DOI: 10.1111/j.1471-0528.2006.01235.x
General obstetrics
www.blackwellpublishing.com/bjog
Internal iliac artery ligation for arresting
postpartum haemorrhage
VM Joshi, SR Otiv, R Majumder, YA Nikam, M Shrivastava
KEM Hospital, Pune, India
Correspondence: Dr VM Joshi, A-47, Tulshibagwale Colony, Sahakarnagar, Parvati, Pune 411009, Maharashtra, India.
Email drvivek_joshi@yahoo.co.in; s_otiv@vsnl.com
Accepted 29 November 2006. Published OnlineEarly 25 January 2007.
Objective To study the role of internal iliac artery ligation
(IIAL) in arresting and preventing postpartum haemorrhage
(PPH).
Design Retrospective chart review of women undergoing
therapeutic IIAL for PPH or prophylactic IIAL for risk of PPH.
Setting Tertiary care hospital in Pune, India.
Sample Women admitted to King Edward Memorial (KEM)
Hospital, Pune, India, who underwent IIAL to control
or prevent PPH.
Methods Bilateral IIAL was performed in all women.
Main outcome measures Need for re-laparotomy or hysterectomy
to control haemorrhage, complications of the procedure.
Results Out of 110 women who underwent IIAL, 88 had
therapeutic IIAL for PPH from atony (36), genital tract injury
(23), placenta praevia (21), placental abruption (4), uterine
inversion (3) or coagulopathy (1). Hysterectomy was performed
after IIAL failed to arrest haemorrhage in 33 (39.3%) of 84 women
(excluding 4 with vaginal lacerations). Hysterectomy was more
likely with uterine rupture (79%) than with nontraumatic PPH
(up to 27%). Failure to control haemorrhage by IIAL was evident
immediately, and bleeding arrested by IIAL did not recur to
require later laparotomy in any woman. Out of 22 women at high
risk for PPH undergoing prophylactic IIAL at caesarean section,
none had subsequent haemorrhage. One woman had an iliac vein
injury that was repaired with no further morbidity. There were
no ischaemic complications either during inpatient stay or
up to 6 weeks.
Conclusions IIAL is useful in the treatment and prevention of
PPH from any cause. Early resort to IIAL effectively prevents
hysterectomy in women with atonic PPH. In traumatic PPH, IIAL
facilitates hysterectomy or repair as indicated and prevents
reactionary haemorrhage.
Keywords Internal iliac artery ligation, PPH.
Please cite this paper as: Joshi V, Otiv S, Majumder R, Nikam Y, Shrivastava M. Internal iliac artery ligation for arresting postpartum haemorrhage.
BJOG 2007;114:356–361.
Introduction
Postpartum haemorrhage (PPH) is a major cause of worldwide maternal mortality ranging from 13% in developed
countries to 34% in developing countries.1 It is reportedly
responsible for over 125 000 maternal deaths each year and
is associated with morbidity in 20 million women per year.2
Major PPH or loss of over 1000 ml of blood occurs in 1–5% of
deliveries. Uterine atony is the common cause of PPH that
accounts for 80% of cases.3 Other causes include retained
placental fragments, lower genital tract lacerations and uterine rupture. Known risk factors for occurrence of atonic
PPH include a history of PPH, history of retained placenta,
placental abruption, placenta praevia, uterine fibroids,
hydramnios, multiple pregnancies, augmentation of labour,
prolonged labour and instrumental delivery. Although an
356
assessment of risk factors is important, PPH typically occurs
unpredictably and no parturient is exempt from the risk of
PPH.
When PPH continues despite aggressive medical treatment,
early consideration should be given to surgical intervention.
The choice of procedure will depend on the parity of the
women and her desire for childbearing, the extent of haemorrhage and, most importantly, the experience and judgement
of the surgeon. In most catastrophic situations, hysterectomy
is preferred in order to arrest further blood loss and compromise with certainty. Although a life-saving procedure, it may
not be appropriate for women who need to preserve their
reproductive potential. Haemostatic procedures that preserve
the uterus include uterine cavity tamponade, selective uterine
artery embolisation, uterine artery ligation and uterine brace
sutures.
