Journal of Visceral Surgery (2011) 148, e95—e102

REVIEW

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques O. Morel a,∗,b,c, C. Malartic c, J. Muhlstein c, E. Gayat d, P. Judlin c, P. Soyer e, E. Barranger a a

Service de gynécologie-obstétrique, hôpital Lariboisière, université Paris 7 Diderot, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France b Fondation Premup, 4, avenue de l’observatoire, 75270 Paris cedex 06, France c Maternité régionale universitaire de Nancy, université Nancy I Henri-Poincaré, 10, rue du Dr.-Heydenreich, 54000 Nancy, France d Département d’anesthésie-réanimation, SMUR, hôpital Lariboisière, université Paris 7 Diderot, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France e Service de radiologie viscérale et vasculaire, hôpital Lariboisière, université Paris 7 Diderot, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France Available online 7 April 2011

KEYWORDS Severe postpartum bleeding; Surgical hemostasis; Arterial ligation

Summary In cases of serious bleeding postpartum, resuscitation and surgical techniques are complementary and should be adapted to both the etiology and severity of bleeding. In extremely severe cases, the performance of a hysterectomy should not be delayed. For women with stable hemodynamic status, so-called ‘‘conservative’’ surgical techniques can instead be used. In this study, we describe and discuss the indications and feasibility of various techniques of vascular ligation. Uterine mattress suture compression techniques and abdomino-pelvic packing are also described. When conservative management is feasible, the first line approach should be bilateral distal ligation of the uterine arteries: this simple and low-risk technique is immediately effective in 80% of cases. If bleeding persists, uterine devascularization can be completed by a triple ligation as described by Tsirulnikov, with or without supplemental proximal ligation of the uterine arteries. This procedure should be performed in preference to the so-called ‘‘stepwise ligation sequence’’, which involves ligation of the ovarian pedicles and poses a risk of subsequent ovarian failure. Bilateral hypogastric artery ligation is also an effective and widely used first-line technique for experienced surgeons. This approach is technically challenging for less-experienced surgeons and is reserved for cases of failed triple ligation. © 2011 Elsevier Masson SAS. All rights reserved.

Introduction Postpartum hemorrhage (PPH) is the leading cause of maternal death in France. Prevention and initial management of women with PPH has been the subject of national guidelines published in 2004. Maneuvers to perform and the adminis-

∗

Corresponding author. E-mail address: [email protected] (O. Morel).

tration of oxytocin and sulprostone to increase uterine tone are now well-defined. In case of failure of of sulprostone infusion or of hemodynamic instability, more invasive treatments must be carried out without delay [1]. Arterial embolization, conservative or radical surgical management, and intrauterine balloon tamponnade are then the management options. There is no consensus regarding management strategy for women with severe PPH with persistent bleeding despite the administration of sulprostone. Choices must be jointly decided, taking

1878-7886/$ — see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2011.02.002

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Persistent bleeding for more than 30 minutes after administration of sulprostone

Post-Caesarean section after abdominal closure

Vaginal delivery

- During caesarean section or - If there is hemoperitoneum

Alternative

Intrauterine balloon tamponnade

Interventional radiology available Rapid medical transport possible

No Yes Failure

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

ARTERIAL EMBOLISATION

Figure 1.

Decision tree: options for management of severe postpartum hemorrhage.

into account the technical equipment of the hospital facility, the experience of the personnel, and the possibility of transfer to a tertiary center [2]. The choice of treatment depends on several factors: the obstetrical situation (particularly vaginal versus caesarean delivery), the site of origin and volume of bleeding, the patient’s hemodynamic tolerance, the technical means available (intensive care, availability of interventional radiology) and human factors (surgical experience). A full assessment of the hemorrhagic lesion(s) at the outset is essential to decision making: a complex wound of the birth canal does not justify an abdominal surgical intervention as first-line therapy, nor does a hemorrhagic diathesis due to amniotic fluid embolism. Conversely, the presence of hemoperitoneum in the early post-partum is an indication for immediate surgical exploration.

Indications for surgical management There is currently no level of evidence sufficient to confirm the superiority of one treatment over another for severe PPH. The reported results are descriptive and anecdotal in support of a particular technique [3]. Moreover, the definitions of severity vary from one study to another and are often imprecise. It seems that conservative surgical techniques, arterial embolization, and intrauterine balloon tamponnade (still an uncommon practice in France) have comparable efficacy, with a primary success rate of 80—90%.

