Radiol Oncol 2024; 58(3): 397-405. doi: 10.2478/raon-2024-0037
397
research article
Emergency and prophylactic uterine artery 
embolization in gynecology and obstetrics – a 
retrospective analysis
Polona Vihtelic1,2, Eva Skuk2,3, Natasa Kenda Suster2,3, Marina Jakimovska Stefanovska2,3, 
Peter Popovic1,2
1 Clinical Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
2 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
3 Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
Radiol Oncol 2024; 58(3): 397-405.
Received 21 February 2024 
Accepted 21 June 2024
Correspondence to: Assoc. Prof. Peter Popovič, M.D., Ph.D., Clinical Institute of Radiology, University Medical Centre Ljubljana, Zaloška 
cesta 7, SI-1000 Ljubljana, Slovenia. E-mail: peter.popovic@kclj.si
Polona Vihtelič and Eva Skuk contributed equally to this work.
Disclosure: No potential conflicts of interest were disclosed.
This is an open access article distributed under the terms of the CC-BY license (https://creativecommons.org/licenses/by/4.0/).
Background. This study aimed to evaluate the safety and efficacy of emergency and prophylactic uterine artery 
embolization (UAE) in our clinical practice, including technical success, clinical success, and associated complica-
tions. 
Patients and methods. In this retrospective study, we analyzed 64 women who underwent emergency (n =18) and 
prophylactic (n = 46) UAE. Indications for emergency UAE included postpartum hemorrhage or severe hemorrhage 
during pregnancy termination, while prophylactic UAE was performed prior to surgical removal of retained products 
of conception (RPOC), delivery with abnormal placental implantation, or pregnancy termination (cervical pregnancy 
or fetal anomalies accompanied by abnormal placental implantation). Technical success of UAE was defined as 
complete exclusion of the vascular lesion and contrast stasis on the final angiogram, while clinical success was de-
fined as cessation of bleeding after UAE Termination without a hysterectomy.
Results. The overall clinical success of UAE in our study was 97% (62/64). All embolization procedures were technically 
and clinically successful in the prophylactic group without life-threatening hemorrhages or hysterectomies (100% suc-
cess rate, 46/46). However, while 100% technical success was similarly attained in the emergency group, bleeding was 
successfully controlled in 89% of cases (16/18). In two patients with significant blood loss (over 2000 mL), embolization 
failed to achieve hemostasis, resulting in persistent bleeding and subsequent hysterectomy. 
Conclusions. UAE is a safe and effective procedure for managing primary postpartum hemorrhage or severe hem-
orrhage during pregnancy termination and for decreasing the risk of severe hemorrhage during surgical removal of 
RPOC, delivery with abnormal placental implantation, or pregnancy
Key words: postpartum hemorrhage; retained products of conception; endovascular treatment; uterine artery em-
bolization; hysterectomy; fertility
Introduction
Complications during pregnancy include severe 
life-threatening hemorrhage that can occur during 
vaginal or cesarean delivery, pregnancy termina-
tion, or surgical removal of retained products of 
conception (RPOC).
Primary postpartum hemorrhage (PPH) is a 
leading cause of obstetric morbidity and mortality 
globally, accounting for more than 100,000 mater-
Radiol Oncol 2024; 58(3): 397-405.
