Hypogastric artery ligation for obstetric hemorrhage

Ligation of the hypogastric arteries has been recommended for control of obstetric hemorrhage. However, specific information regarding its effectiveness is lacking. The hospital charts of 19 patients undergoing bilateral hypogastric artery ligation for the control of otherwise intractable obstetric hemorrhage were reviewed. Indications included uterine atony (15), lateral extension of a low-transverse uterine incision (three), and placenta accreta (one). This procedure was effective in controlling bleeding in eight of 19 patients (42%). Hysterectomy was necessary in the remaining 11 patients. In these patients, blood loss, operating time, and intraoperative morbidity was increased when compared with a group of 59 patients undergoing emergency hysterectomy for obstetric hemorrhage without prior ligation of the hypogastric arteries. Surgical approaches to hypogastric artery ligation are discussed.     

Angiographic evaluation of hepatoma for surgical treatment.

Celiac and superior mesenteric arteriography of 60 patients with primary carcinoma of the liver was evaluated retrospectively to select patients properly for hepatic lobectomy, ligation of the hepatic artery or temporary occlusion of the hepatic artery. The angiograms were studied from the viewpoints of origin of the hepatic artery, location of hepatomas, macroscopic type of hepatomas, tumor supplying arteries, patency of the portal vein and coexistence of cirrhosis of the liver. It is stressed that an exact knowledge of these items before operation is important in performing any type of surgical treatment for patients with hepatomas. Resectability of the tumor in the present series of patients was possible in 11 patients, and in the recently seen patients with nonresectable hepatomas, ligation or repeated temporary occlusion of the hepatic artery or both have been performed with postoperative infusion chemotherapy.     

Ligature des artères iliaques internes face aux hémorragies obstétricales graves en milieu africain

ObjectivesAssess the efficiency of internal iliac arteries ligation in intractable obstetrical hemorrhage and ascertain success or failure factors.Patients and methodsIt was a retrospective study which concerned 159 patients who underwent internal iliac arteries ligation for persistent and severe obstetrical hemorrhage from March 1992 to February  2007. Arrest of hemorrhage after ligation with survival of the patient was considered as successful; was considered as failure, persistence of hemorrhage in spite of the ligation or patient death.ResultsInternal iliac arteries ligation allowed hemorrhage control in 84,3% of cases. Main etiology of hemorrhage were: uterine atony (42,8%), abruptio placentae (31,4%). Coagulation disorders and hypovolemic shock, consequences of long delay of management were identified as bad prognosis factors. Blood transfusion was also singled out as a factor likely to ameliorate prognosis, especially in hemodynamic precarious situations. Surgical complications incidence was 1,89%, represented by two internal iliac vein lesions and one ureteral section successfully repaired.Discussion and conclusionInternal iliac arteries ligation is a prerequisite treatment of severe postpartum hemorrhage. The outcome is better when it is performed precociously (p = 0,0000003) before the happening of disseminated intra vascular coagulation (p = 0,006), hemodynamic troubles (p = 0,0099) and acute severe anemia (p = 0,02). It is a good alternative to arterial embolization in Africa.     

Hypogastric artery ligation for severe hemorrhage in obstetric patients

Ligation of the hypogastric arteries (HAL) was first introduced into surgery by the end of the 19(th) century to control intractable hemorrhage from the uterus of women with advanced cervical cancer. At present, HAL is one in a spectrum of operative methods to control life-threatening postpartum hemorrhage before hysterectomy. Bilateral ligation of the internal iliac artery does not result in complete blockage of but to a significant decrease in blood supply to the female pelvic organs. Soon after ligation three previously existent collateral circulations will develop. Due to the smaller caliber of these arteries, the arterial pulse and pulse pressure are virtually eliminated. The effectiveness of HAL in avoiding hysterectomy for postpartum hemorrhage has been reported in up to 50% of cases. HAL has no adverse effect on subsequent fertility or pregnancy outcome, however, assessment for intrauterine fetal growth restriction is recommended. This safe and effective procedure should be taught during obstetric and gynecologic training.     

