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Bouchghoul H, Madar H, Resch B, Pineles BL, Mattuizzi A, Froeliger A, Sentilhes L. Uterine-sparing surgical procedures to control postpartum hemorrhage. Am J Obstet Gynecol 2024; 230:S1066-S1075.e4. [PMID: 37729440 DOI: 10.1016/j.ajog.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/05/2022] [Accepted: 06/12/2022] [Indexed: 09/22/2023]
Abstract
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.
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Affiliation(s)
- Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Benoit Resch
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France; Department of Gynecologic Surgery, Clinique Mathilde, Rouen, France
| | - Beth L Pineles
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center, Houston, TX
| | - Aurélien Mattuizzi
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.
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Song KH, Choi ES, Kim HY, Ahn KH, Kim HJ. Patient blood management to minimize transfusions during the postpartum period. Obstet Gynecol Sci 2023; 66:484-497. [PMID: 37551109 PMCID: PMC10663398 DOI: 10.5468/ogs.22288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/11/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023] Open
Abstract
Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.
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Affiliation(s)
- Kwan Heup Song
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
| | - Eun Saem Choi
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Ho Yeon Kim
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
| | - Ki Hoon Ahn
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Hai Joong Kim
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
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Pan W, Chen J, Zou Y, Yang K, Liu Q, Sun M, Li D, Zhang P, Yue S, Huang Y, Wang Z. Uterus-preserving surgical management of placenta accreta spectrum disorder: a large retrospective study. BMC Pregnancy Childbirth 2023; 23:615. [PMID: 37633887 PMCID: PMC10464453 DOI: 10.1186/s12884-023-05923-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/14/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND The two-child policy implemented in China resulted in a surge of high-risk pregnancies among advanced maternal aged women and presented a window of opportunity to identify a large number of placenta accreta spectrum (PAS) cases, which often invoke severe blood loss and hysterectomy. We thus had an opportunity to evaluate the surgical outcomes of a unique conservative PAS management strategy for uterus preservation, and the impacts of magnetic resonance imaging (MRI) in PAS surgical planning. METHODS Cross-sectional study, comparing the outcomes of a new uterine artery ligation combined with clover suturing technique (UAL + CST) with the existing conservative surgical approaches in a maternal public hospital with an annual birth of more than 20,000 neonates among all placenta previa cases suspecting of PAS between January 1, 2015 and December 31, 2018. RESULTS From a total of 89,397 live births, we identified 210 PAS cases from 400 singleton pregnancies with placenta previa. Aside from 2 self-requested natural births (low-lying placenta), all PAS cases had safe cesarean deliveries without any total hysterectomy. Compared with the existing approaches, the evaluated UAL + CST had a significant reduction in intraoperative blood loss (β=-312 ml, P < .001), RBC transfusion (β=-1.08 unit, P = .001), but required more surgery time (β = 16.43 min, P = .01). MRI-measured placenta thickness, when above 50 mm, can increase blood loss (β = 315 ml, P = .01), RBC transfusion (β = 1.28 unit, P = .01), surgery time (β = 48.84 min, P < .001) and hospital stay (β = 2.58 day, P < .001). A majority of percreta patients resumed normal menstrual cycle within 12 months with normal menstrual fluid volume, without abnormal urination or defecation. CONCLUSIONS A conservative surgical management approach of UAL + CST for PAS is safe and effective with a low complication rate. MRI might be useful for planning PAS surgery. CLINICAL TRIAL REGISTRATION NUMBER ChiCTR2000035202.
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Affiliation(s)
- Wenxia Pan
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Juan Chen
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Yinrui Zou
- Havy International (Shanghai) Ltd, Building 25, No.1665, Kongjiang Road, Yangpu District, Shanghai, 200092, China
| | - Kun Yang
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Qingfeng Liu
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Meiying Sun
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Dan Li
- Department of Radiology, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Ping Zhang
- Department of Ultrasound, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Shixia Yue
- Department of Nursery, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Yuqiang Huang
- Department of Pediatric Cardiology, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China.
| | - Zhaoxi Wang
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Kirstein 3, 02215, Boston, MA, USA
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Post SE, Rood KM, Kiefer MK. Interventions of Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:367-383. [PMID: 37204172 DOI: 10.1097/grf.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Postpartum hemorrhage is a common and potentially life-threatening obstetric complication, with successful management relying heavily on early identification of hemorrhage and prompt intervention. This article will review the management of postpartum hemorrhage, including initial steps, exam-specific interventions, medical therapy, minimally invasive, and surgical interventions.
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Affiliation(s)
- Sara E Post
- Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio
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Abstract
OBJECTIVE This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock. TARGET POPULATION All pregnant patients. BENEFITS, HARMS, AND COSTS Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays. EVIDENCE Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists. RECOMMENDATIONS
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Robinson D, Basso M, Chan C, Duckitt K, Lett R. Directive clinique n o 431 : Hémorragie post-partum et choc hémorragique. J Obstet Gynaecol Can 2022; 44:1311-1329.e1. [PMID: 36567098 DOI: 10.1016/j.jogc.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Giouleka S, Tsakiridis I, Kalogiannidis I, Mamopoulos A, Tentas I, Athanasiadis A, Dagklis T. Postpartum Hemorrhage: A Comprehensive Review of Guidelines. Obstet Gynecol Surv 2022; 77:665-682. [DOI: 10.1097/ogx.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Nabhan AE, AbdelQadir YH, Abdelghafar YA, Kashbour MO, Salem N, Abdelkhalek AN, Nourelden AZ, Eshag MME, Shah J. 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. Front Surg 2022; 9:983297. [PMID: 36117806 PMCID: PMC9474733 DOI: 10.3389/fsurg.2022.983297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/11/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Ayman Essa Nabhan
- Faculty of Medicine, Al Andalus University, Tartus, Syria
- International Medical Research Association (IMedRA), Cairo, Egypt
| | - Yossef Hassan AbdelQadir
- International Medical Research Association (IMedRA), Cairo, Egypt
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yomna Ali Abdelghafar
- International Medical Research Association (IMedRA), Cairo, Egypt
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Muataz Omar Kashbour
- International Medical Research Association (IMedRA), Cairo, Egypt
- Radiology department, National cancer institute, Misurata, Libya
| | - Nour Salem
- International Medical Research Association (IMedRA), Cairo, Egypt
- Faculty of Medicine, University of Constantine 3 Salah Boubnider, Constantine, Algeria
| | - Abdelrahman Naeim Abdelkhalek
- International Medical Research Association (IMedRA), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Anas Zakarya Nourelden
- International Medical Research Association (IMedRA), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mona Muhe Eldeen Eshag
- International Medical Research Association (IMedRA), Cairo, Egypt
- Faculty of Medicine, University of Bahri, Khartoum, Sudan
| | - Jaffer Shah
- New York State Department of Health, Albany, NY, United States
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9
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Chuang YC, Peng FS, Tu FC, Chang CY, Lin TY. An intracardiac thrombus as a cause of cardiac arrest during a cesarean delivery. Am J Obstet Gynecol 2022; 227:324-326. [PMID: 35487328 DOI: 10.1016/j.ajog.2022.04.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/01/2022]
Affiliation(s)
| | | | - Fung-Chao Tu
- Far Eastern Memorial Hospital, New Taipei, Taiwan
| | | | - Tzu-Yu Lin
- Far Eastern Memorial Hospital, New Taipei, Taiwan.