Vihtelic P et al. / Emergency and prophylactic uterine artery embolization398
nal deaths annually. Pathologic postpartum hem-
orrhage, which occurs in up to 10% of deliveries, 
is characterized by excessive blood loss during 
childbirth, defined as more than 500 mL for vagi-
nal deliveries and more than 1,000 mL for cesarean 
births. Postpartum hemorrhage is further classi-
fied based on the time of its occurrence. Primary 
postpartum hemorrhage refers to excessive bleed-
ing within 24 hours after delivery, whereas sec-
ondary postpartum hemorrhage describes bleed-
ing that occurs anytime within six weeks after 
birth.1-4 The most common causes of primary PPH 
are summarized in the 4 T mnemonics and include 
uterine atony, trauma (birth canal lacerations), tis-
sue (retained/abnormal placenta), and thrombin 
(coagulopathies). Uterine atony accounts for ap-
proximately 70% of cases of PPH and can lead to 
hemorrhagic shock, which may progress to en-
dothelial damage and disseminated intravascular 
coagulation (DIC).1-5 Placental causes, including 
abruption or placental implantation abnormalities 
(placenta previa, accreta, percreta, increta), are less fre-
quent conditions but can also lead to severe post-
partum hemorrhage.2,3
Retained products of conception (RPOC) re-
fer to persistent placental and/or fetal tissue that 
remains in the uterine cavity after a vaginal or 
cesarean delivery, miscarriage, or pregnancy ter-
mination.6-9 The estimated prevalence of RPOC is 
approximately 1% in term pregnancies and is more 
frequent after medical termination of pregnancy 
or miscarriage.8 Recent literature reports a newly 
identified form of RPOC with highly vascularized 
characteristics on Doppler ultrasound observa-
tions. According to the literature, the occurrence 
rate of this particular entity is estimated to be 
around 18%.6 RPOC is associated with long-term 
complications, such as intrauterine adhesions, 
menstrual abnormalities, infertility, recurrent 
pregnancy loss, and placental complications.3,6-8
Hemorrhage during pregnancy termination oc-
curs in less than 1% of abortions. Bleeding may 
result from uterine atony, placental abnormalities 
spectrum, lacerations, and coagulopathies.3,9
Cervical pregnancy is a rare form of ectopic 
pregnancy, where pregnancy implants in the en-
docervical canal, and it accounts for less than 1% 
of all ectopic pregnancies. The incidence is esti-
mated to be 1 in 9,000 pregnancies. The condition 
requires pregnancy termination, and the main po-
tential complication is a high risk of severe hemor-
rhage.10,11
Selective transcatheter uterine artery emboli-
zation was first reported in 1979 as a second-line 
therapy for severe persistent postpartum hemor-
rhage.4 Subsequent publications have further es-
tablished the efficacy and safety of endovascu-
lar methods in controlling uterine bleeding and 
achieving hemostasis.1-5 In 2017, the American 
College of Obstetricians and Gynecologists incor-
porated transcatheter arterial embolization (TAE) 
into their recommendations for managing post-
partum hemorrhage, emphasizing the importance 
of preserving the uterus and potentially future fer-
tility. Additionally, the International Federation of 
Gynecology and Obstetrics recognized the safety 
and efficacy of TAE in their 2022 PPH management 
guidelines, stating that this technique is a viable op-
tion for patients prioritizing fertility preservation.4
Embolic agents include absorbable gelatin 
sponges, microspheres, liquid agents, and cy-
anoacrylate glue. The preferred embolic mate-
rial in our practice is the gelatin sponge, as this is 
the most frequently studied embolic agent in the 
treatment of postpartum hemorrhage, which tem-
porarily (3 – 6 weeks) occludes the target vessel. 
Subsequent recanalization of the arteries has a 
theoretical advantage for patients desiring future 
fertility.1,5
Imaging findings 
PPH and pregnancy termination-related hemor-
rhage are conditions that require immediate in-
tervention; therefore, imaging is often limited to 
digital subtraction angiography during an endo-
vascular procedure. Computer tomography angi-
ography (CTA) is routinely not performed in the 
preprocedural assessment of postpartum hem-
orrhage due to time delay in the setting of active 
bleeding and radiation exposure to radiosensitive 
tissue in a typically young patient. However, CTA 
can be used when the underlying cause or location 
of hemorrhage is uncertain or if there is a recur-
rence of bleeding after an initially successful em-
bolization.12
FIGURE 1. Patient distribution for prophylactic and 
emergency uterine artery embolization (UAE).
Radiol Oncol 2024; 58(3): 397-405.
