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Controlling of profuse pelvic haemorrhage
in obst and gynae by
hypogastric artery ligation
Pregnancy the most dangerous journey of mankind…
Definition WHO defines PPH as blood loss of more than 500
ml following vaginal delivery or more than 1000 ml
after caesarean section.
However, various authors suggest that PPH
should be diagnosed with any amount of blood
loss that threatens the hemodynamic stability of
the woman.
Causes of Maternal Death
Infection14.9%
Haemorrhage
24.8%
Indirect causes19.8%
Other direct causes7.9%
Unsafe abortion12.9%
Obstructed labour6.9%
Eclampsia12.9%
Haemorrhage is the biggest and fastest
killer
Postpartum Hemorrhage
PPH is a serious, Life-threatening obstetric problem.
One of the leading causes of maternal morbidity and mortality.
In developing countries mainly due to three delays: -
1. Delay in seeking care.
2. Delay in reaching care.
3. Delay in receiving care.
• 11% women with live birth i.e. 14 million
women / year
• 3.9% in vaginal deliveries
• 6.4% in Cesarean section .
• Higher with high risk factor
• 10% overall.
• Mismanagement of III stage results in
higher incidence of PPH
Incidence of PPH
The Four Ts Mnemonic – Causes of PPH
Four Ts Causes Incidence (%)
1st Tone Atonic uterus 90
2nd
Trauma
Lacerations, hematomas,
inversion, rupture
07
3rd Tissue Retained tissue,
Invasive placenta
03
4th
Thrombin
Coagulopathies Less than1
Am Fam Physician 2007;75:875-82.
‘Prevention is easier
and better than cure’
Prevention of PPH ???
It can be achieved by Active management of 3rd stage of labour
Recognition Referral Responsiveness
“While managing PPH Time lapsed should not be counted in a minute---one has not lost one minute ,but 60 seconds” Ian Donald
PPH Treatment Protocol
PPH Treatment Protocol
Treatment Protocol Of Primary Atonic PPH
(1st T)
Management Management of of Shock Uterine atonicity
Replacement of blood * Conservative medical or its component management
* Surgical management
- Conservative surgery
- Radical surgery
Stepwise Management of Atonic PPHStep I - Bleeding continues
- 15 methyl PGF2 250g every 15-30 mint.
Step II - a) Bimanual compression
b) Aortic compression
Step III - Transvaginal options
- Uterine packing
- Tamponade
Step IV - Compression sutures
B.Lynch, Hayman, Cho Square
Step V -Other surgical measures
- stepwise uterine devascularisation
Step VI - Hysterectomy
Ligation of hypogastric artries was first introduced into surgery by the end of the 19th century to control massive haemorrhage from uterus of woman with advanced cervical cancer.
At present it is one of operative methods to arrest life threatening PPH before hysterectomy when medical treatment fails to arrest haemorrhage.
Back ground
One of the effective method used by experienced gynaecologic surgeons tat does not result in complete blockage but to a significant result in decrease blood supply to pelvic organs.
Helps in avoiding hystrectomy in 50% of cases in pts with PPH.
First reports of successful BHA ligation was published in 1890.
Many gynaecologists fear that the cessation of blood supply may cause damage to pelvic organs,but this fear is unfounded.
Its not life saving procedure but also save uterus.
Several pregnancies reported to full term after bilateeral ligation of hypogastric arteries.
Management of PPH is synonymous to the working
of a military operational head quarters it requires:
TACTICAL ANALOGUE
* Quick reaction time (20 mins)
* Interactive team (Anesth, Intensivist, Bl bank)
* Well equipped OT (Controlled envioroment)
* Dedicated mission and objective depending on local
scenario (suturing : vs ligation : hem evac : O.H.)
* Fall back options ( Uterine Art. & Hypogastric Art.)
* Collateral damage (bladder and bowel)
* Attrition rates (tissue trauma / septicaemia)
* Escape routes (packing / drain)
Aorta divides into common iliacs at fourth lumbar
The CIA divides into EIA and IIA (HA)
at sacrum
EIA goes along psoas to form femoral
HA drops medio inf into the pelvic fossa
Bony landmark for bifurcation of CIA is sacral prom
Left CIA division fractionally higher (sigmoid)
ANATOMY of HA
Internal Iliac Artery(Anatomy-Surgical dissection)
HA is a retro peritoneal structure Anterio-medially covered by
peritoneum and fibrous fascia
Ureters cross from lateral to medial at bifurcation
Anterio laterally lie EIA and obturator nerve
Posterio medially is the Internal iliac vein
To the right terminal end of ileum and ceacum overlap
To the left lower Inf border of sigmoid colon
Post Division Ant Division
Parietal Parietal Visceral
Ilio lumbar Obturator Obl. Umbelical
Lateral sacral Int pudendal Uterine
Superior Gluteal Inf Gluteal Vaginal
Sup. Vesical
Inf. Vesical
M. Haemorrhoidal
Division of Hypogastric Artery
Areas of Anastomosis
I. Lumbar Art (Aorta) Circumflex Iliac (EIA) ↔ Ilio LumbarII. Middle Sacral (Aorta) ↔ Lateral Sacral III. Superior Heamorrhoidal ↔ Middle
Heamorrhoidal (Br of Inf Mesentric)
Anastomosis is ipsilateral (vertical) and horizontal along midline. In bilateral HAL horizontal coll. Ceases
Collateral Circulation
Aortography (OLSON) Collaterals present but flow from HA forwards gradient 50 to 70 After HA ligation reverse flow from Lumbar/
Middle Sacral and Sup. Heamorrhoidal.
