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Table 1 Summary of key recommendations

From: CIRSE standards of practice on gynaecological and obstetric haemorrhage

Indications For genital bleeding following vaginal or caesarean delivery or due to surgical complications, including post hysterectomy, OHE should be considered, particularly if bleeding is due to spontaneous pseudoaneurysm rupture.
Prophylactic balloon catheter occlusions and/or uterine embolisation can be used for patients undergoing planned hysterectomy, as well as for those who wish to have conservative management with uterine sparing techniques.
If all medical measures and surgical interventions are unsuccessful, uterine artery embolisation (UAE) should be performed before hysterectomy if the woman is haemodynamically stable enough to be moved and there is an embolisation service available nearby. Embolisation can also be undertaken in a theatre environment where there is access to hybrid theatre facilities.
Contraindications Uterine rupture and eversion should be treated with surgery, however there are no absolute contraindications regarding OHE.
Imaging In a slower intermittent bleed, and/or if relevant for the procedure, ultrasound, CT and MR may be helpful prior to proceeding to catheter angiography.
Triple-phase CT protocols are recommended, with an unenhanced scan followed by arterial phase (30 s) and a delayed portal venous phase (60–70 s).
Procedure In PPH, arterial embolisation is preferentially performed with non-permanent embolic material i.e. resorbable pledgets in both uterine arteries.