Vihtelic P et al. / Emergency and prophylactic uterine artery embolization 399
Doppler ultrasound and magnetic resonance 
imaging can identify placental irregularities, cer-
vical pregnancy, and vascularization in the case 
of RPOC. These two imaging techniques are of-
ten required in planning delivery and the proper 
treatment protocol for pregnancy termination or 
RPOC.11-13 In the case of RPOC, ultrasound helps 
us to assess the degree of vascularization. The 
marked vascularity feature is established in the 
presence of an exuberant color Doppler signal 
(Figure 2A).6-8
Contrast-enhanced CT has a limited role in the 
evaluation of hypervascular RPOC due to inaccu-
racy in soft tissue assessment. RPOC on CT shows 
an intensely enhanced heterogenous mass in the 
uterine cavity during the arterial phase or extrava-
sation of intravenous contrast in case of large ar-
terial hemorrhage in the postpartum period.14-15 
Pelvic MRI provides more detailed information 
if the diagnosis of hypervascularity in RPOC is 
unclear and there is no urgency.7,14 Key MRI find-
ings include intracavitary uterine soft-tissue mass 
with variable T1 and T2 signal intensities, variable 
amounts of enhancing tissue, and variable degrees 
of myometrial thinning and obliteration of the 
junctional zone (Figure 3A).14,16
Digital subtraction angiography (DSA) is 
the gold standard for evaluating blood vessels 
A B
C D E
FIGURE 2. (A) Transvaginal ultrasonography in a 34-year-old female with vaginal bleeding after spontaneous termination 
of pregnancy at 12 weeks of gestation. Color Doppler ultrasound showed a 45 x 30 mm mass in the uterus with increased 
vascularity suggestive of retained products of conception. (B) Pelvic arteriogram demonstrating numerous spiral arteries in 
the uterus fed by both right and left uterine arteries, confirming the diagnosis of RPOC. (C) Left uterine arteriogram in the same 
patient before prophylactic embolization with absorbable gelatin sponge particles showing numerous spiral arteries. Post-
embolization left (D) and right (E) uterine arteriogram demonstrating successful embolization. Subsequently, surgical resection 
of retained products of conception was successfully performed.
Radiol Oncol 2024; 58(3): 397-405.
Vihtelic P et al. / Emergency and prophylactic uterine artery embolization400
and confirming intrauterine vascular lesions.6 
Angiographic findings include enlarged and tor-
tuous uterine arteries with well-defined focal 
masses made up of vascular tangles, a focal blush 
of contrast, early venous return, extravasation, 
and pseudoaneurysm (Figures 2B, D; 3B, D).6,8 
However, the presence of active extravasation on 
DSA is relatively rare in cases of postpartum hem-
orrhage, particularly in cases of uterine atony. The 
required rate of bleeding for angiographic detec-
tion is typically around 1−2 mL/min, which may be 
too low to detect in cases of uterine atony.17
Treatment options
Severe acute uterine cavity bleeding during vagi-
nal/cesarean delivery, pregnancy termination, and 
removal of RPOC is initially managed by complete 
emptying of the contents of the uterine cavity, uter-
ine massage, uterotonics, fluid resuscitation, and 
tranexamic acid administration. In some patients, 
further mechanical (intrauterine balloon tampon-
ade) or sometimes surgical (internal iliac artery li-
gation) interventions are required.18 Hysterectomy 
has traditionally been considered the last and de-
finitive treatment option.4,12,13 To avoid the sterility 
and significant morbidity associated with emer-
gent hysterectomy, uterine artery embolization has 
been emphasized as a minimally invasive therapy 
for rapidly controlling hemorrhage that is refrac-
tory to standard gynecological treatment.5
In some cases of uterine hemorrhage, immediate 
hemodynamic instability is not a predominant con-
cern, but according to imaging findings (ultrasound 
and MRI), a high risk for severe hemorrhage is ex-
pected with further gynecological intervention. 
