Journal of Visceral Surgery (2011) 148, e95e102

REVIEW

Pelvic arterial ligations for severe post-partumhemorrhage. Indications and techniques

O. Morela,,b,c, C. Malarticc, J. Muhlsteinc, E. Gayatd,P. Judlinc, P. Soyere, E. Barrangera

a Service de gyncologie-obsttrique, hpital Lariboisire, universit Paris 7 Diderot, 2, rueAmbroise-Par, 75475 Paris cedex 10, Franceb Fondation Premup, 4, avenue de lobservatoire, 75270 Paris cedex 06, Francec Maternit rgionale universitaire de Nancy, universit Nancy I Henri-Poincar, 10, rue duDr.-Heydenreich, 54000 Nancy, Franced Dpartement danesthsie-ranimation, SMUR, hpital Lariboisire, universit Paris 7Diderot, 2, rue Ambroise-Par, 75475 Paris cedex 1e Service de radiologie viscrale et vasculaire, hpDiderot, 2, rue Ambroise-Par, 75475 Paris cedex 1

KEYWORDSSevere postpartbleeding;Surgical hemostasis;Arterial ligation

tpartbot

hystewith stable hemodynamic status, so-called conservative surgical techniques can instead be

Introduction

Postpartum hemornal death in Francwomen with PPH hpublished in 2004.

Corresponding auE-mail address: o

1878-7886/$ see fdoi:10.1016/j.jviscsuused. In this study, we describe and discuss the indications and feasibility of various techniquesof vascular ligation. Uterine mattress suture compression techniques and abdomino-pelvic pack-ing are also described. When conservative management is feasible, the rst line approach shouldbe bilateral distal ligation of the uterine arteries: this simple and low-risk technique is immedi-ately effective in 80% of cases. If bleeding persists, uterine devascularization can be completedby a triple ligation as described by Tsirulnikov, with or without supplemental proximal liga-tion of the uterine arteries. This procedure should be performed in preference to the so-calledstepwise ligation sequence, which involves ligation of the ovarian pedicles and poses a risk ofsubsequent ovarian failure. Bilateral hypogastric artery ligation is also an effective and widelyused rst-line technique for experienced surgeons. This approach is technically challenging forless-experienced surgeons and is reserved for cases of failed triple ligation. 2011 Elsevier Masson SAS. All rights reserved.

rhage (PPH) is the leading cause of mater-e. Prevention and initial management ofas been the subject of national guidelinesManeuvers to perform and the adminis-

thor.livier.morel17@gmail.com (O. Morel).

tration of oxytocin and sulprostone to increase uterine toneare now well-dened.

In case of failure of of sulprostone infusion or of hemody-namic instability, more invasive treatments must be carriedout without delay [1]. Arterial embolization, conservativeor radical surgical management, and intrauterine balloontamponnade are then the management options. There is noconsensus regarding management strategy for women withsevere PPH with persistent bleeding despite the administra-tion of sulprostone. Choices must be jointly decided, taking

ront matter 2011 Elsevier Masson SAS. All rights reserved.rg.2011.02.002Available online 7 April 2011

umSummary In cases of serious bleeding posare complementary and should be adapted toextremely severe cases, the performance of a0, Franceital Lariboisire, universit Paris 70, France

um, resuscitation and surgical techniquesh the etiology and severity of bleeding. Inrectomy should not be delayed. For women

e96 O. Morel et al.

Persistent bleeding for more than 30 minutes after

administration of sulprostone

Interventional radiology available Rapid medical transport possible

Vaginal delivery - During caesarean section or - If there is hemoperitoneum

ARTERIAL EMBOLISATION

Yes SURGICAL HEMOSTASIS - Uterus conserving by vascular ligation or uterine mattress suture plication.

Failure

No

Post-Caesarean section after abdominal closure

Intrauterine balloon tamponnade

Alternative

Figure 1. Decision tree: options for management of severe postpartum hemorrhage.

into account the technical equipment of the hospital facil-ity, the experiencetransfer to a tertia

The choice otors: the obstetricaesarean deliverbleeding, the patinical means avainterventional radrience). A full asat the outset is ewound of the binal surgical intera hemorrhagic diaConversely, theearly post-partumexploration.

