Journal of Visceral Surgery (2011) 148, e95e102

REVIEW

Pelvic arterial ligations for severe post-partum

hemorrhage. Indications and techniques
O. Morel a,,b,c, C. Malartic c, J. Muhlstein c, E. Gayat d,
P. Judlin c, P. Soyer e, E. Barranger a
a

Service de gyncologie-obsttrique, hpital Lariboisire, universit Paris 7 Diderot, 2, rue

Ambroise-Par, 75475 Paris cedex 10, France
b
Fondation Premup, 4, avenue de lobservatoire, 75270 Paris cedex 06, France
c
Maternit rgionale universitaire de Nancy, universit Nancy I Henri-Poincar, 10, rue du
Dr.-Heydenreich, 54000 Nancy, France
d
Dpartement danesthsie-ranimation, SMUR, hpital Lariboisire, universit Paris 7
Diderot, 2, rue Ambroise-Par, 75475 Paris cedex 10, France
e
Service de radiologie viscrale et vasculaire, hpital Lariboisire, universit Paris 7
Diderot, 2, rue Ambroise-Par, 75475 Paris cedex 10, France
Available online 7 April 2011

KEYWORDS
Severe postpartum
bleeding;
Surgical hemostasis;
Arterial ligation

Summary In cases of serious bleeding postpartum, resuscitation and surgical techniques

are complementary and should be adapted to both the etiology and severity of bleeding. In
extremely severe cases, the performance of a hysterectomy should not be delayed. For women
with stable hemodynamic status, so-called conservative surgical techniques can instead be
used. In this study, we describe and discuss the indications and feasibility of various techniques
of vascular ligation. Uterine mattress suture compression techniques and abdomino-pelvic packing are also described. When conservative management is feasible, the rst line approach should
be bilateral distal ligation of the uterine arteries: this simple and low-risk technique is immediately effective in 80% of cases. If bleeding persists, uterine devascularization can be completed
by a triple ligation as described by Tsirulnikov, with or without supplemental proximal ligation of the uterine arteries. This procedure should be performed in preference to the so-called
stepwise ligation sequence, which involves ligation of the ovarian pedicles and poses a risk of
subsequent ovarian failure. Bilateral hypogastric artery ligation is also an effective and widely
used rst-line technique for experienced surgeons. This approach is technically challenging for
less-experienced surgeons and is reserved for cases of failed triple ligation.
2011 Elsevier Masson SAS. All rights reserved.

Introduction
Postpartum hemorrhage (PPH) is the leading cause of maternal death in France. Prevention and initial management of
women with PPH has been the subject of national guidelines
published in 2004. Maneuvers to perform and the adminis-

Corresponding author.
E-mail address: olivier.morel17@gmail.com (O. Morel).

tration of oxytocin and sulprostone to increase uterine tone

are now well-dened.
In case of failure of of sulprostone infusion or of hemodynamic instability, more invasive treatments must be carried
out without delay [1]. Arterial embolization, conservative
or radical surgical management, and intrauterine balloon
tamponnade are then the management options. There is no
consensus regarding management strategy for women with
severe PPH with persistent bleeding despite the administration of sulprostone. Choices must be jointly decided, taking

1878-7886/$ see front matter 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.jviscsurg.2011.02.002

e96

O. Morel et al.

Persistent bleeding for more

than 30 minutes after
administration of sulprostone

Post-Caesarean section after

abdominal closure

Vaginal delivery

- During caesarean section

or
- If there is hemoperitoneum

Alternative

Intrauterine balloon
tamponnade

Interventional radiology available

Rapid medical transport possible

No
Yes
Failure

SURGICAL HEMOSTASIS
- Uterus conserving by vascular
ligation or uterine mattress suture
plication.

ARTERIAL EMBOLISATION

Figure 1.

