Prophylactic Internal Iliac Artery Ligation Health Essay

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 the fix of the ruptured uterine wall was done ( group A ), and the fixed group, where ruptured womb was repaired by conventional methods ( group B ). Informed consent was taken from all patients.

Consequences: The ligation group showed an important statistical difference when compared with the fix group sing intra-operative clip; the 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 arterial 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 arterial ligation ( IIAL ), hysterectomy.

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Introduction

Postpartum bleeding ( PPH ) is a major 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 milliliters or more in the first 24 hr following bringing of the babe, significant autumn in the hematocrit, or the demand of blood transfusion has 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 an 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 incomplete, distinguished by whether or non the serous coat of the womb is involved. ( 10 ) In the former, the uterine contents including the foetus and on occasion placenta may be discharged into the peritoneal pit, whereas in the latter the serous coat is integral and the fetus and placenta are inside the uterine pit. ( 11 ) The complete assortment appears to be more unsafe for the two assortments. ( 12 ) Rupture of the womb during labor 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 the 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 the most ruinous state of affairs, hysterectomy is preferred in order to collar farther blood loss and via media with certainty. ( 15 ) Although a life-saving process, it may not be appropriate for adult females who need to continue their generative potency. The hemostatic processes that preserve the uterus include uterine pit tamponage, selective uterine arterial embolization, uterine arterial ligation, and uterine brace sutures. ( 16 ) ISSN 1110-0834Internal iliac arterial 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 arterial 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 arteries. ( 19-23 ) The purpose of this survey was to measure the function of bilateral IIAL in instances of terrible station Partum bleeding due to the sidelong rupture womb in comparison 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 was indiscriminately allocated into two groups: Group A=35 patients ( ligation group ): adult females were subjected to bilateral IIAL followed by a fix of the uterine wall.

Group B =15 patients ( fix merely group ): adult females were subjected to conventional methods of a uterine fix.

All patients were counseled for the process and informed consent was obtained.

The 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 suture ( 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 the Statistical Package for Social Sciences ( SPSS/version 15 ) package.

The statistical trials used are as follow:

Athematic mean, standard divergence, Chui-square trial, and Fisher exact trial was used for categorized parametric quantities, while for numerical information, the 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 fixed 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 the group ( A ) was 45.5A±4.68 proceedings, while it was 98.5A±8.98 proceedings in the 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 proceedings. The average blood volume transfused intra-operatively in the group ( A ) was 1750A±71.6 milliliter, compared to 2980A±120.8 milliliters in the group ( B ), this difference is statistically important as P= 0.0001. In group ( A ), Four patients ( 11.4 % ) had a hysterectomy, and 6 patients ( 17.1 % ) had extra hemostatic vaginal sutures for extended vaginal cryings after IIAL. In group ( B ) seven patients ( 46.7 % ) had hysterectomy and 10 patients ( 66.7 % ) had haemostatic vaginal sutures. These differences are statistically important as P= 0.0058 and 0.0005 severally. These findings revealed a higher incidence of extra secondary processes in the group ( B ).

There was no ureteric ligation or hurt recorded in the group ( A ), on the other manus in the 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.

Postoperative events

All patients were transferred postoperatively to intensive attention unit ( ICU ) the average continuance of ICU stay was 38A±5.99 hours in the 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 the group ( A ) which is statistically important less compared to 9 patients ( 60.0 % ) in the group ( B ) were complicated with disseminated intravascular coagulopathy ( DIC ). The entire volume of blood collected from intra-abdominal drain over 48 hours postoperatively was 211A±23.85 milliliter in the group ( A ), while it was 751A±68.98 milliliter in the group ( B ). These revealed a higher incidence of station operative complications in group B. Merely one patient ( 2.9 % ) died from pneumonic intercalation in the group ( A ), and another one ( 6.7 % ) died in the group ( B ) due to monolithic hypovolemia and daze.

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 %.

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 arterial ligation and salve the womb. IIAL in such state of affairs 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 fornical cryings and hematoma, uterine arterial 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 a venereal piece of land, it is besides helpful in commanding postoperative bleeding after an abdominal or vaginal hysterectomy where no unequivocal hemorrhage point is noticeable.

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