Surgical Management of Postpartum Hemorrhage
A 27-year-old primigravida has 900 mL of postpartum bleeding after vaginal delivery. The uterus stays atonic despite oxytocin, misoprostol, carboprost and bimanual compression, and she is taken to theatre. She strongly wishes to preserve fertility. Blood pressure is 92/56 mm Hg with pulse 118 beats/min. Which structure is most appropriate to ligate to control the bleeding?
- A.Internal iliac arteryCorrect
- B.External iliac artery
- C.Internal iliac vein
- D.Utero-ovarian ligament
Explanation
Bilateral internal iliac, or hypogastric, artery ligation is the classic fertility-sparing vascular procedure for postpartum haemorrhage unresponsive to medical management. Ligation of the anterior division distal to the posterior division reduces pulse pressure in the distal arterial bed by roughly 85%, converting a high-pressure arterial system into a low-pressure venous-like circulation that allows clot to form, while an extensive pelvic collateral network from the lumbar, middle sacral, superior rectal and ovarian vessels preserves uterine viability and future fertility. Reported pregnancies after the procedure confirm this. In practice the stepwise surgical sequence is uterine compression sutures such as the B-Lynch, then bilateral uterine artery ligation, then internal iliac ligation, with hysterectomy as the last resort, and interventional radiology embolisation is an alternative when the woman is stable and the service is available. Internal iliac ligation is technically demanding because of the proximity of the ureter, which crosses at the bifurcation, and the underlying internal iliac vein. Ligating the external iliac artery would cause acute limb ischaemia and does not supply the uterus. Venous ligation does not control arterial bleeding and risks thrombosis. The utero-ovarian ligament carries only the ovarian anastomotic vessels and its ligation is insufficient for major haemorrhage while threatening ovarian blood supply.
Why each option
- A.
- Correct. Bilateral internal iliac artery ligation markedly reduces distal pulse pressure, permits clot formation, and preserves the uterus and future fertility.
- B.
- The external iliac artery supplies the lower limb, not the uterus, and ligating it causes limb ischaemia without controlling uterine bleeding.
- C.
- Ligating a vein does not stop arterial inflow and adds a risk of venous thrombosis and embolism.
- D.
- The utero-ovarian ligament carries only anastomotic ovarian vessels; ligation is inadequate for major haemorrhage and may compromise ovarian perfusion.
Reference: ACOG Practice Bulletin No. 183, Postpartum Hemorrhage, reaffirmed 2024
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