Ligaduras vasculares no tratamento cirúrgico da hemorragia pós-parto / Vascular ligations in the surgical treatment of postpartum hemorrhage

Hemorragia pós-parto é a maior causa de histerectomia periparto. Esta revisão descreve e ilustra as técnicas de ligaduras vasculares utilizadas no tratamento cirúrgico da hemorragia pós-parto. São apresentados os detalhes técnicos da ligadura das artérias uterinas, da ligadura das conexões útero-ovarianas, da ligadura tríplice de Tsirulnikov, das ligaduras sequenciais de AbdRabbo e de Morel e da ligadura das artérias ilíacas internas. Também são revistos os fatores que dificultam o sucesso dessas técnicas. As ligaduras vasculares são estratégias eficientes para o controle hemorrágico durante cesarianas e devem integrar o conjunto de técnicas que preservam o útero no tratamento da hemorragia pós-parto.(AU)

Postpartum hemorrhage is the major cause of peripartum hysterectomy. This review describes and illustrates the techniques of vascular ligations used in the surgical treatment of postpartum hemorrhage. The technical details of the uterine arteries ligation, of the ligation of the utero-ovarian connections, of the Tsirulnikov triple ligation, of the AbdRabbo and Morel sequential ligations and of the internal iliac arteries ligation are presented. The factors that hinder the success of these techniques also are reviewed. Vascular ligations are efficient strategies for hemorrhagic control during cesarean sections and should integrate the set of techniques that preserve the uterus in the treatment of postpartum hemorrhage.(AU)

Vaginal misoprostol versus bilateral uterine artery ligation in decreasing blood loss in trans-abdominal myomectomy: a randomized controlled trial

Background: Uterine leimyomas are tumors of the smooth muscles and the connective tissues of the uterus. They are considered to be the most common benign pelvic tumor affecting about 20% of women above the age of 35. The diverse symptomatology of fibroids can be attributed to size, number and location of the tumors. The common symptoms include menorrhagia, infertility, abdominal mass and pressure effects

Aim of the Work: The aim of this study is to compare between the effect of medical [preoperative vaginal misoprostol] and non-medical [bilateral uterine artery ligation] regarding their efficacy to decrease blood loss in trans- abdominal myomectomy

Patients and Methods: Prospective randomized controlled interventional clinical trial. The study was conducted in Ain Shams University Maternity Hospital, Cairo, Egypt in the period between August 2015 till December 2016. It was approved by the Ethical Research Committee, Obstetrics and Gynecology Department, Ain Shams University, Cairo, Egypt. It included 60 women recruited from those attending the outpatient gynecology clinic, seeking treatment for symptomatic uterine myomas

Results: The current study revealed that there was no statistically significant difference between both groups regarding operative time, blood loss and postoperative hospital stay. Conclusion: A single pre-operative dose of 400 micrograms of vaginal misoprostol is as effective as uterine artery ligation in decreasing blood loss in transabdominal myomectomy. Misoprostol is a simple, cheap, fast, available and applicable tool that can be administered even an hour preoperatively

Recommendations: Preoperative vaginal misoprostol is an effective practical tool in decreasing blood loss in transabdominal myomectomy. Investigation of misoprostol use in larger population groups and with different dosages and administration routes, together with comparison of other methods used to reduce bleeding during myomectomy, is recommended

Interventional radiology and endovascular surgery in the treatment of ectopic pregnancies / Radiologia intervencionista e cirurgia endovascular no tratamento das prenhezes ectópicas

The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. In the field of obstetrics, these advances include temporary occlusion of the iliac arteries to the management of placenta accreta and/or prior, arteriovenous fistulas after embolization of uterine curettage and management of ectopic uterine and extra-uterine pregnancies. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents major therapeutic challenge, especially when exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery. Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers.