Absence of flow velocity waveform changes in uterine arteries after bilateral internal iliac artery ligation

A case is reported of bilateral internal iliac artery ligation during cesarean delivery for intractable hemorrhage. Uterine artery Doppler flow velocity waveforms were documented before and after the procedure. After the ligation the uterine arteries could still be visualized in the appropriate anatomic location, and no changes in Doppler flow velocity waveforms were documented.     

Spontaneous rupture of liver during pregnancy: current therapy

Spontaneous hepatic rupture secondary to severe pregnancy-induced hypertension is associated with a high rate of maternal and fetal mortality. Numerous types of surgical management have been described, but a uniform surgical approach has not been accepted. The purpose of this review was to examine modes of surgical therapy reported in the literature since 1976, as well as the 11-year experience at our institution. Twenty-eight cases were extracted from the literature and seven more were identified at our institution. The incidence in our population was one per 45,145 live births. Among 27 cases managed by packing and drainage, an 82% overall survival was achieved, whereas only 25% of eight patients undergoing hepatic lobectomy survived (P = .006). Hepatic hemorrhage with persistent hypotension unresponsive to blood products should be managed by evacuating the hematoma, packing the damaged liver, and draining the operative site. More aggressive surgical techniques, such as hepatic artery ligation or hepatic lobectomy, should be reserved for refractory cases.     

Hepatoportal arteriovenous fistula in primary carcinoma of the liver.

The correlation between the portal circulation and esophageal varices was evaluated in 80 patients with a primary carcinoma of the liver, with special regard being given to the significance of an hepatoportal arteriovenous fistula. Hepatoportal arteriovenous fistula was found in eight patients. Esophageal varices were observed 32 of all patients with a hepatoma. On the other hand, variceal lesions were found in 17 of 52 patients without compared with all patients with an hepatoportal arteriovenous fistula. A fatal hemorrhage was frequently encountered in the patients with the fistula. It was suggested that a rational treatment for those with the triple lesions--hepatoma, esophageal varices and hepatoportal arteriovenous fistula--may be ligation of the hepatic artery.     

Hepatic hemangioendotheliomas in infancy

Multicentric hepatic hemangioendotheliomas are vascular lesions of the liver that usually present in the infant with hepatomegaly, high output congestive heart failure and cutaneous hemangiomas. The diagnosis, pathologic and physiologic conditions and treatment were discussed. Two of the patients we studied and 117 from the literature were reviewed. A total of 38 patients survived and 57 died with or without medical treatment. Thirteen patients survived and five died after ligation of the hepatic artery. Five patients survived and three died after embolization of the hepatic artery. (formula; see text) Of 119 patients with MHH, 81 (68 per cent) had congestive heart failure; 40 survived and 41 died. Of 56 patients with localized hepatic angiomas, 19 had congestive heart failure. Only two of the patients died of heart failure. Fifty localized hepatic angiomas in infancy that were treated with local resection or lobectomy were reviewed. Forty-six patients survived and four died of hemorrhage. Four patients survived and two died with or without medical treatment. Plans for management of multiple hepatic hemangioendotheliomas and localized hepatic angiomas in infancy were proposed.     

Circumferential Vault Excision and Reconstruction: Technical Description of Management of Intractable Secondary Vault Hemorrhage after Hysterectomy in Resource-Limited Settings

Hemorrhage after gynecologic surgery is an infrequent complication. It can be divided based on time of onset into primary and secondary. Secondary hemorrhage is a life-threatening complication with a reported incidence of .17% to .45%. When the etiology cannot be ascertained and when the hemorrhage does not respond to conservative management, it is aptly labeled as an intractable hemorrhage. Numerous techniques have been used to manage secondary hemorrhage, including vaginal exploration and securing of the bleeding vessels, laparotomy and ligation of uterine and internal iliac arteries, and transarterial embolization of uterine or internal iliac vessels using interventional radiologic modalities. Circumferential vault excision and reconstruction is a methodic technique to effectively control this condition using a total laparoscopic route with systematic and easily replicable steps.     