Indications fo

There is currentlyrm the superiorsevere PPH. The rdotal in support othe denitions ofand are often imgical techniques,balloon tamponnadhave comparable8090%.

Obstetrical con

Management mustto the obstetricalsus, three obstetriapproach from the during caesarea

for an embolizacal techniques a

for hemoperitoneum or retroperitoneal hematoma: Thisto unerinepatill-cointepita

al dthe

s onn tail, se (Firious

ble

tonyion oat et whnal rnd thncesity eintessuroun

ite inalso

e duay oresuies oy spebleeedtheive sf sucof the personnel, and the possibility ofry center [2].

f treatment depends on several fac-cal situation (particularly vaginal versusy), the site of origin and volume ofents hemodynamic tolerance, the tech-ilable (intensive care, availability ofiology) and human factors (surgical expe-sessment of the hemorrhagic lesion(s)ssential to decision making: a complexrth canal does not justify an abdomi-vention as rst-line therapy, nor doesthesis due to amniotic uid embolism.presence of hemoperitoneum in theis an indication for immediate surgical

r surgical management

no level of evidence sufcient to con-ity of one treatment over another foreported results are descriptive and anec-f a particular technique [3]. Moreover,severity vary from one study to anotherprecise. It seems that conservative sur-arterial embolization, and intrauterinee (still an uncommon practice in France)efcacy, with a primary success rate of

text

be decided, from the rst, accordingsituation. Although there is no consen-cal situations seem to mandate a surgicaloutset:

n section: Here, it makes no sense to opttion procedure, since conservative surgi-re immediately applicable;

may be duefrom the ut

when thedespite wetransfer foror inter-hos

After vaginsection and inlogical to focution or ballooapproaches faA decision treoptions for se

Etiology of

For uterine aing the situatwe believe thline treatmenby interventiolaparotomy, athe consequesufcient qualagement withsomewhat rea

Complex wbleeding desptreatment are[9].

Hemorrhagtion (DIC) (as mbe treated by

Abnormalitreta) are a vermay be possiwithout the nligation. Onceand conservatthe chances orecognized uterine rupture or to bleedingincision post-cesarean section;

ents hemodynamic status is unstablenducted resuscitation and wherever arventional radiology is not feasible (intral).

elivery or after a completed caesareanabsence of hemoperitoneum, it seems

less invasive treatment options (emboliza-mponnade) whenever possible. If theseurgical treatment is a secondary option.g. 1) summarizes the available treatmentpostpartum hemorrhage.

eding

without hemoperitoneum (and exclud-f hemorrhage during caesarean section),mbolization should be the preferred rstenever it is feasible [4,5]. Managementadiology is signicantly less invasive thane results are satisfactory. With regard toin terms of future fertility, no data of

xists to objectively compare surgical man-rventional radiology, although studies areing on this point [68].ds of the birth canal with persistentitial well-conducted transvaginal surgicalan excellent indication for embolization

e to disseminated intravascular coagula-ccur after amniotic uid embolus) shouldscitation and medical therapy [10].f placentation (placenta accreta or perc-cial situation. Conservative management

in the absence of placental eradicationfor systematic vascular embolization orplacenta has been removed, embolizationurgical techniques may be attempted, butcess are very low [1114].

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques e97

Figure 2. Operative view: hypogastric artery ligation, righthypogastric (1); the ligature must be placed about 2 cm below theiliac bifurcation (2) using a ligature passer or right angle dissector,after identication of the ureter (3).

Conservative surgery to control bleeding(non-hysterectomy)

Techniques of vascular ligation

Patient positionIt is essential toextent of bleedingbe positioned supilimbs and drapingassessment of blee

Bilateral ligationThe rst cases of hin the 1960s (Fig.in the armamentapostpartum bleedi

This techniqueincision used for Cthe gesture. The uward and laterallybroad ligament shpelvic ligament, wbifurcation of the iartery (internal iliwidely opening theinjury. On the leftalong Toldts fasciatic identicationa ligature passer acare not to injureof the origin of thbe placed within 2ation entails a higof the procedure,iliac artery. An idtralateral side [16absorbable suture

Some authors htion of the infundito maximize thesuccess rate of biwidely in the literorrhage such as umajor source of fa

Figure 3. Operative view: distal ligation of the uterine arteries:the round ligament is divided (1); right uterine artery (2).