Decision tree: options for management of severe postpartum hemorrhage.

into account the technical equipment of the hospital facility, the experience of the personnel, and the possibility of
transfer to a tertiary center [2].
The choice of treatment depends on several factors: the obstetrical situation (particularly vaginal versus
caesarean delivery), the site of origin and volume of
bleeding, the patients hemodynamic tolerance, the technical means available (intensive care, availability of
interventional radiology) and human factors (surgical experience). A full assessment of the hemorrhagic lesion(s)
at the outset is essential to decision making: a complex
wound of the birth canal does not justify an abdominal surgical intervention as rst-line therapy, nor does
a hemorrhagic diathesis due to amniotic uid embolism.
Conversely, the presence of hemoperitoneum in the
early post-partum is an indication for immediate surgical
exploration.

Indications for surgical management

There is currently no level of evidence sufcient to conrm the superiority of one treatment over another for
severe PPH. The reported results are descriptive and anecdotal in support of a particular technique [3]. Moreover,
the denitions of severity vary from one study to another
and are often imprecise. It seems that conservative surgical techniques, arterial embolization, and intrauterine
balloon tamponnade (still an uncommon practice in France)
have comparable efcacy, with a primary success rate of
8090%.

Obstetrical context
Management must be decided, from the rst, according
to the obstetrical situation. Although there is no consensus, three obstetrical situations seem to mandate a surgical
approach from the outset:
during caesarean section: Here, it makes no sense to opt
for an embolization procedure, since conservative surgical techniques are immediately applicable;

for hemoperitoneum or retroperitoneal hematoma: This

may be due to unrecognized uterine rupture or to bleeding
from the uterine incision post-cesarean section;
when the patients hemodynamic status is unstable
despite well-conducted resuscitation and wherever a
transfer for interventional radiology is not feasible (intra
or inter-hospital).
After vaginal delivery or after a completed caesarean
section and in the absence of hemoperitoneum, it seems
logical to focus on less invasive treatment options (embolization or balloon tamponnade) whenever possible. If these
approaches fail, surgical treatment is a secondary option.
A decision tree (Fig. 1) summarizes the available treatment
options for serious postpartum hemorrhage.

Etiology of bleeding
For uterine atony without hemoperitoneum (and excluding the situation of hemorrhage during caesarean section),
we believe that embolization should be the preferred rst
line treatment whenever it is feasible [4,5]. Management
by interventional radiology is signicantly less invasive than
laparotomy, and the results are satisfactory. With regard to
the consequences in terms of future fertility, no data of
sufcient quality exists to objectively compare surgical management with interventional radiology, although studies are
somewhat reassuring on this point [68].
Complex wounds of the birth canal with persistent
bleeding despite initial well-conducted transvaginal surgical
treatment are also an excellent indication for embolization
[9].
Hemorrhage due to disseminated intravascular coagulation (DIC) (as may occur after amniotic uid embolus) should
be treated by resuscitation and medical therapy [10].
Abnormalities of placentation (placenta accreta or percreta) are a very special situation. Conservative management
may be possible in the absence of placental eradication
without the need for systematic vascular embolization or
ligation. Once the placenta has been removed, embolization
and conservative surgical techniques may be attempted, but
the chances of success are very low [1114].

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques

e97

Figure 2. Operative view: hypogastric artery ligation, right

hypogastric (1); the ligature must be placed about 2 cm below the
iliac bifurcation (2) using a ligature passer or right angle dissector,
after identication of the ureter (3).

Conservative surgery to control bleeding

(non-hysterectomy)
Techniques of vascular ligation
Patient position and set-up
It is essential to continually assess the persistence and
extent of bleeding during surgery (Fig. 1). The patient should
be positioned supine with sufcient clearance of the lower
limbs and draping of the operative eld to permit ongoing
assessment of bleeding throughout the procedure.

