Aim: to measure the function of internal iliac arteria ligation as an effectual method of commanding station partum bleeding due to sidelong uterine rupture.
Subjects and methods: A randomized controlled survey was conducted on 50 pregnant adult females who were admitted to Shatby University Maternity Hospital between June 2006 and August 2008, all of them were diagnosed as station partum bleeding due to sidelong uterine rupture. The patients were indiscriminately allocated to 2 groups, the ligation group where ligation of internal iliac arteria followed by fix of ruptured uterine wall was done ( group A ) , and the fix group, where ruptured womb was repaired by conventional methods ( group B ) . Informed consent was taken from all patients.
Consequences: The ligation group showed a important statistical difference when compared with the fix group sing intra-operative clip ; sum of blood transfused intra-operatively ; continuance of intensive attention unit stay, need for extra surgical intervention such as hysterectomy or extra vaginal hemostasis, and the incidence of complications as disseminated intravascular coagulopathy, and ureteric hurt.
Decision ; internal iliac arteria ligation is considered an alternate effectual method to hysterectomy in instances of sidelong uterine rupture, taking to diminish maternal morbidity.
Cardinal words: postpartum bleeding ( PPH ) , uterine rupture, internal iliac arteria ligation ( IIAL ) , hysterectomy.
Introduction
Post partum bleeding ( PPH ) is a major
cause of world-wide mortality runing from 13 %
in developed states to 34 % in developing states. ( 1 ) it is responsible for over 125,000 maternal deceases each twelvemonth and is associated with morbidity in 20 million adult females per twelvemonth. ( 2 )
Traditionally, PPH is defined as hemorrhage from the venereal piece of land of 500 milliliter or more in the first 24 hr following bringing of the babe, a significant autumn
in the hematocrit or the demand of blood transfusion have besides been proposed. ( 2-5 ) Uterine atonicity is
the common cause of PPH that accounts for 80 %
of instances ; other causes include maintained placental fragments, lower venereal piece of land lacerations and uterine rupture. ( 6 )
Uterine rupture is a ruinous obstetric complication. Although an uncommon event, it continues to be associated with a high rate of perinatal and maternal morbidity and mortality. ( 7 ) The chief hazard factor for uterine rupture is a scarred womb, normally secondary to a anterior cesarean bringing. Consequently, most of the recent reappraisals on uterine rupture have focused on adult females trying vaginal birth after old cesarean bringing ( VBAC ) . ( 8 ) Rupture of the unscarred womb is a rare obstetric complication, with an estimated incidence of 1 in 8000-15,000 bringings. ( 9 )
There are two types of uterine rupture, complete and uncomplete, distinguished by whether or non the serous coat of the womb is involved. ( 10 ) In the former the uterine contents including foetus and on occasion placenta, may be discharged into the peritoneal pit, whereas in the latter the serous coat is integral and foetus and placenta are inside the uterine
pit. ( 11 ) The complete assortment appears to be more unsafe of the two assortments. ( 12 ) Rupture of womb during labour is more unsafe than that happening in gestation because daze is greater and infection is about inevitable. ( 13,14 )
When PPH continues despite aggressive medical intervention, early consideration should be given
to surgical intercession. The pick of process will depend on the para of the adult females and her desire for childbirth, the extent of bleeding and, most significantly, the experience and opinion of the sawbones. In most ruinous state of affairss, hysterectomy is preferred in order to collar farther blood loss and via media with certainty. ( 15 ) Although a life-saving process, it may non be appropriate for adult females who need to continue their generative potency. Haemostatic processs that preserve the uterus include
uterine pit tamponage, selective uterine arteria embolisation, uterine arteria ligation and uterine brace suturas. ( 16 )
ISSN 1110-0834Internal iliac arteria ligation ( IIAL ) for the control of profuse pelvic hemorrhage has long been recognized as a life-saving process. ( 17 ) The American College of Obstetricians and Gynaecologists continues to recommend the usage of hypogastric arteria ligation in
the direction of intraoperative intractable bleeding during pelvic surgery or in instances of obstetric bleeding. ( 18 ) The construct that surcease of blood supply may do harm to pelvic variety meats has been proved to be incorrect. On the contrary, in the instance of pelvic bleeding unmanageable by conservative methods, prompt intercession may non merely salvage the life of the patient but besides her womb. There are several studies of gestations carried to full term after bilateral ligation of the hypogastric arterias. ( 19-23 ) The purpose of this survey was to measure the function of bilateral IIAL in instances of terrible station partum bleeding due to sidelong rupture womb in comparing to the conventional uterine fix merely in such instances.
