Conservative and Nonconservative Surgical Management of Postpartum Hemorrhage
Postpartum hemorrhage still remains the leading cause of maternal mortality and morbidity especially in the developing world. Once medical management fails, surgical steps should start without time lag and in a systematic way. Transvaginal compression of the uterine artery can be an effective first aid while resuscitative measures are undertaken and arrangements for definitive surgical steps are made. Procedures like brace stitches, stepwise devascularization, and internal iliac artery ligation come under conservative surgical procedures. Once the laparotomy is done, immediate clamping of the lower end of the aorta with atraumatic common iliac artery clamp will arrest the bleeding and prevent further deterioration of the patient. Obstetric hysterectomy for atonic PPH is seldom required but, when bleeding persists, will have to be resorted to without delay. The aortic clamp has revolutionized management of placenta previa percreta by reducing the need for blood transfusion and damage to the bladder. Lower genital tract trauma has become a more significant contributor to PPH due to the widespread use of misoprostol. These days, internal iliac artery ligation is needed less frequently except in cases of lower genital tract trauma. Stepwise surgical approach starting with conservative procedures like brace stitch and going up to the radical ones like hysterectomy will help in reducing morbidity and mortality in cases of postpartum hemorrhage.
KeywordsIliac Artery Uterine Artery Internal Iliac Artery Common Iliac Artery Postpartum Hemorrhage
We are grateful to the management and colleagues at Mother Hospital, Thrissur, especially Dr. Philo Akkarapatty and Mrs. Suseela, head nurse in charge of labor room. This report is based on the experience gained from that hospital in managing postpartum hemorrhage. The initial trials of the transvaginal uterine artery clamps as well as the common iliac/aortic clamps were done in the same hospital.
Figures 17.4, 17.5, 17.6, 17.7, and 17.8 are reproduced from the book “A Comprehensive Textbook of Postpartum Haemorrhage, 2nd Edition,” edited by Arulkumaran S, Karoshi M, Keith LG, Lalonde AB, and B-Lynch C, Chapter 53 “Initial Interventions to Combat Hemorrhage During Cesarean Section and Internal Iliac Artery Ligation” (by V P Paily). I am grateful to Sapiens Publishing who have given free permission for reproduction of the contents for educational purposes.
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