Bilateral ligation of hypogastric arteries

The rst cases of hypogastric artery ligation were published
in the 1960s (Fig. 2). This is the oldest surgical procedure
in the armamentarium of conservative treatment of severe
postpartum bleeding [15].
This technique requires a low abdominal approach; the
incision used for Caesarean section is usually sufcient for
the gesture. The uterus must be externalized and pulled forward and laterally away from the side to be ligated. The
broad ligament should be opened under the infundibulopelvic ligament, with the assistant retracting the uterus. The
bifurcation of the iliac trunk is identied and the hypogastric
artery (internal iliac) is dissected over a distance of 3 cm,
widely opening the vascular sheath to limit the risk of venous
injury. On the left, mobilization of the sigmoid mesentery
along Toldts fascia may facilitate exposure. After systematic identication of the ureter, a ligature is placed using
a ligature passer about 2 cm below the bifurcation, taking
care not to injure the vein. Ligation should be downstream
of the origin of the gluteal artery, and therefore should not
be placed within 2 cm of the iliac bifurcation. Proximal ligation entails a high risk of buttock claudication. At the end
of the procedure, we check the pulsations of the external
iliac artery. An identical gesture is performed on the contralateral side [16]. The ligation should be performed using
absorbable suture material.
Some authors have additionally proposed bilateral ligation of the infundibulopelvic ligaments and round ligaments
to maximize the chances of successful hemostasis. The
success rate of bilateral hypogastric artery ligation varies
widely in the literature, from 4293% [17]. Causes of hemorrhage such as uterine atony and placenta accreta are a
major source of failures.

Figure 3. Operative view: distal ligation of the uterine arteries:

the round ligament is divided (1); right uterine artery (2).

Possible complications include venous injury, ureteral ligation or injury, ligation of the external iliac artery, and
peripheral nerve injury. The rate of complications varies
widely from one series to another and seems to depend
essentially on the experience of operators.

Bilateral uterine artery ligation

This is also an old technique, the rst cases of bilateral uterine artery ligation were published by Waters in 1952 and
OLeary in 1966 [18,19] (Fig. 3). This is an easy procedure
to perform.
The technique requires an abdominal approach for which
the caesarean incision is adequate. The peritoneum should
be opened laterally to allow identication of the right and
left uterine artery pedicles. The vesico-uterine peritoneum
should be reected and division of the round ligaments
may or may not be necessary to expose the pedicles. The
uterus is exteriorized and pulled upwards: this tension
allows identication of the vessels serving the lower segment and placement of the ligature at a safe distance from
the ureters. An absorbable suture ligature which includes
the myometrium is placed 2 cm below the usual line of hysterotomy for cesarean section. This mass ligature includes
the ascending branch of uterine artery without the need to
isolate it from myometrium. An identical ligation is then
performed on the opposite side. This ligation technique has
also been described using the vaginal route, but it seems
more dangerous [20]. The reported success rate varies from
80 to 96% of cases. Failures have been reported in cases of
abnormal placentation and severe DIC.
This technique does not present any particular risk
of complication, apart from technical errors: placing the
sutures too low increases the risk of ureteral injury.

Tsirulnikov triple ligation

In 1979, Tsirulnikov proposed a more complete uterine
devascularization by ligation of the utero-ovarian arteries and the arteries of the round ligament [21] (Fig. 4).
After ligation-division of the round ligament with its pedicle artery, and opening of the vesico-uterine peritoneum,
the ascending branch of the uterine artery is ligated using
the technique described by OLeary. The utero-ovarian ligament is then ligated. A contralateral triple ligation is then

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O. Morel et al.
the previous one and requires a greater mobilization of the
uterine arteries with dissection of the broad ligament laterally on either side; this is essential to identify and protect
the ureters. The ligature here should be placed just above
the crook of the uterine artery. We routinely ligate and
divide the round ligaments to facilitate development of the
elements of the broad ligament inferiorly and laterally, and
the ureter is identied in a systematic way.
The nal step described by AbdRabbo is bilateral ligation
of the ovarian pedicle in the infundibulopelvic ligament.
In a series of 103 patients, AbdRabbo reported successful
hemostasis in 100% and reported no complications. However,
it seems that this approach carries a high risk of ovarian
failure [6]. We do not, therefore, recommend ligation of
the ovarian arteries.