Method
This survey was conducted on 50 pregnant adult females who were admitted to Shatby University Maternity Hospital between June 2006 and August 2008, all of them were diagnosed as terrible station partum bleeding due to sidelong uterine rupture which might be extended to the vagina ( Diagnosis was confirmed during Laparotomy ) .
The sample group were indiscriminately allocated into two groups:
Group A=35 patients ( ligation group ) : adult females were subjected to bilateral IIAL followed by fix of uterine wall.
Group B =15 patients ( fix merely group ) : adult females were subjected to conventional methods of uterine fix.
All patients were counselled for the process and informed consent was obtained.
Technique of internal iliac ligation was done as follow:
The womb is lifted out of the pelvic girdle in order to observe the extent of the hurt.
The uterine tear is inspected and examined carefully from the vertex downwards.
The hemorrhage borders of the womb are held with Green Armytage clinch ( or pealing forceps ) .
The vesica is dissected from the lower uterine section by crisp and blunt dissection so mobilized downwards.
The external iliac pulsings are felt and followed up to the bifurcation of the common iliac arteria, and the ureter is identified.
The peritoneum on the sidelong side of the bifurcation of the common iliac arteria is opened by a longitudinal scratch in such a manner that the ureter remains attached to the median peritoneal contemplation exposing the retroperitoneal anatomy.
The internal iliac arteria is traced and carefully dissected off from the underlying vena. Figure ( 1 & A ; 2 )
A dual yarn of absorbable sutura ( Vicryl ) stuff is passed underneath the arteria and tied. Figure ( 3 )
Femoral arteria pulsings are identified after binding the ligatures.
Statistical methods:
Statistical analysis was done utilizing Statistical Package for Social Sciences ( SPSS/version 15 ) package.
The statistical trials used are as follow:
Arthematic mean, standard divergence, Chui-square trial and Fisher exact trial was used for categorised parametric quantities, while for numerical informations, t-test was used. The degree of significance was 0.05.
Consequence
In the ligation group ( group A ) , the age ranged from 24 - 39 old ages with a mean of 32.85A±6.57 and para ranged from 1-4 with a mean of 2.45A±1.01, while in the fix group ( group B ) their age ranged from 27-42 old ages with a mean of 33.9A±7.06 and the para ranged from 1-4 with a mean of 2.622A±1.05, severally. There was no statistically important difference between the two groups sing age and para. Both groups were compared as respects intra-operative and, postoperative events
Intraoperative events:
The average intra-operative clip in group ( A ) was 45.5A±4.68 proceedingss, while it was 98.5A±8.98 proceedingss in group ( B ) . The intra-operative clip is statistically important longer in group B as P= 0.0001. The clip needed for one-sided IIAL ranged between three to seven proceedingss. The average blood volume transfused intra-operatively in group ( A ) was 1750A±71.6 milliliter, compared to 2980A±120.8 milliliters in group ( B ) , this difference is statistically important as P= 0.0001.
In group ( A ) , Four patients ( 11.4 % ) had hysterectomy, and 6 patients ( 17.1 % ) had extra haemostatic vaginal suturas for extended vaginal cryings after IIAL. In group ( B ) seven patients ( 46.7 % ) had hysterectomy and 10 patients ( 66.7 % ) had haemostatic vaginal suturas. These difference, are statistically important as P= 0.0058 and 0.0005 severally. These findings revealed a higher incidence of extra secondary processs in group ( B ) .