ª 2007 The Authors Journal compilation ª RCOG 2007 BJOG An International Journal of Obstetrics and Gynaecology
Internal iliac artery ligation
Internal iliac artery ligation (IIAL) has been advocated as
an effective means of controlling intractable PPH and preventing maternal death. The rationale for this is based on
the haemodynamic studies of Burchell,4 which showed that
IIAL reduced pelvic blood flow by 49% and pulse pressure
by 85%, resulting in venous pressures in the arterial circuit
thus promoting haemostasis. However, the reported success
rate of IIAL varies from 40 to 100%,5 and the procedure averts
hysterectomy in only 50% of cases.6 Failures were more
evident in atonic PPH than in other causes of PPH.7 IIAL
is thought to be technically difficult, and although much
quicker than a hysterectomy, it is seldom attempted. We
present a case series of IIAL performed over 13 years at our
institution and define the role of IIAL for various indications
in obstetrics.
Methods
The study was carried out from April 1993 to April 2006 in
King Edward Memorial (KEM) Hospital, Pune, India, which
is a tertiary care centre for high-risk obstetrics. Most operative
procedures were performed by Consultant Obstetricians
(V.M.J., S.R.O., R.M.), whereas some were performed by lecturers (Y.A.N., M.S.) with more than 2 years experience after
qualifying, supervised by the principal author (V.M.J.). All
the Consultants were experienced with Gynaecologic cancer
surgery. Therapeutic IIAL was performed in women with
PPH either at caesarean section or at laparotomy performed
at a variable time after vaginal or caesarean delivery. IIAL was
also performed prophylactically at caesarean section in
women with a high-risk factor for developing PPH, such as
coagulopathy, placenta praevia or placental abruption, in the
absence of any evident haemorrhage.
Women with atonic PPH at vaginal delivery or caesarean
section were initially treated with massage and uterotonics
such as oxytocin infusion and carboprost injections 250 mcg
at appropriate intervals. Failure to restore the uterine tone
and arrest the blood loss despite these measures led to the
decision to do IIAL.
During caesarean section for placenta praevia, failure to
control bleeding from the placental bed by pressure or by
under running the bleeding sites with absorbable sutures led
to the decision to do IIAL.
All the four women with placental abruption had undergone caesarean section and developed atonic PPH that failed
to respond to uterotonics and hence were subjected to IIAL.
Three women with uterine inversion were referred from other
hospitals. After repositioning the uteri at laparotomy, they
developed atonic PPH that failed to respond to uterotonics
and were subjected to IIAL. One woman with HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome developed atonic PPH after a forceps delivery. As the
bleeding did not respond to uterotonics and fresh frozen
plasma transfusions, she underwent IIAL but even that could
not halt the bleeding and required hysterectomy.
At caesarean section in women with placental abruption
(eight), placenta praevia (four), HELLP (eight), ITP (one)
and acute hepatitis with coagulopathy (one), a prophylactic
IIAL was performed in the absence of any significant uterine
bleeding.
The women were placed in the semi-lithotomy position as
it permitted assessment of vaginal bleeding. When quick
access was required in high-risk situations like rupture uterus
or shock, a midline infraumbilical incision was preferred,
otherwise a Pfannenstiel incision was used. The uterus was
pulled out of the abdominal incision and bowels were packed
away. On the left side, it was sometimes necessary to incise the
sigmoid mesocolon and mobilise the sigmoid colon medially
in order to expose adequately the area overlying the iliac
vessels. After identifying the ureter at the pelvic brim, the
peritoneum was incised starting from a point just proximal
to the bifurcation of the common iliac artery proceeding
caudally along the external iliac artery for a length of about
8 cm. Using gentle finger dissection, the ureter was retracted
medially exposing the retroperitoneal anatomy. Using a long
haemostat, the fascia around the internal iliac artery was dissected completely to free the artery from its adjacent structures and to clarify the anatomical relationship of the internal
iliac artery with the iliac veins (Figure 1). A right-angled
clamp was passed beneath the internal iliac artery from lateral
to medial side about 4 cm distal to its origin (Figure 2). As the
posterior division usually branches off proximal to this, no
attempt was made to locate it. Using a nonabsorbable suture
(linen), the internal iliac artery was ligated singly. Pulsations
of the femoral artery and dorsalis pedis were identified after
tying the ligature. In cases of nontraumatic haemorrhage,
Figure 1. Retroperitoneal anatomy showing right psoas major, external
iliac artery and vein, internal iliac artery and vein and ureter.
ª 2007 The Authors Journal compilation ª RCOG 2007 BJOG An International Journal of Obstetrics and Gynaecology
357
Joshi et al.