Such cases may include vaginal/cesarean delivery 
with abnormal placentation, pregnancy termina-
tion with abnormal placentation, termination of 
cervical pregnancy, and surgical removal of highly 
vascularized RPOC (Figure 2, 3).3,6,7,12,13 In these cas-
es, prophylactic uterine artery embolization (UAE) 
is performed prior to surgical removal of RPOC, de-
livery, or pregnancy termination to reduce the risk 
of hemorrhage, offering a safe alternative to hyster-
ectomy and, therefore, preserving fertility.6-8
FIGURE 3. (A) Abdominal magnetic resonance imaging 
in a 35-year-old woman with singleton pregnancy at 
the 33rd week of gestation with suspected placenta 
accrete. The placenta covers the whole anterior part 
of the uterine wall. On T2-weighted MR images, there is 
marked thinning of the myometrium at the placental-
myometrial interface, with MRI signs of placenta 
accrete and placenta increta. On the left cranial part 
of the junction, there is suspected placental invasion 
through the entire uterine wall, suspicious for placenta 
percreta. (B-E) Selective uterine angiography and 
embolization following delivery in the same 35-year-
old woman with placenta accrete. Left (B) and right (D) 
uterine angiogram confirming the diagnosis of RPOC 
with numerous voluminous spiral arteries before prophylactic embolization. Left (C) and right (E) post-embolization angiogram 
after successful selective uterine artery embolization with absorbable gelatin sponge particles to reduce vascularity prior to 
surgical removal. After embolization, the placental tissue was successfully resected, and hysterectomy was prevented. 
A B C
D E
Radiol Oncol 2024; 58(3): 397-405.
Vihtelic P et al. / Emergency and prophylactic uterine artery embolization 401
Patients and methods
Study population
This retrospective single-center study was con-
ducted at the University Medical Centre Ljubljana 
and was approved by the National Medical 
Ethics Committee of the Republic of Slovenia on 
December 8, 2021 (ref. no. 0120-285/2021/11). The 
study analyzed clinical data over a ten-year period 
(from 2012 to 2022). The data were obtained from 
the hospital information system of the University 
Medical Centre Ljubljana, the Perinatal Information 
system of the Republic of Slovenia, and from the 
completed patient questionnaires. 
A total of 64 patients were included in the 
analysis and divided into two main categories – 
women who underwent prophylactic (46 patients) 
or emergency (18 patients) UAE. Patients in the 
prophylactic group were treated with UAE with 
the goal of decreasing the risk of massive bleed-
ing during surgical removal of RPOC, pregnancy 
termination, or delivery. Patients in the emergency 
group were treated with UAE to control acute uter-
ine cavity hemorrhage during pregnancy termina-
tion or delivery that was refractory to standard gy-
necological management. In both indications, the 
ultimate goal was to reduce blood loss and avoid 
an emergency hysterectomy.
The following data were collected from the 
medical records: age of patients, gynecological 
history, gestational week at pregnancy termina-
tion or delivery, indication for pregnancy termina-
tion, placental abnormalities, cause of PPH, type 
of UAE (prophylactic/emergency), estimated total 
blood loss during pregnancy termination, delivery 
or gynecological procedure and the necessity for 
hysterectomy. 
The clinical diagnoses were made by a complete 
gynecological examination, followed by a sono-
graphic assessment with a color Doppler ultra-
sound. Pelvic magnetic resonance imaging (MRI) 
was performed in indecisive cases and when there 
was no urgency. All patients underwent a diagnos-
tic uterine digital subtraction angiography to con-
firm the diagnosis of intrauterine vascular lesion 
or hemorrhage before embolization. The decision 
on endovascular treatment was made by a multi-
disciplinary team, including gynecologists/obste-
tricians and interventional radiologists.
UAE procedure
Pelvic angiography was performed via a trans-
femoral approach under local anesthesia, followed 
by a selective bilateral or unilateral uterine artery 
angiography (Figure 2, 3). In all cases, a 5-French 
sheath was inserted into the right common femo-
ral artery, followed by catheterization and angi-
ography of the internal iliac artery to identify the 
uterine arteries on both sides as well as potential 
sites of bleeding. Next, selective catheterization 
of uterine arteries with a microcatheter (Progreat, 
Terumo) was performed to decrease the risk of in-
ducing vasospasm. Arterial feeder pedicles were 
embolized by absorbable gelatin sponge particles 
(Marbagelan), microspheres, and balloon occlu-
sion at the level of the internal iliac artery. The 
embolization was completed after contrast stasis as 
determined by fluoroscopy and confirmed by bi-
lateral uterine artery angiography. 