In HA Major Reduction in pulse pressure helps stabilize the clot formation
Collaterals have smaller diameter ( 40 to 50%) which inhibits rapid gradient and blood flow, thus avoiding trip hammer effect.
Haemodynamics
On cessation of TRIP HAMMER effect the pelvic arterial system is converted to a Venus like system.
* The drop in pulse pressure 84% --- B/L HAL 75% --- U/L HAL * The Mean arterial pressure ↓ 25% --- B/L
HAL ↓ 22% --- U/L
HAL THIS HELPS STABLE CLOT FORMATION
Haemodynamics
Internal Iliac Artery Ligation
Conditions indicating ligation –
Atonic uterus refractory to
other measures
Abruptio placentae with
uterine atony
Abdominal pregnancy with
pelvic implantation of the
placenta & placenta accreta
Internal Iliac Artery Ligation
T Therapeutic indications
Before or after hysterectomy for PPH
Continuous bleeding from the broad ligament base;
profuse bleeding from pelvic side-wall or vaginal angle
Diffuse bleeding without , clearly identifiable vascular
bed
Ruptured uterus in which uterine artery may be torn at
its origin from internal iliac artery
Where extensive lacerations of cervix have occurred
following difficult instrumental delivery
Large adequate incision preferably midline vertical ( Decreases op time and improves success rate) Vis peritoneum opened . Identify ureter, EIA, EIV and obturator nerve If hematoma, destruction, edema proceed carefully Trace Common Iliac and follow medially into pelvis
fossa ( Ureteric crossing a GIVE AWAY) Contd.
Procedure
Dissect fascia anterior to HA generally
1 to 2 layers Tease it vertically Visualize HA and lift gently with babcock about 1 to 2 cms below
bifurcation..
Cont….
Areolar tissue that connects HA and HV posterio-medially blunt dissected carefully.
A right angled clamp (MIXTER, ADSONS) passed posteriorly preferable lateral to medial
Care not to damage EIV and HV
Feed a silk or linen (40) (non- absorbable) long, single or doubled into the tip of the Mix by holding the suture taut on an artery forceps
Either retake the same suture around or take a second suture below the first
Lift the suture and check for pulsations in EIA
Conti….
Recheck ureter EIA, CI and bleeding from Venus plexus and then tie
Recheck pulsations in EIA ( Rule out Spasm) Do not transect vessel
< 1 to 9 % depending on experience of surgeon and condition of pt.
EIA Spasm, thrombosis Injury to HV, EIV Tying wrong structures– ureter,
EIA, CI Necrosis of buttocks, perineum,
bladder mucosa Bladder Atony Circulatory disturbances of
lower extremities.
Complications
Authors Year Method No of Women
Success Rates
Evans et al 1985 Internal iliac artery ligation
14 6/14 (42.8%)
Fernandez et al
1988 Internal iliac artery ligation
8 8/8 (100%)
Chattopadhyay et al
1990 Bilateral Hypogastric artery ligation
29 19/29 ( 65%)
Ledee et al 2001 Bilateral Hypogastric artery ligation
48 43/48 (89.5%)
Int. Iliac/Success rate
Concomitant severe venous bleeding Coagulopathy and DIC intervening Irreversible hypovolumic shock (Time
Factor) We had 3 failures ( not due to procedure) * Couvelaries UT due to coagulopathy * Vault, paracervical tears due to abberant vsl * Rupture Uterus due to hypovolumic shock
Failures (2% -- 8%)
Ovarian Art Ligation (↓ collateral by 12-15%)
Selective arterial transcatheter embolization (by autologous blood clot/ gel foam/
oxidized cellulose, CO2 Wire coils / Baloon catheter / IBS Monomer Look out for coagulopathy.
Incase of Failures
Before HAL
You can attempt COMPRESSION OF AORTA by Harris’s compressor or Debakey clamp
Temporary tamponade decreases pressure by 60 to 70%
You can attempt COMPRESSING COMMON ILIACS or pinching uterine arteries for tamponade and helping clot formation
Conducted between 1 jan 1990 to 31 dec 2004 at semmelweis university hospital in Budapest.
117 pts undergoing HAL during surgery. In this study 37 pts e sever PPH, HAL is
performed.significant outcome.in 13 cases uterus preserved.because of decrease in blood flow ,bleeding control is achieved quickly evenly in DIC.not a single pt died in this institute due to haemorrhage.
Retrospective study by Papp et al
Sucessful outcome of this procedure in haemorrhage in early obstetric cases( uterine perforation,cervical pregnancies,miscarriages in which bleeding is due to DIC), caesarean deliveries,laprotomies,cerical malgnancies.
Only in one patient who in which this procedure is not sufficient due to DIC.
Based on experience of this study the HAL has been introduced as aroutine method in management of profuse pelvic haemorrhages refractory to conservative methods and in the prophylactic reduction of blood flow in operation where profuse haemorrhage is expected..
Reported by Nizard and coworkers in 68 Patients.
No effect on future fertility and pregnancy outcome
Fertility and pregnancy outcome after HAL
HAL HAL is an EMERGENCY, LIFE SAVING, SALVAGE Surgery
“Go in Quick and come Out Fast”
“No matter where a woman delivers, giving birth
should be a moment of joy, not a sentence to
death”
Thank you