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10
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Altal OF, Qudsieh S, Ben-sadon A, Hatamleh A, Bataineh A, Halalsheh O, Amarin Z. Cervical tourniquet during cesarean section to reduce bleeding in morbidly adherent placenta: a pilot study. Future Sci OA. [PMID: 35369280 PMCID: PMC8965796 DOI: 10.2144/fsoa-2021-0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 02/07/2022] [Indexed: 11/23/2022] Open
Abstract
Objective: To evaluate a modified surgical technique aiming to reduce bleeding and preserve fertility in morbidly adherent placenta by cervical tourniquet in cesarean sections. Methods: The cesarean section operations and the cervical ligation approach were performed by a single expert consultant obstetrician. The general demographics and clinical characteristics for all participants were collected and studied. Results: Eleven participants were involved. The uterus was preserved in nine patients, whereas two patients had hysterectomy. The mean blood loss was 1688.8 ml for patients whose uterus was preserved. The mean length of stay was 5.5 days. Conclusion: Cervical ligation is a simple method that can be applied by junior and experienced obstetricians to preserve the uterus. Placenta accreta is the abnormal adhesion of placenta into the uterine wall. It carries a significant risk for hysterectomy, intrapartum and postpartum hemorrhage, and maternal morbidity and mortality. As the preservation of fertility and femininity is desired by many women, numerous methods were adapted to avoid hysterectomy in patients with placenta accreta. In this study, we describe and evaluate a novel technique to preserve the uterus by ligating the cervix with a Foley catheter.
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Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W, Ramasauskaite D, Lloyd I, Chandraharan E, Miller S, Burke T, Ossanan G, Andres Carvajal J, Ramos I, Hincapie MA, Loaiza S, Nasner D. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet 2022; 157 Suppl 1:3-50. [PMID: 35297039 PMCID: PMC9313855 DOI: 10.1002/ijgo.14116] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Maria Fernanda Escobar
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,Tygerberg Hospital, Cape Town, South Africa
| | - Eythan R Barnea
- Society for Investigation or Early Pregnancy (SIEP), New York, New York, USA
| | - Wanda Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Diana Ramasauskaite
- Center of Obstetrics and Gynecology, Vilnius University Medical Faculty, Vilnius, Lithuania
| | - Isabel Lloyd
- Department of Obstetrics and Gynecology, Universidad de Panamá, Panama City, Panamá.,Hospital Santo Tomas, Panama City, Panamá
| | - Edwin Chandraharan
- Department of Obstetrics and Gynecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Thomas Burke
- Division of Global Health and Human Rights, Massachusetts General Hospital, Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, USA
| | - Gabriel Ossanan
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Javier Andres Carvajal
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Isabella Ramos
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Maria Antonia Hincapie
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Sara Loaiza
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Daniela Nasner
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
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- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia
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Klangsin S, Booncharoen P, Suwanrath C. Conservative Surgical Management of Early Postpartum Hemorrhage: A 12-Year Experience in a Tertiary Care Center in the South of Thailand. J Obstet Gynaecol India 2022; 72:180-185. [PMID: 35928068 PMCID: PMC9343488 DOI: 10.1007/s13224-022-01628-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022] Open
Abstract
Background/Purpose of the Study To evaluate the success rate and predictive factors of success in conservative surgical management of early postpartum hemorrhage (PPH). Methods A retrospective study was conducted at a tertiary care hospital in the south of Thailand, from January 2006 to December 2017. PPH with conservative surgical management including Bakri balloon tamponade, B-Lynch uterine compression sutures, arterial embolization, vessel ligations, and combined surgical procedures was reviewed. The procedures were considered successful if bleeding could be controlled without subsequent hysterectomy. Multivariate logistic regression analysis was used to identify predictive factors for success of conservative surgical treatment. Results Among 39,327 deliveries, 1461 (3.7%) patients had early PPH, and 92 cases received conservative surgical management. Most patients (92.4%) underwent cesarean section. Median (IQR) blood loss before conservative surgery was 1800 (1100, 2575) mL, and median (IQR) time from early PPH to conservative surgical management was 41 (25.5, 60.0) minutes. The overall success rate of conservative surgical management was 80.4%, meanwhile the postoperative complication rate was 27.2%. The predictive factors significantly associated with success were maternal age < 35 years (odds ratio [OR] 4.53, 95% confidence interval [CI] 1.27-16.23; p = 0.02), blood loss before conservative surgery < 1800 mL (OR 5.82, 95% CI 1.45-23.33; p = 0.01), and time to start conservative surgery ≤ 40 min (OR 4.76, 95% CI 1.13-20.12; p = 0.03). Conclusion The overall success rate of conservative surgical procedures was high. Maternal age < 35 years, blood loss before conservative management < 1800 mL, and time to conservative surgery ≤ 40 min were predictive factors of success.
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13
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Saucedo López A, García Briones A, Velázquez Merino A, Corona Alvarado E, Gómez Fernández A. Morbimortalidad en pacientes sometidas a ligadura de arterias hipogástricas con riesgo de hemorragia obstétrica. Clínica e Investigación en Ginecología y Obstetricia 2021. [DOI: 10.1016/j.gine.2021.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Fuchs A, Parthasarathy KN, Coots A, Chauhan NR, Jiang X. Large Retroperitoneal Hematoma: A Rare Intraoperative Complication of Total Vaginal Hysterectomy. Cureus 2021; 13:e16760. [PMID: 34476135 PMCID: PMC8403485 DOI: 10.7759/cureus.16760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 11/05/2022] Open
Abstract
Retroperitoneal (RP) hematoma is a rare complication of total vaginal hysterectomy. A 45-year-old female G4P3013 with a history of abnormal uterine bleeding refractory to treatment by endometrial ablation and stress urinary incontinence underwent total vaginal hysterectomy, bilateral salpingectomy, bilateral uterosacral ligament suspension, anterior colporrhaphy, and cystoscopy. After the hysterectomy the left uterine artery pedicle was hemostatic; however, the patient became hemodynamically unstable and anemic. Laparoscopy revealed a stable zone III RP hematoma. Intraoperative observation revealed no further expansion of the hematoma. Left iliac angiography and aortography revealed there was no extravasation from the uterine arteries and gonadal vessels. Four days post-operative abdominal CT showed a stable hematoma. Hemodynamic instability resolved over the post-operative course. RP hematoma must be included in the differential for the evaluation of acute intraoperative hemodynamic instability with an unclear source.
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Affiliation(s)
- Anna Fuchs
- Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, USA
| | | | - Abigail Coots
- Trauma, Acute Care Surgery, and Surgical Critical Care, Reading Hospital Tower Health, Reading, USA
| | - Nikunj R Chauhan
- Interventional Radiology, Reading Hospital Tower Health, Reading, USA
| | - Xuezhi Jiang
- Obstetrics and Gynecology, Reading Hospital Tower Health, Reading, USA
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Yevstifeieva A, Krzeszowiak J, Lastovetskyi I, Mazurek A. Variations in branching patterns of internal iliac artery according to Adachi's classification - Literature review and presentation of a case. Translational Research in Anatomy 2021; 24:100119. [DOI: 10.1016/j.tria.2021.100119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Sanders AP, Hobson SR, Kobylianskii A, Papillon Smith J, Allen L, Windrim R, Kingdom J, Murji A. Internal iliac artery ligation-a contemporary simplified approach. Am J Obstet Gynecol 2021; 225:339-340. [PMID: 34097908 DOI: 10.1016/j.ajog.2021.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/23/2021] [Accepted: 05/06/2021] [Indexed: 11/29/2022]
Abstract
Bilateral ligation of the anterior division of the internal iliac arteries can be a lifesaving intervention for severe pelvic hemorrhage. The procedure results in decreased pelvic perfusion and promotes coagulation. The classical method of internal iliac artery ligation involved extensive retroperitoneal dissection with complete circumferential isolation of the vessel to allow the passage of a suture around the artery. This can be surgically challenging and fraught with risks of inadvertent injury to the surrounding iliac veins. We propose a contemporary technique that requires limited dissection of the anterior division of the internal iliac artery. A few millimeters of space is created on either side of the artery by spreading right-angle forceps parallel to the vessel. The artery is occluded by 2 large vascular clips. Because circumferential vessel dissection is not necessary with this technique, there is limited disruption of the delicate underlying internal iliac vein. In addition, this approach may decrease the risk of inadvertent injury to the adjacent external iliac vein. By showcasing the ease of our approach to internal iliac artery ligation, we hope to empower surgeons with an alternative approach to this lifesaving procedure.