Study endpoints and definitions
This study aimed to evaluate the safety and efficacy 
of UAE in a cohort of 64 patients who underwent 
the procedure for the management of obstetric or 
gynecologic hemorrhage. The study focused on 
analyzing technical success, clinical success, and 
complications.
Pregnancy termination (also called abortion) 
was defined as the cessation of pregnancy before 
the 22nd gestational week or when the fetus weighs 
less than 500 g. Conversely, the termination of 
pregnancy beyond the 22nd gestational week was 
categorized as delivery. 
Technical success was defined as the emboliza-
tion of bilateral or unilateral uterine arteries with 
complete exclusion of the vascular lesion and con-
trast stasis on the final angiogram. Clinical success 
was defined as cessation of bleeding after UAE 
without a hysterectomy. 
Postembolization complications were docu-
mented according to the criteria of the Society of 
Interventional Radiology.19 To confirm the efficacy 
of the interventional procedure and uterine surgi-
cal treatment, patients were carefully monitored 
on outpatient follow-up visits with referring ob-
stetricians or gynecologists until confirmation of 
the absence of any re-bleeding or uterine irregu-
larities.
Results
The age range of the women included in the study 
was 22 – 45 years (mean 34 ± 6). Among them, 46 
patients (72%) were treated with prophylactic UAE 
and 18 (28%) with emergency UAE.
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Vihtelic P et al. / Emergency and prophylactic uterine artery embolization402
In the prophylactic UAE group (Table 1), the 
patients were further subdivided into four sub-
groups based on both timing and cause of preg-
nancy termination and cause of RPOC. 
We performed UAE prior to pregnancy termi-
nation in cases involving fetal anomalies accom-
panied by placental abnormalities (5 patients) or 
cervical pregnancy (4 patients). Minimal blood 
loss was observed during the subsequent gyneco-
logical procedure, and no hysterectomies were 
required in both cases. Additionally, 8 patients 
underwent embolization prior to delivery due to 
placental abnormalities with or without accom-
panied fetal anomalies. No hysterectomies were 
required despite slightly higher blood loss in this 
group, including one patient with a blood loss of 
1,800 mL. Lastly, we performed embolization due 
to highly vascularized RPOC in 21 patients after 
pregnancy termination (Figure 2) and in 8 patients 
after delivery (Figure 3), followed by safe surgical 
removal, and hysterectomies were avoided in all 
cases within these two groups.
In the second study group (18 patients), emboli-
zation was performed as an emergency interven-
tion to manage uncontrolled bleeding during preg-
nancy termination or delivery (Table 2). Among 
these patients, three required embolization during 
pregnancy termination due to excessive bleeding 
TABLE 1. Clinical overview of the prophylactic uterine artery embolization (UAE) group
PROPHYLACTIC UAE Number of cases Intervention
Blood loss during 
gynecological 
procedure
Hysterectomy
BEFORE PREGNANCY TERMINATION
Fetal anomalies
accompanied by
placental abnormalities
5 Embolization → pregnancy termination
300–400 mL
(median 300 mL) 0
Cervical pregnancy 4 Embolization → pregnancy termination
100–400 mL
(median 250 mL) 0
BEFORE DELIVERY
Placental abnormalities 
with or without fetal 
anomalies 
8 Embolization → vaginal/cesarean delivery
200–1,800 mL
(median 400 mL) 0
AFTER PREGNANCY TERMINATION
Retained products of 
conception (RPOC) 21
Embolization → surgical 
removal of RPOC 100– 400 mL 0
AFTER DELIVERY
Retained products of 
conception RPOC 8
Embolization → surgical 
removal of RPOC 100– 500 mL 0
TABLE 2. Clinical overview of the emergency uterine artery embolization (UAE) group
EMERGENCY UAE Number of cases Intervention
Blood loss during 
gynecological 
procedure
Hysterectomy
DURING PREGNANCY TERMINATION
Hemorrhage 3 Pregnancy termination 
→ hemorrhage → 
embolization
2x 300 mL
1x 1,000 mL
0
DURING DELIVERY
Uterine atony 10 Hemorrhage after 
vaginal/Cesarean 
delivery → intrauterine 
balloon tamponade → 
embolization
8x < 1,000 mL
1x > 2,000 mL
1x > 3,000 mL
2
Placental abnormalities 5
Hemorrhage after 
vaginal/Cesarean 
delivery → intrauterine 
balloon tamponade → 
embolization
< 800 mL 0
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Vihtelic P et al. / Emergency and prophylactic uterine artery embolization 403
despite standard gynecological treatment. The 
embolization procedure effectively achieved he-
mostasis. 
