Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 323e325

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Taiwanese Journal of Obstetrics & Gynecology

journal homepage: www.tjog-online.com

Research Letter

Temporary loop ligation of the abdominal aorta during cesarean

hysterectomy for reducing blood loss in placenta accrete
Mai-lian Long, Chun-xia Cheng, Ai-bin Xia*, Rui-zhen Li
Department of Gynaecology and Obstetrics, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China

a r t i c l e i n f o
Article history:
Accepted 11 August 2014

Placenta accreta is a condition in which the placenta is abnormally attached to the uterus. It is an important cause of massive
peripartum hemorrhage and a source of maternal morbidity and
mortality in modern obstetrics, accounting for 46% of cesarean
hysterectomies (CHs) [1]. The incidence of placenta accreta has
increased over the past century from 1/7000 deliveries to 1/2500
deliveries because of the rising rate of caesarean deliveries [2].
Various methods for managing placenta accreta have been
described in the literature. These range from conservative methods
to hysterectomy. We report here a case in which an innovative
procedure, temporary loop ligation of the abdominal aorta, was
performed during CH for placenta accreta, following which there
was a dramatic decrease in intraoperative blood loss.
A 33-year-old Chinese woman (gravida 3, para 1) was referred to
us at 36 weeks' gestation for cesarean delivery with suspected
placenta accreta. She had experienced a previous full-term cesarean delivery 4 years before. During a prenatal examination, color
Doppler ultrasound scan revealed complete placenta previa and
she was referred to our hospital. The color Doppler ultrasound
performed at our hospital showed that the placenta had completely
covered the cervical ostium. There was a low echogenic area
approximately 70 mm  14 mm between the placental edge and
the cervical ostium. To clearly identify the relationship between the
location of the placenta and the uterine scar, magnetic resonance
imaging was performed. It showed features characteristic of complete placenta previa including outward bulging of the lower
uterine segment. The demarcation between the placenta and

* Corresponding author. Department of Gynaecology and Obstetrics, The Third

Xiangya Hospital of Central South University, Tongzipo, Road Number 138,
Changsha, Hunan 410013, China.
E-mail address: 245180977@qq.com (A.-b. Xia).

uterine muscle layer was unclear, with heterogeneous signal intensity extending into the uterine muscle layer.
After detailed consultation with a professor of general surgery,
we decided to perform a temporary loop ligation of the abdominal
aorta during CH to minimize operative blood loss. Cesarean delivery
was performed under general anesthesia. During the operation, we
found the lower uterine segment to be purplish blue and bulging
outward with abundant vascular engorgement. A viable female infant weighting 2920 g with 1-minute and 5-minute Apgar scores of
8 and 9, respectively, was delivered through a longitudinal hysterotomy incision. After the fetus was delivered, the abnormally
adherent placenta was left in situ. The professor of general surgery
performed an abdominal aorta ligation. A retroperitoneal dissection
was initially performed to separate the infrarenal abdominal aorta
(IAA), approximately 3e4 cm from the inferior vena cava, between
the fourth lumbar and aortic bifurcation. A No. 14 gauge catheter
was then inserted through the rear end of the abdominal aorta and
loop ligation was performed (Figure 1). After meticulously dissecting the uterine ligaments and vessels, a rapid hysterectomy was
performed, and the cervical vault was repaired. The surgical procedure was successful, with an estimated blood loss of 400 mL,
which is lower than the average level of 3000e5000 mL [3]. The
excised uterus was collected for pathological examination. Pathologic examination results revealed that the placenta had invaded
the myometrium and reached the serosa, which was in accordance
with placental implantation. The patient was discharged on the 7th
postoperative day with no postoperative sequelae.
Dangerous placenta previa is encountered in women with a
history of cesarean delivery and in cases where the placenta adheres
to or implants into the uterine scar [4]. These patients have a high
risk of fatal hemorrhaging during the operative process. Research
has shown that 90% of such patients experience intraoperative
blood loss >3000 mL, with 10% of these types of patients suffering
from blood loss >10,000 mL [5]. Uterine bleeding caused by
placenta previa, with an average blood loss of 3000e5000 mL, is a
terrible situation, which can be a serious threat to both the health of
the mother and the infant. A rapid and effective hemostasis method
to reduce intraoperative bleeding, or a hysterectomy, is needed.
The existing methods for achieving hemostasis include uterotonic drugs, intrauterine packing (e.g., Bakri balloon), external
compression with uterine sutures (e.g., B-Lynch and hemostatic

http://dx.doi.org/10.1016/j.tjog.2014.08.006
1028-4559/Copyright 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.