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Affiliation(s)
- Ari P Sanders
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Peter Lougheed Centre, University of Calgary, Calgary, Alberta, Canada
| | - Sebastian R Hobson
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anna Kobylianskii
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Papillon Smith
- Department of Obstetrics and Gynecology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Lisa Allen
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rory Windrim
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John Kingdom
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ally Murji
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
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Win SS, Lasimbang HB, Lynn AUng SN, Yeap TB. How B-Lynch suture and bilateral internal iliac artery ligation saved the uterus of a young patient with severe postpartum haemorrhage. BMJ Case Rep 2021; 14:e244226. [PMID: 34385222 PMCID: PMC8362738 DOI: 10.1136/bcr-2021-244226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 11/03/2022] Open
Abstract
Obstetric haemorrhage is the leading cause of maternal death worldwide (27.1%) and more than 66% of its deaths were classified as postpartum haemorrhage (PPH). The most common cause of PPH is uterine atony. Obstetrician should be skillful in managing obstetric emergencies; especially pertaining to PPH. Application of the B-Lynch suture on an atonic uterus is one of the surgical options in PPH patients who wish to conserve the uterus and it has a very high success rate.We present a primigravida patient who developed massive primary PPH followed by disseminated intravascular coagulation, which was successfully managed with B-Lynch suture and bilateral internal iliac artery ligation. We described in detail regarding the management of massive PPH and application of these surgical procedures on the atonic uterus with an attempt to preserve the uterus and future fertility in this young patient.
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Affiliation(s)
- San San Win
- Reproductive Health Department, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Helen Benedict Lasimbang
- Reproductive Health Department, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Sai Nay Lynn AUng
- Reproductive Health Department, Mahidol University Institute for Population and Social Research, Nakorn Pathom, Thailand
| | - Tat Boon Yeap
- Department of Anaesthesiology & Intensive Care, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
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Liu C, Gao J, Liu J, Wang X, He J, Sun J, Liu X, Liao S. Predictors of Failed Intrauterine Balloon Tamponade in the Management of Severe Postpartum Hemorrhage. Front Med (Lausanne) 2021; 8:656422. [PMID: 34336876 PMCID: PMC8319466 DOI: 10.3389/fmed.2021.656422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/22/2021] [Indexed: 11/13/2022] Open
Abstract
To identify the factors predicting intrauterine balloon tamponade (IUBT) failure for severe postpartum hemorrhage (PPH) after delivery, we conducted a retrospective cohort study of women who underwent IUBT for severe PPH after delivery from October 1, 2016 until September 30, 2017. The failure of IUBT was defined as the need of additional surgical procedures or uterine embolization. A total of 99,650 deliveries occurred during the study period. Among the patients, 106 cases of severe PPH were managed with IUBT, and the global success rate was 70.8% (75/106). Least absolute shrinkage and selection operator (LASSO) regression was performed to select the potential risk factors predicting IUBT failure. The associated risk factors-obesity, multiple gestation, cesarean delivery, estimated blood loss (EBL), and placenta accreta spectrum (PAS)-were included in multivariate logistic models. Ultimately, these models identified multiple gestation, EBL, and PAS as independent risk factors for IUBT failure. In conclusion, IUBT is an effective method for severe PPH. The presence of factors affecting IUBT failure should be recognized early, and other modalities of management should be anticipated.
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Affiliation(s)
- Congcong Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xietong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Jing He
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingxia Sun
- Department of Obstetrics and Gynecology, The First Clinical Hospital Affiliated to Harbin Medical University, Harbin, China
| | - Xiaowei Liu
- Department of Obstetrics and Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Shixiu Liao
- Department of Obstetrics and Gynecology, Henan Provincial People's Hospital, Zhengzhou, China
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Affiliation(s)
- Jessica L Bienstock
- From the Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore
| | - Ahizechukwu C Eke
- From the Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore
| | - Nancy A Hueppchen
- From the Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore
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Ruiz Labarta FJ, Pintado Recarte MP, Joigneau Prieto L, Bravo Arribas C, Bujan J, Ortega MA, De León-Luis JA. Factors Associated with Failure of Bakri Balloon Tamponade for the Management of Postpartum Haemorrhage. Case Series Study and Systematic Review. Healthcare (Basel) 2021; 9:healthcare9030295. [PMID: 33800388 PMCID: PMC7999507 DOI: 10.3390/healthcare9030295] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Postpartum haemorrhage (PPH) is an unpredictable obstetric emergency that requires a multidisciplinary approach. Bakri balloon tamponade (BBT) is recommended when PPH does not respond to medical treatment. Nowadays few published studies have performed a multivariate analysis to determine the variables independently associated with BBT failure. Methods: Our study purpose was to determine the variables independently associated with BBT failure: first, in a large single-centre cohort study between 2010 and 2020, and second, in a systematic literature review using Medline and the Cochrane Library. Maternal and perinatal variables, PPH characteristics, technique-related variables and complications were recorded in the case series study, comparing between successful and failed BBT patients. Study characteristic and variables significantly associated with BBT failure were recorded in the systematic review. All studies used a logistic regression test. Results: The case series included 123 patients. The profile of these patients were primiparous, with vaginal delivery and a full-term new-born. BBT was successful in 81.3% of cases. Five studies were included in the systematic review, providing data from 551 patients. BBT was successful in 79.5% of cases. Conclusions: Maternal age, caesarean delivery, ≥7 red blood cells units (RBCU) transfused and curettage before BBT insertion, history of caesarean section, pre-pregnancy obesity, anteriorly placed placenta, placenta accreta, caesarean delivery, estimated blood loss before insertion of BBT, long operation duration, and coagulopathy were independent factors for BBT failure.
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Affiliation(s)
- Francisco Javier Ruiz Labarta
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (F.J.R.L.); (M.P.P.R.); (L.J.P.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - María Pilar Pintado Recarte
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (F.J.R.L.); (M.P.P.R.); (L.J.P.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Laura Joigneau Prieto
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (F.J.R.L.); (M.P.P.R.); (L.J.P.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Coral Bravo Arribas
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (F.J.R.L.); (M.P.P.R.); (L.J.P.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Julia Bujan
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain;
- Ramón y Cajal Institute of Healthcare Research (IRYCIS), 28034 Madrid, Spain
- University Center for the Defense of Madrid (CUD-ACD), 28047 Madrid, Spain
| | - Miguel A. Ortega
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain;
- Ramón y Cajal Institute of Healthcare Research (IRYCIS), 28034 Madrid, Spain
- University Center for the Defense of Madrid (CUD-ACD), 28047 Madrid, Spain
- Pathological Anatomy Service, Central University Hospital of Defense-UAH, 28047 Madrid, Spain
- Correspondence: ; Tel.: +34-91-885-45-40; Fax: +34-91-885-48-85
| | - Juan A. De León-Luis
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (F.J.R.L.); (M.P.P.R.); (L.J.P.); (C.B.A.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
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Vanwinkel S, Claes L, Van den Bosch T. Obstetrical outcome after B-Lynch sutures and ligation of uterine arteries: A case report. Case Rep Womens Health 2021; 30:e00303. [PMID: 33777709 PMCID: PMC7985276 DOI: 10.1016/j.crwh.2021.e00303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/26/2022] Open
Abstract
Objective To illustrate the obstetrical outcome after B-Lynch sutures and ligation of the uterine arteries. Case A 26-year-old nulliparous woman. A caesarean section performed for obstructed labour was complicated by uterine atony. A B-Lynch uterine compression suture technique was used combined with ligation of the ascending branches of the uterine arteries. Before the subsequent fertility treatment, gel instillation sonography and power Doppler imaging showed a normal uterine cavity and restored myometrial vascularization. Subsequent caesarean section showed external adhesions on the anterior uterine serosa. A healthy baby of normal weight was delivered. There was focal placenta accreta; the underlying myometrium was strikingly thinner and prone to inversion. Discussion After B-Lynch sutures and ligation of the ascending branches of the uterine arteries, the pregnancy was subsequently uncomplicated. The potential association between B-Lynch sutures and placenta accreta or uterine inversion in a subsequent pregnancy has to be assessed in further studies. This case report illustrates how 3D gel instillation sonography is a valuable tool to evaluate the integrity of the uterine cavity. 3D gel instillation sonography gives the best evaluation of the uterus after B-Lynch sutures have been used. Normal fertility and pregnancy are possible after B-Lynch sutures have been used. Normal fertility and pregnancy are possible after ligation of the uterine arteries. B-Lynch sutures and ligation of the uterine arteries are useful in postpartum haemorrhage.