Table 1. Indications for IIAL (n = 110)
Indication
Number of women (%)
Uterine atony
Placenta praevia
Genital tract injury
Placental abruption
Coagulopathy
Uterine inversion
Total
36 (32.7)
25 (22.7)
23* (20.9)
12 (10.9)
11 (10)
3 (2.7)
110 (100)
*Out of 23 women, 4 had traumatic PPH from vaginal lacerations.
Figure 2. Safe method of passing right-angled clamp from lateral to
medial side below the internal iliac artery.
once IIAL was performed, the control of haemorrhage was
confirmed by improvement in vital signs as well as decrease in
amount of vaginal bleeding. If bleeding continued unabated,
decision for hysterectomy was taken. In uterine rupture, IIAL
was performed at the outset. Following this, decision to repair
the trauma or resort to hysterectomy was influenced by the
extent and location of injury as well as by control of haemorrhage. In extensive vaginal lacerations, suturing was performed after IIAL.
Results
Over a period of 13 years from April 1993 to April 2006, 110
women underwent IIAL at KEM Hospital, Pune, India.
Eighty-eight women had IIAL for PPH after vaginal or
caesarean delivery in the KEM hospital or in other referring
hospitals. In addition, prophylactic IIAL was performed in 22
women at high risk of PPH during caesarean section at KEM
hospital.
Uterine atony was the common indication for therapeutic
IIAL (32.7%). Other indications were placenta praevia,
traumatic PPH, placental abruption and uterine inversion
(Table 1). Out of 11 women with coagulopathy, 9 had HELLP
syndrome and 1 each had ITP and acute liver disease.
Out of 23 women with genital tract injury, 19 had uterine
rupture and 4 had extensive vaginal lacerations. In cases of
uterine rupture, early IIAL as well as the extent and location of
damage determined the feasibility of conservation of uterus.
Out of 19 women who had uterine rupture, the uterus could
be repaired in only 4 women and the others underwent hysterectomy. However, IIAL performed at the outset helped in
repairing the uterus or doing the hysterectomy. In four
women with vaginal laceration, direct suturing of the lacerated and friable walls provoked further bleeding. IIAL
arrested the blood loss and facilitated suturing of the tissues
properly.
358
In women with PPH, whether IIAL was performed primarily at caesarean section or at an interval after delivery, once
haemostasis was achieved and the abdomen closed, haemorrhage did not recur.
After successful control of haemorrhage with IIAL, no
woman had delayed haemorrhage requiring re-laparotomy.
However, failure of IIAL to arrest uterine bleeding was evident immediately before closure of the abdomen, enabling
a timely decision to proceed to hysterectomy.
Out of 106 (excluding 4 women who had traumatic PPH
from vaginal lacerations) women where IIAL was performed,
33 women required hysterectomy, giving an overall uterine
salvage rate of 68.8%. The uterine salvage rate in women
where therapeutic ligation of internal iliac artery (n = 84)
was performed was 60.7% (Table 2). Among 19 women with
uterine rupture who underwent IIAL, 15 required hysterectomy, giving a uterine salvage rate of 21%. Women with nontraumatic PPH (n = 65), who had IIAL fared better with only
18 requiring hysterectomy to control uterine bleeding, giving
a uterine salvage rate of 73%.
Prophylactic ligation was performed in 22 women, and
none of these women required hysterectomy (Table 3).
Table 2. Hysterectomy in women undergoing IIAL for uterine
haemorrhage (n = 84*)
Indication
Uterine atony
Placenta praevia
Uterine rupture
Placental abruption
Uterine inversion
HELLP syndrome
Total
Total number
of women
Hysterectomy
carried out,
n (%)
Uterine
salvage
rate (%)
36
21
19
4
3
1
84
13 (36.2)
3 (14.3)
15 (79)
0 (0)
1 (33.3)
1 (100)
33 (39.3)
63.8
85.7
21
100
66.6
0
60.7
*Out of 88 women who underwent therapeutic IIAL, 4 had
traumatic PPH from vaginal lacerations.
ª 2007 The Authors Journal compilation ª RCOG 2007 BJOG An International Journal of Obstetrics and Gynaecology
Internal iliac artery ligation
Table 3. Hysterectomy in women who underwent prophylactic IIAL
(n = 22)
Indication
Placental abruption
Placenta praevia
Coagulopathy
Total
Number of
women
Hysterectomy
Uterine
salvage
rate (%)
8
4
10
22
0
0
0
0
100
100
100
100
The time interval between the onset of haemorrhage from
uterine atony and IIAL influenced the uterine salvage rate
(Table 4).