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M.-l. Long et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 323e325

Figure 1. (AeD) Operative photographs showing the retroperitoneal dissection that was initially performed to separate the infrarenal abdominal aorta, approximately 3e4 cm from
the inferior vena cava, between the fourth lumbar and aortic bifurcation. A No. 14 gauge catheter was then inserted through the rear end of the abdominal aorta and loop ligation
was performed.

multiple square suturing), selective devascularization by ligation or

embolization of the uterine artery, and abdominal aortic occlusion
with balloon catheterization [1,6e9]. Placenta percreta is one of the
most serious complications of placenta previa and is frequently
associated with severe obstetric hemorrhage usually necessitating
hysterectomy [10]. Some methods of hemostasis, such as uterotonic
drugs, intrauterine packing, and external compression with uterine
suture, are unsuitable for this condition. Hemostasis can be achieved effectively and applied to more common cases with selective
devascularization by embolization of different arteries such as the
uterine arteries, the internal iliac arteries, and the descending
aorta. However, some unexpected shortcomings or complications
can still occur.
Greenberg et al [11] and Sewell et al [12] reported two cases in
which two patients with placenta accreta who underwent prophylactic common and internal iliac balloon catheterization,
respectively, suffered from severe complications of the popliteal
artery and iliac artery thromboembolism. In addition, Shrivastava
et al [3] reported a large case-control study of 69 patients in whom
CH for placenta accreta was performed. In their study, no signicant
differences were found in estimated blood loss between 19 patients
who had received preoperative internal iliac artery balloon catheter
(BC) placement plus hysterectomy and 50 patients who received
hysterectomy alone. Three of the 19 patients who received BC had
suffered from severe complications. One patient had a femoral artery thrombosis, the second patient was noted to have an internal
iliac artery thrombosis and groin hematoma, and the third patient
experienced an internal iliac artery dissection with 80e90% occlusion. In cases of abnormal placentation that presents with
extensive vascular collateral anastomosis in the gravid pelvis and a
degree of markedly increased uteroplacental blood ow, the utility
of intra-arterial balloon catheterization for the prevention of obstetric hemorrhage remains unclear.

In cases with advanced or extensive forms of placenta percreta, a

higher degree of pelvic devascularization provided by aortic balloon
occlusion may allow for not only a rapid control of bleeding during
hysterectomy, but also a decrease in the hysterectomy rate, as it gives
the operator time to achieve hemostasis or hysterectomy. Panici et al
[9] reported a case-control study of intraoperative aorta balloon occlusion in patients with placenta previa accreta/increta. In their study,
15 patients with preoperative internal abdominal artery BC [intraabdominal balloon occlusion (IABO)] placement were compared
with 18 patients who had refused IABO. Signicant decreases in the
incidence of hysterectomy were noted, blood loss was minimal, and
no IABO-related complications were found. In some cases, the aorta
BC is superior to catheterization of the internal iliac arteries, which is
more complex to dislodge and for which complete control of bleeding
is difcult to achieve [13]. Thus, it was more commonly used in
placenta previa to control serious intraoperative bleeding.
Recently, Chou et al [14] reported a case of temporary crossclamping of the IAA during CH to minimize operative blood loss
in placenta previa increta/percreta. The aorta was cross-clamped
using a Cosgrove ex clamp because it is exible and can be
easily moved. In this case, the estimated blood loss was 2000 mL,
the duration of aortic cross-clamping was 1 hour, and the patient
experienced no postoperative sequelae. According to the literature,
temporary cross-clamping of the IAA is much easier than IABO,
however, it needs a specic and costly clamp, which poor patients
cannot afford.
In the case we have reported here, a similar method of temporary loop ligation for the abdominal aorta was selected. The loop
ligation was performed using a No. 14 gauge catheter during CH.
This rapidly reduced intraoperative hemorrhaging and limited the
estimated blood loss to only 400 mL. Qu et al [15] had observed that
safe time limits in various levels of abdominal aorta clamping,
including high level (T12 level, above the celiac trunk artery),

M.-l. Long et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 323e325

medium level (L2, above the renal artery), and low level (L4, above
the common iliac artery) were between 25 minutes and 30 minutes. However, Masamoto et al [13] reported a case of aortic
balloon occlusion in CH for placenta percreta, in which the aortic
occlusion was sustained for 80 minutes. The duration of aortic loop
ligation was 30 minutes, which is within the recommended safe
time limit, and no postoperative complication was found.
Temporary loop ligation of the abdominal aorta has the same
effect as aortic balloon occlusion in the control of placenta previa
bleeding. It is simpler and less expensive to perform, requiring a No.
14 gauge catheter. Complications, such as acute renal failure caused
by balloon slide, ectopic embolism caused by contrast medium
overow, abdominal aortic intima injury, a punctured femoral artery
and lower limb thrombosis, and puncture site hematomas, occur less
frequently. An aortic balloon occlusion must be performed under
radiographic monitor, which exposes both the patient and the fetus
to a relatively long period of radiation during the procedure. As can
be seen from previous research, there are some obvious advantages
to temporary loop ligation of the abdominal aorta. Thus, in the
present case we chose this method to control bleeding during CH.
We are encouraged by the obvious decrease in operative blood
loss with temporary loop ligation of the abdominal aorta during CH.
However, further studies in a larger number of cases are needed to
evaluate the safety and efcacy of this procedure.
Conicts of interest
The authors have no conicts of interest relevant to this article.
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