Possible complications include venous injury, ureteral lig-ation or injury, ligation of the external iliac artery, andperipheral nerve injury. The rate of complications varies

onethe

rineold tation66 [1

queinceralrteryectot beriorcatiemen a

um icesabram

thecribus [2asesentaiqueon,w in

triplulniktionrter-divid opbradesligaand set-upcontinually assess the persistence andduring surgery (Fig. 1). The patient shouldne with sufcient clearance of the lowerof the operative eld to permit ongoingding throughout the procedure.

of hypogastric arteriesypogastric artery ligation were published2). This is the oldest surgical procedure

rium of conservative treatment of severeng [15].requires a low abdominal approach; theaesarean section is usually sufcient forterus must be externalized and pulled for-

away from the side to be ligated. Theould be opened under the infundibulo-ith the assistant retracting the uterus. Theliac trunk is identied and the hypogastricac) is dissected over a distance of 3 cm,vascular sheath to limit the risk of venous, mobilization of the sigmoid mesenterya may facilitate exposure. After system-of the ureter, a ligature is placed usingbout 2 cm below the bifurcation, takingthe vein. Ligation should be downstreame gluteal artery, and therefore should notcm of the iliac bifurcation. Proximal lig-

h risk of buttock claudication. At the endwe check the pulsations of the external

entical gesture is performed on the con-]. The ligation should be performed usingmaterial.ave additionally proposed bilateral liga-bulopelvic ligaments and round ligamentschances of successful hemostasis. Thelateral hypogastric artery ligation variesature, from 4293% [17]. Causes of hem-terine atony and placenta accreta are ailures.

widely fromessentially on

Bilateral uteThis is also anine artery ligOLeary in 19to perform.

The technithe caesareanbe opened latleft uterine ashould be remay or may nuterus is extallows identiment and placthe ureters. Athe myometriterotomy forthe ascendingisolate it fromperformed onalso been desmore dangero80 to 96% of cabnormal plac

This technof complicatisutures too lo

TsirulnikovIn 1979, Tsirdevascularizaies and the aAfter ligationcle artery, anthe ascendingthe techniqueament is thenseries to another and seems to dependexperience of operators.

artery ligationechnique, the rst cases of bilateral uter-were published by Waters in 1952 and

8,19] (Fig. 3). This is an easy procedure

requires an abdominal approach for whichision is adequate. The peritoneum shouldly to allow identication of the right andpedicles. The vesico-uterine peritoneum

ed and division of the round ligamentse necessary to expose the pedicles. Theized and pulled upwards: this tensionon of the vessels serving the lower seg-nt of the ligature at a safe distance frombsorbable suture ligature which includess placed 2 cm below the usual line of hys-rean section. This mass ligature includesnch of uterine artery without the need toyometrium. An identical ligation is thenopposite side. This ligation technique hased using the vaginal route, but it seems0]. The reported success rate varies from. Failures have been reported in cases oftion and severe DIC.does not present any particular risk

apart from technical errors: placing thecreases the risk of ureteral injury.

e ligationov proposed a more complete uterineby ligation of the utero-ovarian arter-ies of the round ligament [21] (Fig. 4).sion of the round ligament with its pedi-ening of the vesico-uterine peritoneum,nch of the uterine artery is ligated usingcribed by OLeary. The utero-ovarian lig-ted. A contralateral triple ligation is then

e98 O. Morel et al.

1

2

3

Figure 4. Schematic: vascular ligation by the Tsirulnikov tech-nique [21]. Sequence: uterine artery ligation (1), round ligamentligation (2 utero-ovarian ligament ligation (3).

performed in identical fashion. The author reports a successrate of 100% in a series of 24 patients. This technique carriesthe same risk of ureteral injury in case of technical error.

Stepwise sequential ligationThis technique was described by AbdRabbo in 1994 [22](Fig. 5). In principle, uterine devascularization is performedin progressive stages. Progression to each next step is per-formed if bleeding persists ten minutes after the previousligation.

The initial step is bilateral distal ligation of uterine arter-ies using the previously described technique of OLeary.