Injury to the internal iliac vein that occurred in one woman
was repaired by passing a figure of ‘8’ black silk 3-0 gauge
suture around the defect in the vein and then incorporating
adventitia of the internal iliac artery in the same suture.
There were no ischaemic complications like gluteal muscle
ischaemia or bladder ischaemia in the postoperative period
either during inpatient stay or up to 6 weeks.
There were three maternal deaths unrelated to PPH; two
women with fulminant hepatitis succumbed to hepatic failure
after the seventh postoperative day and one had HELLP
syndrome and died of hepatorenal failure on postoperative
day 25.
Six women conceived after IIAL. These pregnancies continued till term, with no evidence of fetal growth restriction.
Discussion
PPH can cause exsanguination rapid enough to be fatal in
spite of the immediate availability of blood products. One
of the reasons for this could be the delay in resorting to
surgical techniques once conservative measures have failed.8,9
The authors believe that the life-saving technique of IIAL is
underutilised in the management of PPH, probably due to
fear of injury to iliac veins. Thorough knowledge of retroper-
itoneal anatomy and meticulous operative technique can
minimise these complications. Since the internal iliac vein lies
directly posterior to the internal iliac artery, passing the rightangled clamp in a controlled manner in close proximity to the
posterior wall of the artery prevents perforating the underlying internal iliac vein. It is imperative to dissect the internal
iliac artery completely from the surrounding fascia for the
passage of the right-angled clamp without resistance. Resistance to the passage of the right-angled clamp implies inadequate dissection around the internal iliac artery. Forceful
passage of the clamp in such a situation incurs the risk of
injury to the adjacent vein. It is safer to withdraw the clamp,
complete the dissection of fascia around the artery and then
pass the clamp under the artery. Some authors have advised
the use of Babcock forceps to elevate the internal iliac artery
to facilitate the passage of right-angled clamp.10 However, the
Babcock forceps itself may obstruct surgeon’s operative field.
While passing the right-angled clamp beneath the internal
iliac artery, the operator has better control at the point of
entry than at the point of exit. Hence, we believe that passing
the clamp from lateral to medial side is safer. If the clamp is
passed from medial to lateral side, the tip of the clamp may
injure the laterally located external iliac vein (Figure 3).
Ideally, the internal iliac arteries should be ligated distal to
the posterior division to get optimum decrease in pulse pressure in the uterine circulation. However, in emergency situations, it is not advisable to try locating the posterior division
as this could be time consuming and may injure the internal
iliac vein. Since the posterior division is given off within 3 cm
from the bifurcation, most of the times what is ligated beyond
3 cm from bifurcation is the anterior division of internal iliac
artery.
Selective arterial embolisation is an option in managing
PPH if the women is haemodynamically stable. Current
indications include haemorrhage due to vaginal or cervical
Table 4. Timing of IIAL and uterine salvage in uterine atony (n = 36)
Timing of IIAL
At caesarean section
Laparotomy after
vaginal delivery
Re-laparotomy after
caesarean section
Number of
women
Hysterectomy
Uterine
salvage
rate (%)
20
14
3
8
85
43
2
1
50
Figure 3. Tip of right-angled clamp passed from medial to lateral side
may injure the external iliac vein.
ª 2007 The Authors Journal compilation ª RCOG 2007 BJOG An International Journal of Obstetrics and Gynaecology
359
Joshi et al.
lacerations or persistent bleeding after hysterectomy. Round
the clock, availability of a skilled interventional radiologist
and the radiologic set-up in proximity is a prerequisite. Complications like post-procedure fever, uterine and bladder
necrosis,11,12 ischaemic nerve injury,13 vascular perforation
and infection have been reported.
Uterine artery ligation is a promising technique in the
management of PPH as occlusion of the uterine artery
reduces 90% of the blood flow. It is useful in uterine atony,
but in uterine trauma, when the avulsed uterine artery
retracts into the broad ligament forming a haematoma, it
is difficult to do a uterine artery ligation and salvage the
uterus. IIAL in such situations is helpful as the pressure
and flow of circulation decrease distal to the ligation and
enabling one to readily locate the bleeder and ligate it
securely. Similarly, in cases of deep forniceal tears and
haematomas, uterine artery ligation or even hysterectomy
does not stop the haemorrhage. In such cases, blood loss
could be arrested after IIAL as vaginal artery is a direct
branch of anterior division of internal iliac artery.
