Morbimortalidad en pacientes sometidas a ligadura de arterias hipogástricas con riesgo de hemorragia obstétrica / Morbi-mortality in patients undergoing ligation of hypogastric arteries at risk of obstetric haemorrhage

Antecedentes: La hemorragia obstétrica es la principal causa de mortalidad materna en países subdesarrollados; representan un tercio de las muertes. Existen técnicas quirúrgicas alternativas para detener la hemorragia como lo es la ligadura de arterias hipogástricas. Objetivo: Determinar la morbimortalidad materna en pacientes sometidas a ligadura de arterias hipogástricas con riesgo de hemorragia obstétrica de junio a diciembre de 2012 en el Hospital General Regional n.o 36 del Instituto Mexicano del Seguro Social, Puebla (HGR n.o 36, IMSS, Puebla). Material y métodos: Estudio descriptivo, observacional, transversal, retrospectivo, homodémico. Se incluyeron pacientes con riesgo de hemorragia obstétrica sometidas a «ligadura de arterias hipogástricas» de junio a diciembre de 2012 en el HGR n.o 36, IMSS, Puebla, de cualquier edad materna y gestacional. El tipo y tamaño de muestra fue finita, no probabilística. Método estadístico: descriptivo y odds. Resultados: Treinta y ocho pacientes se sometieron a ligadura de arterias hipogástricas. Edad promedio: 26,9 años. El acretismo placentario (44,74%) fue la indicación más frecuente (odds=0,78), seguida de hipotonía uterina (7,89%; odds=0,07) y placenta previa (7,89%; odds=0,07). Se registraron 22 (57,8%) pacientes con hemorragia obstétrica, 15 (68,18%) contaron con antecedente de cesárea previa (odds=2,12). La razón de probabilidad de culminar en histerectomía por hemorragia obstétrica odds=4,2. Se documentó un (2,63%) paciente con complicación ureteral posterior a la ligadura (odds=0,027). Mortalidad materna y perinatal del 0%. Conclusión: La complicación posterior a la ligadura de arterias hipogástricas se presentó en un paciente con ligadura ureteral. No hubo complicaciones vasculares. La mortalidad materna y perinatal fue de 0 pacientes.(AU)

Background: Obstetric haemorrhage is the leading cause of maternal death in underdeveloped countries, accounting for a third of deaths. There are alternative surgical techniques to stop bleeding, such as ligation of the hypogastric arteries. Objective: To determine maternal morbidity and mortality in patients sometimes linked to hypogastric arteries at risk of obstetric haemorrhage from June to December 2012 in Hospital General Regional n.o 36, Instituto Mexicano del Seguro Social, Puebla (HGR # 36, IMSS, Puebla). Material and methods: Descriptive, observational, cross-sectional, retrospective, homodemic study. Patients at risk of obstetric haemorrhage undergoing “hypogastric artery ligation” from June to December 2012 were included in the HGR # 36, IMSS, Puebla, of any maternal and gestational age. Sample type and size was finite, not probabilistic. Statistical method: descriptive and Odds. Results: Thirty-eight patients underwent a ligation of the hypogastric arteries. Average age: 26.9 years. Placental accretion (44.74%) was the most frequent indication Odds=.78, subsequent uterine hypotonia (7.89%) Odds=.07 and placenta previa (7.89%) Odds=.07. 22 (57.8%) patients with obstetric haemorrhage were considered, 15 (68.18%) had a history of prior caesarean section Odds=2.12. The probability ratio of completing a hysterectomy for obstetric haemorrhage=4.2. One (2.63%) patient with ureteral complication after ligation was documented Odds=.027. Maternal and perinatal mortality in 0 patient. Conclusion:The complication after ligation of the hypogastric arteries presented in 1 patient with ureteral ligation. There were no vascular complications. Maternal mortality was 0%. Perinatal mortality was 0%.(AU)

Massive obstetric haemorrhage on post caesarean subtotal hysterectomy due to late detection of occult placenta percreta: A case report.

INTRODUCTION: Placenta accreta syndrome is a significant cause of maternal mortality and morbidity. Therefore, a multidiscipline approach is essential to overcome this life-threatening disorder for the mother and fetus. PRESENTATION OF CASE: A 32-year-old women gravida 3 parity 2, 34 weeks gestation come due to recurrent antepartum haemorrhage. She had twice prior caesarean section. Ultrasound assessment suggests total placenta previa and elevating suspicion to placenta accreta. However, intraoperatively its sign is unavailable. Although we have done subtotal hysterectomy, massive bleeding still occurring. Therefore, we present management of unexpected placenta percreta. DISCUSSION: Management of unexpected placenta percreta involves prenatal diagnosis, haemoglobin optimization, surgical management anticipating haemorrhage, dedicated maternal ICU, blood bank providing massive transfusion and blood component. CONCLUSION: Close monitoring is important in catastrophe management of Placenta Accreta Syndrome.

