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