Uterine-sparing surgical procedures to control postpartum hemorrhage.

Postpartum hemorrhage remains one of the principal causes of maternal mortality in the United States and throughout the world. Its management, which must be multidisciplinary (obstetrics, midwifery, anesthesiology, interventional radiology, and nursing), depends on the speed of both diagnosis and implementation of medical and surgical treatment to control the hemorrhage. The aim of this work is to describe the various techniques of vessel ligation and of uterine compression for controlling and treating severe hemorrhage, and to present the advantages and disadvantages of each. It is not difficult to perform vessel ligation of the uterine arteries: O'Leary's bilateral ligation of the uterine artery, Tsirulnikov's triple ligation, and AbdRabbo's stepwise uterine devascularization (that is, stepwise triple ligation). These procedures are associated with a high success rate (approximately 90%) and a low complication rate. Bilateral ligation of the internal iliac (hypogastric) arteries is more difficult to perform and potentially less effective (approximately 70% effectiveness) than the previously mentioned procedures. Its complication rate is low, but the complications are most often serious. There is no evidence that future fertility or subsequent obstetrical outcomes are impaired by ligation of either the uterine or internal iliac arteries. There are many techniques used for uterine compression sutures, and none has shown clear superiority to another. Uterine compression suture has an effectiveness rate of approximately 75% after failure of medical treatment and approximately 80% as a second-line procedure after unsuccessful vessel ligation. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but is probably around 5%. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but probably ranges between 5% and 10%. The methodologic quality of the studies assessing uterine-sparing surgical procedures remains limited, with no comparative studies. Accordingly, no evidence suggests that any one of these methods is better than any other. Accordingly, the choice of surgical technique to control hemorrhage must be guided firstly by the operator's experience. If the hemorrhage continues after a first-line uterine-sparing surgical procedure and the patient remains hemodynamically stable, a second-line procedure can be chosen. Nonetheless, the application of these procedures must not delay the performance of a peripartum hysterectomy in cases of hemodynamic instability.

A Successful Pregnancy after Laparoscopic Surgery: Severe Recurrent Pelvic Arteriovenous Malformation Managed by Laparoscopic Internal Iliac Artery Ligation.

STUDY OBJECTIVE: To show a case of severe pelvic arteriovenous malformation (AVM) treated by laparoscopic internal iliac artery ligation after 2 uterine artery embolization (UAE) procedures, where successful pregnancy was achieved after surgery. DESIGN: Stepwise demonstration of the technique with a video. SETTING: Chinese PLA General Hospital. INTERVENTIONS: A 36-year-old woman with heavy menstrual bleeding was diagnosed with pelvic AVM by computed tomography scan. Before surgical intervention, she underwent 2 UAE procedures that temporarily reduced menstrual blood loss. Finally, we performed a laparoscopic internal iliac artery ligation on her. After the surgery, she conceived naturally. During the cesarean section, no AVMs were found. CONCLUSION: Laparoscopic internal iliac artery ligation can be a choice for patients who still have severe symptoms of AVM after UAE.

Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020.

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.

No. 383-Screening, Diagnosis, and Management of Placenta Accreta Spectrum Disorders.

BACKGROUND: Placenta accreta spectrum (PAS) disorders are a potentially life-threatening complication of pregnancy that demand coordinated interdisciplinary care to achieve safer outcomes. The rising incidence of this disease is due to a growing number of uterine surgical procedures, including the rising incidence of pregnancy following Caesarean section. OBJECTIVE: To provide current evidence-based guidelines on the optimal methods used to effectively screen, diagnose, and manage PAS disorders. METHODS: Members of the guideline committee were selected on the basis of their ongoing expertise in managing this condition across Canada and by practice setting. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated diagnostic tests, surgical procedures, and clinical outcomes. EVIDENCE: Published literature, including clinical practice guidelines, was retrieved through searches of Medline and The Cochrane Library to March 2018 using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized controlled trials, and observational studies written in English. Searches were updated on a regular basis and incorporated in the guideline to July 2018. VALUES: The quality of evidence in this document was graded using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. RESULTS: This document reviews the evidence regarding the available diagnostic and surgical techniques used for optimal management of women with suspected PAS disorders, including anaesthesia and practical considerations for interdisciplinary care. BENEFITS, HARMS, AND COSTS: Implementation of the guideline recommendations will improve awareness of this disease and increase the proportion of affected women receiving interdisciplinary care in regional centres. CONCLUSIONS: Interdisciplinary team-based care providing accurate diagnostic services, coordinated planning, and safer surgery deliver effective care with improved clinical outcomes in comparison with alternative management. SUMMARY STATEMENTS: RECOMMENDATIONS.