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Affiliation(s)
- S Vanwinkel
- Department of Obstetrics and Gynaecology, University Hospitals UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - L Claes
- Department of Obstetrics and Gynaecology, Regional Hospital RZ Tienen, Kliniekstraat 45, 3300 Tienen, Belgium
| | - T Van den Bosch
- Department of Obstetrics and Gynaecology, University Hospitals UZ Leuven, Herestraat 49, 3000 Leuven, Belgium.,Laboratory for Tumor Immunology and Immunotherapy KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Shrestha R, Shrestha S, Sitaula S, Basnet P. Anatomy of Internal Iliac Artery and Its Ligation to Control Pelvic Hemorrhage. JNMA J Nepal Med Assoc 2020; 58:826-830. [PMID: 34504379 PMCID: PMC7654485 DOI: 10.31729/jnma.4958] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Indexed: 11/01/2022] Open
Abstract
Pelvic hemorrhage is a major cause of maternal morbidity and mortality in developing countries. A sound clinical judgment, adequate assessment, and preparation of the patient are the best preoperative means to avoid its occurrence. Bilateral internal iliac artery ligation is a life-saving procedure to control massive obstetric and gynecological hemorrhage when other measures fail. This procedure significantly reduces the pulse pressure and rate of blood flow abolishing the‘triphammer effect’ of arterial pulsation and subsequently resulting in sluggish blood flow allowing effective thrombosis within the small bleeding vessels. This has helped to save many lives and uteruses for more than a century. No tissue necrosis occurs due to ample collateral circulation in the pelvis from the major pelvic anastomoses. An increased understanding of retroperitoneal anatomy and regional variations of the internal iliac artery is needed to reduce the risk of intraoperative and postoperative complications. Keywords: internal iliac artery ligation;operative complications;pelvic anastomoses;pelvic hemorrhage;retroperitoneal anatomy.
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Affiliation(s)
- Ramesh Shrestha
- Department of Obstetrics and Gynaecology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Sapana Shrestha
- Master in Nursing, Women’s Health and Development, Maharajgunj Nursing Campus, Kathmandu, Nepal
| | - Sarita Sitaula
- Department of Obstetrics and Gynaecology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Pritha Basnet
- Department of Obstetrics and Gynaecology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
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İçen MS, Findik FM, Akin Evsen G, Ağaçayak E, Yaman Tunç S, Evsen MS, Gül T. Hypogastric artery ligation in postpartum haemorrhage: a ten-year experience at a tertiary care centre. J OBSTET GYNAECOL 2020; 41:536-540. [PMID: 32496842 DOI: 10.1080/01443615.2020.1755623] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study investigated patients who underwent bilateral hypogastric artery ligation (BHAL) due to postpartum haemorrhage (PPH). Patients who underwent BHAL because of PPH following a conservative treatment were included in this study. Placental abnormalities were referred to as placenta accreta. A total of 130 BHAL procedures took place at the study hospital as a result of PPH. Of these, 39 (30%) were referred to the hospital. The rate of BHAL requirement was 62 out of 10,000 births. Among the 130 patients, the most frequent indication for BHAL was placenta accreta (58.5%). Haematological parameters were poorer among the referral patients. Four of the exitus patients (80%) were referral patients. The mortality rate among the referral patients was 10.25%, whereas this rate was only 1.01% among the patients who gave birth at the hospital. PPH is a life-threatening condition that requires immediate medical attention. BHAL, with its fertility-preserving features, is a good option that can be employed in all PPH patients. BHAL not only preserves patients' fertility, but it also gives them a higher chance of survival.IMPACT STATEMENTWhat is already known on this subject? PPH is a life-threatening condition. Due to the worldwide increase in caesarean sections, placenta accreta has also increased. BHAL is a vital treatment method for PPH.What do the results of this study add? Placenta accreta is one of the most common causes of PPH. Traditional hysterectomy rates can be reduced by replacing this treatment with BHAL in this group of patients. Without early intervention in PPH, a patient's mortality risk can increase by up to 10 times. As research and surgeons' experience grows, PPH can be controlled with treatments with less complex modalities without the need for BHAL.What are the implications of these findings for clinical practice and/or further research? The need for BHAL should be kept in mind when addressing PPH, especially in cases of placenta accreta. The need for hypogastric artery ligation, which is a more aggressive treatment for the surgical correction of the pathology, can be reduced as surgeons' experience increases. Early intervention and/or referral in cases of PPH is of great importance.
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Affiliation(s)
- Mehmet Sait İçen
- Department of Gynecology and Obstetrics, Medical Faculty of Dicle University, Diyarbakir, Turkey
| | - Fatih Mehmet Findik
- Department of Gynecology and Obstetrics, Medical Faculty of Dicle University, Diyarbakir, Turkey
| | - Gamze Akin Evsen
- Department of Gynecology and Obstetrics, Medical Faculty of Dicle University, Diyarbakir, Turkey
| | - Elif Ağaçayak
- Department of Gynecology and Obstetrics, Medical Faculty of Dicle University, Diyarbakir, Turkey
| | - Senem Yaman Tunç
- Department of Gynecology and Obstetrics, Medical Faculty of Dicle University, Diyarbakir, Turkey
| | - Mehmet Sıddık Evsen
- Department of Gynecology and Obstetrics, Medical Faculty of Dicle University, Diyarbakir, Turkey
| | - Talip Gül
- Department of Gynecology and Obstetrics, Medical Faculty of Dicle University, Diyarbakir, Turkey
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Sucu S, Ozcan HÇ, Misirlioglu M, Guralp O, Kaya B. Temporary Clamping of Bilateral Common Iliac Artery During Cesarean Hysterectomy for the Management of Placenta Percreta. Eur J Obstet Gynecol Reprod Biol 2020; 250:188-94. [PMID: 32460227 DOI: 10.1016/j.ejogrb.2020.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate whether bilateral common iliac artery (CIA) temporary clamping reduces blood loss during cesarean-hysterectomy of placenta percreta cases. STUDY DESIGN A total of 32 women, who underwent cesarean-hysterectomy under bilateral CIA temporary clamping (n = 12) and without any arterial clamping or ligation (control group, n = 20) due to placenta percreta in Gaziantep University Hospital were retrospectively evaluated. The intra- and postoperative outcomes such as blood loss, blood transfusion and complications were compared between the two groups. RESULTS Age, parity, body-mass-index and gestational-age were similar in the two groups. The estimated blood loss was lower in the temporary clamping of CIA group than the control group (595 ± 172 mL vs 1450 ± 662 mL, P < 0.001). The number of intraoperative packed-red-blood-cells (0.17 ± 0.58 units vs 1.85 ± 1.46 units, P = 0.002) and fresh-frozen-plasma (0.17 ± 0.58 units vs 1.7 ± 1.49 units, P = 0.005) transfusions were lower in the CIA temporary clamping group than the control group. The rate of women, who received blood/blood products were significantly lower in the CIA temporary clamping group compared to the control group (75 % vs 16 %, P = 0.001). Duration of operation was longer in the CIA temporary clamping group (140 ± 38 min vs 90 ± 25 min, p = 0.001). No complication or maternal death was encountered during this study. CONCLUSION Bilateral CIA temporary clamping method reduces the intraoperative blood loss and the amount of intraoperative blood/blood product transfusions during cesarean-hysterectomy due to placenta percreta.