Hypogastric artery ligation in postpartum haemorrhage: a ten-year experience at a tertiary care centre.

This study investigated patients who underwent bilateral hypogastric artery ligation (BHAL) due to postpartum haemorrhage (PPH). Patients who underwent BHAL because of PPH following a conservative treatment were included in this study. Placental abnormalities were referred to as placenta accreta. A total of 130 BHAL procedures took place at the study hospital as a result of PPH. Of these, 39 (30%) were referred to the hospital. The rate of BHAL requirement was 62 out of 10,000 births. Among the 130 patients, the most frequent indication for BHAL was placenta accreta (58.5%). Haematological parameters were poorer among the referral patients. Four of the exitus patients (80%) were referral patients. The mortality rate among the referral patients was 10.25%, whereas this rate was only 1.01% among the patients who gave birth at the hospital. PPH is a life-threatening condition that requires immediate medical attention. BHAL, with its fertility-preserving features, is a good option that can be employed in all PPH patients. BHAL not only preserves patients' fertility, but it also gives them a higher chance of survival.IMPACT STATEMENTWhat is already known on this subject? PPH is a life-threatening condition. Due to the worldwide increase in caesarean sections, placenta accreta has also increased. BHAL is a vital treatment method for PPH.What do the results of this study add? Placenta accreta is one of the most common causes of PPH. Traditional hysterectomy rates can be reduced by replacing this treatment with BHAL in this group of patients. Without early intervention in PPH, a patient's mortality risk can increase by up to 10 times. As research and surgeons' experience grows, PPH can be controlled with treatments with less complex modalities without the need for BHAL.What are the implications of these findings for clinical practice and/or further research? The need for BHAL should be kept in mind when addressing PPH, especially in cases of placenta accreta. The need for hypogastric artery ligation, which is a more aggressive treatment for the surgical correction of the pathology, can be reduced as surgeons' experience increases. Early intervention and/or referral in cases of PPH is of great importance.

Outcomes of hypogastric artery ligation and transcatheter uterine artery embolization in women with postpartum hemorrhage.

OBJECTIVE: This study aimed to report our experience of emergent bilateral hypogastric (internal iliac) artery ligation (HAL) in the management of intractable postpartum hemorrhage (PPH) in a tertiary care center. MATERIALS AND METHODS: Patients with severe postpartum hemorrhage that could not be controlled with conservative management were retrospectively reviewed from January 2013 to December 2017. Data were retrieved from patients' hospital records. Two cases involving both transcatheter uterine artery embolization (TAE) and HAL were excluded. A total of 40 patients were included in the analysis during this period. The inclusion criteria were gestational age ≥24 weeks and primary severe PPH (blood loss ≥1500 mL within 24 h after birth). RESULTS: A total of 40 patients with intractable PPH were included after a thorough review of their medical records. Nine of them required HAL during the study period. Causes of PPH included uterine atony, placental abruption, vaginal/cervical laceration, uterine rupture, and placenta accreta. Hemorrhage was effectively controlled in 8 of 9 patients (88.9%) in the group undergoing bilateral HAL even though their initial conditions were poor. All patients with HAL did not have to undergo hysterectomy. No immediate complications developed. There were two maternal deaths in the group undergoing TAE. CONCLUSION: Bilateral HAL is an effective life-saving procedure for severe intractable PPH and should be performed as soon as possible when obstetric emergency conditions are indicated.

Prophylactic Hypogastric Artery Ligation during Placenta Percreta Surgery: A Retrospective Cohort Study.

Objective To evaluate if prophylactic hypogastric artery ligation (HAL) decreases surgical blood loss and blood products transfused. Study Design This is a retrospective cohort study comparing patients with placenta percreta undergoing prophylactic HAL at the time of cesarean hysterectomy versus those who did not. Data were presented as means ± standard deviations, proportions, or medians with interquartile ranges. Demographic and clinical data were compared in the groups using Student's t -test for normally distributed data or the Mann-Whitney U test for nonnormally distributed data. Fisher's exact test was used for proportions and categorical variables. Data are reported as significant where p was <0.05. Results There were 26 patients included in the control group with no HAL and 11 patients included in the study group. Estimated blood loss for the study group was 1,000 mL versus 800 mL in the control. Units of PRCBs transfused were 4.5 units in the study group versus 2 units for the control group. None of these measures were found to be statistically significant. Conclusion Our data suggest there was no benefit in the use of prophylactic HAL in decreasing surgical blood loss or amount of blood products transfused in patients who had a cesarean hysterectomy performed for placenta percreta. Précis Prophylactic HAL does not decrease blood loss during surgery for placenta percreta.