Strategy for implementation of vascular

ligation for serious pph: a proposal for a new
sequence of vascular ligations
Figure 4. Schematic: vascular ligation by the Tsirulnikov technique [21]. Sequence: uterine artery ligation (1), round ligament
ligation (2 utero-ovarian ligament ligation (3).

performed in identical fashion. The author reports a success

rate of 100% in a series of 24 patients. This technique carries
the same risk of ureteral injury in case of technical error.

Stepwise sequential ligation

This technique was described by AbdRabbo in 1994 [22]
(Fig. 5). In principle, uterine devascularization is performed
in progressive stages. Progression to each next step is performed if bleeding persists ten minutes after the previous
ligation.
The initial step is bilateral distal ligation of uterine arteries using the previously described technique of OLeary.
If bleeding persists, the second stage is a proximal ligation of the uterine arteries including the cervico-vaginal
pedicles. This ligation is performed a few centimeters below

3
1

Figure 5. Schematic: stepwise sequential ligation: step one:

distal ligation of the uterine arteries (1); step two: distal ligation
of uterine arteries (2); step 3: ligation of the infundibulopelvic ligaments and ovarian vessels (3).

Rapidity of treatment is a major factor in the effectiveness

of surgical management [23]. The choice of technique
transuterine mattress sutures or vessel ligationmust
remain primarily a function of operator experience. Since no
technique of conservative surgical management has demonstrated superior efcacy compared to another, it seems
logical to favor the technique with the lowest risk of surgical
complications.

Surgical strategy based on etiology

For uterine atony, we favor distal ligation of the uterine
arteries as described by OLeary as rst line treatment. This
is the easiest and least risky ligation to perform. We are
usually content with just this method, which is immediately
effective in most cases.
If bleeding persists, the operator can proceed to the
Tsirulnikov triple-ligation. Continuous evaluation of ongoing
bleeding and the patients hemodynamic tolerance govern
the need (and possibility) of conservative surgical management.
Hypogastric artery ligation is technically more complex to perform and carries a higher-risk of failure and
complications; in our practice, its use is limited to cases
of failure of mattress suture compression or the sequence
of Tsirulnikov ligations, as a nal effort before resorting to
hysterectomy. This ligation is performed in the last instance
because of its higher operative risks.
When rebleeding occurs despite hypogastric ligation,
arteriography often demonstrates revascularization of the
uterine arteries from proximal anastomotic branches (Fig. 6)
[24]. This potential for secondary revascularization of the
uterus from various pelvic anastomotic branches has led us
to prefer distal ligation of vessels in direct contact with the
uterine muscle.
The combination of different conservative techniques
has not been recommended in the literature. This view
does not seem justied, however, since each technique was
evaluated in isolation. There is no argument validating the
superiority of any one technique over another in any particular situation. If previous steps have failed, ligation of
hypogastric artery ligation is worth an attempt, as long as
the patients hemodynamic status remains stable. Throughout the course of these various ligation procedures, optimal
patient resuscitation and ongoing dialogue with the anesthesia team is essential for appropriate care.

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques

e99

Figure 7. Schematic: vascular ligation (sequence recommended

by the authors): distal ligation of uterine arteries (1), ligation of
the round ligaments (2), ligation of utero-ovarian ligaments (3);
proximal ligation of uterine arteries (4).

Figure 6. Arteriography (revascularization distal to hypogastric

artery ligation): subtraction image showing the area of ligation (1),
revascularization by a downstream anterior branch (2).

