Management of obstetric hemorrhage; an observational study highlighting the efficacy of uterine artery ligation

Background: Obstetrical hemorrhage is leading cause of maternal mortality. UAE is termed safe and effective method for resolving hemorrhage. objective of this study was to determine efficacy of uterine artery ligation in management of obstetrical hemorrhage.Methods: This cross sectional observational using non-probability convenient sampling technique was carried out for six months. After ethical approval, females between 18 to 35 years diagnosed with obstetrical hemorrhage, uterine atony refractory to medical treatment, having active bleeding from placental side or having normal coagulation profile were while females with post-partum hemorrhage because of retained products of conception, due to genital tract trauma or with disseminated intravascular coagulation were excluded. Analysis of data was done using SPSS version 23.0. Quantitative variables were reported as mean and standard deviation and for qualitative variables, frequency and percentages. Chi-square test was applied keeping p-value of <0.05 as statistically significant.Results: From 109 females with mean age 47±5.25 years. In comparison of parity distribution, 62 (56.88%) were multiparous and 47 (43.12%) were primiparous. Type of bleeding observed was antepartum 36(33.03%), peripartum 39 (35.78%) and postpartum in 34 (31.19%). Efficacy of uterine artery ligation in management of obstetric hemorrhage was observed to be 35 (32.11%). The efficacy of uterine artery ligation in management of obstetric hemorrhage in three categories of age groups reported significant association (p=0.0005) and type of bleeding (p=0.025).Conclusions: Efficacy of UAE in different types of obstetrical hemorrhage reported in our study was lower than expected in about one-third of females.

Fertility preserving surgical approach to uterine arteriovenous malformation / Philippine Journal of Obstetrics and Gynecology

@#Arteriovenous malformations (AVM) are vascular disorders with a mixture of arterial, venous and small capillary-like channels with fistulous connections. Uterine arteriovenous malformations are rare cause of abnormal uterine bleeding with only a few reported cases. They may arise from pregnancy, miscarriage, previous cesarean section or other uterine surgery and gestational trophoblastic disease. Diagnosis can be made through angiography or doppler ultrasonography. Traditionally, uterine AVMs are treated with hysterectomy but with the advances in technology, minimally invasive conservative approaches such as radiologic arterial embolization or laparoscopic uterine artery ligation have become available. We present a case of a 29-year-old, G2P1 (1011) who had a three- month history of heavy, intermittent vaginal bleeding from uterine arteriovenous malformation after a miscarriage. Laparoscopic bilateral uterine artery occlusion, offered a minimally invasive treatment with high symptomatic effectiveness.

A case report on broad ligament fibroid mistaken as pregnancy

Leiomyoma is the commonest benign uterine condition arising from smooth muscles. Extra uterine leiomyoma is rare. The incidence of broad ligament fibroid is less than 1%. Because of its rarity broad ligament fibroid poses specific diagnostic difficulties causing an error in making the final diagnosis and therefore the management. Here we report a case of rare broad ligament fibroid got neglected sadly in this modern era, where the facilities like USG which can easily diagnose this rare entity are readily available. Presented as ANC with no labor pains and accidentally diagnosed as a case of huge broad ligament fibroid. Managed surgically by myomectomy with conservation of uterus and bilateral internal iliac artery ligation for minimizing bleeding.

Repeated broad ligament hematomas managed by uterine artery embolization: time to execute

Selective arterial embolization (SAE) of the uterine arteries is an alternative to surgery when medical management fails in cases of intractable posrtpartum haemorrhage. It is highly efficacious with low complication rate. Here we report a case of repeated broad ligament haematoma managed by selective uterine artery embolization. Present case 28year old P4L4 was referred from a district hospital as post LSCS case with broad ligament haematoma. Patients general condition was very poor at the time of admission. She underwent laparotomy twice and finally uterine artery embolization for repeated broad ligament haematoma and responded. Massive obstetric haemorrhage remains a significant cause of maternal morbidity and mortality. The threshold for uterine artery embolization (UAE) in women with obstetric haemorrhage should be low, as it is coupled with a high clinical effectiveness rate, low complication rate and preservation of fertility. However, it requires an infrastructure, multidisciplinary approach, as well as speedy and effective interaction between various specialties.