Obstetrical context Management must be decided, from the first, according to the obstetrical situation. Although there is no consensus, three obstetrical situations seem to mandate a surgical approach from the outset: • during caesarean section: Here, it makes no sense to opt for an embolization procedure, since conservative surgical techniques are immediately applicable;

• for hemoperitoneum or retroperitoneal hematoma: This may be due to unrecognized uterine rupture or to bleeding from the uterine incision post-cesarean section; • when the patient’s hemodynamic status is unstable despite well-conducted resuscitation and wherever a transfer for interventional radiology is not feasible (intra or inter-hospital). After vaginal delivery or after a completed caesarean section and in the absence of hemoperitoneum, it seems logical to focus on less invasive treatment options (embolization or balloon tamponnade) whenever possible. If these approaches fail, surgical treatment is a secondary option. A decision tree (Fig. 1) summarizes the available treatment options for serious postpartum hemorrhage.

Etiology of bleeding For uterine atony without hemoperitoneum (and excluding the situation of hemorrhage during caesarean section), we believe that embolization should be the preferred first line treatment whenever it is feasible [4,5]. Management by interventional radiology is significantly less invasive than laparotomy, and the results are satisfactory. With regard to the consequences in terms of future fertility, no data of sufficient quality exists to objectively compare surgical management with interventional radiology, although studies are somewhat reassuring on this point [6—8]. Complex wounds of the birth canal with persistent bleeding despite initial well-conducted transvaginal surgical treatment are also an excellent indication for embolization [9]. Hemorrhage due to disseminated intravascular coagulation (DIC) (as may occur after amniotic fluid embolus) should be treated by resuscitation and medical therapy [10]. Abnormalities of placentation (placenta accreta or percreta) are a very special situation. Conservative management may be possible in the absence of placental eradication without the need for systematic vascular embolization or ligation. Once the placenta has been removed, embolization and conservative surgical techniques may be attempted, but the chances of success are very low [11—14].

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

Conservative surgery to control bleeding (non-hysterectomy) Techniques of vascular ligation Patient position and set-up It is essential to continually assess the persistence and extent of bleeding during surgery (Fig. 1). The patient should be positioned supine with sufficient clearance of the lower limbs and draping of the operative field to permit ongoing assessment of bleeding throughout the procedure.

Bilateral ligation of hypogastric arteries The first cases of hypogastric artery ligation were published in the 1960’s (Fig. 2). This is the oldest surgical procedure in the armamentarium of conservative treatment of severe postpartum bleeding [15]. This technique requires a low abdominal approach; the incision used for Caesarean section is usually sufficient for the gesture. The uterus must be externalized and pulled forward and laterally away from the side to be ligated. The broad ligament should be opened under the infundibulopelvic ligament, with the assistant retracting the uterus. The bifurcation of the iliac trunk is identified and the hypogastric artery (internal iliac) is dissected over a distance of 3 cm, widely opening the vascular sheath to limit the risk of venous injury. On the left, mobilization of the sigmoid mesentery along Toldt’s fascia may facilitate exposure. After systematic identification of the ureter, a ligature is placed using a ligature passer about 2 cm below the bifurcation, taking care not to injure the vein. Ligation should be downstream of the origin of the gluteal artery, and therefore should not be placed within 2 cm of the iliac bifurcation. Proximal ligation entails a high risk of buttock claudication. At the end of the procedure, we check the pulsations of the external iliac artery. An identical gesture is performed on the contralateral side [16]. The ligation should be performed using absorbable suture material. Some authors have additionally proposed bilateral ligation of the infundibulopelvic ligaments and round ligaments to maximize the chances of successful hemostasis. The success rate of bilateral hypogastric artery ligation varies widely in the literature, from 42—93% [17]. Causes of hemorrhage such as uterine atony and placenta accreta are a major source of failures.

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 ligation or injury, ligation of the external iliac artery, and peripheral nerve injury. The rate of complications varies widely from one series to another and seems to depend essentially on the experience of operators.