In complete placenta praevia, the placental site receives
a significant proportion of its arterial blood supply from
the descending cervical and vaginal arteries. These arteries
continue to perfuse the lower segment even after uterine
artery ligation, which fails to control haemorrhage.14 In these
circumstances, IIAL is more effective by diminishing the
blood flow in the uterine, cervical and vaginal vessels. The
technique of stepwise devascularisation of uterus, which
includes bilateral uterine and ovarian artery ligation, is effective in decreasing the blood loss, but uterine ischaemia
followed by synechiae formation, premature ovarian failure
and secondary amenorrhoea has been reported subsequent to
this procedure.15
The B-Lynch suture has been reported to successfully
control refractory uterine bleeding in several case series. The
suture envelops and compresses the uterus, producing a result
similar to manual compression, but failures can occur16 for
various technical reasons,17,18 with severe uterine atony and in
the presence of coagulopathy.19 Delayed ischaemic necrosis
of the myometrium has been recently reported even after
applying the sutures correctly.20 The uterine brace compression sutures can be used only for achieving haemostasis
in atonic PPH and are less useful in placenta praevia. It has
no application in uterine rupture or bleeding from vaginal
lacerations.
IIAL not only contributes to the prevention of hysterectomy but also in cases where hysterectomy cannot be prevented, it facilitates hysterectomy as in cases of uterine
trauma.14 IIAL performed at the outset decreases the bleeding,
clears the operative field and thus enables the surgeon to
avoid blindly clamping and ligating tissues submerged in
a pool of blood. This is particularly helpful in reducing the
risk of ureteric injury. IIAL also facilitates repair of vaginal
360
lacerations that bleed profusely with each suture through the
vaginal wall. Although IIAL is not a substitute for meticulous
repair of vaginal lacerations, in four women with extensive
vaginal lacerations where suturing was not possible, IIAL
arrested the bleeding and enabled suturing.
We observed that some women having high-risk factors for
PPH like placenta praevia, placental abruption, HELLP syndrome, ITP and infective hepatitis undergoing caesarean section required a laparotomy for reactionary haemorrhage in
the immediate postoperative period. A re-laparotomy in such
compromised situations not only exposed the women to the
risks of anaesthesia and emergency surgery but almost always
culminated in a hysterectomy as a definitive treatment.
Hence, we subsequently started doing prophylactic IIAL at
caesarean section in all women with these high-risk factors.
With this protocol re-laparotomy was averted in all such
cases. Since the morbidity of IIAL in experienced hands is less
than that of a re-laparotomy, we believe that such a concurrent prophylactic ligation of internal iliac arteries is justified
when one is doing a caesarean section for women with highrisk factors for PPH.
The injuries that can occur to the iliac veins are due to
perforation either by haemostat during dissection of fascia
around the internal iliac artery or by the tip of right-angled
clamp that is passed beneath the internal iliac artery. In the
event of such an injury, suction and good illumination with
the use of fibreoptic light source facilitate location of these
injuries. These venous perforations can be sealed by passing
a figure of 8 suture around the defect in the vein with black
silk gauge 3-0 and then incorporating adventitia of the internal iliac artery in the same suture to give support to the
injured vein. Given the usefulness of IIAL in prevention
and treatment of PPH, one could explore other methods of
occluding the internal iliac artery (like applying a clip on the
vessel) that do not entail dissection around the artery and
incur the possibility of venous injury.
Fear of vascular injury and recurrence of haemorrhage
commonly deter an obstetrician from resorting to IIAL.
We observed that once the uterine bleeding was controlled
during surgery, it did not recur in the postoperative period
in any woman in whom the uterus was conserved. Similarly,
there was no reactionary haemorrhage from the pedicles
in any woman where hysterectomy was carried out after
IIAL.
In conclusion, IIAL is a valuable procedure in treatment of
PPH and its prevention in high-risk women. Unlike other
procedures, it can be reliably used in all causes of PPH. Early
resort to IIAL is the key to prevent hysterectomy in women
with uterine atony. In traumatic PPH, IIAL facilitates repair
or hysterectomy when indicated and prevents reactionary
haemorrhage. All obstetricians caring for parturient women
should familiarise themselves with this procedure and lower
their threshold for its use in emergent situations. j
ª 2007 The Authors Journal compilation ª RCOG 2007 BJOG An International Journal of Obstetrics and Gynaecology
Internal iliac artery ligation
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