Severe hydronephrosis secondary to uterine artery pseudoaneurysm in the early second trimester of pregnancy: A case report.

BACKGROUND: Uterine artery pseudoaneurysm (UAP) normally presents genital bleeding in the puerperal period, and severe hydronephrosis rarely presents during pregnancy. We report a rare case of severe ureteral obstruction accompanied by uterine artery pseudoaneurysm in the early second trimester of pregnancy, which was successfully treated by surgical intervention. CASE PRESENTATION: A 42-year-old nulligravid woman who had undergone myomectomy 3 years earlier was referred to our hospital for acute left abdominal pain at the 17th week of gestation. Ultrasonography showed severe left hydronephrosis and a 6-cm mass in the parauterine space. Color Doppler ultrasonography revealed a spinning turbulent flow pattern inside the mass lesion. Contrast-enhanced computed tomography revealed the left uterine artery feeding blood flow to the mass and left ureteral obstruction by the mass. These results indicated left hydronephrosis secondary to left uterine artery pseudoaneurysm. To resolve the problem, laparotomy was performed. As uterine artery isolation was impossible, ligation of the left internal iliac artery and releasing of the ureteral obstruction were carried out. The hydronephrosis and abdominal pain promptly resolved after the surgery. Thereafter, fetal development proceeded normally in the remaining months of the pregnancy. A healthy baby was delivered through cesarean section at 36 weeks gestational age. At the cesarean section, the left lower uterine segment where the UAP had been present was not visible because of the firm adhesion in around it. CONCLUSIONS: Uterine artery pseudoaneurysm can cause hydronephrosis in the early second trimester of pregnancy. Ligation of the unilateral internal iliac artery is a safe and effective intervention to block the blood flow to the uterine artery pseudoaneurysm during pregnancy, when uterine artery ligation seems not possible. In the pregnancy after previous surgical procedures to the uterus, uterine artery pseudoaneurysm should be considered in the differential diagnosis of symptomatic hydronephrosis.

Which uterine sparing technique should be used for uterine atony during cesarean section? The Bakri balloon or the B-Lynch suture?

PURPOSE: To evaluate various aspects of two popular uterine sparing techniques, the B-Lynch uterine compression suture and Bakri balloon tamponade, in severe postpartum hemorrhage (PPH). METHODS: 21 women who underwent the Bakri balloon procedure and 24 women who underwent the B-Lynch suture as primary uterus-sparing methods, due to PPH not responding to medical treatment, were retrospectively evaluated. RESULTS: The success rates of the B-Lynch procedure and the Bakri balloon were 79.1 and 80 %, respectively. The success rates of the B-Lynch + IIAL and the Bakri balloon + IIAL were 91.6 and 95 %, respectively. There was no significant difference in success rates, mean duration of time to stop bleeding, estimated blood loss, transfused packed red blood cells or mean duration of hospital stay between the B-Lynch and the Bakri balloon groups. The duration of operation was significantly longer in the Bakri balloon compared to the B-Lynch group (p = 0.01). CONCLUSION: In our study, the Bakri balloon and the B-Lynch suture had similar success rates in uterine atony during CS. The advantages of the B-Lynch suture include rapid application with no need for lithotomy position or extra material; whereas the Bakri balloon is less invasive and easier to learn, but more time consuming and expensive compared to the B-Lynch suture. We suggest that the B-Lynch suture may be preferred in uterine atony during CS in low resource settings; however, the less invasive Bakri balloon should be the first line in full resource settings. Further studies are needed to evaluate the advantages and disadvantages of the two methods.

