Preface

Incontrollable obstetrical bleeding is one of themajor causes of maternal death and stands as firstamong the nightmares of the Obstetrician especially ifworking in under resourced countries, in rural hospi-tals.

Of the two, up to now recommend procedures,hysterectomy or internal iliac arteries ligation, the ge-nerally recommended, without delay, caesarean hyste-rectomy or hysterectomy especially if performed onnulliparous young women who may wish to have mo-re children may result in devastating emotionaland/or cultural consequences, while the internal iliac

arteries ligation stays, quite frequently, beyond thetraining and skills of the Obstetrician.

To our experience, so far, only the uterine ligationmeets both the above requirements, conservation ofthe uterus and ability to conceive and being withinthe skills of the surgeon.

The uterine arteries, ligation, successfully em-ployed in quite a variety of obstetrical conditions(ranging from uterine atony to placenta previa andplacenta percreta) presents with a higher success rate(80 to 96%) where compared to internal iliac arteriesligation (60%).

It is a procedure which, although described as backas in the 1950s (Waters, 1952, Tsirulnikov, 1960) hasin the past years been unduly neglected as revealed bythe quite few references of this technique as comparedto the ones of internal arteries ligation or hysterectomy.

As the incontrollable uterine bleeding may occurafter a vaginal delivery or during caesarean section,the devascularization may, therefore, be dealt with,vaginally or abdominally.

SUMMARY: Uterine devascularization.

E. DOMINI, S. GUAZZINI, C. ORLOTTI

Uterine devascularization is a valuable alternative to hysterec-tomy or internal iliac arteries ligation in case of otherwise intractableobstetrical haemorrhage. Has a higher success rate as compared to thatof internal iliac arteries ligation. Can be dealt with, vaginally or th-rough abdomen, in this case may be employed curatively or preventi-vely.

RIASSUNTO: La devascolarizzazione uterina.

E. DOMINI, S. GUAZZINI, C. ORLOTTI

La devascolarizzazione uterina una semplice ed efficace alter-nativa allisterectomia o alla legatura delle arterie ipogastriche in casodemorragie uterine incontrollabili. Ha una percentuale di successo su-periore a quella della legatura delle arterie iliache interne. di sem-plice esecuzione, pu essere attuata per via vaginale o laparotomica; inquestultimo caso pu essere impiegata a scopo terapeutico e come pro-filassi qualora si temano degli interventi particolarmente sanguinosi.Lapproccio vaginale una tecnica semplice, che pu essere attuata an-che da personale poco esperto. particolarmente indicata nei Paesi arisorse limitate.

Giorn. It. Ost. Gin. Vol. XXVIII - n. 9Settembre 2006

Uterine devascularizationE. DOMINI*, S. GUAZZINI**, C. ORLOTTI***

KEY WORDS: PPH - Uterine devascularization - Uncontrollable obstetrical bleeding.Emorragie ostetriche incontrollabili - Emorragie del post partum - Legatura delle a. uterine Devascolarizzazione uterina.

*Consultant Obstetrician Gynecologist, St. Kizito Hospital, Matany, Uganda**Universit degli Studi di Firenze Scuola di Specializzazione in Ginecologia ed Ostetricia(Direttore: M. Marchionni)***I/C Surgery St. Kizito Hospital, Matany Copyright 2006, CIC Edizioni Internazionali, Roma

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Before we start describing the procedures we strainon the mental attitude to be kept while dealing withan otherwise intractable obstetrical haemorrhage Donot hesitate in performing the hereby described pro-cedures; they are not dangerous ones and also ifperformed when not strictly necessary they will, by noway, harm the patient or impair her ability to concei-ve; while delaying them, in case of profuse bleeding,especially in sub-Saharan Africa where anaemia is en-demic, may easily lead to disaster.

The vaginal approach: the Authors feel very muchindebted to Dr. Hebish and Huch for their excellentwork first describing this minimally invasive, easy toperform, time and life saving procedure; life saving asno precious time is wasted by taking the Pt. to Thea-tre and organising it for the operation to start.

Since we got acquainted with this technique, itwas employed twice, preventing us from turning tothe abdominal approach, not always easy in rural ho-spitals.

The procedure is as follows, we are freely quotingfrom the original paper.

Pt. is placed in lithotomic position, a short IV Li-ne passed, (if Pt. has collapsed consider the femoralgateway); an Oxytocin and 50% dextrose drip started;mild sedation or ketamine may be given (ketaminehas the advantage of slightly raising the BP); a self re-taining urinary bladder catheter is, also, passed. Theanterior and posterior cervical lips are clamped with asponge holding forceps. A 2 cm horizontal incision ismade in the anterior cervix about 1 cm beneath theestimated vaginocervical fold and the bladder is re-flected in the natural plane using a swab or a stick. Agentle but firm traction is used to pull the uterusdownwards and sideways towards the controlateral si-de of the intended ligature, to maximise cephalad andlateral access; at this point we put a third sponge hol-ding forceps on the margin of the cervix where the li-gation will be placed and with the index finger we feelfor the uterine artery - whose pulsation is readily pal-pable and sometimes visible.