Attempts to combine different conservative surgical

treatments should not delay ultimate hysterectomy if the
patient is hemodynamically unstable.
In cases of abnormal placental attachment, if a placental
conserving technique is not feasible, staged ligation may be
offered; this often requires total uterine devascularization.
However, hysterectomy is usually necessary after placental
extirpation.
For low segment hemorrhage due to placenta previa,
the low segment can be devascularized by proximal ligation of the uterine arteries and cervical pedicles (cf.
staged ligature), or by hypogastric artery ligation. Mattress compression sutures of the lower segment may also
be placed.
For non-uterine bleeding such as severe vagino-cervical
birth trauma, or vaginal hematoma inaccessible to transvaginal treatment, proximal vascular ligation still may be useful
if embolization is not available. In such cases, hypogastric
artery ligation may be effective.

Proposal for a new management sequence of

vessel ligation
On the same principle of a staged sequence of ligations until
bleeding is controlled, we propose a new approach combining those described by Tsirulnikov and AbdRabbo, based on
our own experience and literature review (Fig. 7).
It seems logical, as we have previously discussed, to perform distal uterine artery ligation as the preferred rst step;
the technique is easy to perform, safe, and immediately
effective in 80% of cases.
The second step in our sequence is round ligament ligation.

The third step is ligation of the utero-ovarian ligaments

(rather than the infundibulopelvic ligaments, because of
risks to future fertility).
The fourth step for persistent bleeding is proximal uterine artery ligation.
The fth and ultimate step in the sequence is hypogastric
artery ligation.

Alternatives: techniques of uterine

compression and mattress sutures
Compression techniques aim to achieve hemostasis by
compression of the myometrium with transxing sutures.
The procedure is usually preceded by bimanual compression
of the uterus to see if myometrial bleeding stops.
The two most common techniques are the B-Lynch plication technique described by B-Lynch et al. [25] and multiple
mattress sutures described by Cho et al. [26].
For the B-Lynch plication, a Pfannenstiel or low midline approach via the Caesarean incision is sufcient. A low
segment hysterotomy is rst performed after reection of
the bladder ap. For previous cesarean section, the uterine suture is reopened. The uterine cavity is visualized and
the uterus exteriorized. Absorbable transxion sutures are
passed in a U-shaped pattern through the fundus. (Fig. 8),
and then tied between the entry and exit points over the
low segment.
The technique described by Cho et al. is to place Ushaped absorbable mattress sutures with a straight needle
in a series of horizontal rows to compress the myometrium
from front to back. Several rows of multiple sutures are
placed in a quilted square pattern, taking care to avoid the
interstitial portion of the fallopian tubes.
Because of the thickness of myometrium that must be
transxed, these techniques require swaged needles of considerable length. These approaches are no more effective
than vessel ligation, and are not simple to perform in our
experience. They do, however, present an increased risk of
subsequent endometrial synechia, and are not preferred as

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O. Morel et al.

Intrauterine tamponnade
Packing of the uterine cavity with laparotomy pads for uterine atony was described many years ago. The current trend
in intrauterine tamponnade is the use of dedicated inatable balloons [28]. This technique is minimally invasive and
seems to have similar efcacy to surgical approaches and
interventional radiology [3]. This practice remains marginal
in France but is likely to be more widely used in the future.

Hysterectomy for control of hemorrhage

Figure 8. Operative view: uterine mattress sutures as described

by B-Lynch et al. [25]: The passage of absorbable suspenders
sutures through the uterine fundus.

The main risk is to delay too long in performing hysterectomy

when hemorrhagic shock is unresponsive to various conservative procedures, surgical treatments or embolization [23].
The classic procedure is a supracervical hysterectomy sparing the ovaries. Placenta previa or placenta accreta can
cause bleeding of the uterine isthmus or cervix requiring
total hysterectomy including cervicectomy.
Indications for urgent hysterectomy are cataclysmic hemorrhage severe enough to prevent transfer to an expert
center or hemorrhage that persists despite the abovementioned conservative techniques.

rst line treatment. Some teams combine myometrial mattressing techniques with uterine vessel ligation [6].