Laparoscopic ligation of hypogastric arteries using the Hulka clip to arrest massive vaginal bleeding due to stage IIb cervical carcinoma

A woman experienced severe vaginal bleeding from an exophytic, eroded cervical carcinoma. When vaginal tamponade and blood transfusion were ineffective in stopping the hemorrhage, bilateral laparoscopic ligation of the hypogastric arteries was performed. A Hulka clip was used to collapse the artery walls. Two months post-operatively a second, minor episode of bleeding occurred. This might have been avoided by ligating the ovarianuterine anastomosis.     

Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization.

A case of severe postpartum hemorrhage is reported. Three separate surgical procedures failed to reveal the source of bleeding, and standard surgical techniques, including bilateral ligation of the hypogastric arteries, were unsuccessful in producing hemostasis. However, angiography successfully identified the specific bleeding vessel, and transcatheter embolization with Gelfoam fragments quickly and effectively stopped the hemorrhage. The authors consider angiographic embolization to be an effective alternative approach to the control of pelvic hemorrhage and recommend that the technique be considered prior to surgical intervention.     

B-Lynch suture, intrauterine balloon, and endouterine hemostatic suture for the management of postpartum hemorrhage due to placenta previa accreta

Objective

To report our experience with a new conservative management approach to treat postpartum hemorrhage (PPH) due to placenta previa accreta.

Methods

A retrospective study of 9 patients with placenta previa accreta who underwent a conservative management protocol. The protocol consists of preventive radiological catheterization of the descending aorta, cesarean delivery, use of Affronti endouterine square hemostatic sutures, and placement of an intrauterine Bakri balloon in conjunction with B-Lynch suture. In the event of failure of the protocol, subsequent management employs ligation and/or reversible embolization of the uterine arteries followed by hysterectomy if unsuccessful.

Results

Conservative management of PPH was successful in all 9 patients evaluated and avoided the need for ligation and/or reversible embolization of the uterine arteries.

Conclusion

Management of PPH is dictated by several considerations including hemodynamic status and desire to preserve fertility. The initial results of this conservative protocol for treatment of PPH in high-risk patients with placenta previa accreta are encouraging.     

Embolisation of uterine arteries or laparascopic uterine artery ligation as possible treatment of uterine leiomyoma

Background Many women with symptomatic uterine leiomyomata wish to preserve their uterus. Novel organ- and fertility-preserving treatment options such as embolisation of uterine arteries or laparascopic uterine artery ligation have frequently been discussed as viable alternatives to myomectomy. This article strives to bring together the conclusions of major studies on novel organ-preserving treatment alternatives for uterine myoma.Methods Minimally invasive organ-preserving laparascopic myomectomy remains the best treatment option for patients with symptomatic fibroids who wish to retain their uterus. However, in certain cases other options such as embolisation or laparascopic ligation of uterine arteries can serve as viable alternativesResults A failure rate of up to 39% and complications such as reduced fertility because of ovarian failure after transcatheter embolisation of uterine arteries might restrict the use of this method.Conclusions For postmenopausal women, transcatheter embolisation of uterine arteries is a possible treatment alternative. Laparascopic ligation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries might also be viable for young women who desire to preserve future fertility. Further data and studies on the long-term follow-up after ligation are yet to come.     

