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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 50-51

Use of bulldog vascular clamps and vessel loops to reduce intraoperative bleeding during cesarean hysterectomy for placenta percreta


Department of OBGY, Apollo Hospital, Chennai, Tamil Nadu, India

Date of Web Publication11-Mar-2019

Correspondence Address:
Juhul Patel
Department of OBGY, Apollo Hospital, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_58_18

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  Abstract 


Placenta percreta is a potentially life-threatening condition that requires a multidisciplinary team approach for optimal management. Bulldog vascular clamps were used to reduce the severity of bleeding among two patients undergoing cesarean hysterectomy for placenta percreta. Permanent hypogastric artery ligation can cause serious intraoperative and postoperative complications, especially when performed by inexperienced surgeons. Placing a bulldog vascular clamp across the internal iliac artery can reduce intraoperative bleeding and prevent serious complications associated with permanent hypogastric artery ligation.

Keywords: Bulldog clamp, cesarean hysterectomy, hypogastric artery ligation, placenta percreta, postpartum hemorrhage


How to cite this article:
Patel J, Arunachalam V, Munjal R. Use of bulldog vascular clamps and vessel loops to reduce intraoperative bleeding during cesarean hysterectomy for placenta percreta. Apollo Med 2019;16:50-1

How to cite this URL:
Patel J, Arunachalam V, Munjal R. Use of bulldog vascular clamps and vessel loops to reduce intraoperative bleeding during cesarean hysterectomy for placenta percreta. Apollo Med [serial online] 2019 [cited 2019 Jul 16];16:50-1. Available from: http://www.apollomedicine.org/text.asp?2019/16/1/50/253866




  Introduction Top


Postpartum hemorrhage causes 25% of all maternal deaths worldwide and is the leading cause of maternal morbidity and mortality following vaginal or cesarean delivery.[1],[2] Every year, postpartum hemorrhage is estimated to cause approximately 125,000 maternal deaths and is associated with morbidity among 20 million women.[1],[2],[3]

It is caused by several obstetric conditions, including uterine atony and placental problems such as placenta accreta spectrum disorders, trauma, and lacerations.[1],[2],[3],[4] Several techniques are known to prevent postpartum hemorrhage, including uterine cavity tamponade, uterine artery ligation, uterine artery embolization, precesarean prophylactic balloon catheterization, uterine compression sutures, hypogastric artery ligation, and hysterectomy.[4]

Placenta percreta is a potentially life-threatening condition that requires a multidisciplinary team approach for optimal management. The incidence of placenta percreta has been increasing along with an increase in the cesarean delivery rate.[1],[2],[3] Cesarean hysterectomy is the most commonly performed procedure among women with placenta percreta who do not wish to retain fertility.[1],[2],[3] However, an alternative to cesarean hysterectomy has been suggested: precesarean prophylactic balloon catheterization leaving the placenta in situ, followed by methotrexate or interval hysterectomy[1],[2],[3],[4]

Hypogastric artery ligation – a surgical procedure used to prevent hysterectomy in cases of intraoperative bleeding or to prevent bleeding in patients undergoing cesarean hysterectomy – has become an important conservative treatment option for obstetric hemorrhage; however, it is associated with serious complications.[4] The overall ischemic complication rate associated with hypogastric artery ligation has been reported to be 22.6%, including buttock claudication (12.2%), buttock necrosis (4.8%), spinal cord ischemia (4.0%), colonic ischemia (2.5%), and bladder necrosis (0.8%).[4] Furthermore, hypogastric artery ligation is associated with serious intraoperative complications such as internal iliac venous injury and ureteral damage.[1],[2],[3],[4]

The bulldog vascular clamp is commonly used for cardiovascular and urologic surgery; however, there are no reports of its use to prevent obstetric hemorrhage, to my knowledge. In the present report, temporary occlusion of the hypogastric artery using the bulldog vascular clamp is described [Figure 1]. Clinical experience with this technique indicates that it might prevent the morbid complications associated with hypogastric artery ligation and precesarean prophylactic balloon catheterization thus could be a suitable alternative.
Figure 1: Hypogastric artery clamping by bulldog vascular clamp and vessel loop

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  Case Report Top


Overall, two pregnant patients with placenta percreta were referred for cesarean hysterectomy during the third trimester. The diagnosis of percreta was made by ultrasonography confirmed with magnetic resonance imaging. Both these patients provided informed consent to undergo cesarean hysterectomy (including the use of vascular clamps) and for publication (including images from surgery).

In each case, a midline incision was performed and the newborn was delivered from the uterine fundus. After delivery, removal of the placenta was not attempted and the fundal incision was closed using Vicryl 1 sutures. The retroperitoneum was then opened parallel to the external iliac artery, and anatomic structures were identified, including the left and right external iliac vessels, internal iliac vessels, and ureters. Next, a common metallic bulldog vascular clamp was placed across the hypogastric artery to reduce intraoperative bleeding during hysterectomy. Hysterectomy was performed as usual, and the bulldog clamp was removed at the end of the procedure.

Hysterectomy in each of the two patients was completed within 1 h. There were no complications. Intraoperative bleeding was <500 mL in both patients. Both patients were discharged without complications.


  Discussion Top


Permanent hypogastric artery ligation can cause serious intraoperative and postoperative complications, especially when performed by inexperienced surgeons. Placing a bulldog vascular clamp across the internal iliac artery can reduce intraoperative bleeding and prevent serious complications associated with permanent hypogastric artery ligation.


  Conclusion Top


Widespread use of this technique could reduce severe morbidity among patients with placenta percreta undergoing cesarean hysterectomy and among women who require internal iliac artery ligation for postpartum bleeding of any cause and pelvic bleeding due to oncologic or other causes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yildiz C, Akkar OB, Karakuş S, Cetin A, Yanik A. Hypogastric artery ligation for obstetrical hemorrhage: Clinical experience in a tertiary care center. Turk J Med Sci 2015;45:1312-6.  Back to cited text no. 1
    
2.
World Health Organization. Guidelines for Management of Postpartum Haemorrhage and Retained Placenta. Geneva, Switzerland: World Health Organization: 2009.  Back to cited text no. 2
    
3.
Simsek Y, Yilmaz E, Celik E, Turkcuoglu I, Karaer A, Turhan U, et al. Efficacy of internal iliac artery ligation on the management of postpartum hemorrhage and its impact on ovarian reserve. Turk J Obstet Gynecol 2012;9:153-8.  Back to cited text no. 3
    
4.
Chitragari G, Schlosser FJ, Ochoa Chaar CI, Sumpio BE. Consequences of hypogastric artery ligation, embolization, or covera. J Vasc Surg 2015;62:1340-7.  Back to cited text no. 4
    


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