If bleeding persists, the second stage is a proximal lig-ation of the uterine arteries including the cervico-vaginalpedicles. This ligation is performed a few centimeters below

3

Figure 5. Schemadistal ligation of theof uterine arteries (2aments and ovarian

the previous one and requires a greater mobilization of theuterine arteries with dissection of the broad ligament later-ally on either side; this is essential to identify and protectthe ureters. The ligature here should be placed just abovethe crook of the uterine artery. We routinely ligate anddivide the round ligaments to facilitate development of theelements of the broad ligament inferiorly and laterally, andthe ureter is identied in a systematic way.

The nal step described by AbdRabbo is bilateral ligationof the ovarian pedicle in the infundibulopelvic ligament.

In a series of 103 patients, AbdRabbo reported successfulhemostasis in 100% and reported no complications. However,it seems that this approach carries a high risk of ovarianfailure [6]. We do not, therefore, recommend ligation ofthe ovarian arteries.

Strategy for implementation of vascularligation for serious pph: a proposal for a newsequence of vascular ligations

Rapidity of treatment is a major factor in the effectivenessof surgical management [23]. The choice of techniquetransuterine mattress sutures or vessel ligationmustremain primarily a function of operator experience. Since notechnique of consestrated superior elogical to favor thecomplications.

Surgical strategyFor uterine atony,arteries as describis the easiest andusually content wieffective in most c

If bleeding perTsirulnikov triple-lbleeding and thethe need (and posment.

Hypogastric arplex to performcomplications; inof failure of mattof Tsirulnikov ligathysterectomy. Thisbecause of its high

When rebleediarteriography ofte

s froentiaarioul lige.natiorecjust

solatanyon.rteryemoof titatesse1

2

tic: stepwise sequential ligation: step one:uterine arteries (1); step two: distal ligation); step 3: ligation of the infundibulopelvic lig-vessels (3).

uterine arterie[24]. This potuterus from vto prefer distauterine muscl

The combihas not beendoes not seemevaluated in isuperiority ofticular situatihypogastric athe patients hout the coursepatient resuscthesia team isrvative surgical management has demon-fcacy compared to another, it seemstechnique with the lowest risk of surgical

based on etiologywe favor distal ligation of the uterine

ed by OLeary as rst line treatment. Thisleast risky ligation to perform. We are

th just this method, which is immediatelyases.sists, the operator can proceed to theigation. Continuous evaluation of ongoingpatients hemodynamic tolerance governsibility) of conservative surgical manage-

tery ligation is technically more com-and carries a higher-risk of failure andour practice, its use is limited to casesress suture compression or the sequenceions, as a nal effort before resorting toligation is performed in the last instanceer operative risks.ng occurs despite hypogastric ligation,n demonstrates revascularization of them proximal anastomotic branches (Fig. 6)l for secondary revascularization of thes pelvic anastomotic branches has led usation of vessels in direct contact with the

n of different conservative techniquesommended in the literature. This viewied, however, since each technique wasion. There is no argument validating theone technique over another in any par-

If previous steps have failed, ligation ofligation is worth an attempt, as long asdynamic status remains stable. Through-hese various ligation procedures, optimalion and ongoing dialogue with the anes-ntial for appropriate care.

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques e99

Figure 6. Arteriogartery ligation): subtrevascularization by

Attempts to ctreatments shouldpatient is hemody

In cases of abnoconserving techniqoffered; this oftenHowever, hysterecextirpation.

For low segmethe low segmentation of the utestaged ligature),tress compressionbe placed.

For non-uterinebirth trauma, or vanal treatment, proif embolization isartery ligation ma

Proposal for a nvessel ligationOn the same princbleeding is controing those describeour own experienc

It seems logicalform distal uterinethe technique iseffective in 80% of

The second stetion.