There was no ureteric ligation or hurt recorded
in group ( A ) , on the other manus in group ( B ) the ureter was ligated on the same side during fix of the tear without exposing the ureter in 2 instances. Fortunately, both discovered intra-operatively and managed. No other complications were recorded in either group. ( Table I )
Postoperative events
All patients were transferred postoperatively to intensive attention unit ( ICU ) the average continuance of ICU stay was 38A±5.99 hours in group ( A ) , compared to 70A±6.85 hours in group B, which is statistically important as P= 0.0001.
On the other manus, 5 patients ( 14.3 % ) in group ( A ) which is statistically important less compared to 9 patients ( 60.0 % ) in group ( B ) were complicated
with disseminated intra vascular coagulopathy ( DIC ) . The entire volume of blood collected from intra-abdominal drain over 48 hours postoperatively was 211A±23.85 milliliter in group ( A ) , while it was 751A±68.98 milliliter in group ( B ) . These revealed a higher incidence of station operative complications in group B. Merely one patient ( 2.9 % ) died from pneumonic intercalation in group ( A ) , and another one ( 6.7 % ) died in group ( B ) due to monolithic hypovolemia and daze. ( Table II )
Fig. 1: Lateral uterine rupture with terrible station
partum bleeding
Fig. 2: Retroperitoneal anatomy demoing the
great vass.
Fig. 3: A dual yarn of absorbable sutura stuff is passed underneath the arteria
utilizing right angled artery forceps and tied.
Table I: Comparison between the two studied groups sing intra-operative events.
Group A
`` n=35 ''
Group B
`` n=15 ''
Trial of significance
Intra-operative clip ( min. )
45.5A±4.68
98.5A±8.98
T = 4.30
P = 0.0001*
Sum of blood transfused intra-operatively ( milliliter )
1750A±71.6
2980A±120.8
T = 5.21
P = 0.0001*
Need for hysterectomy
4 ( 11.4 % )
7 ( 46.7 % )
X2 = 7.60
P = 0.0058*
Need for extra vaginal haemostatic suturas
6 ( 17.1 % )
10 ( 66.7 % )
X2 = 11.83
P = 0.0005*
Ureteric ligation
0 ( 0.0 % )
2 ( 13.3 % )
Field-effect transistor
P = 0.085
Datas are presented as Mean + SD
* P is important if & lt ; 0.05
Field-effect transistor: Fisher Exact 's Trial
Table II: Comparison between the two studied groups sing post-operative events.
Group A
`` n=35 ''
Group B
`` n=15 ''
Trial of significance
Duration of ICU stay in hours
38A±5.99
70A±6.85
T = 4.25
P = 0.001*
Incidence of DIC
5 ( 14.3 % )
9 ( 60.0 % )
X2 = 10.88
P = 0.0009*
Entire sum of blood collected in drain over 48 hours ( milliliter )
211A±23.85
751A±68.98
T = 6.21
P = 0.0001*
Maternal mortality
1 ( 2.9 % )
1 ( 6.7 % )
Field-effect transistor
P = 0.524
Datas are presented as Mean + SD * P is important if & lt ; 0.05
Field-effect transistor: Fisher Exact 's Test DIC: disseminated intra vascular coagulopathy
Intensive care unit: intensive attention unit
Discussion
Uterine rupture is a serious obstetric complication, with high morbidity and mortality, peculiarly in less and least developed states. The most of import defect of the information available is the deficiency of distinction between uterine rupture with and without old cesarean subdivision. Overall, most rates ranged between 0.1 % and 1 % . Maternal mortality ranged between 1 % and 13 % , and perinatal mortality between 74 % and 92 % . ( 24 )
Uterine artery ligation is a promising technique
in the direction of PPH as occlusion of the uterine arteria reduces 90 % of the blood flow. It is utile in uterine atonicity, but in uterine injury, when the avulsed uterine arteria retracts into the wide ligament organizing a hematoma, it is hard to make a uterine arteria ligation and salve the womb. IIAL in such state of affairss is helpful as the force per unit area and flow of circulation lessening distal to the ligation and enabling one to readily turn up the hemophiliac and ligate it firmly. Similarly, in instances of deep forniceal
cryings and hematoma, uterine arteria ligation or
even hysterectomy does non halt the bleeding. In such instances, blood loss could be arrested
after IIAL as vaginal arteria is a direct subdivision
of anterior division of internal iliac arteria. Since it
is a safe, rapid and really effectual method of commanding shed blooding from venereal piece of land, it is besides helpful in commanding postoperative bleeding after abdominal or vaginal hysterectomy where no unequivocal hemorrhage point is noticeable.