From cephalad and behind the bladder, at the le-vel the pulsation is felt, a curved, round bodied, need-le with N 1 chromic catgut is led to the myometrium(1 cm medially to the margin of uterus) encircles thevein and the artery, comes out and the stitch is liga-ted; by further gentle traction on the thread three mo-re rounds of running suture are passed and then tied.

In case the Obstetrician does not feel confidentwith this procedure a very same result can be obtainedby placing two sponge holding forceps on each mar-gin of the cervix-LUS and leaving them in place for24 h.

The abdominal approach may be employed curati-vely or preventively.

Curatively; it is over 15 years since one of theAuthors (Domini E., 1990) first started employing,curatively, this procedure; at the very beginning, assuggested by Tsirulnikov, by legating ascending bran-ches of uterine arteries, terminal branches of the ova-rian arteries and round ligament a.; but it was soonfelt it to be quite redundant a treatment, as in mostcases bleeding was controlled by the only ascendinguterine arteries ligation; it was therefore resolved to astepwise approach; to start with the ligation of theascending branches of uterine arteries and proceed,if bleeding not under control, with the ligation of theterminal branch of the ovarian arteries and then ofthe round ligament ones. The indication is any in-controllable obstetrical bleeding independent fromthe cause it derives from; placenta previa, uterineatony, Couvelhaire uterus due to abruptio placentae,or in case of otherwise incontrollable post partumhaemorrhage.

Procedure: the uterus is delivered from the abdo-minal cavity and raised; it will result in the nar-rowing of the uterine arteries and the amount ofblood supplied to the uterus will be reduced, by thesame time the ureters will be displaced downwards.

In case of LUS caesarean section follow the 2 x 3rule (two cm below hysterotomy, three cm medial tothe margin of the uterus). The bladder, if needed, isreflected off this part of the uterus as to free the abo-ve mentioned area (2x3); a Mayo curved, round bo-died needle with N 1 chromic catgut is led from theanterior uterine wall up to the posterior one and, inorder to avoid including the round ligament in the su-ture, transfixes the avascular area below the round li-gaments; the stitch is tied, the arteries is not cut.

The uterus, usually, will go pale, show fibrillarycontractions and will contract or at least becomes fir-mer; and most likely the bleeding, will stop right af-ter.

If the control of the bleedings does not appear sa-tisfactory a further steps consists of the ligation of theterminal branch of the ovarian artery, near to the cor-nua; this step usually is not necessary as the uterinearteries provide more than the 90% of the blood sup-ply of the uterus; Tsirulnikov also recommends liga-tion of the round ligament.

About the timing of this procedure, in case of Cae-sarean section, we first apply, bilaterally, a curvedklemmer (which are always present in our caesareansection set) to the uterine arteries, then complete therepair of the hysterotomy and then we proceed withthe ligation of uterine arteries.

The ligated uterus is then compressed with a warmpack to expel any collected blood, and covered with a

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E. Domini e Coll.

sterile towel, thighs are flexed and knees kept to-gether, the vagina is mopped out and observed for 10minutes, if bleeding has stopped, the abdomen can beclosed.

Preventively; when a severe uterine bleeding is ex-pected; the ascending branch of the uterine arteries

can be easily identified as quoted by Couvelhaire; it isthe area where the uterine artery stops being mobileand starts being adherent to the uterus, it is well abo-ve the cervical branches and 3 c and far away from theureters. That is the place where the stitch has to be ap-plied.

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Uterine devascularization

1. COUVELAIRE A.: Introduction la chirurgie uterine obstetri-cale. Steinheil, Paris, 1913.

2. DOMINI E., TIMON D.: Manuale di Ostetricia e GinecologiaTropicale. 342-345 CIC Edizioni Internazionali, Roma, 1990.

3. HEBISH G., HUCH A.: Vaginal artery ligation avoids highblood loss and puerperal hysterectomy in post partum haemorrha-ge. Obstetrics & Gynecology 100: 574-578, 2002.

4. FAHMY K.: Uterine artery ligation to control post partum hae-morrhage. Int. J. of Obstetrics and Gynaecology 25(5): 363-7,1987.

5. OLEARY J.A.: Uterine artery ligation in the control of postcesa-

rean haemorrhage. J Reprod Med Mar, 40(3): 189-93, 1995.6. SALVAT J., SCHMIDT M.H., GUILBERT M., MARTINO

A.: Vascular ligation for severe obstetrical haemorrhage: review ofthe literature. J Gynecol Obstet Biol Reprod (Paris) 31(17):629-39, 2002.

7. TSIRULNIKOV VERSPYCK E., RESH B., SERGENT F.,MARPEAU L.: Surgical uterine devascularization for placentaaccreta, immediate and long term follow up. Acta Obstet Gyne-col. Scand 84 (5): 444-7, 2005.

8. WATERS E.G.: Surgical Management of postpartum haemor-rhage with particular reference to ligation of uterine arteries. AmJ Obstet Gynecol 64: 1143-8, 1952.

Bibliografia

Gentile Lettore,

il Giornale Italiano di Ostetricia e Ginecologia

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