What is the role of uterine artery ligation in the treatment of postpartum hemorrhage (PPH)?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Answer

Uterine artery ligation is a relatively simple procedure and can be highly effective in controlling bleeding from uterine sources. These arteries provide approximately 90% of uterine blood flow. The uterus is grasped and tilted to expose the vessels coursing through the broad ligament immediately adjacent to the uterus. Ideally, place the stitch 2 cm below the level of a transverse lower uterine incision site. A large atraumatic (round) needle is used with a heavy absorbable suture. Include almost the full thickness of the myometrium to anchor the stitch and to ensure that the uterine artery and veins are completely included. The needle is then passed through an avascular portion of the broad ligament and tied anteriorly. Opening the broad ligament is unnecessary. Perform bilateral uterine artery ligation. While the uterus may remain atonic, blanching is usually noted and blood flow is greatly diminished or arrested.

Local oozing may be controlled with direct injection or compression with warm saline packs. In a series of 265 cases, a 95% success rate was reported using this procedure in PPH unresponsive to uterotonics in patients who had cesarean births. [64] Another series of 103 cases had a 100% success rate if a stepwise approach was taken. [65] After initial uterine artery ligation, subsequent stitches were placed 2-3 cm below the initial stitches following bladder mobilization, and, finally, ovary artery ligation was performed if required. Menstrual flow and fertility were not adversely affected.


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