IIAL was performed for the first clip by Kelly ( 25 ) with a success rate 95 % and without any major complication. Mukherjee et Al ( 26 ) performed 36
instances of IIAL with a success rate of 83.3 % in 6 old ages. The principle for IIAL as an effectual agencies of commanding intractable PPH and forestalling maternal decease is based on the haemodynamic surveies of Burchell, ( 27 ) which showed that IIAL reduced pelvic blood flow by 49 % and pulse force per unit area by 85 % , ensuing in venous force per unit areas in the arterial circuit therefore advancing hemostasis by a simple coagulum formation. However, the reported success rate of IIAL varies from 40 to 100 % , ( 28 ) and the process averts hysterectomy in merely 50 % of instances. ( 29 )
Papp et Al, ( 30 ) published aA reappraisal of indicants and results for 117 instances of bilateral hypogastric arteria ligation over 15 old ages ( 1990-2004 ) . They documented that, apart from a little lesion to the hypogastric vena, no complications were observed. Bleeding was efficaciously controlled in all 37 obstetric instances. In 13 of these instances, the womb
was preserved even when there was cervical gestation, placenta previa, placental breaking off, uterine atonicity, and uterine rupture, and 4 adult females were delivered of mature babies. Bleeding was efficaciously controlled in 41 of 80 gynaecological instances. Contraceptive decrease of pelvic blood flow was the indicant for the process in 39 cases.The womb was preserved in merely a few of the 41 controlled instances, but one adult female ( so far ) was delivered of a mature baby.
In our survey we evaluated the efficaciousness of ligation of internal iliac arteria in instances of rupture womb. Results showed less operative clip and sum
of blood transfused for replacing in comparing
to the fix group. In add-on, the womb was preserved in most of the instances, merely 4 patients ( 11.4 % ) had hysterectomy, and 6 patients ( 17.1 % ) had extra vaginal suturas for hemostasis. There were no ureteric or great vessel hurts. The post-operative events, showed short ICU stay
and less incidence of complications as DIC was
merely seen in 5 patients ( 14.3 % ) , besides it is fertility salvaging process. The fright of vascular hurt and return of bleeding normally deter an obstetrician from fall backing to IIAL. We observed that one time the uterine hemorrhage was controlled during surgery, it did non repeat in the postoperative period in any adult female in whom the womb was conserved.
As there is free inosculation providing pelvic variety meats, vascular lack following ligature have non proved to be a job, even after bilateral IIAL. Khelifi et Al. ( 31 ) have evaluated internal
iliac arterias in 13 adult females after ligation
by color Doppler echography in the 4th
twenty-four hours after intercession and so monthly until repermeabilization of the internal iliac arterias.
In all instances, the first test showed down-side
the ligature, a flow inversion with an of import pelvic indirect circulation. The following Doppler test showed repermeabilization of the hypogastric arterias after an mean interval of 5 months.
Pappz et Al. ( 21 ) have reported a successful gestation after internal iliac arteria ligation with normal
flow speed in uterine arterias. Wagaarachchi
and Fernando ( 22 ) observed successful gestation in 50 % of the instances following bilateral ligation.
Therefore, Internal iliac arteria ligation decreases the hemorrhage, clears the operative field and therefore enables the sawbones to avoid blindly clamping
and ligating tissues submerged in a pool of blood. This is peculiarly helpful in cut downing the hazard of ureteric hurt. Internal iliac arteria ligation besides facilitates fix of vaginal lacerations that bleed abundantly with each sutura through the vaginal
wall. It represents an option to the hysterectomy and preserves the child-bearing maps of
some females because of the subsequent vascular recanalization. All accoucheurs caring for parturient adult females should familiarise themselves with this process as it should be an built-in portion of obstetric and gynaecological preparation.