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Koh PR, Di Filippo D, Bisits A, Welsh AW. Bimanual examination for clot evacuation: a retrospective cohort study of women with postpartum haemorrhage after vaginal delivery. BMC Pregnancy Childbirth 2020; 20:245. [PMID: 32334562 PMCID: PMC7183670 DOI: 10.1186/s12884-020-02916-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bimanual clot evacuation (BCE) is a simple clinical manoeuvre that may reduce need for surgical intervention in the management of severe postpartum haemorrhage (PPH). We sought to determine whether performing BCE in cases of severe PPH after vaginal birth reduces the need for surgical intervention. METHODS A retrospective chart review of women who delivered vaginally with a severe PPH between January 1, 2011 and December 31, 2014 in a single tertiary women's hospital in Sydney, Australia was conducted. Severe PPH was classified as a blood loss ≥1000mls. The need for surgical management (including operating theatre uterine exploration or evacuation, intrauterine balloon tamponade, repair of significant trauma, uterine or internal iliac artery ligation, B-Lynch suture insertion or hysterectomy) was the primary outcome measure, as expressed by need for operating theatre utilisation. RESULTS From a cohort of 438, 149 women (34.0%) had BCE, of whom 29 (19.5%) required surgical management compared to 103 of 289 women with no BCE (35.6%); an odds ratio (OR) of 0.38 for BCE (confidence interval 0.20-0.72; p = 0.003). Early BCE (< 1 h of delivery) was associated with a further reduction in surgery (OR 0.24; confidence interval 0.08-0.70; p = 0.009) compared to late BCE (> 1 h of delivery). There was no reduction in estimated blood loss (p = 0.86) or blood transfusion (p = 0.71) with BCE. CONCLUSION Our study suggests BCE reduces theatre utilisation in the context of severe PPH following vaginal delivery. Prospective trials are needed to determine whether BCE should be endorsed as a treatment modality for PPH post-vaginal delivery.
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Affiliation(s)
- Pui Ru Koh
- School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - Daria Di Filippo
- School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - Andrew Bisits
- Department of Obstetrics, Royal Hospital for Women, Sydney, NSW, Australia
| | - Alec W Welsh
- School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia. .,Department of Maternal-Fetal Medicine, Royal Hospital for Women, Locked Bag 2000, Barker Street, Randwick, NSW, 2031, Australia.
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Surbek D, Vial Y, Girard T, Breymann C, Bencaiova GA, Baud D, Hornung R, Taleghani BM, Hösli I. Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion. Arch Gynecol Obstet 2020; 301:627-641. [PMID: 31728665 PMCID: PMC7033066 DOI: 10.1007/s00404-019-05374-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/31/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic. METHOD We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting. RESULTS PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications. CONCLUSION PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.
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Affiliation(s)
- Daniel Surbek
- Department of Obstetrics and Gynaecology, Bern University Hospital, Insel Hospital, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland.
| | - Yvan Vial
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Thierry Girard
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Christian Breymann
- Obstetric Research-Feto Maternal Haematology Unit, University Hospital Zurich, Zurich, Switzerland
| | | | - David Baud
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - René Hornung
- Department of Obstetrics and Gynaecology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | | | - Irene Hösli
- Clinic of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland
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Putra AD. Experience in Removal of Placenta Accreta with Uterus Preservation as a New Surgical Technique in Women with Previous Cesarean Deliveries. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2019.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andi Darma Putra
- Division of Gynecology–Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Indonesia, Jakarta Pusat, Jakarta, Indonesia
- Department of Obstetrics and Gynecology, Rumah Sakit Dr. Cipto Mangunkusumo Hospital, Jakarta Pusat, Jakarta, Indonesia
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Abstract
The internal iliac artery is the main vascular supply of pelvic visceral structures. All pelvic surgeons must know the anatomic landmarks and basic steps of internal iliac artery ligation in order to stop massive pelvic hemorrhage. This cadaveric demonstration and clinical review of the internal iliac artery shows the anatomic landmarks and basic steps of internal iliac artery ligation.
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Affiliation(s)
- İlker Selçuk
- Clinic of Gynecologic Oncology, Health Sciences University, Zekai Tahir Burak Woman’s Health Training and Research Hospital, Ankara, Turkey
| | - Bora Uzuner
- Department of Anatomy, Kafkas University Faculty of Medicine, Kars, Turkey
| | - Erengül Boduç
- Department of Anatomy, Kafkas University Faculty of Medicine, Kars, Turkey
| | - Yakup Baykuş
- Department of Obstetrics and Gynecology, Kafkas University Faculty of Medicine, Kars, Turkey
| | - Bertan Akar
- Clinic of Obstetrics and Gynecology, VM Medical Park Kocaeli Hospital, Kocaeli, Turkey
| | - Tayfun Güngör
- Clinic of Gynecologic Oncology, Health Sciences University, Zekai Tahir Burak Woman’s Health Training and Research Hospital, Ankara, Turkey
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Bouet PE, Madar H, Froeliger A, El Hachem H, Schinkel E, Mattuizi A, Sentilhes L. Surgical treatment of postpartum haemorrhage: national survey of French residents of obstetrics and gynecology. BMC Pregnancy Childbirth 2019; 19:91. [PMID: 30866846 PMCID: PMC6415489 DOI: 10.1186/s12884-019-2237-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/26/2019] [Accepted: 03/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and one of the leading causes of maternal mortality worldwide. Many medical treatments and interventions are available nowadays, but surgical treatment is sometimes required when less invasive methods are unsuccessful. This study aimed to assess the theoretical and practical knowledge of French residents of Obstetrics and Gynecology concerning the surgical treatment of postpartum haemorrhage. Study design We performed a questionnaire study for senior residents of Obstetrics and Gynecology in France (fourth and fifth year of training). An anonymous survey was sent by email. Between December 2013 and April 2014, a total of 370 residents responded. Result The response rate was 47.6% (176/370). Only 156 questionnaires were fully completed and included for analysis. In all, 74% (115/156) of residents reported not mastering sufficiently or at all the technique for bilateral ligation of uterine arteries, 79% (123/156) for uterine compression sutures, 95% (148/156) for ligation of the internal iliac arteries, and 78% (122/156) for emergency peripartum hysterectomy. More than half of respondents (55%, 86/156) stated that they had not mastered any of these techniques. Conclusion An alarmingly high number of French senior residents in Obstetrics and Gynecology report that they have not acquired the sufficient surgical skills during their training to be able to perform the surgeries required for the management of PPH. Electronic supplementary material The online version of this article (10.1186/s12884-019-2237-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pierre-Emmanuel Bouet
- Department of Obstetrics and Gynecology, Montreal University Hospital, Montreal, Canada.