O advento da radiologia intervencionista tornou possível avanços notáveis no diagnóstico e no tratamento de diversas situações, na área de ginecologia e obstetrícia. No campo da obstetrícia, esses avanços incluem oclusão temporária das artérias hipogástricas para o manejo de placenta acreta e/ou prévia, embolização de fístulas arteriovenosas após curetagem uterina e manejo de prenhezes ectópicas uterinas e extrauterinas. A gravidez ectópica não tubária, seja cervical, abdominal, ovariana ou na cicatriz de cesárea, muitas vezes representa grande desafio terapêutico, principalmente quando há desejo de manutenção da fertilidade. As opções terapêuticas mais utilizadas para o tratamento de prenhez ectópica não tubária, são: terapia sistêmica com metotrexato e ressecção cirúrgica do saco gestacional ectópico; porém a abordagem intervencionista com injeção direta de metotrexato no saco gestacional ou quimiembolização intra-arterial das artérias uterinas, apresentam-se na literatura recente, como modalidades terapêuticas viáveis, seguras, eficazes, com baixa morbidade, menor tempo de internação e rápida recuperação clínica. Devido ao diminuto arsenal de materiais utilizados e à crescente formação de especialistas na área, a intervenção radiológica, como opção de tratamento nas prenhezes ectópicas, é financeiramente viável e apresenta acessibilidade considerável no mundo e na maioria do centros médicos brasileiros.

Oclusão laparoscópica das artérias uterinas no tratamento de leiomiomas uterinos / Laparoscopic uterine artery occlusion in the treatment of uterine leiomyomas

A procura por procedimentos menos invasivos, e o desejo das mulheres de manter o útero, fazem da oclusão laparoscópica das artérias uterinas no tratamento de leiomiomas uterinos uma alternativa. Este trabalho teve como objetivo revisar os estudos sobre essa cirurgia. Os resultados após as intervenções cirúrgicas relatam redução volumétrica do útero e leiomiomas, com melhora dos sintomas e menos dor no pós-operatório em relação à embolização das artérias uterinas, técnica que utiliza o mesmo conceito da desvascularização do tumor. Quanto ao futuro reprodutivo, os dados não são bem definidos e apresentam-se conflitantes. As recorrências dos sintomas e possível necessidade de novas cirurgias complementares podem causar insatisfação entre as pacientes. Novos estudos são necessários para melhor definir o papel dessa opção terapêutica no tratamento de leiomiomas uterinos

The search for less invasive surgical procedures, and the desire of women to keep the uterus, make laparoscopic occlusion of the uterine arteries an alternative in the treatment of uterine leiomyomas. Current paper reviewed studies on this type of surgery, volume reduction of uterus and leiomyomas, with improvement in symptoms and less pain in the postoperative period in relation to uterine artery embolization, a technique The results showed that after surgical intervention a decrease occurred in uterus volume and leiomyomas, with symptom improvement and less pain in the postoperative period when compared to the embolization of the uterine arteries, a technique that uses the same concept of devascularization of the tumor. Data are not clear with regard to future reproduction and they prove to be conflicting. The recurrence of symptoms and the need for other complementary surgeries may be a cause of dissatisfaction among the patients. Further studies are required to define convincingly the role of the therapeutic option in the treatment

Histopathological and histochemical studies of the ovary and uterus of the female dog after ligation of the supplying arteries

The present study was undertaken to study the histopathological and histochemical studies of the ovary and uterus of female dog after ligation of the supplying arteries. Twelve adult female dogs were divided into three groups. Unilateral ligation of the internal iliac, uterine and ovarian arteries was done in group I, II and III, respectively. All animals were sacrificed one month after the operation. Samples were taken from the ovaries and uterine horns of both the ligated and nonligated sides for histological and histochemical studies. Unilateral ligationof either internal iliac, uterine or ovarian arteries was followed by histopathological changes in the uterine horns of both sides. However, the degenerative changes were more marked at the horns of the ligated sides. The endometrial glands of both uterine horns showed negative PAS and alkaline phosphatase activies after unilateral ligation of the internal iliac or uterine arteries. However, after ligation of the ovarian artery, the endometrial glands of the ligated side showed weak PAS reaction and moderate alkaline phosphatase activity. Those of the contralateral side showed a strong activity. Concerning the ovary, unilateral ligationof the internal iliac or uterine arteries was followed by marked degenerative changes in the ipsilateral ovary and the contralateral ovary was normal in appearance. However, ligationof the ovarian artery was followed by atrophic changes in the ovary of the ligated side. That of the contralateral side showed compensatory hypertrophy of the graafian follicles. Ligation of the internal iliac or uterine arteries was followed by strong activity of the alkaline phosphatase enzyme in the growing follicles and corpus lutii of both ipsilateral and contralateral ovaries. There was also a strong activity of the alkaline phosphatase in the hypertrophied follicles of the contralateral ovary following ligation of the ovarian artery