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Internal iliac artery ligation: a life saving procedure.

INTRODUCTION: Internal iliac artery supplies the pelvic viscera. Bilateral ligation of the internal iliac arteries is a safe, rapid and very effective method of controlling bleeding from genital tract. Bilateral ligation of internal iliac arteries is also helpful in controlling atonic postpartum hemorrhage. It is lifesaving in postoperative hemorrhage after abdominal or vaginal hysterectomy where no definitive bleeding point is detectable.

It is also helpful in massive broad ligament hematoma, in torn vessels retracted within the broad ligament Following ligation of internal iliac artery, there is a reduction of 85% in pulse pressure and 48% in the blood flow in the arteries distal to the ligation. (1) Thereby the arterial pressure approaches the venous pressure and is rendered more amenable to hemostasis by a simple clot formation. Any late post-operative complications/sequelae were not seen in our patients.

MATERIAL AND METHODS: A total of seven emergency internal iliac ligations (EIIAL) were performed during two years from January 2012 to December 2013. This was done as a life saving measure to control intra-peritoneal or external hemorrhage or both. All cases were done via intraperitoneal route.

Associated operations like subtotal or total hysterectomy and ligation was done when indicated. Patients were analyzed in terms of death and associated complications. Types of hemorrhage and their primary causes are analyzed in Table 1. One case of ruptured uterus occurred in post-cesarean pregnancy.

It was associated with broad ligament hematoma. Two cases of central placenta praevia had excessive lower segment intruterine bleeding after separation of placenta which was not controlled by other measures, so EIIAL was done with subtotal hysterectomy. In two patient of placenta accrete with partial separation patient had excessive intrauterine bleeding EIIAL with subtotal hysterectomy was done. Following abdominal Hysterectomy one patient presented with excessive intra peritoneal & pervaginal bleeding & shock where definite source of bleeding could not be found EIIAL was done to save life of that patient

EIIAL was done in one patient who had pudandle vessel injury during sacrspinous colpopexy for vault prolapse.

RESULTS: EIIAL was done in seven cases in two years to control obstetric and gynecological hemorrhage. Internal iliac artery ligations were done even after hysterectomy or repair of injury to the uterus as the bleeding vessel had retracted within broad ligament hematoma. We were able to control hemorrhage in all the seven cases. Seven cases were discharged in good condition. Five patients came back for post-operative checkup after 6 weeks and all of them were without any major problem. Two patients were lost to follow up.

DISCUSSION: Bilateral internal iliac artery ligation is an effective life-saving method to control obstetrical and gynecological hemorrhage and a hysterectomy can often be avoided. Ligation of internal iliac artery was first performed by Kelly (2) with a success rate 95% and without any major complication. Mukherjee et al (3) performed 36 cases of internal artery ligation with a success rate of 83.3% in 6 years. We have a small series of only seven cases in two years because now a days internal iliac artery ligation is usually not required for atonic post parturn hemorrhage as other simpler and effective methods are available.

Step-wise devascularization of uterus and compression sutures of the uterus are found very effective. (4) Angiografically directed arterial embolization has also been reported to be very effective in controlling hemorrhage but this modern facility is not available in most of the centers of our country. We were able to control hemorrhage in all seven cases. However, even when uterus is preserved, ligation of these arteries does not hamper future reproductive function. (5)

Wagaarachchi and Fernando (6) observed future pregnancy in 50% of the cases following bilateral ligation of internal iliac artery. Bilateral ligation of internal iliac artery is a safe, rapid and effective way of controlling obstetric and gynecological hemorrhage. We also have preserved uterus in one of our young patient for her further child bearing capacity.

DOI: 10.14260/jemds/2014/3154

REFERENCES:

(1.) Burchell RC Physiology of internal iliac artery ligation J Obstet Gynaecol Br Common w 1968; 72: 642-51.

(2.) Kelly HA. Ligation of internal iliac arteries for hemorrhage in hysterectomy for carcinoma uteri. Bull Johns Hopkins Hosp 1894; 5: 53.

(3.) Mukherjee P, Das C, Mukherjee G et al. Emergency internal iliac artery ligation for obstetrical and gynecological hemorrhage. J Obstet. Gynaecol. Ind 2002; 52: 147-9.

(4.) Mukherjee P, Biswas P. Compression suture in post-partum hemorrhage. J Obstet Gynaecol Ind 2003; 53: 158-9.

(5.) Oleszczuk D, Cebulak K, Skret A et al. Long term observation of patients after bilateral ligation of internal iliac arteries. Ginekol Pol 1995; 66: 533-6.

(6.) Wagaarachchi PT. Fernando L. Fertility following ligation of internal iliac arteries for life-threatening obstetric haemorrhage: case report. Hum Reprod 2000; 15: 1311-3. Emergency internal iliac artery ligation.

AUTHORS:

1. Smita Bhat

2. Sudhir Bhave

PARTICULARS OF CONTRIBUTORS:

1. Associate Professor, Department of Obstetrics and Gynaecology, Bharati Vidyapeeth Medical College & Hospital, Sangli.

2. Professor, Department of Obstetrics and Gynaecology, Bharati Vidyapeeth Medical College & Hospital, Sangli.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Smita Bhat, Bharati Vidyapeeth Medial College & Hospital, Sangli.

Email: bhatsmita2@gmail.com

Date of Submission: 11/07/2014. Date of Peer Review: 12/07/2014. Date of Acceptance: 04/08/2014. Date of Publishing: 08/08/2014.
Table 1: Shows Type of hemorrhage, its primary cause & no of cases

Type of haemorrhages       Primary cause                     No. of
                                                             cases

Intra-abdominal bleeding   Abdominal hysterectomy              01
                             for broad ligament fibroid
Intrauterine bleeding      Central placenta praevia            02
                             was seen.
Intrauterine bleeding      Placenta accrete with partial       02
                             separation of placenta
Haematoma in para          Sacrospinous vault suspension       01
  rectal space               for vault prolapse.
Broad ligament haematoma   Post caesarian pregnancy            01

Table 2: Associated operation

Type of operation       No of cases

Subtotal hysterectomy       04
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Title Annotation:ORIGINAL ARTICLE
Author:Bhat, Smita; Bhave, Sudhir
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Aug 11, 2014
Words:955
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