Effects of Internal Iliac Artery Ligation on Stress and Urge Incontinence: A Retrospective Evaluation.

INTRODUCTION: Does bilateral internal iliac artery ligation (BIIAL), a fundamental intervention in the treatment of postpartum hemorrhage, increase the risk of urinary incontinence (UI)? This study aims to shed light on the effects of BIIAL on bladder perfusion and urinary system integrity, thereby elucidating urinary function disorders following pelvic surgery. METHODS: Demographic and medical data were collected from a total of 192 female patients, with and without the application of BIIAL. Urinary incontinence conditions were assessed using the Questionnaire for Urinary Incontinence Diagnosis (QUID) test. The data collection process was conducted according to ethical standards, and the results were analyzed to determine the types of incontinence. RESULTS: In the group that underwent BIIAL, the number of pregnancies and births was statistically higher compared to the control group. A significant effect of BIIAL was seen in cases of urge urinary incontinence (UUI), while no meaningful impact was detected on stress urinary incontinence (SUI). After the BIIAL procedure, an increase in the rate of urinary leakage was seen in certain cases. CONCLUSION: Bilateral internal iliac artery ligation has proven to be a safe and effective intervention in the management of postpartum hemorrhage. The findings suggest a potential impact of BIIAL on UUI but not on SUI. Comprehensive and long-term prospective studies are needed to further investigate the effects of BIIAL on pelvic blood flow and bladder functions.

Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations.

The internal iliac artery (IIA) is the main arterial vessel of the pelvis. It supplies the pelvic viscera, pelvic walls, perineum, and gluteal region. In cases of severe obstetrical or gynecologic hemorrhage, IIA ligation can be a lifesaving procedure. Regrettably, IIA ligation has not gained widespread popularity, primarily due to limited surgical training and concerns regarding possible complications, including buttock claudication, impotence, and urinary bladder and rectum necroses. Nowadays, selective arterial embolization or temporary balloon occlusion are increasingly utilized alternatives, which can be applied preoperatively or intraoperatively for threatening severe genital or pelvic bleeding. However, IIA ligation retains its relevance, as the previously described procedures are not always available and have limitations. This article provides a step-by-step guide to the IIA ligation procedure and its possible complications. It also includes a detailed description of the anatomy of the IIA and pelvic arterial anastomoses. This review highlights the importance of a thorough understanding of pelvic anatomy as a prerequisite for safe IIA ligation and posits that training in this procedure should be an integral part of obstetrics and gynecology curricula.

A successful bilateral iliac arteries ligation as an emergency management to a life-threatening AVM bleeding: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Uterine arteriovenous malformation (AVM) is a defect due to direct connection between uterine arteries and veins, it has wide range of symptoms and severity, usually causes vaginal bleeding which may be mild or severe and may cause death in some rare cases. Diagnostic methods may include ultrasound, MRI, CT and/or angiography which reveal a high blood flow hypoechoic mass. Many options have been applied as management procedures, including invasive and noninvasive procedures, aiming to save patient life and stop bleeding or preserve fertility in the less severe cases. CASE PRESENTATION: 21 years old primigravida patient developed episodes of severe vaginal bleeding due to AVM after complete molar pregnancy evacuation and chemotherapy, managed successfully by bilateral internal iliac artery ligation and applying compression sutures on the uterus and continuing with compound medical treatment, trying to preserve fertility and ability to get pregnant in the future. CLINICAL DISCUSSION: We point out AVM types, its sings, symptoms and the diagnostic procedures. We discuss the bilateral iliac artery ligation and applying modified compression sutures on uterus as possible emergency managements to AVM when there is a threatening on life due to huge bleeding. We also mentioned the other surgical and medical treatments. CONCLUSION: We confirm the importance of keeping AVM in mind as a possible diagnose when there is unknown cause vaginal bleeding. Consider doing bilateral iliac artery ligation and applying the modified compression sutures as emergency procedures to stop or reduce AVM bleeding.