Does bilateral uterine artery ligation have negative effects on ovarian reserve markers and ovarian artery blood flow in women with postpartum hemorrhage? / 대한생식의학회지

OBJECTIVE: Bilateral uterine artery ligation (UAL) is a fertility-preserving procedure used in women experiencing postpartum hemorrhage (PPH). However, the long-term effects of this procedure on ovarian function remain unclear. The aim of this study was to investigate whether bilateral UAL compromised ovarian reserve and ovarian blood supply. METHODS: This prospective study included 49 women aged between 21 and 36 years who had undergone a cesarean section for obstetric indications. Of these, 25 underwent uterine bilateral UAL to control intractable atonic PPH. The control group consisted of 24 women who had not undergone bilateral UAL. Standard clinical parameters, the results of color Doppler screening, and ovarian reserve markers were assessed in all participants at 6 months after surgery. The clinical parameters included age, parity, cycle history, body mass index, and previous medication and/or surgery. Color Doppler screening findings included the pulsatility index (PI) and resistance index (RI) for both the uterine and ovarian arteries. The ovarian reserve markers included day 3 follicle-stimulating hormone (FSH) levels, antral follicle count, and anti-Müllerian hormone (AMH) levels. RESULTS: There were no significant differences in the ovarian reserve markers of day 3 FSH levels, antral follicle count, and AMH levels between the study and control groups (p>0.05 for all). In addition, no significant differences were observed in the PI and RI indices of the uterine and ovarian arteries (p>0.05 for all). CONCLUSION: In this study, we showed that bilateral UAL had no negative effects on ovarian reserve or ovarian blood supply, so this treatment should be used as a fertility preservation technique to avoid hysterectomy in patients experiencing PPH.

Comparison of rat models of intrauterine growth retardation established by three different methods / 中国比较医学杂志

Objective Intrauterine growth retardation (IUGR) is characterized by low birth weight of neonates. The aim of this study was to provide a reference for the establishment of IUGR models in scientific research, by comparing the experimental data of different rat models of IUGR established by three commonly-used methods. Methods A total of 20 pregnant rats on the day 0 of gestation were divided into 4 groups, with 5 rats in each group (n=5). Among them, 3 groups of rats were treated with alcohol intervention (group A), uterine artery ligation (group U), and low protein diet (LP group), respectively, to establish rat models of IUGR, and the fourth group served as the normal control group (CON group). Fetal rats were taken through cesarean section on the 20th day of gestation. The body mass, brain mass, placental mass, two-kidney mass, body length and tail length of the fetal rats were measured, and the incidence rate of IUGR, stillbirth rate and their brain to placenta ratio were calculated. The fetal rats in each group were continuously raised and the body mass, perirenal fat pad mass and some organ masses were determined at the 3rd, 6th and 12th weeks. Results The average body mass of the fetal rats in the groups A, U and LP group was significantly lower than that of the normal control group (P＜ 0. 05), and the incidence rate of IUGR of the fetal rats was significantly higher than that of the normal control group (P＜ 0. 05). In addition, the stillbirth rate of pregnant rats in the group U was significantly higher than those of the group A and LP group (P ＜ 0. 05). After raising the rats for 3 weeks, the average body mass of rats in the three experimental groups was significantly lower than that of the normal control group (P ＜ 0. 05), and after raising for 6 weeks, the average body mass in the three experimental groups was still lower than that of the normal control group, but with a non-significant difference (P＞ 0. 05). However, after raising for 12 weeks, the average body mass of the rats in the group A and LP group was significantly higher than that of the normal control group (P ＜ 0. 05). Conclusions Rat models of IUGR can be successfully established either by alcohol intervention, uterine artery ligation or low protein diet. The IUGR model established by low protein diet has the advantages of a higher incidence rate of IUGR and lower stillbirth rate, being more suitable for animal model research. As regards the catch-up growth, the average body mass of the rats during the postpartum period and lactation period after delivered by cesarean section in the group A and LP group is lower than that of the normal control group, but after lactation the rats grow faster than those in the normal control group, indicating the existence of a catch-up growth in the group A and LP group.

