Controlling of profuse pelvic haemorrhage in obstetrics and

by dr sadaf ijaz

1. Controlling of profuse pelvic haemorrhage in obst and gynae by hypogastric artery ligation

2. Pregnancy the most dangerous journey of mankind…

3. 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.

4. Causes of Maternal Death Infection 14.9% Haemorrhage 24.8% Indirect causes 19.8% Other direct causes 7.9% Unsafe abortion 12.9% Obstructed labour 6.9% Eclampsia 12.9% Haemorrhage is the biggest and fastest killer

5. 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.

6. 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

7. The Four Ts Mnemonic – Causes of PPH Four Ts Causes Incidence (%) 1 st Tone Atonic uterus 90 2 nd Trauma Lacerations, hematomas, inversion, rupture 07 3 rd Tissue Retained tissue, Invasive placenta 03 4 th Thrombin Coagulopathies Less than1 Am Fam Physician 2007;75:875-82.

8. ‘Prevention is easier and better than cure’

9. Prevention of PPH ??? It can be achieved by Active management of 3 rd stage of labour

10. Recognition Referral Responsiveness

11. “While managing PPH Time lapsed should not be counted in a minute---one has not lost one minute ,but 60 seconds” Ian Donald

12. PPH Treatment Protocol

13. PPH Treatment Protocol

14. Treatment Protocol Of Primary Atonic PPH (1 st T) Management Management of of Shock Uterine atonicity Replacement of blood * Conservative medical or its component management * Surgical management - Conservative surgery - Radical surgery

15. Stepwise Management of Atonic PPH Step I - Bleeding continues - 15 methyl PGF 2  250g 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

16. Ligation of hypogastric artries was first introduced into surgery by the end of the 19 th 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

17. 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.

18. 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.

19. Management of PPH is synonymous to the working of a military operational head quarters it requires: TACTICAL ANALOGUE

20. * 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)

21. 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

22. Internal Iliac Artery (Anatomy-Surgical dissection)

23. 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

24. 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

25. Areas of Anastomosis I . Lumbar Art (Aorta) Circumflex Iliac (EIA) ↔ Ilio Lumbar II. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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….

32. 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

33. 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….

34. Recheck ureter EIA, CI and bleeding from Venus plexus and then tie Recheck pulsations in EIA ( Rule out Spasm) Do not transect vessel

35. < 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

36. 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

37. 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%)

38. Ovarian Art Ligation (↓ collateral by 12-15%) Selective arterial transcatheter embolization (by autologous blood clot/ gel foam/ oxidized cellulose, CO 2 Wire coils / Baloon catheter / IBS Monomer Look out for coagulopathy . Incase of Failures

39. 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

40. 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

41. 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.

42. 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..

43. Reported by Nizard and coworkers in 68 Patients. No effect on future fertility and pregnancy outcome Fertility and pregnancy outcome after HAL

44. HAL HAL is an EMERGENCY, LIFE SAVING, SALVAGE Surgery “ Go in Quick and come Out Fast”

45. “No matter where a woman delivers, giving birth should be a moment of joy, not a sentence to death”

46. Thank you