Laparoscopic Ligation of Uterine Vasculature for Fertility-Sparing Management of Postabortal Hemorrhage

STUDY OBJECTIVE

To present a surgical video in which bilateral uterine vasculature was ligated laparoscopically in order to preserve the uterus in a patient with postabortal hemorrhage.

DESIGN

A case report (Canadian Task Force classification III).

SETTING

A tertiary referral center in New Haven, CT.

INTERVENTIONS

This is a step-by-step demonstration of laparoscopic ligation of the uterine vasculature in a patient with postabortal hemorrhage. The patient was a 33-year-old Para 4014 woman who presented with postabortal hemorrhage after she underwent an urgent dilation and evacuation for the management of symptomatic placenta accreta at 19 weeks of pregnancy. The patient underwent a physical examination when she presented to the emergency department with postabortal hemorrhage. She was hemodynamically stable, and the examination was negative for cervical or vaginal lacerations. Coagulation studies were negative for any coagulopathy. A pelvic ultrasound did not show any retained products of conception. As per the Society of Family Planning guidelines, uterine massage was performed, and uterotonics (i.e., methylergonovine maleate 0.2 mg intramuscularly and misoprostol 1000 mg per rectum) were given [1]. The postabortal hemorrhage persisted despite medical therapy with an approximate blood loss of 600 mL over 2 hours. An intrauterine tamponade balloon was placed, and the patient then underwent a uterine angiogram and bilateral uterine artery embolization secondary to continued vaginal bleeding despite medical management. She was closely monitored and noted to have another 500 mL of blood loss over 2 hours after completion of uterine artery embolization. At this point, she was resuscitated with 2 U red blood cells because she developed symptoms of hemodynamic instability. Her hematocrit was increased suboptimally after transfusion with stabilization of her vitals. The patient was then counseled on her surgical options because she had failed medical management, intrauterine balloon tamponade, and uterine artery embolization. She stated a strong desire to preserve her uterus. Given her overall hemodynamic stability, laparoscopic ligation of the uterine vessels was proposed, which she agreed on [2]. Risks of the laparoscopic approach were explained to the patient, which included injury to the uterus, ureters, blood vessels, and nerves as well as the possibility of conversion to laparotomy. The surgery started with exploration of the peritoneal cavity. Her uterus was noted to be significantly enlarged with many engorged vessels. In order to decrease the risk of uterine perforation in this bulky and highly vascular uterus, the surgeon decided not to place a uterine manipulator. The retroperitoneum was entered at the right pelvic sidewall. Pararectal and paravesical spaces were then developed. Ureterolysis was performed in order to free its peritoneal and uterine artery attachments. The uterine artery was skeletonized cephalad to the hypogastric bifurcation and was ligated with 5-mm vascular clips. The attention was then turned to the ovarian vessels at the cornu of the uterus. Peritoneal avascular windows were created inferior and superior to the vessels. The blood supply was then ligated with an absorbable suture, and the ligature was secured using the extracorporeal knot tying technique. The same steps were repeated on the left pelvic sidewall. The procedure was completed once excellent hemostasis was assured. Besides the technical steps of the procedure, pelvic anatomic landmarks have also been emphasized in this video for educational purposes.

MEASUREMENTS AND MAIN RESULTS

Laparoscopic ligation of the uterine vasculature was performed without any complications. The operative time was 65 minutes, and blood loss was minimal. The patient had an uneventful postoperative course and was discharged home the day after her laparoscopic surgery.

CONCLUSION

The uterus was preserved with this minimally invasive approach for the management of postabortal hemorrhage. Laparoscopic ligation of the uterine vessels should be considered in hemodynamically stable patients who desire future fertility when managing postabortal hemorrhage.

Uterine artery pseudoaneurysm: its occurrence after non-traumatic events, and possibility of "without embolization" strategy

OBJECTIVES

Uterine artery pseudoaneurysm (UAP) has been considered to occur very rarely after traumatic delivery/abortion, and is usually detected after its rupture, yielding massive bleeding. Our hypothesis is: some UAP may be undetected without massive bleeding and may spontaneously resolve, and, thus, may not require transarterial embolization (TAE). We attempted: (1) to detect both ruptured and non-ruptured UAP, thereby characterizing candidates of spontaneously resolving UAP, and (2) to confirm that UAP is not rare and not always associated with traumatic events.

STUDY DESIGN

This was a retrospective observational study of 50 women with angiographically confirmed UAP and treated by TAE. Angiograms and medical charts were retrieved to examine the associations among symptoms, ultrasound findings, and extravasation. Gray-scale ultrasound was performed for all women after delivery or abortion as our routine practice.

RESULTS

UAP occurred in 3-6/1000 deliveries and 40% occurred after non-traumatic deliveries/abortion. While 36% had active vaginal bleeding at admission, 64% did not. While 100% of patients with current active bleeding showed extravasation from the pseudoaneurysmal sac, patients without it showed a varied incidence of extravasation depending on the bleeding pattern/history and ultrasound findings. Interestingly, all patients with current bleeding (-), bleeding history (+), and ultrasound-discernable-intrauterine low echoic mass (-) were devoid of extravasation, suggesting that UAP may show progression to thrombosis and, thus, resolve spontaneously.

CONCLUSIONS

UAP may not be so rare and not associated with traumatic delivery/abortion. Some UAP may resolve, and, thus, may not require TAE, at least immediately.