What is the role of internal iliac 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

Internal iliac artery ligation can be effective to reduce bleeding from all sources within the genital tract by reducing the pulse pressure in the pelvic arterial circulation. One study indicated that pulse pressure was reduced by 77% with unilateral ligation and by 85% with bilateral ligation. [66] Hypogastric artery ligation is much more difficult to perform, more commonly associated with damage to nearby structures, and less likely to succeed than uterine artery ligation. One study reported a success rate of 42%. In patients who undergo hypogastric artery ligation, uterine artery ligation has usually already failed.

Prerequisites for the procedure include a stable patient, an operator experienced in the procedure, and a desire to maintain reproductive potential. The retroperitoneal space is entered by incising the peritoneum between the fallopian tube and the round ligament. The ureter must be identified and reflected medially with the attached peritoneum. The external iliac artery is identified on the pelvic sidewall and followed proximally to the bifurcation of the common iliac artery. The ureter passes over the bifurcation. The internal iliac artery is identified and followed distally approximately 3-4 cm from its point of origin. The loose areolar tissue is carefully cleared from the artery. A right-angle clamp is passed beneath the artery at this point, with great care to avoid damage to the underlying internal iliac vein.

A recommendation is to pass the clamp from lateral to medial in order to minimize the chance of damage to the adjacent external iliac vessels. Gentle elevation of the artery with a Babcock clamp facilitates this maneuver.

Ligate the artery with heavy absorbable suture, but do not divide it. Palpate the femoral and distal pulses before and after the ligation to ensure that the external or common iliac artery was not inadvertently ligated. If possible, place the ligation distal to the posterior division of the artery because this decreases the risk of subsequent ischemic buttock pain. Identification of the posterior division may be difficult, and ligation 3 cm from the internal iliac artery origin usually ensures that it is not included.

Hysterectomy is required if internal iliac artery ligation is unsuccessful. Patients in whom internal iliac artery ligation has failed have greater morbidity than those in whom the procedure has not been attempted. The likelihood of benefit from the procedure must be balanced against the potential risks. The advent of more effective uterotonic agents, the fact that most cases of intractable hemorrhage are now related to abnormalities of placentation that are diagnosed or suggested before delivery, and the option of embolization have lessened the use of hypogastric artery ligation. The number of surgeons comfortable using this procedure and the opportunities to teach it are rapidly declining.


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