Bilateral uterine artery ligation This is also an old technique, the first cases of bilateral uterine artery ligation were published by Waters in 1952 and O’Leary in 1966 [18,19] (Fig. 3). This is an easy procedure to perform. The technique requires an abdominal approach for which the caesarean incision is adequate. The peritoneum should be opened laterally to allow identification of the right and left uterine artery pedicles. The vesico-uterine peritoneum should be reflected and division of the round ligaments may or may not be necessary to expose the pedicles. The uterus is exteriorized and pulled upwards: this tension allows identification of the vessels serving the lower segment and placement of the ligature at a safe distance from the ureters. An absorbable suture ligature which includes the myometrium is placed 2 cm below the usual line of hysterotomy for cesarean section. This mass ligature includes the ascending branch of uterine artery without the need to isolate it from myometrium. An identical ligation is then performed on the opposite side. This ligation technique has also been described using the vaginal route, but it seems more dangerous [20]. The reported success rate varies from 80 to 96% of cases. Failures have been reported in cases of abnormal placentation and severe DIC. This technique does not present any particular risk of complication, apart from technical errors: placing the sutures too low increases the risk of ureteral injury.

Tsirulnikov triple ligation In 1979, Tsirulnikov proposed a more complete uterine devascularization by ligation of the utero-ovarian arteries and the arteries of the round ligament [21] (Fig. 4). After ligation-division of the round ligament with its pedicle artery, and opening of the vesico-uterine peritoneum, the ascending branch of the uterine artery is ligated using the technique described by O’Leary. The utero-ovarian ligament is then ligated. A contralateral triple ligation is then

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O. Morel et al. the previous one and requires a greater mobilization of the uterine arteries with dissection of the broad ligament laterally on either side; this is essential to identify and protect the ureters. The ligature here should be placed just above the crook of the uterine artery. We routinely ligate and divide the round ligaments to facilitate development of the elements of the broad ligament inferiorly and laterally, and the ureter is identified in a systematic way. The final step described by AbdRabbo is bilateral ligation of the ovarian pedicle in the infundibulopelvic ligament. In a series of 103 patients, AbdRabbo reported successful hemostasis in 100% and reported no complications. However, it seems that this approach carries a high risk of ovarian failure [6]. We do not, therefore, recommend ligation of the ovarian arteries.

3

2

1

Strategy for implementation of vascular ligation for serious pph: a proposal for a new sequence of vascular ligations Figure 4. Schematic: vascular ligation by the Tsirulnikov technique [21]. Sequence: uterine artery ligation (1), round ligament ligation (2 utero-ovarian ligament ligation (3).

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

Stepwise sequential ligation This technique was described by AbdRabbo in 1994 [22] (Fig. 5). In principle, uterine devascularization is performed in progressive stages. Progression to each next step is performed if bleeding persists ten minutes after the previous ligation. The initial step is bilateral distal ligation of uterine arteries using the previously described technique of O’Leary. If bleeding persists, the second stage is a proximal ligation of the uterine arteries including the cervico-vaginal pedicles. This ligation is performed a few centimeters below

3 1

2

Figure 5. Schematic: ‘‘stepwise’’ sequential ligation: step one: distal ligation of the uterine arteries (1); step two: distal ligation of uterine arteries (2); step 3: ligation of the infundibulopelvic ligaments and ovarian vessels (3).

Rapidity of treatment is a major factor in the effectiveness of surgical management [23]. The choice of technique— –transuterine mattress sutures or vessel ligation——must remain primarily a function of operator experience. Since no technique of conservative surgical management has demonstrated superior efficacy compared to another, it seems logical to favor the technique with the lowest risk of surgical complications.

Surgical strategy based on etiology For uterine atony, we favor distal ligation of the uterine arteries as described by O’Leary as first line treatment. This is the easiest and least risky ligation to perform. We are usually content with just this method, which is immediately effective in most cases. If bleeding persists, the operator can proceed to the Tsirulnikov triple-ligation. Continuous evaluation of ongoing bleeding and the patient’s hemodynamic tolerance govern the need (and possibility) of conservative surgical management. Hypogastric artery ligation is technically more complex to perform and carries a higher-risk of failure and complications; in our practice, its use is limited to cases of failure of mattress suture compression or the sequence of Tsirulnikov ligations, as a final effort before resorting to hysterectomy. This ligation is performed in the last instance because of its higher operative risks. When rebleeding occurs despite hypogastric ligation, arteriography often demonstrates revascularization of the uterine arteries from proximal anastomotic branches (Fig. 6) [24]. This potential for secondary revascularization of the uterus from various pelvic anastomotic branches has led us to prefer distal ligation of vessels in direct contact with the uterine muscle. The combination of different conservative techniques has not been recommended in the literature. This view does not seem justified, however, since each technique was evaluated in isolation. There is no argument validating the superiority of any one technique over another in any particular situation. If previous steps have failed, ligation of hypogastric artery ligation is worth an attempt, as long as the patient’s hemodynamic status remains stable. Throughout the course of these various ligation procedures, optimal patient resuscitation and ongoing dialogue with the anesthesia team is essential for appropriate care.