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Hady El Hachem
- Department of Obstetrics and Gynecology, Clemenceau Medical Center, Beirut, Lebanon
| | - Elsa Schinkel
- Clinical Research Center, Angers University Hospital, Angers, France
| | - Aurélien Mattuizi
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
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Verit FF, Çetin O, Keskin S, Akyol H, Zebitay AG. Does bilateral uterine artery ligation have negative effects on ovarian reserve markers and ovarian artery blood flow in women with postpartum hemorrhage? Clin Exp Reprod Med 2019; 46:30-35. [PMID: 30827075 PMCID: PMC6436468 DOI: 10.5653/cerm.2019.46.1.30] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 12/03/2018] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Bilateral uterine artery ligation (UAL) is a fertility-preserving procedure used in women experiencing postpartum hemorrhage (PPH). However, the long-term effects of this procedure on ovarian function remain unclear. The aim of this study was to investigate whether bilateral UAL compromised ovarian reserve and ovarian blood supply. Methods This prospective study included 49 women aged between 21 and 36 years who had undergone a cesarean section for obstetric indications. Of these, 25 underwent uterine bilateral UAL to control intractable atonic PPH. The control group consisted of 24 women who had not undergone bilateral UAL. Standard clinical parameters, the results of color Doppler screening, and ovarian reserve markers were assessed in all participants at 6 months after surgery. The clinical parameters included age, parity, cycle history, body mass index, and previous medication and/or surgery. Color Doppler screening findings included the pulsatility index (PI) and resistance index (RI) for both the uterine and ovarian arteries. The ovarian reserve markers included day 3 follicle-stimulating hormone (FSH) levels, antral follicle count, and anti-Müllerian hormone (AMH) levels. RESULTS There were no significant differences in the ovarian reserve markers of day 3 FSH levels, antral follicle count, and AMH levels between the study and control groups (p>0.05 for all). In addition, no significant differences were observed in the PI and RI indices of the uterine and ovarian arteries (p>0.05 for all). CONCLUSION In this study, we showed that bilateral UAL had no negative effects on ovarian reserve or ovarian blood supply, so this treatment should be used as a fertility preservation technique to avoid hysterectomy in patients experiencing PPH.
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Affiliation(s)
- Fatma Ferda Verit
- Department of Obstetrics and Gynecology, Suleymaniye Maternity, Research and Training Hospital, University of Health Sciences, Istanbul, Turkey
| | - Orkun Çetin
- Department of Obstetrics and Gynecology, Yuzuncu Yil University Medical Faculty, Van, Turkey
| | - Seda Keskin
- Department of Obstetrics and Gynecology, Ordu University Medical Faculty, Ordu, Turkey
| | - Hürkan Akyol
- Department of Obstetrics and Gynecology, Suleymaniye Maternity, Research and Training Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ali Galip Zebitay
- Department of Obstetrics and Gynecology, Suleymaniye Maternity, Research and Training Hospital, University of Health Sciences, Istanbul, Turkey
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Wang CY, Pan HH, Chang CC, Lin CK. Outcomes of hypogastric artery ligation and transcatheter uterine artery embolization in women with postpartum hemorrhage. Taiwan J Obstet Gynecol 2019; 58:72-76. [DOI: 10.1016/j.tjog.2018.11.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2018] [Indexed: 10/27/2022] Open
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Leduc D, Senikas V, Lalonde AB. No. 235-Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage. Journal of Obstetrics and Gynaecology Canada 2018; 40:e841-e855. [DOI: 10.1016/j.jogc.2018.09.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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33
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Leduc D, Senikas V, Lalonde AB. No 235 - Prise en charge active du troisième stade du travail: Prévention et prise en charge de l'hémorragie postpartum. Journal of Obstetrics and Gynaecology Canada 2018; 40:e856-e873. [DOI: 10.1016/j.jogc.2018.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Limbachiya D, Kenkre M, Shah S, Kumari R. Circumferential Vault Excision and Reconstruction: Technical Description of Management of Intractable Secondary Vault Hemorrhage after Hysterectomy in Resource-Limited Settings. J Minim Invasive Gynecol 2019; 26:760-5. [PMID: 30366116 DOI: 10.1016/j.jmig.2018.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/16/2018] [Accepted: 10/16/2018] [Indexed: 11/21/2022]
Abstract
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.
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Ahrari Khafi MS, Mogheiseh A, Salavati S, Karimi S. Angiography of ovarian and uterine vessels of the dog. Anim Reprod Sci 2018; 195:329-333. [DOI: 10.1016/j.anireprosci.2018.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/22/2018] [Accepted: 06/24/2018] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To compare the rates of invasive procedures (surgical or vascular) for hemorrhage control between a perinatal network that routinely used intrauterine balloon tamponade and another perinatal network that did not in postpartum hemorrhage management. METHODS This population-based retrospective cohort study included all women (72,529) delivering between 2011 and 2012 in the 19 maternity units in two French perinatal networks: a pilot (in which balloon tamponade was used) and a control network. Outcomes were assessed based on discharge abstract data from the national French medical information system. General and obstetric characteristics were included in two separate multivariate logistic models according to the mode of delivery (vaginal and cesarean) to estimate the independent association of the network with invasive procedures. RESULTS Invasive procedures (pelvic vessel ligation, arterial embolization, hysterectomy) were used in 298 women and in 4.1 per 1,000 deliveries (95% CI 3.7-4.6). The proportion of women with at least one invasive procedure was significantly lower in the pilot network (3.0/1,000 vs 5.1/1,000, P<.01). Among women who delivered vaginally, the use of arterial embolization was also significantly lower in the pilot than the control network (0.2/1,000 vs 3.7/1,000, P<.01) as it was for those who delivered by cesarean (1.3/1,000 vs 5.7/1,000, P<.01). After controlling for potential confounding factors, the risk of an invasive procedure among women who delivered vaginally remained significantly lower in the pilot network (adjusted odds ratio [OR] 0.14, 95% CI 0.08-0.27), but not for women who delivered by cesarean (adjusted OR 1.19, 95% CI 0.87-1.61). CONCLUSION The use of intrauterine balloon tamponade in routine clinical practice was associated with a significantly lower use of invasive procedures for hemorrhage control among women undergoing vaginal delivery.
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Kaya B, Usluogullari B, Yurttutan N, Sahan M, Güralp O, Malik E. Does ligation of internal iliac artery for postpartum hemorrhage affect clitoral artery blood flow and postpartum sexual functions? Eur J Obstet Gynecol Reprod Biol 2017; 219:124-128. [DOI: 10.1016/j.ejogrb.2017.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 10/23/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
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Soyama H, Miyamoto M, Sasa H, Ishibashi H, Yoshida M, Nakatsuka M, Takano M, Furuya K. Effect of routine rapid insertion of Bakri balloon tamponade on reducing hemorrhage from placenta previa during and after cesarean section. Arch Gynecol Obstet 2017. [DOI: 10.1007/s00404-017-4446-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Dohbit JS, Foumane P, Nkwabong E, Kamouko CO, Tochie JN, Otabela B, Mboudou E. Uterus preserving surgery versus hysterectomy in the treatment of refractory postpartum haemorrhage in two tertiary maternity units in Cameroon: a cohort analysis of perioperative outcomes. BMC Pregnancy Childbirth 2017; 17:158. [PMID: 28558661 PMCID: PMC5450395 DOI: 10.1186/s12884-017-1346-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/24/2017] [Indexed: 11/21/2022] Open
Abstract
Background Little evidence exists on the efficacy and safety of the different surgical techniques used in the treatment of postpartum haemorrhage (PPH). We aimed to compare uterus preserving surgery (UPS) versus hysterectomy for refractory PPH in terms of perioperative outcomes in a sub-Saharan African country with a known high maternal mortality ratio due to PPH. Methods This was a retrospective cohort study comparing the perioperative outcomes of all women managed by UPS (defined as surgical interventions geared at achieving haemostasis while conserving the uterus) versus hysterectomy (defined as surgical resection of the uterus to achieve haemostasis) for PPH refractory to standard medical management in two tertiary hospitals in Cameroon from January 2004 to December 2014. We excluded patients who underwent hysterectomy after failure of UPS. Comparison was done using the Chi-square test or Fisher exact test where appropriate. Bonferroni adjustment of the p-value was performed in order to reduce the chance of obtaining false-positive results. Results We included 24 cases of UPS against 36 cases of hysterectomy. The indications of surgery were dominated by uterine rupture and uterine atony in both groups. Types of UPS performed were seven bilateral hypogastric artery ligations, seven hysterorraphies, six bilateral uterine artery ligations, three B-Lynch sutures and one Tsirulnikov triple ligation with an overall uterine salvage rate of 83.3%. Types of hysterectomies were 26 subtotal hysterectomies and 10 total hysterectomies. UPS was associated with maternal deaths (RR: 2.3; 95% CI: 1.38–3.93.; p: 0.0015) and postoperative infections (RR: 1.96; 95% CI: 1.1–3.49; p: 0.0215). The association of UPS with maternal death was not attenuated after Bonferroni correction. Hysterectomy had no statistically significant adverse outcome. Conclusion Hysterectomy is safer than UPS in the management of intractable PPH in our setting. The choice of UPS as first-line surgical management of PPH in resource-limited settings should entail diligent anticipation of these adverse maternal outcomes in order to lessen the perioperative burden of PPH.