Peritoneal packing

Non-surgical alternatives: uterine artery

embolization and endometrial balloon
tamponnade
Embolization
Hemostatic arterial embolization has been used for decades
for uncontrollable bleeding associated with severe trauma
or inoperable pelvic gynecologic and urologic cancers. Sporadic reports of its use to control PPH have been published
over the last twenty years.
The procedure is performed in an interventional radiology suite with anesthesiologists and obstetricians in
attendance to continue resuscitation and clinical monitoring
during the embolization. Sulprostone should be discontinued
approximately 30 minutes prior to arteriography to minimize
the risk of arterial spasm, a source of failure of embolization.
A femoral artery approach under local anesthesia is used
for conventional catheterization of the internal iliac arteries. Pre-embolization angiography allows identication and
analysis of the uterine artery [27].
The embolization should be bilateral in all cases because
of the rich anastomotic network in the pelvis, particularly across the uterus. Vessels are occluded using
absorbable gelatin fragments (Curaspon ), resulting in a
temporary reduction of arterial ow for a few days.
During this period, uterine blood supply is provided
by accessory branchesessentially via the ovarian and
round ligament arteries. The success rate of embolization
reported in the literature is greater than 90% regardless of
etiology.
Secondary embolization can be performed if bleeding
recurs after initial conservative surgical treatment by whatever surgical technique [24].

Severe DIC due to catastrophic bleeding or amniotic uid

embolism may impose the need for pelvic peritoneal packing if vascular ligations are no longer feasible for control of
diffuse tissue bleeding. The principle is the same as in the
placement of peri-hepatic packing [29].
Although packing for PPH is only rarely described in the
literature, it remains a critical technique for maternal salvage in extreme situations. Packing is left in place up to a
maximum of 48 hours with broad-spectrum antibiotic coverage, and packs are removed surgically when the bleeding
diathesis has been controlled.

Conclusion
Postpartum hemorrhages are serious and often lifethreatening. Rapid response is one of the key points of
successful management. Treatment strategies depend primarily on the patients hemodynamic tolerance. Decisions
must be based on ongoing dialogue between the obstetrician and anesthesiologist. When surgical intervention is
decided, uterine conservation should be the goal as long as
the patients hemodynamic status allows. Since the various
different approaches have comparable efcacy, the surgeon
should focus preferentially on techniques with the least risk,
according to his personal experience. For the untrained or
inexperienced operator, rst-line uterine artery ligation is
the technique of choice.
A nal resort to hysterectomy should not be delayed in
patients with poor hemodynamic tolerance.

Disclosure of interest
The authors declare that they have no conicts of interest
concerning this article.

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques

KEY POINTS
For women with severe postpartum bleeding
which persists despite the administration of
sulprostone, management strategy must be
cooperatively decided by obstetricians and
anesthetists, depending on the technical
capacities of the center, the experience of
operators, and the possibility of eventual transfer
to a tertiary center
When surgical treatment is indicated for
serious postpartum bleeding, uterine conserving
techniques should be attempted in women who
are hemodynamically controlled
In the most severe cases, hysterectomy should not
be delayed
Vascular ligation should always be bilateral in
cases of serious postpartum bleeding
When conservative management is feasible,
distal ligation of the uterine arteries should be
performed as rst line therapy
If bleeding persists despite uterine artery ligation,
a Tsirulnikov triple ligation (uterine, round
ligament, and utero-ovarian arteries), possibly
supplemented by distal ligation of the uterine
arteries, may improve the devascularization
Bilateral hypogastric artery ligation is technically
more complicated to perform by less experienced
surgeons, and should be reserved for cases of
failed triple ligation
Staged sequential ligation, involving ligation of
the ovarian pedicles/infundibulopelvic ligament,
presents a risk of subsequent ovarian failure and
should be reserved for failure of triple ligation
When hemodynamic status permits, vessel
ligation may be associated with other types of
treatment: uterine mattress suture compression,
intrauterine balloon tamponnade, or selective
arterial embolization.

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