Effect of uterine compression suture in the prevention and treatment of postpartum hemorrhage of cesarean section / 中国基层医药

Objective To analyze the clinical effect of uterine artery ligation combined with modified uterine compression suture in the prevention and treatment of postpartum hemorrhage.Methods A total of 107 patients with refractory cesarean section who were treated with uterine artery ligation combined with modified uterine compression suture were selected as treatment group.Of the patients treated with conventional treatment,83 patients were included in the control group.The effective hemostasis rate,clinical curative effect,incision infection,postpartum hemorrhage,blood transfusion rate,mattress rate and postoperative morbidity were compared between the two groups.Results The amount of intraoperative blood loss (1 106 ± 458.78) mL in the treatment group was significantly higher than (753.6 ±302.30)mL in the control group,the difference was statistically significant (t =1.892,P ＜ 0.05).The 24h total blood loss of the the treatment group [(1 028.89 ± 375.87) mL] was significantly higher than (813.87 ± 312.15) mL of the control group (t =3.872,P ＜ 0.05).The postoperative 24h blood loss in the treatment group [(70.86 ±19.30)mL] was lower than (73.50 ± 21.20)mL in the control group,and the difference was not statistically significant (t =0.045,P ＞ 0.05).The transfusion rate in the treatment group was 27.10％,which in the control group was higher than 10.84％,the difference was statistically significant between the two groups (x2 =7.722,P ＜ 0.05).The effective hemostasis rate in the treatment group was 99.66％ (106/107),which was significantly higher than 96.39％ in the control group (x2 =6.263,P ＜ 0.05).The rate of puerperal infection was 7.48％ in the treatment group,which in the control group was 6.02％,there was no significant difference between the two groups (P ＞ 0.05).The incision infection rate and postoperative morbidity rate were 0.00％ in the treatment group and the control group,and the two groups were treated with Ⅱ / A healing.Conclusion Uterine artery ligation combined with improved uterine compression suture in the prevention and treatment of postpartum hemorrhage has good hemostasis effect,hysterectomy rate is low,it is worthy of promoting and application.

Application valuation of uterine artery ligation in laparoscopic myomectomy / 中国医师进修杂志

Objeetive To analyze the application valuation of uterine artery ligation in laparoscopic myomectomy.Methods Seventy-five hysteromyoma patients who underwent laparoscopic myomectomy were collected.The patients were divided into 2 groups by random digits table method,33 cases underwent uterine artery ligation before laparoscopic myomectomy (experiment group),and 42 cases only received laparoscopic myomectomy (control group).The prognosis and postoperative recurrence rate were compared between the 2 groups.Results The duration of operation,amount of bleeding,length of stay,laparotomy rate,postoperative residual cavity hematoma formation rate,improving rate and recurrence rate in experiment group were better than those in control group [(42.46 ±37.22) min vs.(73.23 ±48.82) min,(143.12 ±81.46) ml vs.(214.70 ± 149.19) ml,(5.17 ± 1.08) d vs.(9.21 ± 1.20) d,12.1％(4/33) vs.28.6％(12/42),18.2％(6/33) vs.31.0％ (13/42),93.9％ (31/33) vs.81.0％ (34/42),12.1％ (4/33) vs.23.8％ (10/42)],there were statistical differences (P ＜ 0.05).Conclusions Uterine artery ligation in laparoscopic myomectomy is safe and effective.It can decrease the duration of operation,amount of bleeding,length of stay,laparotomy rate and postoperative residual cavity hematoma formation rate.

Treatment Outcomes of Uterine Artery Embolization and Laparoscopic Uterine Artery Ligation for Uterine Myoma

In treating women with leiomyoma and who wish to preserve their uterus, laparoscopic uterine artery ligation or uterine artery embolization should be considered as possible options. This study was performed to evaluate the efficacy of laparoscopic uterine artery ligation and uterine artery embolization in treating uterine myoma. The treatment outcomes of 23 patients who underwent uterine artery embolization and 17 laparoscopic uterine artery ligation were evaluated. The uterine volume reduced 3 months after uterine artery embolization, but thereafter no significant changes were observed. On the other hand, the uterine volumes were only slightly reduced 3 months after laparoscopic uterine artery ligation, and slightly more reduced 6 months later. The average reduction in the case of laparoscopic uterine artery ligation was about 58.5%. After laparoscopic uterine artery ligation, 20% of the patients complained of vaginal spotting. Furthermore, the mechanism of volume reduction was evaluated using specimens obtained from a biopsy taken after each procedure. The results suggested that laparoscopic uterine artery ligation results mainly in physiologic cell death, that is apoptosis, whereas, the corresponding result is cell necrosis for uterine artery embolization. Uterine artery embolization and laparoscopic uterine artery ligation are both effective in relieving the symptoms caused by uterine myoma, and therefore both procedures can be used in place of hysterectomy or myomectomy.

