No mention of hypogastric artery ligation?

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Although I enjoyed the article on postpartum hemorrhage, I was disappointed that the authors left out hypogastric artery ligation when they discussed management options for intractable hemorrhage. Bilateral ligation is effective and can spare patients from hysterectomy.

Eric Rothschild, MD
Fort Lauderdale, Fla

Dr. Stitely and Dr. Gherman respond: Technique is useful in select circumstances

Although we did not mention it in our article, we do agree that hypogastric artery ligation is useful in select circumstances. However, under emergent conditions in the face of ongoing massive hemorrhage, the technique can be risky. The decision to use it should be based on the physician’s level of surgical skill and, to a more limited degree, clinical experience. Many chief residents graduating today have rarely, if ever, performed this procedure. Even some seasoned obstetricians have never had the opportunity to practice it. Moreover, small community-based hospitals may not have the surgical assistants or instruments necessary for this technique, whereas the other conservative measures described in our paper, such as the B-Lynch suture, are easily executed by inexperienced providers, involve limited maternal morbidity, and take only a few moments to perform.

Although hypogastric artery ligation can reduce pulse pressure by 50%, maternal risks include vascular injury to the hypogastric artery or iliac vein, ureteral damage, sloughing of the gluteal muscles, and femoral artery insufficiency. There is also a concern that hypogastric artery ligation will fail and could potentially delay hysterectomy, leading to more blood loss. In Clark’s series, 57% of patients (11/19) required hysterectomy after hypogastric artery ligation. These patients had more blood loss and significant intraoperative morbidity, compared with patients who underwent hysterectomy without it.1

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