rectum. Endoscopy is a common method for the diagnosis and treatment of Dieulafoy's lesions. However, in the case of a high risk lesion, angiography, laparoscopy or laparotomy can be performed instead. We experienced a rare case of bleeding from a Dieulafoy's lesion with pseudoaneurysm in the sigmoid colon. Angiography with embolization was performed, but the patient expired due to rebleeding. We report on this case along with a review of the relevant literature.

Emergent hysterectomy and angiographic embolization for the management of obstetrical hemorrhage: 8-year experiences / 대한산부인과학회지

OBJECTIVE: To compare the clinical characteristics and outcome of hysterectomy and angiographic embolization in the management of obstetrical hemorrhage unresponsive to conservative management. METHODS: We retrospectively analyzed 88 patients who underwent hysterectomy and 53 patients who underwent angiographic embolization for the management of obstetrical hemorrhage from January 1999 to July 2007. We analyzed the maternal characteristics and outcomes by the review of medical records and telephone interview. Nonparametric test was performed for comparison of both groups. RESULTS: Angiographic embolization for the management of obstetrical hemorrhage is on the increase year by year, consisting of about three quarters of total cases in the last year. The most common indication of hysterectomy was abnormal placentation (68.2%) followed by uterine atony (25.0%). For the embolization, the most common indication was uterine atony (54.7%) followed by abnormal placentation (17%). The median pre-operative hemoglobin was significantly lower in embolization group than hysterectomy group [8.3 (3.8~12.7 g/dL) vs. 10.8 (2.4~13.7 g/dL), P<0.001]. There was no difference in the total transfusion amount of packed RBC between the two groups. The median hospital stay was shorter in embolization group [8 (5~57 days) vs. 6 (3~14 days), P<0.001]. Overall success rate of embolization was 89% and procedure-related acute complications were not occurred. Of the total population, there was one maternal death in the hysterectomy group. We found that most women who underwent the embolization resume normal menstruation. CONCLUSION: Angiographic embolization for the management of obstetrical hemorrhage is more commonly performed in recent years. Angiographic embolization was associated with shorter hospital stay, reasonable success rate, and minimal complication rate.

Clinical Profiles of Patients who Undergone Emergency Angiographic Embolization at Emergency Department

PURPOSE: Hemodynamically unstable pelvic fractures represent therapeutic challenges for the trauma team. The authors of this article have studied the clinical profiles of the angiographic intervention population at the emergency department during four years (2005~2009) to develop clinical guidelines for preventing deaths due to multiple trauma and for predicting the prognosis during initial evaluation. METHODS: We performed a retrospective review of 34 patients who had undergone angiographic interventions at the emergency department and compared the differences in clinical variables between survivors and non-survivors. RESULTS: Representative values were compared between survivors and non-survivors : RTS (revised trauma score) 7.006 (6.376~7.841) vs. 6.128 (4.298~6.494), PRC (packed red cell) units 5.5 (2.0~11.0) vs. 15 (8.0~18.5), and lactate (mmol/L) 3.0 (1.0~7.0) vs. 8.5 (3.5~10.5). RTS (p<0.01) and PRC units before angiographic interventions (p=0.01) and lactate (p=0.02) had correlations to the final outcomes. CONCLUSION: The availability of an angiographic suite and persistent hypotension after adequate fluid resuscitation for pelvic trauma are good indications of angiographic intervention for pelvic hemorrhage.

A Case of Ruptured Left Gastric Artery Pseudoaneurysm Complicating Percutaneous Endoscopic Gastrostomy (PEG) / 대한소화기내시경학회지

Percutaneous endoscopic gastrostomy (PEG) is an effective method for delivering enteral nutrition to patients with dysphagia, cerebrovascular accidents, Parkinsonnism, dementia, and head and neck cancer. PEG is generally regarded as safe and it is associated with low risks of morbidity and mortality. The complications of the PEG are known to be mostly minor and they include wound infection, gastric leakage, bleeding, ileus, pneumoperitoneum and aspiration pneumonia. We recently experienced a ruptured pseudoaneurysm of the left gastric artery, which was occurred as a complication during PEG insertion in a 73-year-old female. To the best of our knowledge, this is the first case report in Korea about successful angiographic embolization for a ruptured pseudoaneurysm of the left gastric artery and this was associated with a PEG procedure.

Recent Trends in the Management of Postpartum Hemorrhage / 대한산부인과학회지

The management of postpartum hemorrhage remains one of the significant challenges to clinical practitioners of obstetrics. Massive postpartum hemorrhage is a major cause of maternal death and morbidity. Early postpartum hemorrhage refers to bleeding within the first 24 hours after delivery; late of delayed postpartum hemorrhage occurs more than 24 hours but less than six weeks after delivery. Uterine atony remains the most common cause with many patients presenting with no known risk factors. Postpartum bleeding can result from uterine atony, genital tract lacerations or hematomas, retained placenta, uterine inversion and acquired or inherited coagulopathies. Every obstetrics unit should have protocols available to deal with hemorrhage and have specific guidelines for patients who object to blood transfusions for various reasons. Placement and utilization of arterial catheters for uterine artery embolization is becoming more widespread. Timely hysterectomy should be performed for signs of refractory bleeding. Application of medical and surgical principles combined with recent new technologic advances will help the obstetrician avoid disastrous outcomes for both mother and fetus.