Complications Following Temporary Bilateral Internal Iliac Artery Ligation for Pelvic Hemorrhage Control in Trauma.

Background: Temporary bilateral internal iliac artery ligation (TBIIAL) is an option for surgical control of pelvic hemorrhage after trauma. Concerns persist that complications, particularly gluteal necrosis, following TBIIAL should preclude its use, despite a lack of formal research on TBIIAL complications. This study aimed to define complications following TBIIAL for emergent control of traumatic pelvic bleeding.Study Design: Patients undergoing TBIIAL after blunt trauma (2008-2020) at our level 1 trauma center were included without exclusions. Demographics, clinical/injury data, and outcomes were collected. Descriptive statistics summarized study variables. Multivariable analysis of factors independently associated with mortality after TBIIAL was performed.Results: In total, 77 patients undergoing emergent TBIIAL after blunt trauma were identified. Median age was 46 [IQR 29-63] years. Most patients (n = 70, 91%) were severely injured (ISS ≥16), with 43% undergoing resuscitative thoracotomy prior to TBIIAL. No local complications (gluteal necrosis, iatrogenic injury, fascial dehiscence, surgical site infection) after TBIIAL occurred over the 13-year study period. In the first 28 days after injury, median hospital-, ICU-, and ventilator-free days were 0. Mortality was 70% (n = 54). On multivariable analysis, older age was the only variable independently associated with in-hospital mortality (OR 1.081, P = .028).Conclusion: Zero cases of gluteal necrosis, iatrogenic injury to surrounding structures, or surgical site infection/fascial dehiscence of the exploratory laparotomy occurred over the study period. High concern for gluteal necrosis after TBIIAL in severely injured trauma patients is unfounded and should not prevent a surgeon from obtaining prompt pelvic hemorrhage control with this technique among patients in extremis.

Therapeutic effect of Internal iliac artery ligation and uterine artery ligation techniques for bleeding control in placenta accreta spectrum patients: A meta-analysis of 795 patients.

Placenta accreta spectrum (PAS) can cause complications like hysterectomy or death due to massive pelvic bleeding. We aim to evaluate the efficacy of two different arterial ligation techniques in controlling postpartum haemorrhage and minimizing bleeding complications. We searched six databases. 11 studies were finally included into our review and analysis. We graded their quality using the Cochrane tool for randomized trials and the NIH tool for retrospective studies. Our analysis showed that internal iliac artery ligation has no significant effect on bleeding control (MD = -248.60 [-1045.55, 548.35] P = 0.54), while uterine artery ligation significantly reduced the amount of blood loss and preserved the uterus (MD = -260.75, 95% CI [-333.64, -187.86], P < 0.00001). Uterine artery ligation also minimized the need for blood transfusion. Bleeding was best controlled by combining both uterine artery ligation with uterine tamponade (MD = 1694.06 [1675.34, 1712.78], P < 0.00001). This combination also showed a significant decrease in hysterectomy compared to the uterine artery ligation technique alone. Bilateral uterine artery ligation in women with placenta accreta spectrum can effectively reduce the amount of bleeding and the risk of complications. The best bleeding control tested is a combination of both, uterine artery ligation and cervical tamponade. These techniques may offer an easy and applicable way to preserve fertility in PAS patients. Larger randomized trials are needed to define the best technique.

Is there a role of prophylactic bilateral internal iliac artery ligation on reducing the bleeding during cesarean hysterectomy in patients with placenta percreta? A retrospective cohort study.