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Affiliation(s)
- Julius Sama Dohbit
- Department of Obstetrics and Gynaecology, Gynaeco-Obstetric and Paediatric Hospital, Yaounde, Cameroon.,Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Pascal Foumane
- Department of Obstetrics and Gynaecology, Gynaeco-Obstetric and Paediatric Hospital, Yaounde, Cameroon.,Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Elie Nkwabong
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon.,Department of Obstetrics and Gynaecology, University Hospital Centre, Yaounde, Cameroon
| | - Christelle Ogolong Kamouko
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Joel Noutakdie Tochie
- Department of Surgery and sub-Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon. .,Health and Human development (2HD) Research Group, Douala, Littoral Region, Cameroon.
| | | | - Emile Mboudou
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon.,Department of Obstetrics and Gynaecology, Gynaeco-Obstetric and Paediatric Hospital, Douala, Cameroon
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Feng S, Liao Z, Huang H. Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study. Anaesthesia 2017; 72:853-858. [PMID: 28401537 DOI: 10.1111/anae.13895] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2017] [Indexed: 02/05/2023]
Abstract
We performed an impact study on the introduction of routine placement of internal iliac artery balloon catheters for the management of haemorrhage during caesarean section in women with placenta accreta. We identified 11 women, with prenatally diagnosed placenta accreta/increta/percreta before this change in practice, who acted as controls, and 30 women who had iliac artery balloons placed. The balloons were inflated in 27 cases. The median (IQR [range]) intra-operative blood loss was 1100 (800-2600 [500-6000]) ml in controls, compared with 1000 (600-2513 [400-15000]) ml in women with iliac artery balloons (p = 0.64). Six (54%) controls received intra-operative blood transfusion compared with 14 (47%) women with iliac artery balloons (p = 0.66). Caesarean hysterectomy was performed in 3 (27.3%) controls and 13 (43.3%) women with iliac artery balloons (p = 0.48). Balloon catheter insertion was associated with a shortened postoperative hospital stay, 6 (5-7 [4-12] days in controls vs. 5 (4-6 [3-10]) in the iliac artery balloon group (p = 0.033). General anaesthesia was used in six (54%) controls, but all women with iliac artery balloons. This study demonstrates that prophylactic balloon occlusion of the internal iliac arteries did not reduce intra-operative haemorrhage or caesarean hysterectomy in women with placenta accreta undergoing caesarean section. In addition, it has a significant impact on the choice of anaesthetic technique.
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Affiliation(s)
- S Feng
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Z Liao
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - H Huang
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China.,Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China
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Kehila M, Derouich S, Chelli D, Touhami O, Marzouk SB, Khedher SB, Chanoufi MB, Boudaya F. [Which surgical strategy to adopt for the management of postpartum haemorrhage and how to improve the effects of hypogastric arteries ligation?]. Pan Afr Med J 2017; 25:96. [PMID: 28292059 PMCID: PMC5325502 DOI: 10.11604/pamj.2016.25.96.9242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 08/24/2016] [Indexed: 11/11/2022] Open
Abstract
L'objectif était d'identifier les facteurs de succès de la ligature bilatérale des artères hypogastriques et évaluer sa place dans le traitement chirurgical des hémorragies du post-partum. Nous avons réalisé une étude rétrospective regroupant tous les cas d'hémorragie du post-partum ayant nécessité un traitement chirurgical entre Janvier 2008 et Décembre 2011. L'étude a concerné 88 patientes (0,47% du total des accouchements). L'atonie utérine était l'étiologie la plus fréquente (64,8 % des patientes). La ligature bilatérale des artères hypogastriques a été réalisée chez 81,8% des patientes. Quand elle était le premier geste chirurgical réalisé, son taux de succès était de 66%. Ce taux était variable en fonction de l'étiologie de l'hémorragie, de la présence ou non de troubles de l'hémostase et du temps écoulé entre le diagnostic et la réalisation du geste chirurgical. En cas atonie utérine, l'association d'une deuxième technique conservatrice lorsque la première était insuffisante, a permis d'arrêter le saignement dans 98% des cas. La ligature des artères hypogastriques est une technique chirurgicale efficace pour le traitement de l'hémorragie du post-partum. Son taux de succès est augmenté par sa réalisation précoce ainsi que son association à d'autres techniques conservatrices.
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Affiliation(s)
- Mehdi Kehila
- Service C, Centre de Maternité et de Néonatologie de Tunis, Faculté de médecine de Tunis, Université Tunis El Manar, Tunisie
| | - Sadok Derouich
- Service C, Centre de Maternité et de Néonatologie de Tunis, Faculté de médecine de Tunis, Université Tunis El Manar, Tunisie
| | - Dalenda Chelli
- Service A, Centre de Maternité et de Néonatologie de Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunisie
| | - Omar Touhami
- Service C, Centre de Maternité et de Néonatologie de Tunis, Faculté de médecine de Tunis, Université Tunis El Manar, Tunisie
| | - Sofiene Ben Marzouk
- Service de Réanimation, Centre de Maternité et de Néonatologie de Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunisie
| | - Sonia Ben Khedher
- Service C, Centre de Maternité et de Néonatologie de Tunis, Faculté de médecine de Tunis, Université Tunis El Manar, Tunisie
| | - Mohamed Bedis Chanoufi
- Service C, Centre de Maternité et de Néonatologie de Tunis, Faculté de médecine de Tunis, Université Tunis El Manar, Tunisie
| | - Fethia Boudaya
- Service A, Centre de Maternité et de Néonatologie de Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunisie
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Rauf M, Ebru C, Sevil E, Selim B. Conservative management of post-partum hemorrhage secondary to placenta previa-accreta with hypogastric artery ligation and endo-uterine hemostatic suture. J Obstet Gynaecol Res 2016; 43:265-271. [DOI: 10.1111/jog.13215] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/29/2016] [Accepted: 09/23/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Melekoglu Rauf
- Department of Obstetrics and Gynecology; Faculty of Medicine, University of Inonu; Malatya Turkey
| | - Celik Ebru
- Department of Obstetrics and Gynecology; Faculty of Medicine, University of Inonu; Malatya Turkey
| | - Eraslan Sevil
- Department of Obstetrics and Gynecology; Faculty of Medicine, University of Inonu; Malatya Turkey
| | - Buyukkurt Selim
- Department of Obstetrics and Gynecology; Faculty of Medicine, University of Cukurova; Adana Turkey
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Rezk M, Saleh S, Shaheen A, Fakhry T. Uterine packing versus Foley's catheter for the treatment of postpartum hemorrhage secondary to bleeding tendency in low-resource setting: A four-year observational study. J Matern Fetal Neonatal Med 2016; 30:2747-2751. [PMID: 27855529 DOI: 10.1080/14767058.2016.1262342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of uterine packing versus Foley's catheter tamponade for controlling postpartum hemorrhage (PPH) secondary to bleeding tendency after vaginal delivery. METHODS This was a prospective observational study conducted on 92 patients with primary PPH due to bleeding tendency following vaginal delivery who were unresponsive to uterotonics and bimanual compression of the uterus. Patients were divided into two groups, Uterine packing group (n = 45) and Foley catheter group (n = 47). The primary outcome was the success rate of the procedure. Secondary outcome addressed the maternal complications. RESULTS The use of uterine packing resulted in stoppage of active bleeding in 93.3% of cases compared to only 68.1% in the Foley's catheter group (p < 0.05). Although the rate of minor complications namely fever, pain and urinary complaints were higher in the uterine packing group, it does not reach to a significant difference when compared to the Foley's catheter (p > 0.05). Six cases who failed to Foley catheter tamponade underwent emergency hysterectomy with no cases in the uterine packing group. CONCLUSIONS The use of uterine packing to arrest PPH is simple, quick and safe procedure to avoid further surgical interventions and to preserve the fertility in low-resource setting.