The efficacy of internal iliac artery ligation in obstetric hemorrhage

During 1966 to 1982, 18 patients with severe obstetric hemorrhage underwent hypogastric artery ligation at our institution. Eight of 14 patients or 57 per cent (excluding three pregnancies which were terminated and a planned cesarean hysterectomy) had failed hypogastric artery ligations necessitating hysterectomy. Placenta accreta accounted for six patients of whom three required a hysterectomy. Uterine laceration was the second largest cause of hemorrhage in five patients, all of whom required a hysterectomy after hypogastric artery ligation failed. Hypogastric artery ligation does have a specific role in the management of obstetric hemorrhage, but it is not without substantial risk of failure. The obstetrician should carefully weigh whether or not the patient can undergo a more conservative procedure at the expense of a delay in the definitive treatment of hemorrhage. The instances presented herein should aid the clinician in deciding what is appropriate management for acute obstetric hemorrhage.     

Angiographic arterial embolization in the management of postoperative vaginal hemorrhage

Recently great success was achieved at the Toronto General Hospital in treating patients with postoperative vaginal hemorrhage by angiographic methods. A retrospective review was performed from 1975 to 1984 on eight patients treated by this technique for nine separate episodes of hemorrhage with a mean estimated blood loss in excess of 5000 ml. Success was achieved in seven episodes despite failure of various vaginal and abdominal approaches. One of the failures was due to previous bilateral hypogastric artery ligation that made the bleeding branch inaccessible to the angiography catheter. The other patient developed bleeding following cesarean section which did not respond to angiographic embolization due to faulty technique. Both of these patients were eventually cured by abdominal surgery. We feel that angiographic embolization is the procedure of choice in the management of postoperative vaginal hemorrhage when conservative management has failed or is inappropriate; it can be lifesaving when all other attempts to stop the hemorrhage have failed.     

Operative Behandlung schwergradiger postpartaler Blutungen

Postpartum hemorrhage occurs in about 1 to 5% of deliveries. Uterine atony is the main cause (75–80%). Despite its association with well-established risk factors, atonic bleeding cannot be anticipated in up to 20% of cases. Therapy of postpartum hemorrhage varies depending on the cause. Conservative treatment of uterine atony is effective in about 90% of patients. Invasive management is needed in 1 to 3 of 1000 deliveries. Uterus-preserving techniques are preferable if contraindications can be excluded. In the literature, success rates of 40 to 100% have been reported for the various non-surgical (uterine tamponade, selective arterial embolization) and surgical methods (ligation of the uterine and hypogastric arteries, stepwise uterine devascularisation, B-Lynch technique, fundus compression suture). Emergency peripartum hysterectomy (total or supracervical) should be reserved for otherwise intractable postpartum hemorrhage, and is associated with a considerable maternal morbidity compared to elective caesarean hysterectomy.     

Uterine compression sutures: surgical management of postpartum hemorrhage

BACKGROUND:It has been estimated that worldwide, over 125,000 women die of postpartum hemorrhage each year. The traditional management of this condition includes the use of oxytocics, such as oxytocin, ergometrine, and prostaglandins, before proceeding to ligation of the internal iliac arteries and even hysterectomy. The B-Lynch technique is a surgical procedure that may be used to arrest postpartum hemorrhage resulting from uterine atony. CASES: This paper describes simple modifications of this technique that make this procedure less complex to perform. Three clinical case scenarios illustrate the context in which the sutures may be used. CONCLUSION: Compression sutures placed into the postpartum uterus may provide a simple first surgical step to control bleeding when routine oxytocic measures have failed. We suggest that the technique we have described is a simple procedure and should be tried before more complex interventions are used.     

Conservative treatment of 12-week cervical pregnancy

A cervical pregnancy is very rare form of ectopic pregnancy. Usually it is associated with unexpected occurrence hemorrhage from the cervix. For this reason the treatment for a cervical pregnancy very often requires an abdominal hysterectomy. To avoid hysterectomy several conservative methods of termination have been used. In this paper has been reported the case of 29 years old woman with a 12-week cervical pregnancy. She had been treated (methotrexate and potassium chloride application, ligation of the uterine arteries, local haemostatic sutures) before evacuation products of conception from the cervix. Post-operative period was uneventful. After a 9 day of postoperative stay the woman was discharged. These behaviour allowed for save of uterus and preserve future fertility.