OBJECTIVES: Our study aims to evaluate the effect of bilateral prophylactic internal iliac artery ligation (IIAL) on bleeding in patients with placenta percreta who undergo cesarean hysterectomy (CH) with the use of blunt dissection technique. MATERIAL AND METHODS: This retrospective cohort study included 96 patients with placenta percreta who underwent planned CH with using the blunt dissection technique to allow better vesico-uterine dissection at the gynecology and obstetrics unit of a university hospital between the years 2017-2019. We carried out bilateral IIAL before CH in the study group (group 1) while we performed only CH in the control group (group 2). RESULTS: Group 1 and Group 2 consisted of 50 and 46 patients; respectively. There was no statistical difference between the two groups as regards to the mean estimated blood loss, the mean transfused blood products, the mean operation time, and the number of complications. In total, 24 patients (25%) had complications with the finding that the most common one was bladder injury (16/96, 16,66%). CONCLUSIONS: Routine bilateral prophylactic IIAL before CH in placenta percreta cases does not have a beneficial effect on decreasing the amount of bleeding and the amount blood transfusion.

Intra-arterial Balloon Occlusion to Reduce Operative Bleeding for Placenta Previa Accreta Spectrum.

Cesarean section for placenta previa accreta spectrum carries a significant risk of massive hemorrhage. Hence, it is necessary to understand the various hemostatic procedures, damage control surgery and resuscitation for massive hemorrhage, and systemic management against hypovolemic shock and coagulopathy. In cases of placenta previa with previous cesarean section, the operation should be performed in a tertiary medical facility with well-trained staff and blood availability for transfusion. Preoperative placement of an intra-arterial balloon occlusion catheter in the common iliac artery or aorta is useful for preventing massive hemorrhage.

Preliminary investigation of bilateral internal iliac artery ligation and anterior tumor separation through laparoscopy before posterior resection of a giant sacral tumor.

BACKGROUND: Surgical is the optimal therapeutic strategy for sacral tumors, and complete resection can effectively improve the recurrence and survival rates. However, the specialized anatomy, massive bleeding and adhesion to the anterior tissue, especially that caused by giant sacral tumors, makes complete resection difficult. The laparoscopic technique provides a new method to resect sacral tumors. METHODS: 34 patients with primary giant sacral tumors who underwent surgical resection were enrolled. After bilateral internal iliac artery ligation and anterior laparoscopic tumor separation, the sacral tumors were successfully resected posteriorly. The clinical, radiological and follow-up data were collected and analyzed. RESULTS: The average operative time was 276.47 min and that for laparoscopy was 76.24 min. The average intraoperative blood loss was 1757.64 ml. No complications associated with laparoscopic surgery, such as intestinal, urinary tract, or vascular injuries, occurred. Ten patients (29.41%) had perioperative complications, including infection, unhealed wounds, and cerebrospinal fluid leaks in 10, 5 and 2 patients, respectively. Patients with complications had significantly longer total (55.00 ± 34.53 vs 25.13 ± 14.60, P = 0.001) and postoperative (39.10 ± 30.61 vs 14.83 ± 10.00, P = 0.002) hospitalization stays than patients without complications. Postoperatively, bowel and bladder dysfunction, intestinal obstruction, pain, and perianal numbness occurred in 21, 5, 8, and 2 patients, respectively. The recurrence rate was 11.76%. CONCLUSIONS: Laparoscopically assisted sacral tumor resection is a technically feasible and effective surgical method to resect giant sacral tumors, with the advantages of reduced operative blood loss during internal iliac artery ligation and anterior tumor separation.

The role of prophylactic internal iliac artery ligation in abnormally invasive placenta undergoing caesarean hysterectomy: a randomized control trial.

Objective: To identify the role of bilateral internal iliac artery (IIA) ligation on reducing blood loss in abnormally invasive placenta (AIP) undergoing caesarean hysterectomy. Methods: In this parallel-randomized control trial, 57 pregnant females with ultrasound features suggestive of AIP were enrolled. They were randomized into two groups; IIA group (n = 29 cases) performed bilateral IIA ligation followed by caesarean hysterectomies, while Control group (n = 28 cases) underwent caesarean hysterectomy only. The main outcome was the difference in the estimated intraoperative blood loss between the two groups. Results: There was no significant difference between the two groups regarding the intraoperative estimated blood loss (1632 ± 804 versus 1698 ± 1251, p value .83). The operative procedure duration (minutes) (223 ± 66 versus 171 ± 41.4, p value .001) varied significantly between the two groups. Conclusions: Bilateral internal iliac artery ligation, in cases of AIP undergoing caesarean hysterectomy, is not recommended for routine practice to minimize blood loss intraoperatively.

