A minimally invasive hemostatic strategy in obstetrics aiming to preserve uterine function and enhance the safety of subsequent pregnancies

Numerous trial-and-error approaches have been taken to achieve effective hemostasis for difficult obstetrical uterine hemorrhage cases. In the field of obstetrics, transcatheter arterial embolization (TAE) is known to be highly effective for controlling uterine hemorrhage and hematoma. This procedure achieves a high hemostasis rate, and the frequency of hysterectomy has thus sharply decreased. Although arterial ligation for massive hemorrhage at the time of cesarean section may fail to control bleeding in a number of cases due to an abundance of collateral circulation pathways, various new hemostatic techniques such as compression sutures of the uterus, uterine tamponade with gauze or a balloon, and intraoperative TAE have become available. However, complications including subsequent endometrial hypoplasia, menstruation disorder, infertility, pregnancy loss, placenta accreta, and uterine rupture have been reported even in cases undergoing successful hemostasis with TAE using absorbable embolus. Against this backdrop, we reconsidered fertility-preserving hemostatic strategies for critical obstetrical hemorrhage under these circumstances, and herein discuss how to select the optimal strategy based on our knowledge of and experience with various hemostatic procedures.