3

2

1

4

Figure 7. Schematic: vascular ligation (sequence recommendedby the authors): distal ligation of uterine arteries (1), ligation ofthe round ligaments (2), ligation of utero-ovarian ligaments (3);proximal ligation of uterine arteries (4).

tepthefertsteptiond ul.

s: tn a

techof this u

to seost cdes

res dLyncvia

erotoap.eopeterio-shapbet

iqueablehorizbacraphy (revascularization distal to hypogastricraction image showing the area of ligation (1),a downstream anterior branch (2).

ombine different conservative surgicalnot delay ultimate hysterectomy if the

namically unstable.rmal placental attachment, if a placentalue is not feasible, staged ligation may berequires total uterine devascularization.tomy is usually necessary after placental

nt hemorrhage due to placenta previa,can be devascularized by proximal lig-

rine arteries and cervical pedicles (cf.or by hypogastric artery ligation. Mat-sutures of the lower segment may also

bleeding such as severe vagino-cervicalginal hematoma inaccessible to transvagi-ximal vascular ligation still may be usefulnot available. In such cases, hypogastricy be effective.

ew management sequence of

iple of a staged sequence of ligations untillled, we propose a new approach combin-

The third s(rather thanrisks to future

The fourthine artery liga

The fth anartery ligation

Alternativecompressio

CompressioncompressionThe procedureof the uterus

The two mtion techniquemattress sutu

For the B-line approachsegment hystthe bladder ine suture is rthe uterus expassed in a Uand then tiedlow segment.

The technshaped absorbin a series offrom front tod by Tsirulnikov and AbdRabbo, based one and literature review (Fig. 7)., as we have previously discussed, to per-artery ligation as the preferred rst step;

easy to perform, safe, and immediatelycases.

p in our sequence is round ligament liga-

placed in a quiltedinterstitial portion

Because of thetransxed, these tsiderable length.than vessel ligatioexperience. Theysubsequent endomis ligation of the utero-ovarian ligamentsinfundibulopelvic ligaments, because ofility).for persistent bleeding is proximal uter-

.timate step in the sequence is hypogastric

echniques of uterinend mattress sutures

niques aim to achieve hemostasis bye myometrium with transxing sutures.sually preceded by bimanual compressione if myometrial bleeding stops.ommon techniques are the B-Lynch plica-cribed by B-Lynch et al. [25] and multipleescribed by Cho et al. [26].h plication, a Pfannenstiel or low mid-the Caesarean incision is sufcient. A lowmy is rst performed after reection ofFor previous cesarean section, the uter-ned. The uterine cavity is visualized andrized. Absorbable transxion sutures areed pattern through the fundus. (Fig. 8),ween the entry and exit points over the

described by Cho et al. is to place U-mattress sutures with a straight needleontal rows to compress the myometriumk. Several rows of multiple sutures aresquare pattern, taking care to avoid theof the fallopian tubes.thickness of myometrium that must be

echniques require swaged needles of con-These approaches are no more effectiven, and are not simple to perform in our

do, however, present an increased risk ofetrial synechia, and are not preferred as

e100 O. Morel et al.

Figure 8. Operative view: uterine mattress sutures as describedby B-Lynch et al. [25]: The passage of absorbable suspenderssutures through the uterine fundus.

rst line treatmentressing technique

Non-surgicalembolizationtamponnade

Embolization

Hemostatic arteriafor uncontrollableor inoperable pelvradic reports of itsover the last twen

The procedureology suite withattendance to contduring the embolizapproximately 30mthe risk of arteriation.

A femoral arterfor conventional cies. Pre-embolizatanalysis of the ute

The embolizatioof the rich anaticularly across tabsorbable gelatintemporary reductDuring this perioby accessory braround ligament arreported in the litetiology.

Secondary embrecurs after initialever surgical techn

Intrauterine tamponnade

Packing of the uterine cavity with laparotomy pads for uter-ine atony was described many years ago. The current trendin intrauterine tamponnade is the use of dedicated inat-able balloons [28]. This technique is minimally invasive andseems to have similar efcacy to surgical approaches andinterventional radiology [3]. This practice remains marginalin France but is likely to be more widely used in the future.

Hysterectomy for control of hemorrhage

The main risk is to delay too long in performing hysterectomywhen hemorrhagic shock is unresponsive to various conser-vative procedures, surgical treatments or embolization [23].The classic procedure is a supracervical hysterectomy spar-ing the ovaries. Placenta previa or placenta accreta cancause bleeding of the uterine isthmus or cervix requiringtotal hysterectomy including cervicectomy.