Applicable Indications and Effectiveness of the Selective Arterial Embolization in the Management of Obstetrical Hemorrhage / 대한산부인과학회잡지

OBJECTIVE: To describe the angiographic embolization as a safe and an effective alternative treatment in the management of obstetrical hemorrhage and in preserving fertility. METHODS: Between March 1999 and May 2003, 43 patients at Asan Medical Center underwent angiographic embolization for the management of obstetrical hemorrhage. All cases received arterial embolization because of obstetrical hemorrhage unresponsive to conservative management or prophylaxis for massive obstetrical hemorrhage. Medical records were reviewed and detailed to collect adequate clinical data such as clinical status, underlying conditions, amount of transfusion, embolization sites, materials of embolization, duration of the procedure, complications associated with embolization, hospital stay, and the success rate. Patients were contacted by telephone to obtain long-term outcome for menstruation, desire for conception, and subsequent pregnancies. RESULTS: We have experienced the clinical successful embolization in 37 (86.0%) of 43 patients of obstetrical hemorrhage resulting from various causes. The main cause of hemorrhage was atony of uterus (n=17), followed by abnormal placentation (n=6), genital tract laceration (n=5). The average amount of blood transfusion was 7.0 units (range; 0-36 units). The average length of the time for the procedure was 68.2 minutes (range; 30-150 minutes). The average duration of hospitalization was 6.4 days (range; 3-20 days). The main complication after embolization was numbness and pain on right lower extremities in 5 cases and vessel dissection occurred in 1 case. But there was no major complication related to the procedure. We were able to follow up 28 patients. In all cases menses resumed spontaneously soon after the procedure. Seven cases of long-term follow-up became pregnant, and 3 cases of them completed gestations giving birth to healthy babies. CONCLUSION: The results suggest that angiographic embolization is a relatively noninvasive and highly effective method for the management of obstetrical hemorrhage and a useful technique for preserving fertility.

Angiographic Embolization as a Treatment of Postoperative Bleeding / 대한정형외과학회잡지

PURPOSE: To evaluate the usefulness of the angiographic embolization for the treatment of postoperative bleeding. MATERIALS AND METHODS: Six patients who suffered massive postoperative bleeding underwent angiographic embolization from March 1998 to June 1999. The initial diagnosis was femoral fractures in 4 patients, infected total hip arthroplasty in a patient, and open humerus fracture in a patient. When angiography revealed arterial tear, embolization was performed. The authors evaluated the effectiveness and the complication of angiographic embolization. RESULT: Five patients had arterial tear and one patient had diffuse bleeding from the granulation tissue. Angiographic embolization was performed in all patients. There were 3 cases of injury of the deep femoral artery, a case of injury of a branch of the subclavian artery, and a case of injury of the superior gluteal artery. After the procedure swelling subsided and the amount of transfusion diminished in all patients. There was no complication related to angiographic embolization. CONCLUSION: When there is suspicion of arterial injury after the operation, angiographic embolization can be used to confirm arterial injury and to control bleeding.

Angiographic embolization in the management of obstetrical hemorrhage / 대한산부인과학회잡지

OBJECTIVE: To investigate whether emergency selective arterial embolization may serve as a safe and effective alternative treatment in the management of intractable pregnancy-associated hemorrhage. METHODS: Between February 1992 and March 1999, 20 patients at Seoul National University Hospital underwent angiographic embolization to control obstetrical hemorrhage. In all cases, hemostatic embolization was performed because of intractable hemorrhage unresponsive to conservative management. All available hospital records were reviewed and detailed to collect adequate clinical data such as specific leading complication, clinical status, estimated blood loss and blood replacement requirements, length of procedure, used emboli, complications associated with the procedure, and its results. RESULTS: We have experienced the successful embolization in 18 of 20 patients of pregnancy-related hemorrhage from the different causes. One of these successful cases required two embolization attempts. Two of these patients needed surgical treatment because of rebleeding after the embolization. The mean length of the time for the procedure was 96.4+/-50.1 minutes (range; 50-260 min.). The average length of hospitalization was 10.4+/-7.7 days (range; 1-36 days). No major complication related to the embolization was found. Two women became pregnant after embolization. CONCLUSIONS: This study indicates that angiographic embolization is a safe and effective method for the control of pregnancy-related hemorrhagic complications unresponsive to conservative management and that it allows maintenance of reproductive ability.

The hemostasis in intractable posterior nasal bleeding with angiographic embolization: A case report

Pseudoaneurysm after Renal Biopsy; Angigraphic Diagnosis and Treatment by Superselective Embolization

The use of superselective embolization was assessed as a treatment for bleeding from arteriovenous fistulas and pseudoaneurysm after renal biopsy procedure. But unless it is sufficiently selective, the procedure results in loss of significant amount of renal parenchyme. We experienced one case of renal arterial pseudoaneurysm, which happened at 5days after percutaneous renal biopsy. Diagnosis of pseudoaneurysm was made by ultrasound examination with Doppler flow and was confirmed with arteriography. The rupture of pseudoaneurysm was occluded by transcatheter embolization with placement of a steel coli and polyvinlyl alcohol from the renal arterial approach. This procedure was allowed non surgical closure of the AV fostula and pseudoaneurysm without significant change of renal function.