blood, 4 of fresh frozen plasma, and 4 of platelets and was transferred to radiology department for SAE. Her haemodynamic status remained stable under continuous perfusion of norepineph- rine during and after SAE. At this point computed tomography of the brain showed a cerebral haemorrhage with intraventricular bleeding, although gynaecological bleeding had stopped by then. After a day in the ICU, two electroencephalograms revealed no cerebral activity; she died the next day. The second patient, aged 38 years, gravida 4, para 4, had vaginal delivery followed by PPH due to cervicovaginal tears, that persisted despite immediate surgical repair and vaginal packing. Cardiorespiratory arrest ensued three hours later, requiring resuscitation and transfusion of 6 whole blood units. After transfer to our department, electrocardiac activity continued but circula- tory activity was insufficient. We performed SAE of left uterine artery and right anterior branch of the hypogastric artery. Because of continued bleeding and haemodynamic instability, a hysterec- tomy followed, with the vaginal tear repaired during aortic cross- clamping. While bleeding stopped after surgery, severe multiorgan failure had already occurred, and she died 30 hours after delivery. Outcome of SAE SAE was effective for 73 patients (71.5%), 14 (13.7%) of whom required a second embolisation during the first 24 hours. The other 29 women required surgery. These included 9 laparotomies with focused limited haemostasis, 7 hysterectomies, 2 uterine artery ligations, and 11 genital tear repairs. In these latter procedures SAE was performed after reparation of any genital tears however 11 patients had still persistent bleeding after initial repair and SAE thus requiring a second surgery. SAE led to a reduction of pelvis blood flow that might have increased the efficiency of secondary surgery. General complications included cardiogenic pulmonary oede- mas related to the haemorrhage in 5 women, transient renal failure in 7, one of whom subsequently developed cortical necrosis and end-stage renal failure, and myocardial ischaemia in 3. Local complications included ischaemia of the lumbar plexus in one patient, and gluteal pain persisting 4 months in another. The mean duration of stay in the intensive care unit was 2.0761.2 days (1–6.2). The factors significantly associated to embolisation success or failure are represented in Table 2. The univariate analysis showed that mode of delivery was correlated with successful SAE: it was successful for 63 of 81 (77.7%) with vaginal deliveries, compared with 11 of 21 patients with caesarean births (52.7%) (p = 0.017). We also analysed the role of different causes of PPH on the outcome of SAE: uterine atony was associated with high rate of success (39 of 44 patients, 88%) (p,0.005). Efficacy of SAE did not differ according to the other causes, but vaginal and cervical tears had a trend towards lower success rates: 9 failures in 20 patients (45%)(p = 0.06). Of the other characteristics considered, failure Arterial Embolisation was significantly associated with shock (18 failures among 46 patients, 39.1%, p = 0.02). When we used multivariate analysis to examine factors that predicted success of arterial embolisation, three variables were significant: good outcome was associated with uterine atony (odds ratio (OR 4.13 (95% CI, 1.35–12.6)), while poor outcome was associated with caesarean delivery (OR 0.16 (95% CI, 0.04–0.5)) and with shock (OR 0.21 (95% CI, 0.07–0.6)). Discussion Efficiency of SAE was 71.5% in the whole study population. Uterine atony that was associated with positive outcome with an overall success rate of 88.6% (OR 4.13, 1.35–12.60). However, caesarean deliveries (OR 0.16, 0.04–0.5) and haemodynamic shock (OR 0.21, 0.07–0.60) were associated with higher failure rates, 47.6% and 39.1%, respectively. SAE is a non-surgical, minimally invasive method of uterine devascularisation [13]. Over the past five years, this technique has become widely used in the treatment of PPH in France [16,18]. Previous studies have reported low morbidity and excellent success rates for SAE, ranging from 85% to 95% [13,16,18]. The literature so far nonetheless has several limitations. Most of the studies are retrospective, and the two largest prospective studies include only 27 and 35 patients [16,18]. The 71% success rate we report here is lower than the rates reported in previous studies. We included all patients with severe life-threatening PPH. All these patients were admitted to the intensive care unit because of haemodynamic instability or severe coagulopathy. The severe condition of the patients in this study may explain this lower success rate. Moreover, the patients described in other studies were treated during the development of the technique since these promising results, not only the indications for SAE have been extended to PPH after caesarean delivery, vaginal or cervical tears, but the severity of illness of the patients treated is more important than the patients in the preliminary studies. Limitations One of the major limitation of the haemodynamic parameter is the difficulty to exactly assess the boold Loss. The use of a systematic collection bag is part of the recommendation of the french college of Obstetrics and Gynecology. However it probably underestimate the real blood loss. This study reports results of SAE performed by 7 different radiologists, compared with only 4 in our previous report [16,18]: the reproducibility of the technique may also be responsible for the lower success rate and this matter deserve an evaluation, the number of cases in this study was not enough to reach statistical significance regarding clinical perfor- mances of the different radiologist. Most of the patients of the current study were transferred from other obstetrics units, because of the severity of their illness. This might have affected their Table 2. Factors significantly associated to embolisation success or failure. Factors Vaginal delivery Caesarean Uterine atony Vaginal and/or cervical tears Haemodynamic shock doi:10.1371/journal.pone.0003819.t002 Successful embolisation (N = 73) Unsuccessful embolisation (N = 29) P (CI) 63/73 (86.3%) 11/73(15%) 39/73 (53%) 11/73 (15%) 28/73 (38.3%) 18/29 (62%) 10/29 (34%) 5/29 (17.2%) 9/29 (31.%) 18/29 (62%) 0.01 0.01 0.06 0.02 ,0.001 PLoS ONE | www.plosone.org 4 November 2008 | Volume 3 | Issue 11 | e3819