Indications for urgent hysterectomy are cataclysmic hem-orrhage severe enough to prevent transfer to an expertcenter or hemorrhage that persists despite the above-mentioned conservative techniques.

pa

e toimpligableeperi-ackinrema

e s8 hos ar

been

emoRapinagepatd onesthine chemooachrefeis popeof crt tpoor

of

eclat. Some teams combine myometrial mat-s with uterine vessel ligation [6].

alternatives: uterine arteryand endometrial balloon

l embolization has been used for decadesbleeding associated with severe traumaic gynecologic and urologic cancers. Spo-use to control PPH have been published

ty years.is performed in an interventional radi-anesthesiologists and obstetricians ininue resuscitation and clinical monitoringation. Sulprostone should be discontinuedinutes prior to arteriography to minimize

l spasm, a source of failure of emboliza-

y approach under local anesthesia is usedatheterization of the internal iliac arter-ion angiography allows identication andrine artery [27].n should be bilateral in all cases because

stomotic network in the pelvis, par-he uterus. Vessels are occluded using

fragments (Curaspon), resulting in aion of arterial ow for a few days.d, uterine blood supply is providednchesessentially via the ovarian andteries. The success rate of embolizationerature is greater than 90% regardless of

olization can be performed if bleedingconservative surgical treatment by what-

Peritoneal

Severe DIC duembolism maying if vasculardiffuse tissueplacement of

Although pliterature, itvage in extremmaximum of 4age, and packdiathesis has

Conclusion

Postpartum hthreatening.successful mamarily on themust be basetrician and andecided, uterthe patientsdifferent apprshould focus paccording to hinexperiencedthe technique

A nal resopatients with

Disclosure

The authors d

ique [24]. concerning this arcking

catastrophic bleeding or amniotic uidose the need for pelvic peritoneal pack-tions are no longer feasible for control ofding. The principle is the same as in thehepatic packing [29].g for PPH is only rarely described in theins a critical technique for maternal sal-ituations. Packing is left in place up to aurs with broad-spectrum antibiotic cover-e removed surgically when the bleedingcontrolled.

rrhages are serious and often life-d response is one of the key points ofment. Treatment strategies depend pri-ients hemodynamic tolerance. Decisions

ongoing dialogue between the obste-esiologist. When surgical intervention isonservation should be the goal as long asdynamic status allows. Since the variouses have comparable efcacy, the surgeonrentially on techniques with the least risk,ersonal experience. For the untrained orrator, rst-line uterine artery ligation ishoice.o hysterectomy should not be delayed inhemodynamic tolerance.

interest

re that they have no conicts of interestticle.

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques e101

KEY POINTS

For women with severe postpartum bleedingwhich persists despite the administration ofsulprostone, management strategy must becooperatively decided by obstetricians andanesthetists, depending on the technicalcapacities of the center, the experience ofoperators, and the possibility of eventual transferto a tertiary center

When surgical treatment is indicated forserious postpartum bleeding, uterine conservingtechniques should be attempted in women whoare hemodynamically controlled

In the most severe cases, hysterectomy should notbe delayed

Vascular ligation should always be bilateral incases of serious postpartum bleeding

When conservative management is feasible,distal ligation of the uterine arteries should beperformed as rst line therapy

If bleeding persists despite uterine artery ligation,a Tsirulnikov triple ligation (uterine, roundligament,supplemenarteries, m

Bilateral hymore compsurgeons,failed tripl

Staged seqthe ovarianpresents ashould be r

When hligation mtreatment:intrauterinarterial em

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Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniquesIntroductionIndications for surgical managementObstetrical contextEtiology of bleeding

Conservative surgery to control bleeding (non-hysterectomy)Techniques of vascular ligationPatient position and set-upBilateral ligation of hypogastric arteriesBilateral uterine artery ligationTsirulnikov triple ligationStepwise sequential ligation

Strategy for implementation of vascular ligation for serious pph: a proposal for a new sequence of vascular ligationsSurgical strategy based on etiologyProposal for a new management sequence of vessel ligation

Alternatives: techniques of uterine compression and mattress sutures

Non-surgical alternatives: uterine artery embolization and endometrial balloon tamponnadeEmbolizationIntrauterine tamponnadeHysterectomy for control of hemorrhage

Peritoneal packingConclusionDisclosure of interestReferences