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2

1

4

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

Figure 6. Arteriography (revascularization distal to hypogastric artery ligation): subtraction image showing the area of ligation (1), revascularization by a downstream anterior branch (2).

Attempts to combine different conservative surgical treatments should not delay ultimate hysterectomy if the patient is hemodynamically unstable. In cases of abnormal placental attachment, if a placental conserving technique is not feasible, staged ligation may be offered; this often requires total uterine devascularization. However, hysterectomy is usually necessary after placental extirpation. For low segment hemorrhage due to placenta previa, the low segment can be devascularized by proximal ligation of the uterine arteries and cervical pedicles (cf. staged ligature), or by hypogastric artery ligation. Mattress compression sutures of the lower segment may also be placed. For non-uterine bleeding such as severe vagino-cervical birth trauma, or vaginal hematoma inaccessible to transvaginal treatment, proximal vascular ligation still may be useful if embolization is not available. In such cases, hypogastric artery ligation may be effective.

Proposal for a new management sequence of vessel ligation On the same principle of a staged sequence of ligations until bleeding is controlled, we propose a new approach combining those described by Tsirulnikov and AbdRabbo, based on our own experience and literature review (Fig. 7). It seems logical, as we have previously discussed, to perform distal uterine artery ligation as the preferred first step; the technique is easy to perform, safe, and immediately effective in 80% of cases. The second step in our sequence is round ligament ligation.

The third step is ligation of the utero-ovarian ligaments (rather than the infundibulopelvic ligaments, because of risks to future fertility). The fourth step for persistent bleeding is proximal uterine artery ligation. The fifth and ultimate step in the sequence is hypogastric artery ligation.

Alternatives: techniques of uterine compression and mattress sutures Compression techniques aim to achieve hemostasis by compression of the myometrium with transfixing sutures. The procedure is usually preceded by bimanual compression of the uterus to see if myometrial bleeding stops. The two most common techniques are the B-Lynch plication technique described by B-Lynch et al. [25] and multiple mattress sutures described by Cho et al. [26]. For the B-Lynch plication, a Pfannenstiel or low midline approach via the Caesarean incision is sufficient. A low segment hysterotomy is first performed after reflection of the bladder flap. For previous cesarean section, the uterine suture is reopened. The uterine cavity is visualized and the uterus exteriorized. Absorbable transfixion sutures are passed in a U-shaped pattern through the fundus. (Fig. 8), and then tied between the entry and exit points over the low segment. The technique described by Cho et al. is to place Ushaped absorbable mattress sutures with a straight needle in a series of horizontal rows to compress the myometrium from front to back. Several rows of multiple sutures are placed in a quilted square pattern, taking care to avoid the interstitial portion of the fallopian tubes. Because of the thickness of myometrium that must be transfixed, these techniques require swaged needles of considerable length. These approaches are no more effective than vessel ligation, and are not simple to perform in our experience. They do, however, present an increased risk of subsequent endometrial synechia, and are not preferred as

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Intrauterine tamponnade Packing of the uterine cavity with laparotomy pads for uterine atony was described many years ago. The current trend in intrauterine tamponnade is the use of dedicated inflatable balloons [28]. This technique is minimally invasive and seems to have similar efficacy to surgical approaches and interventional radiology [3]. This practice remains marginal in France but is likely to be more widely used in the future.

Hysterectomy for control of hemorrhage

Figure 8. Operative view: uterine mattress sutures as described by B-Lynch et al. [25]: The passage of absorbable ‘‘suspenders’’ sutures through the uterine fundus.