A Case of Intrauterine Pregnancy after Laparoscopic Bilateral Uterine Artery Ligation for Treatment Uterine Myoma / 대한산부인과학회잡지

Uterine artery ligation or embolization is a minimally invasive alternative for treatment of symptomatic leiomyoma. However, the experience with pregnancy management and outcome after ablating uterine blood flow is still unknown. We have recently experienced a case of a woman who had two successful spontaneous intrauterine pregnancies after laparoscopic uterine artery ligation to treat uterine myoma for dysmenorrhea and menometrorrhagia.

Altered Expression of Vascular Endothelial Growth Factor in Pregnant Rats with Uterine Artery Ligation / 대한산부인과학회잡지

OBJECTIVE: During pregnancy, the impaired placental perfusion causes complications such as preeclampsia, intrauterine growth restriction and fetal death in utero. In order to investigate the maternal and fetal response to the impaired placental perfusion, the author induced the impaired placental perfusion by the ligation of the rat uterine artery and investigated its effect on the expression of VEGF (vascular endothelial growth factor) in the placenta and serum VEGF level. METHODS: The rats on day 15 of gestation were used for the experiment. They were divided into two groups. The control group consists of the 20 rats that underwent laparotomy without uterine artery ligation. The experimental group consists of the 20 rats that underwent laparotomy and the uterine artery ligation by silk on day 15 of gestation. On day 16, 17, 18 and 19 of gestation, the placental tissues were obtained. The mRNA expressions of the VEGF in the placenta were measured by the relative RT-PCR in the control and experimental group. The localization and intensity of immunohistochemical staining of VEGF in placenta were determined in both groups and the maternal serum levels of VEGF were also measured in both groups. RESULTS: The mRNA expressions of VEGF120 and VEGF164 were significantly increased 48 hours after the ligation (day 17 of gestation) but the mRNA expression of VEGF188 was not changed after the ligation. There was no difference in the location and intensity of immunohistochemical staining of VEGF in the placenta between control and experimental groups. The serum VEGF levels of control group were 9 times as high as those of non-pregnant rats. The significant increases of the serum VEGF levels were noted 48 and 72 hours after the ligation (day 17 and 18 of gestation) but the significant increase was not noted 96 hours after the ligation (day 19 of gestation) as compared to control group. CONCLUSION: This study demonstrated firstly that the experimentally induced reduction of placental perfusion increased expressions of VEGF in the placenta and maternal serum. The results support that the measurement of maternal serum VEGF levels in pregnancy may help the diagnosis of placental insufficiency.

Altered Expression of Vascular Endothelial Growth Factor in Pregnant Rats with Uterine Artery Ligation / 대한산부인과학회잡지

OBJECTIVE: During pregnancy, the impaired placental perfusion causes complications such as preeclampsia, intrauterine growth restriction and fetal death in utero. In order to investigate the maternal and fetal response to the impaired placental perfusion, the author induced the impaired placental perfusion by the ligation of the rat uterine artery and investigated its effect on the expression of VEGF (vascular endothelial growth factor) in the placenta and serum VEGF level. METHODS: The rats on day 15 of gestation were used for the experiment. They were divided into two groups. The control group consists of the 20 rats that underwent laparotomy without uterine artery ligation. The experimental group consists of the 20 rats that underwent laparotomy and the uterine artery ligation by silk on day 15 of gestation. On day 16, 17, 18 and 19 of gestation, the placental tissues were obtained. The mRNA expressions of the VEGF in the placenta were measured by the relative RT-PCR in the control and experimental group. The localization and intensity of immunohistochemical staining of VEGF in placenta were determined in both groups and the maternal serum levels of VEGF were also measured in both groups. RESULTS: The mRNA expressions of VEGF120 and VEGF164 were significantly increased 48 hours after the ligation (day 17 of gestation) but the mRNA expression of VEGF188 was not changed after the ligation. There was no difference in the location and intensity of immunohistochemical staining of VEGF in the placenta between control and experimental groups. The serum VEGF levels of control group were 9 times as high as those of non-pregnant rats. The significant increases of the serum VEGF levels were noted 48 and 72 hours after the ligation (day 17 and 18 of gestation) but the significant increase was not noted 96 hours after the ligation (day 19 of gestation) as compared to control group. CONCLUSION: This study demonstrated firstly that the experimentally induced reduction of placental perfusion increased expressions of VEGF in the placenta and maternal serum. The results support that the measurement of maternal serum VEGF levels in pregnancy may help the diagnosis of placental insufficiency.