Bilateral Internal Iliac Artery Ligation, a Rational Choice of Surgery in Placenta Previa, a Hospital-Based Retrospective Study on the Prevention of Hysterectomy and Control of Postpartum Hemorrhage.

BACKGROUND: Placenta previa is one condition, where the bleeding is from the thinned out lower segment, which faces difficulty in contracting as compared to the upper uterine segment. To combat postpartum hemorrhage and hysterectomy, there were various techniques adopted in obstetric practice. Here the aim is to study the bilateral internal iliac artery ligation (BIL) as a technique to minimize postpartum bleeding and preserve the uterus for future pregnancy. METHODS: This retrospective study was conducted in 31 patients with abnormal placentation. They underwent BIL during LSCS. The surgery was elective in non-bleeding patients and as an emergency in bleeding patients. The primary outcome is to minimize blood loss and postpartum blood transfusion. The secondary outcome is the prevention of hysterectomies after delivery and preservation of the uterus for the mother to have future pregnancies. RESULTS: Out of 31 women, 19 underwent elective surgery (61.3%) and 12 underwent emergency surgery (38.7%). Out of 12 emergency surgeries, 8 needed blood transfusion due to blood loss. Out of 19 elective surgeries, none required the blood transfusion. Blood transfusion was required in 50% of the patient in emergency BIL surgery, whereas none required blood transfusion in elective BIL surgery. Postpartum hysterectomy was avoided in all study participants except one elective surgery patient. CONCLUSION: BIL surgery can be an effective procedure for handling high-risk obstetric hemorrhage in addition to the chances of future fertility through the preservation of uteri.

Is there yet a role for internal iliac artery ligation in obstetric hemorrhage with the current gain in popularity of other uterus sparing techniques?

PURPOSE: To evaluate the success rates and subsequent fertility outcomes of internal iliac artery ligation (IIAL) in uterine atony (primary ligated and secondary added to other uterus sparing techniques), retroperitoneal hematoma, and placenta adherent abnormalities. MATERIAL AND METHODS: Fifty two women who underwent IIAL for different causes of postpartum hemorrhage were retrospectively evaluated. RESULTS: Among 26 women with intractable uterine atony, 12 had primary, and 14 secondary IIAL, due to ongoing bleeding following the B-Lynch suture or the Bakri balloon tamponade. The success rates were 91% and 71.4% in the primary and secondary IIAL groups, respectively. The success rates of IIAL in 12 women with placental adhesion abnormalities and another 12 with obstetric retroperitoneal hematoma were 75% (9/12) and 83% (10/12) respectively. Nine (17%) hysterectomies were performed after failure of IIAL. Two maternal deaths occurred in our study. The rate of achieving pregnancy was not significantly different between the groups. CONCLUSIONS: Hysterectomy rates might be decreased with the addition of IIAL provided that other uterus sparing techniques; B-Lynch or the Bakri balloon was to fail separately. IIAL can save lives in severe obstetric retroperitoneal hematoma. IIAL does not affect fertility even it is combined with other uterus sparing techniques like the Bakri balloon and B-Lynch suture.

Ligating Internal Iliac Artery: Success beyond Hesitation.