The main risk is to delay too long in performing hysterectomy when hemorrhagic shock is unresponsive to various conservative procedures, surgical treatments or embolization [23]. The classic procedure is a supracervical hysterectomy sparing the ovaries. Placenta previa or placenta accreta can cause bleeding of the uterine isthmus or cervix requiring total hysterectomy including cervicectomy. Indications for urgent hysterectomy are cataclysmic hemorrhage severe enough to prevent transfer to an expert center or hemorrhage that persists despite the abovementioned conservative techniques.

first line treatment. Some teams combine myometrial mattressing techniques with uterine vessel ligation [6].

Peritoneal packing

Non-surgical alternatives: uterine artery embolization and endometrial balloon tamponnade Embolization Hemostatic arterial embolization has been used for decades for uncontrollable bleeding associated with severe trauma or inoperable pelvic gynecologic and urologic cancers. Sporadic reports of its use to control PPH have been published over the last twenty years. The procedure is performed in an interventional radiology suite with anesthesiologists and obstetricians in attendance to continue resuscitation and clinical monitoring during the embolization. Sulprostone should be discontinued approximately 30 minutes prior to arteriography to minimize the risk of arterial spasm, a source of failure of embolization. A femoral artery approach under local anesthesia is used for conventional catheterization of the internal iliac arteries. Pre-embolization angiography allows identification and analysis of the uterine artery [27]. The embolization should be bilateral in all cases because of the rich anastomotic network in the pelvis, particularly across the uterus. Vessels are occluded using absorbable gelatin fragments (Curaspon® ), resulting in a temporary reduction of arterial flow for a few days. During this period, uterine blood supply is provided by accessory branches—essentially via the ovarian and round ligament arteries. The success rate of embolization reported in the literature is greater than 90% regardless of etiology. Secondary embolization can be performed if bleeding recurs after initial conservative surgical treatment by whatever surgical technique [24].

Severe DIC due to catastrophic bleeding or amniotic fluid embolism may impose the need for pelvic peritoneal packing if vascular ligations are no longer feasible for control of diffuse tissue bleeding. The principle is the same as in the placement of peri-hepatic packing [29]. Although packing for PPH is only rarely described in the literature, it remains a critical technique for maternal salvage in extreme situations. Packing is left in place up to a maximum of 48 hours with broad-spectrum antibiotic coverage, and packs are removed surgically when the bleeding diathesis has been controlled.

Conclusion Postpartum hemorrhages are serious and often lifethreatening. Rapid response is one of the key points of successful management. Treatment strategies depend primarily on the patient’s hemodynamic tolerance. Decisions must be based on ongoing dialogue between the obstetrician and anesthesiologist. When surgical intervention is decided, uterine conservation should be the goal as long as the patient’s hemodynamic status allows. Since the various different approaches have comparable efficacy, the surgeon should focus preferentially on techniques with the least risk, according to his personal experience. For the untrained or inexperienced operator, first-line uterine artery ligation is the technique of choice. A final resort to hysterectomy should not be delayed in patients with poor hemodynamic tolerance.

Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.

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

KEY POINTS • For women with severe postpartum bleeding which persists despite the administration of sulprostone, management strategy must be cooperatively decided by obstetricians and anesthetists, depending on the technical capacities of the center, the experience of operators, and the possibility of eventual transfer to a tertiary center • When surgical treatment is indicated for serious postpartum bleeding, uterine conserving techniques should be attempted in women who are hemodynamically controlled • In the most severe cases, hysterectomy should not be delayed • Vascular ligation should always be bilateral in cases of serious postpartum bleeding • When conservative management is feasible, distal ligation of the uterine arteries should be performed as first line therapy • If bleeding persists despite uterine artery ligation, a Tsirulnikov triple ligation (uterine, round ligament, and utero-ovarian arteries), possibly supplemented by distal ligation of the uterine arteries, may improve the devascularization • Bilateral hypogastric artery ligation is technically more complicated to perform by less experienced surgeons, and should be reserved for cases of failed triple ligation • Staged sequential ligation, involving ligation of the ovarian pedicles/infundibulopelvic ligament, presents a risk of subsequent ovarian failure and should be reserved for failure of triple ligation When hemodynamic status permits, vessel ligation may be associated with other types of treatment: uterine mattress suture compression, intrauterine balloon tamponnade, or selective arterial embolization.

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