Sclerotherapy with 6% polidocanol solution in patients with placenta accreta.

OBJECTIVE: Placenta accreta is one of the main obstetrical complications worldwide. The aim of this study was to report the experience of managing placenta accreta with a 6% polidocanol solution sclerotherapy. MATERIALS AND METHODS: We selected patients between 37 weeks of gestation and 38 weeks of gestation, diagnosed with placenta accreta, treated at the Maternal Perinatal Hospital "Monica Pretelini Sáenz", Toluca, Mexico, during the period from November 2013 to August 2014. The surgical technique has two steps: (1) fundic-arciform caesarean section followed by a 6% polidocanol sclerosing solution through a 6Fr neonatal feeding tube upon its reaching the placental bed; (2) total abdominal hysterectomy with internal hypogastric artery ligation. RESULTS: Data were collected from 11 patients with a mean age of 33.9 years (range, 26-42 years) and 2.8±0.6 days of hospitalization in the obstetrical intensive care unit. The majority of patients were classified as having pregnancies at an advanced age. All women were multigravidas. Bleeding volume exhibited a range between 2.5 L and 3 L without any case of neonatal death but one mother died because of coagulopathy. CONCLUSION: We conclude that the technique that we are reporting is feasible for implementation in obstetric hospitals, with technical and economic feasibility.

Therapeutic approaches in pelvic bleeding of neoplastic origin.

OBJECTIVES: The aim of this study is to present the main - surgical and non-surgical - therapeutic approaches (or methods) used in the treatment of pelvic bleeding of neoplastic origin. MATERIALS AND METHODS: analysis of the materials found in the literature on this subject. RESULTS: Among the surgical methods used, hypogastric artery ligation is the oldest therapeutic approach in cervical bleedings of neoplastic origin. Due to the frequent recurrence of haemorrhages, mere ligation has been proven not to be sufficient, but necessitating the concomitant ligation of the lumbo-ovarian, round and uterosacral ligaments. In the case of severe bleedings, difficult to control, direct embolization of the hypogastric artery below the level of ligation is usually practiced. As for the non-surgical methods used, we chose to present uterine artery embolization and the application of haemostatic Mohs' paste. Uterine artery embolization consists in the permanent occlusion of the uterine arteries in neoplastic abundant haemorrhages, when the intervention includes the use of permanent embolic material. Stopping the bleeding within the first 24 hours from the embolization means that the intervention has been a success, and provides the patient with the possibility to continue the therapy protocol according to her stadialization. Recent studies of the Japanese researchers have indicated the possibility to use the Mohs' paste for haemostatic purposes on patients with cervical bleedings of medium intensity, in cases of advanced cervical cancer. CONCLUSIONS: With severe haemorrhages - occurring spontaneously or during surgery - the emergency haemostatic intervention consists in the bilateral hypogastric artery ligation. With long-lasting haemorrhages of medium intensity, we usually resort to uterine artery embolization, since this is a minimally invasive method and may also be performed with abundant bleeding under emergency pressure. The application of the Mohs' paste for haemostatic purposes is a new therapeutic method, whose efficiency cannot be yet estimated.

Cesarean scar pregnancy: diagnosis, management, and follow-up.

Cesarean scar pregnancy is a very rare form of pregnancy and a life-threatening situation. It has become an important and serious problem over the last 10 years, as a result of the worldwide increase in cesarean births. In this retrospective series, the diagnosis of cesarean scar pregnancy, management, treatment methods, risk factors, and possibility of subsequent normal pregnancy are discussed, and case descriptions are presented.

Hypogastric artery ligation to treat massive hemorrhage in pelvic fractures with abdominal organ injuries / 中华创伤骨科杂志

Objective To evaluate the effects of hypogastric artery ligation to treat massive hemorrhage in pelvic fractures with abdominal organ injuries. Methods The pelvic fractures of 16 patients were classified as Tile B type in 10 cases and C type in 6. Among them there were 6 open fractures and 20 sites of abdominal visceral injuries. The capacity of retroperitoneal hematoma, which was ruptured in 6 cases, ranged from 800 ～2 500ml with 1 400ml on average. The bleeding volume in the survivals was 1 500～5 800ml with 2 600ml on average. Ligation of bilateral hypogastric artery was carried out in all patients with intra abdominal injuries within 6h. Of them, skeletal traction was used in 7 cases while pelvic external fixation in 5 cases. Results One death occured dut to consumptive coagulopathy with hematorrhea. Of the 15 survivals, bleeding was controlled in 8 cases, decreased in 5 and uncontrolled in 2. The effective rate was 81.3%(13/16) and the survival rate 93.8%(15/16). Conclusion When emergency celiotomy is performed for abdominal injuries, a rational application of hypogastric artery ligation can play a positive role in control of pelvic hematorrhea.