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Affiliation(s)
- Mohamed Rezk
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Menoufia University , Menoufia , Egypt
| | - Said Saleh
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Menoufia University , Menoufia , Egypt
| | - Abdelhamid Shaheen
- a Department of Obstetrics and Gynecology, Faculty of Medicine , Menoufia University , Menoufia , Egypt
| | - Tamer Fakhry
- b Department of General Surgery, Faculty of Medicine , Menoufia University , Menoufia , Egypt
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Revert M, Cottenet J, Raynal P, Cibot E, Quantin C, Rozenberg P. Intrauterine balloon tamponade for management of severe postpartum haemorrhage in a perinatal network: a prospective cohort study. BJOG 2016; 124:1255-1262. [PMID: 27781401 DOI: 10.1111/1471-0528.14382] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of intrauterine balloon tamponade (IUBT) for management of severe postpartum haemorrhage (PPH). To identify the factors predicting IUBT failure. DESIGN Prospective cohort study. SETTING Ten maternity units in a perinatal network. POPULATION Women treated by IUBT from July 2010 to March 2013. METHODS The global IUBT success rate was expressed as the number of women with severe PPH who were successfully treated by IUBT divided by the total number treated by IUBT. IUBT failure was defined as the need for arterial embolisation or surgery. Logistic regression analysis was used to estimate factors predicting IUBT failure. MAIN OUTCOME MEASURES Global IUBT success rate. Factors associated with IUBT failure. RESULTS Intrauterine balloon tamponade was attempted in 226 women: 171 after vaginal delivery (VD) (75.7%) and 55 during or after caesarean delivery (CD) (24.3%). The global success rate was 83.2% (188/226) and was significantly higher after VD (152/171, 88.9%) than CD (36/55, 65.5%, P < 0.01). The percentage of CD was significantly higher in the failure group (50.0 versus 19.1%, P < 0.01), as was mean (SD) estimated blood loss before IUBT: 1508 ± 675 ml versus 1064 ± 476, P < 0.01. Coagulopathy was significantly more frequent in the failure group (50.0% versus 17.2%, P < 0.01). CD [Odds ratio (OR) 3.5; 95% CI 1.6-7.6], estimated blood loss before IUBT (OR 3.2; 95% CI 1.5-6.8) and coagulopathy (OR 5.6; 95% CI 2.5-13.0) were predictive of IUBT failure. CONCLUSION Intrauterine balloon tamponade is an effective method for treating severe PPH. Early balloon deployment before the development of coagulopathy increases its success rate. TWEETABLE ABSTRACT Intrauterine balloon tamponade is effective for achieving haemostasis in intractable postpartum haemorrhages.
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Affiliation(s)
- M Revert
- EA 7285, Versailles Saint Quentin University, Versailles, France
| | - J Cottenet
- Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France.,Bourgogne Franche-Comté University, Dijon, France
| | - P Raynal
- Department of Obstetrics and Gynaecology, André Mignot Hospital, Versailles, France
| | - E Cibot
- Department of Obstetrics and Gynaecology, Poissy Saint-Germain Hospital, Poissy, France
| | - C Quantin
- Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France.,Bourgogne Franche-Comté University, Dijon, France.,Inserm, CIC 1432, Dijon, France.,Dijon University Hospital, Clinical Investigation Center, Dijon, France.,Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), INSERM, UVSQ, Institut Pasteur, Université Paris-Saclay, Villejuif, France
| | - P Rozenberg
- EA 7285, Versailles Saint Quentin University, Versailles, France.,Department of Obstetrics and Gynaecology, Poissy Saint-Germain Hospital, Poissy, France
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Chen Z, Li J, Shen J, Jin J, Zhang W, Zhong W. Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta. Int J Gynaecol Obstet 2016; 135:264-7. [DOI: 10.1016/j.ijgo.2016.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/26/2016] [Accepted: 08/15/2016] [Indexed: 11/15/2022]
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Kaya B, Damarer Z, Daglar K, Unal O, Soliman A, Guralp O. Is there yet a role for internal iliac artery ligation in obstetric hemorrhage with the current gain in popularity of other uterus sparing techniques? J Matern Fetal Neonatal Med 2016; 30:1325-1332. [DOI: 10.1080/14767058.2016.1212333] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ruiz Labarta FJ, Pintado Recarte MP, Alvarez Luque A, Joigneau Prieto L, Perez Martín L, Gonzalez Leyte M, Palacio Abizanda F, Morillas Ramirez F, Perez Corral A, Ortiz Quintana L, De Leon-Luis J. Outcomes of pelvic arterial embolization in the management of postpartum haemorrhage: a case series study and systematic review. Eur J Obstet Gynecol Reprod Biol 2016; 206:12-21. [PMID: 27612214 DOI: 10.1016/j.ejogrb.2016.07.510] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/04/2016] [Accepted: 07/26/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is an unpredictable obstetric emergency that requires a multidisciplinary approach. Pelvic arterial embolization (PAE) is considered as a second-line treatment, although the published results have not been reviewed systematically since 2007. OBJECTIVES To evaluate success and complication rates of PAE to treat PPH in the study hospital between 2009 and 2015, and to perform a systematic review of the literature on the reported efficacy and safety of PAE for the management of PPH. SEARCH STRATEGY A systematic review of articles on PAE in English or Spanish was conducted using Medline and the Cochrane Library. SELECTION CRITERIA All published articles assessing success and complication rates of PAE in cases of PPH. The search was restricted to articles published in English or Spanish between 2000 and 2015, with at least 25 cases. DATA COLLECTION AND ANALYSIS Obstetric variables, maternal haemodynamic state, pre-/postembolization management, technique-related variables, post-PAE evolution and complications were recorded in the case series study. Study characteristics, success rates and PAE-related complication rates were recorded in the systematic review. MAIN RESULTS The case series included 29 patients. The majority of these patients were primiparous, with singleton term pregnancies and spontaneous labour. Caesarean section was performed in 62.1% of patients undergoing PAE for PPH. PAE was successful in 89.6% [95% confidence interval (CI) 78.3-100] of cases. Twenty studies were included in the systematic review, providing data from 1739 patients. PAE was successful in 89.4% (95% CI 87.9-90.9) of cases. The mortality rate was 0.9%, and other major complications were uncommon (1.8%). CONCLUSIONS PAE was found to be a minimally invasive, highly successful and safe technique for the management of PPH. It should be considered in PPH refractory to initial treatment.
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Singh A, Kishore R, Saxena SS. Ligating Internal Iliac Artery: Success beyond Hesitation. J Obstet Gynaecol India 2016; 66:235-41. [PMID: 27651610 DOI: 10.1007/s13224-016-0859-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 02/09/2016] [Indexed: 10/22/2022] Open
Abstract
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.
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Affiliation(s)
- Abha Singh
- Department of Obstetrics and Gynecology, Pt. J.N.M. Medical College, Raipur, India
| | - Ruchi Kishore
- Department of Obstetrics and Gynecology, Pt. J.N.M. Medical College, Raipur, India
| | - Saveri Sarbhai Saxena
- Department of Obstetrics and Gynecology, Pt. J.N.M. Medical College, Raipur, India ; Sarbhai Nursing Home, Mahadev Ghat Road, Daganiya, Raipur, CG India
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Al-Ganadi A. Management of Vascular Injury during Current Peaceful Yemeni Revolution. Ann Vasc Surg 2015; 29:1575-80. [DOI: 10.1016/j.avsg.2015.06.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 06/28/2015] [Indexed: 10/23/2022]
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