Bilateral internal iliac (hypogastric) artery ligation to control obstetric and gynecologic hemorrhage. A ten-year review at the community hospital level

Efficacy of Intra-Uterine Tamponade Balloon in Post-Partum Hemorrhage after Cesarean Delivery: An Impact Study

Invasive therapies (surgery or radiological embolization) are used to control severe post-partum hemorrhage. The intra-uterine tamponade balloon is a potential alternative, well documented after vaginal delivery. However, available data on its use after cesarean delivery remain scarce. This study assessed the efficacy of the intra-uterine tamponade balloon during post-partum hemorrhage in a cesarean delivery setting. Using a retrospective impact design, post-partum hemorrhage-related outcomes before (“pre-balloon” period) versus after implementation of intra-uterine tamponade balloon (“post-balloon” period) were compared. All women with post-partum hemorrhage requiring potent uterotonic treatment with prostaglandins after cesarean delivery over a 9-year period were eligible. The primary outcome was the rate of invasive procedure (conservative surgery, radiological embolization and/or hysterectomy). p < 0.05 was considered statistically significant. A total of 279 patients were included (140 vs. 139). Most baseline characteristics were comparable between the two studied periods. The success rate of the intra-uterine tamponade balloon was 82%, and no related complications occurred. Rates of invasive procedures and transfusion were significantly reduced (28.6% vs. 11.5%, p < 0.001 and 44.3% vs. 28.1%, p = 0.006 respectively) during the “post-balloon” period, and length of hospital stay was shorter (p < 0.001). Implementation of intra-uterine tamponade balloon during post-partum hemorrhage after cesarean delivery appears to be safe and effective, with a decrease in both invasive procedures and transfusion rates.

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.

Internal iliac artery ligation in obstetrics and gynecology. Ten years experience

Twenty-two cases of bilateral internal iliac artery ligation done in the Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India over a period of 10 years (1981-1990) were studied. Various indications and complications were analysed. Internal iliac artery ligation is a life-saving procedure in pelvic hemorrhage. Complications are infrequents.

Internal iliac artery ligation in post-partum hemorrhage

Between 1978 and 1986, internal iliac artery ligation was performed on eight patients undergoing treatment for severe post-partum hemorrhage, and disseminated intra-vascular coagulation (DIVC) combined with causal pathology was detected in five patients. This procedure was effective in controlling bleeding in eight patients and no hysterectomy was necessary. Post-operative follow-up was uncomplicated in six patients. One patient suffered from post-operative occlusion. Another patient suffered from renal failure, due to secondary cortical renal necrosis. Surgery is usually simple and does not pose any technical problems. This technique allows for the conservation of the reproductive functions, and two of the women became pregnant at a later stage. Obstetric hysterectomy can be avoided by using this technique. It is recommended in cases where DIVC does not respond to medical treatment and can furthermore be used by all surgeons.

Bilateral internal iliac artery ligation in cervical pregnancy: conservation of reproductive function

Like other forms of ectopic gestation, cervical pregnancy is a serious complication with potentially life-threatening consequences. Excessive bleeding almost invariably follows an attempt to evacuate this rare ectopic pregnancy. In most reported cases, hysterectomy has been required to control the severe hemorrhage. This paper reports for the first time the successful conservative management of cervical pregnancy in two patients by bilateral internal iliac artery ligation alone. Early recognition of the cervical pregnancy and prompt internal iliac artery ligation are stressed.

Prophylactic internal iliac artery ligation at cesarean hysterectomy

One hundred and eight preplanned cesarean hysterectomies have been evaluated in an effort to determine that advisability of prophylactic bilateral hypogastric artery ligation when there is anticipated heavy bleeding associated with surgery. The data indicates that prophylactic bilateral internal iliac artery ligation is of questionable value in reducing operative bleeding, which can be controlled by more conventional means. However, when used therapeutically, it may be a lifesaving operation. Familiarity with the procedure is necessary for all those performing operative obstetrics and gynecology.