Causes of PPH included uterine atony (10 pa-
tients) and placental abnormalities (5 patients). 
Eight patients with uterine atony-related hemor-
rhage were successfully treated with UAE after 
standard treatment (including intrauterine balloon 
insertion in three patients) had failed. However, 
it is important to note that two cases within this 
group experienced ineffective hemostasis, leading 
to a peripartum emergency hysterectomy. The first 
case involved a patient with a unicornuate uterus 
with severe hemorrhage due to uterine atony fol-
lowing a cesarean section. Following unsuccess-
ful standard treatment, emergency UAE partially 
alleviated the bleeding, but additional blood loss 
ensued, and despite extensive gynecological and 
endovascular efforts, an emergency hysterectomy 
was ultimately required as a final intervention. 
In the second case, the patient experienced uter-
ine atony, rupture, and retroperitoneal hematoma 
following a cesarean delivery of twins, leading to 
significant blood loss. Despite conservative and 
surgical interventions followed by UAE, the bleed-
ing persisted, and the patient progressed to hem-
orrhagic shock. A hysterectomy was eventually 
performed to save the patient’s life. In the last sub-
group (5 patients), we effectively managed hem-
orrhage related to placental abnormalities during 
delivery using UAE. 
Technical and clinical success
The uterine arteries were embolized bilaterally (60 
patients, 94%) or unilaterally in cases involving 
anatomical variants (agenesis of the uterine artery) 
(4 patients, 6%). Nevertheless, the technical success 
rate was 100% as the contrast stasis was success-
fully achieved in all cases, as confirmed by the final 
angiogram. 
Embolization procedures were primarily per-
formed using absorbable gelatin sponge particles 
(57 patients, 89%). In a minority of cases, alterna-
tive occlusion options were employed, including a 
combination of gelatin sponge with microspheres 
(3/64), microspheres (1/64), and temporary balloon 
occlusion at the level of the internal iliac artery 
(3/64). 
In the prophylactic group, a clinical success rate 
of 100% was achieved, indicating that all patients 
experienced successful outcomes. In the emer-
gency group, the clinical success rate was 89%. 
Overall, hemostasis was effectively achieved in 
62 out of 64 patients, resulting in a clinical success 
rate of 97% across the entire cohort.
In the prophylactic group, an estimated medi-
an blood loss of 200 mL was observed during the 
surgical intervention after embolization, and no 
hysterectomies were required. The performance of 
embolization as an emergency procedure was as-
sociated with higher blood loss. Two postpartum 
hysterectomies were necessary for our emergency 
group due to unsuccessful hemostasis despite gy-
necological and endovascular interventions. 
Complications
During the procedures, a single peri-procedural 
complication in the form of uterine artery spasm 
was encountered. This complication was success-
fully managed by administering a short-acting 
vasodilator (nitroglycerin), allowing for the safe 
continuation of the embolization without any fur-
ther problems. 
No major post-procedural complication was re-
corded in our study. However, five patients (8%) 
reported moderate pain in the lower abdomen in 
the immediate post-intervention period, which 
was effectively managed with oral or parenteral 
analgesics. Additionally, no procedure-attribut 
able complications were noted during the subse-
quent outpatient follow-up.
Discussion
The effectiveness of UAE in managing primary 
and secondary postpartum hemorrhage is high, 
and recent literature reports 99% technical suc-
cess, whereas the clinical success rates range from 
87% to 95%.1,17,20,21 In our study, technical success in 
the prophylactic and emergency group was 100%. 
