title: Vaginal uterine artery ligation avoids high blood loss and puerperal hysterectomy in postpartum hemorrhage.
abstract: OBJECTIVE
  To describe a novel, effective, and minimally invasive surgical technique for avoiding excess blood loss and hysterectomy in intractable postpartum hemorrhage. Previously described techniques-uterine artery ligation at various levels, hypogastric (internal iliac) artery ligation, uterine compression-all require an abdominal approach.
  
  
  METHODS
  This procedure, which is quickly learned, is performable in the delivery room with minimal preparation, with or without bladder retraction. A 2-cm horizontal incision is made in the anterior cervix 1 cm beneath the estimated vaginocervical fold and the bladder reflected in the natural plane. Firm but gentle downward traction on the uterus to the contralateral side of the intended ligature maximizes cephalad and lateral access, permitting bilateral uterine artery ligation from laterally under direct vision and/or indirect transcervical palpation.
  
  
  RESULTS
  Between November 1997 and June 2001, 13 women with intractable postpartum hemorrhage chose the vaginal route over laparotomy as a uterus-preserving procedure. Hysterectomy proved necessary in only one case (8%) because of placenta percreta. One woman has since delivered a healthy term infant by cesarean, and uterine vascularization was unimpaired.
  
  
  CONCLUSIONS
  The vaginal route offers a novel, simple, effective, and minimally invasive technique for treating intractable puerperal hemorrhage by uterine artery ligation. Timely intervention avoids hysterectomy and consumption coagulopathy and preserves reproductive potential.
authors.affiliation: Department of Obstetrics, University Hospital, Zurich, Switzerland. gundula.hebisch@fhk.usz.ch
authors.forename: Gundula
authors.initials: G
authors.lastname: Hebisch
authors.forename: Albert
authors.initials: A
authors.lastname: Huch
mesh_terms: D001158:Arteries / Q000601:surgery; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D005260:Female; D006488:Hemostasis, Surgical / Q000379:methods*; D006801:Humans; D007044:Hysterectomy; D008026:Ligation / Q000379:methods; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D006473:Postpartum Hemorrhage / Q000175:diagnosis / Q000601:surgery*; D011247:Pregnancy; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014599:Uterus / Q000098:blood supply; D014621:Vagina / Q000098:blood supply