Bilateral Uterine Artery Ligation - Procedure and Indications

Introduction

Maternal death during childbirth is a serious complication. Every two minutes, one woman dies in the world due to complications caused during delivery. Five percent of pregnant women suffer from bleeding-related complications at the time of delivery globally. Around 0.25 percent of women lose their life due to postpartum hemorrhage. This number is even higher in developing countries. Bilateral uterine artery ligation is a life-saving measure to treat bleeding after delivery.

What Is Postpartum Hemorrhage?

Abnormal bleeding after delivery is known as postpartum hemorrhage. More than 500 milliliters of blood loss after vaginal delivery and 100 milliliters of blood loss after cesarean delivery is known as postpartum hemorrhage. According to the American College of Obstetrics and Gynecology, a total of 1000 milliliters of blood loss within 24 hours of delivery is postpartum hemorrhage. This type of bleeding post-delivery is known as primary postpartum hemorrhage. Bleeding, 24 hours to 12 weeks post-delivery, is known as secondary postpartum hemorrhage. The causes of postpartum hemorrhage are:

1. Uterine Atony: Failure of the contraction of the uterus after delivery is one of the primary reasons for postpartum hemorrhage.

2. Genital Tract Lacerations: This is the injury of the lower genital tract during birth. In this condition, tearing of the tissue and muscle around the vagina occurs.

3. Retained Placenta: This occurs when the placenta does not come out after delivery. This occurs if the placenta is strongly attached to the uterine wall or the placental contraction is not strong enough.

4. Uterine Inversion: The most serious complication is characterized by the collapse of the fundus in the uterine cavity. Excessive traction of the umbilical cord (attached to the baby with the mother) and pressure in the fundus is responsible for this.

5. Abnormal Placentation: In this condition, the placenta is attached deep into the uterine wall and fails to separate after delivery. This condition is called the placenta accreta. Placenta previa is another condition that is also responsible for postpartum hemorrhage. In this condition, the placenta grows at the bottom of the uterus and blocks the opening of the cervix.

6. Abruptio Placentae: This is also known as placental abruption. In this condition separation of the placenta from the inner wall of the uterus occur at an early stage of the pregnancy. This is characterized by fetal hypoxia (less oxygen supply) and maternal bleeding.

7. Coagulation Disorders: Bleeding and coagulation disorders are responsible for excessive bleeding after pregnancy. Disorders like Von Willebrand disease, and hemophilia A and B are responsible for this.

What Is Uterine Artery?

The main blood supply of the uterus is derived from uterine arteries. There are two uterine arteries, one on either side. The uterine artery is delivered from the internal iliac artery. This artery is divided into two parts, known as ascending and descending branches. The ascending artery joins with the ovarian artery. Together these two arteries supply oxygenated blood to the ovary, fallopian tube, and uterus. Various small branches of the uterine artery also supply the muscular outer layer of the uterus. These branches are the arcuate artery, radial artery, spiral artery, and basal artery. The spiral artery supplies the endometrium layer (inner lining of the uterus) and the placenta during pregnancy. The descending branch of the uterine artery supplies the uterine cervix and the vagina.

What Is the Procedure for Uterine Artery Ligation?

As the uterus derives its main blood supply from the uterine artery, stoppage of the blood flow is the most effective way to prevent blood loss.

• A two to three-centimeters-long midline incision is made at the lower portion of the abdomen. The incision is extended from below the umbilicus to the pubic hair.

• Skin and fascia (a connective tissue covering) are separated via forceps, and the rectus muscle is separated via scissors.

• Opening in the peritoneum (covering of the abdomen) near the umbilicus is done through the hand and scissors to access the uterus. Cautions must be maintained to prevent bladder injury during this period.

• The uterus is pulled, and the lower part is exposed.

• The pulsation of the uterine artery is felt at the junction of the uterus and cervix.

• Structuring is done with the help of chromic catgut. During this, suturing needle is passed around the artery and through two to three centimeters of the myometrium (uterine muscle layer).

• Sutures should be placed close to the uterus.

• In cases of tearing of the artery, clamping is done.

• Immediately color of the uterus is changed to blanched with a pinkish hue after successful ligation.

• Usually, a single ligation is done that maintains collateral circulation. This also prevents tissue necrosis.

What Are the Other Methods?

Apart from this, various other methods are employed to stop postpartum hemorrhage. These methods are:

• Manual Aortic Compression: This is the first measure to stop bleeding. In this method, manual pressure by hand is applied to stop bleeding. With the help of the hill of the hand, pressure is applied just above the most prominent portion of the sacrum bone. In another method, aorta compression is done just below the renal arteries. These are extremely difficult methods as finding appropriate anatomical landmarks is necessary for effective compression.

• Intrauterine Balloon Tamponade: In this intrauterine balloon tamponade method, a balloon-like device is placed via the transvaginal route. This is a non-surgical way to stop bleeding via the application of pressure. The inserted balloon is inflated to increase intrauterine pressure. Around 300 milliliters of saline are injected into the balloon for this purpose. Foley Catheter, Bakri balloon, and Sengstaken–Blakemore tube are different types of instruments used in this procedure.

• Internal Iliac Artery Ligation: Ligation of the internal iliac artery on both sides is a challenging procedure. This is often done with the help of vessel loops or tapes along with vascular clamps or Rummel tourniquets. Obesity, a large uterus, and limited access through transverse lower abdominal incision often make this procedure difficult to perform.

• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): In REBOA, an endovascular balloon is inserted into the descending aorta. This balloon is infiltrated to block the blood flow.

Conclusion:

Bleeding after delivery can be dangerous. Excessive bleeding during pregnancy may be responsible for the death of the mother. Several methods can be used to stop bleeding and to prevent loss of life. Bilateral uterine artery ligation is a surgical technique used to stop the blood flow to the uterus and prevent further blood loss.