Clinical success in the prophylactic and emergency 
groups was 100% and 89%, respectively (overall 
clinical success rate of 97%). UAE was unsuccess-
ful in achieving hemostasis in 2 patients with uter-
ine atony following cesarean delivery, resulting in 
blood loss exceeding 2,000 mL and ultimately re-
quiring a hysterectomy. In cases where emboliza-
tion was unsuccessful, gelatin sponge and micro-
spheres were used as the embolization materials. 
Our findings of failed endovascular therapy are 
consistent with those reported in the literature. 
Brown et al. and Sentilhes et al. described predictive 
factors for the failure of UAE, which include blood 
loss of more than 1,500 mL, DIC, large volume 
transfusion (> 5 red blood cell units), and cesarean 
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Vihtelic P et al. / Emergency and prophylactic uterine artery embolization404
delivery.1,2 Sugai et al. suggest that using a gelatin 
sponge as an embolic agent is associated with fail-
ure of the embolization in patients with DIC. The 
formation of a thrombus around the gelatin sponge 
depends on the patient’s coagulation ability, which 
is impaired in DIC patients.22 Furthermore, Lee et 
al. observed a strong association between excessive 
blood loss (> 1,500 mL) accompanied by hemody-
namic shock and instability and poor outcomes of 
UAE in a cohort of 251 patients. Nevertheless, it is 
still recommended that UAE should also be con-
sidered in hemodynamically unstable patients and 
patients with coagulopathies, but these patients re-
quire close monitoring and care.21
Our study suggests that UAE is a safe procedure 
as no major complications were recorded follow-
ing the procedure. A recent systematic review of 26 
studies by Zhang et al. reports a complication rate 
of 13%.20 The majority of complications are minor 
and associated with arterial puncture and angiog-
raphy.2,17 Postembolization syndrome, character-
ized by transient abdominal pain, fever, nausea, 
and mild leukocytosis, is the most frequently re-
ported complication, and it can be effectively man-
aged using analgesic and anti-inflammatory medi-
cations. Other complications, such as neuropathy 
and organ ischemia/uterine infarction, are rare.20 
The effects of UAE on fertility and subsequent 
pregnancy outcomes have not been sufficiently 
studied to date, and most fertility outcomes derive 
from UAE in the case of uterine fibroma.4 Existing 
literature reports no adverse effect on fertility in 
women who underwent pelvic arterial emboliza-
tion in the majority of cases (91-100%).6 Hardeman 
et al. demonstrated no significant difference in fer-
tility outcomes between patients who underwent 
UAE for severe PPH and those who did not under-
go the procedure.23 However, some authors sug-
gest that there may be associated with a slightly 
increased recurrence rate of PPH and a higher risk 
of first-trimester miscarriage in subsequent preg-
nancies.4,5 Although endovascular embolization 
preserves fertility compared to hysterectomy, fur-
ther research is needed to observe the long-term 
effect on uterine function and future pregnancy 
outcomes.6-8,12
Conclusions
Our study findings suggest that UAE is a safe and 
effective procedure for managing severe uterine 
cavity bleeding in PPH or pregnancy termina-
tion hemorrhage, as well as for reducing the risk 
of hemorrhage during surgical removal of highly 
vascularized RPOC, placental abnormalities in 
pregnancy termination /delivery and cervical 
pregnancy termination. It is a minimally invasive, 
uterine-sparing alternative to radical surgical treat-
ment with hysterectomy and a promising option 
for patients desiring future fertility. Early coopera-
tion between gynecologists/obstetricians and in-
terventional radiologists may improve the clinical 
outcomes of UAE. The shortcoming of this study 
is the lack of long-term follow up to access the ef-
fect of UAE on fertility and subsequent pregnancy 
outcomes comprehensively.  
Acknowledement
Authorship contribution statement  
(Contributor Roles Taxonomy, CRediT)
Polona Vihtelic: Writing – original draft, Writing – 
review & editing, Investigation. Eva Skuk: Writing 
– review & editing, Investigation, Project admin-
istration. Nataša Kenda Suster: Conceptualization, 
Resources, Writing – review & editing, Supervision, 
Validation. Marina Jakimovska Stefanovska: Su-
pervision, Resources. Peter Popovič: Conceptu-
alization, Methodology, Investigation, Writing – 
review & editing, Supervision.
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