AIM: To study the outcomes, benefits and complications of internal iliac artery ligation in both obstetric and gynecological cases. OBJECTIVE: To study the outcomes, effectiveness and complications of internal iliac artery ligation (IIAL). METHOD: This is an analytical longitudinal study done among women who have undergone internal iliac artery ligation in Dr. BRAMH a tertiary referral center from July 2013 to June 2015. Follow-up was done through color Doppler analysis of pelvic arteries before discharge, after 6 weeks and after 6 months. RESULT: The efficacy of IIAL was 96.87 %. The mean shock index was 0.94 ± 0.26. Sixty-four women underwent IIAL out of which placenta previa (21.8 %) was the major indication. There were four maternal deaths. There were no intraoperative or ischemic complications. The greater the time interval between onset of hemorrhage and IIAL, the graver the outcome. For all women in whom uterus could be salvaged, resumption of menstrual cycles was seen within 6 months of IIAL. There was a significant decrease in the RI and PI of uterine arteries. In the ovarian arteries, there was a significant increase in RI and no significant change in PI initially. Flow in distal part of ligated internal iliac arteries could be detected in 54 (90 %) women out of 60 after 6 months of ligation of internal iliac arteries. CONCLUSION: IIAL is an effective life-saving method to control obstetric and gynecological hemorrhage, and a hysterectomy can often be avoided. Early resort to IIAL is vital for improving the patient outcome. Uterine perfusion is well maintained, while there may be a decrease in ovarian perfusion. Resumption of menstrual cycles and presence of distal flow in internal iliac artery within 6 months suggest the preservation of future fertility; in order to better understand the impact of IIAL on ovarian functions and future fertility, larger studies with longer follow-up periods need to be conducted.

Emergency peripartum hysterectomy: our experience.

PURPOSE: To investigate the incidence of and reasons for emergency peripartum hysterectomy (EPH) between 2009 and 2013 in our hospital, one of the three hospitals with the highest rates of delivery in Turkey. METHODS: A retrospective study. Seventy-six peripartum hysterectomies were evaluated. We compared the modes of delivery and examined whether bilateral internal iliac artery ligation was performed. RESULTS: The incidence of EPH was 0.77 in 1000. The majority of cases involved multiparity, uterine rupture, placenta praevia, or placental invasion abnormalities. The most frequent reason for EPH was uterine atony (64.5 %). There was no statistically significant relationship with mode of delivery; however, the complication rate and requirement for fresh frozen plasma were significantly (p < 0.01) related to whether bilateral internal iliac artery ligation was performed. CONCLUSION: Uterine atony was the most common indication for EPH. The most important step to avoid performing EPH is to calculate patients' risks for postpartum bleeding. Postpartum haemorrhage may not be preventable, but when it happens, obstetricians must be prepared to perform EPH, and in high-risk patients, to perform internal iliac artery ligation.

A change in the management of intractable obstetrical hemorrhage over 15 years in a tertiary care center.

CONTEXT: Peripartum hysterectomy was the gold standard to save a woman with persistent obstetrical bleeding, but compromised the menstrual and reproductive functions. Bilateral internal iliac artery ligation (BIAL) is a potentially effective, fertility preserving means of controlling pelvic hemorrhage, but with surgical and anesthetic risks and low success. Angiographic embolization has the potential to arrest severe pelvic hemorrhage without removing the uterus and without hazarding general anesthesia in a hemodynamically unstable patient. AIMS: The aim of this study is to discuss change in the management of intractable obstetrical hemorrhage from removing to conserving the uterus over 15 years. SETTINGS AND DESIGN: A retrospective analysis of 122 cases of intractable obstetrical hemorrhage over a period of 15 years (January 1997 to December 2011) was done. We started uterine artery embolization (UAE) in 2007 for obstetrical hemorrhage. The patients were analyzed for maternal characteristics, indications, treatment modality, maternal morbidity, and mortality. STATISTICAL ANALYSIS USED: Descriptive. RESULTS: We analyzed 12,055 deliveries, (6029 cesarean sections; 6026 vaginal deliveries). One hundred and twenty-two cases of intractable obstetrical hemorrhage were managed with obstetrical hysterectomies in 63, UAE in 53 cases and BIAL in six cases. During the period between 1997 and 2006 intractable obstetrical hemorrhage was managed by hysterectomy/internal iliac artery ligation. The last 5 years of the study period had 80 patients with intractable obstetrical hemorrhage, 53 patients underwent arterial embolization and 35 had a hysterectomy and two had internal artery ligation. There was no mortality and significantly less morbidity in embolization group in our study. CONCLUSIONS: Embolization should be tried in patients with intractable obstetrical hemorrhage before proceeding for surgical intervention.