Gynecology & Obstetrics
Open Access
ISSN: 2161-0932
ISSN: 2161-0932
Huma Ahmad Alizai
French Medical Institute for Mothers and Children Kartisakhi, Afghanistan
Posters & Accepted Abstracts: Gynecol Obstet
Background: Bilateral ligation of the uterine vessels (Oâ??Leary stiche) to control PPH (postpartum hemorrhage) has become a firstline
procedure for controlling uterine bleeding in case of PPH. It is preferable to internal iliac artery ligation because the uterine
arteries are more readily accessible, the procedure is technically easier and there is less risk to major adjacent vessels and ureter
ligation. Bilateral ligation of arteries and veins is successful in controlling hemorrhage in over 90 percent of patients. there is a single
case report of uterine necrosis from Morocco following uterine vasculature ligation and uterine compression suture. We report a first
case of uterine and ovarian total necrosis following uterine vascular ligation from Afghanistan. We emphasize a technique to control
PPH that is more logical with less sequela. We can choose other procedures like compression sutures that can play a major role in the
preservation of fertility and is less invasive or primary hysterectomy to prevent the most serious complication of total vessel ligation
like uterine and ovaries necrosis, sepsis, fever and inflammatory syndrome after surgery.
Case presentation: A 30 YO woman G3P3-0-0-2 was presented to the triage room with C/O abdominal pain, malaise, fever, dyspnea,
and diarrhea for last two days. She underwent Cesarean section five days back at another tertiary hospital with an indication of Fullterm
pregnancy+ Second stage of labor+ Failure to progress. During cesarean section, she had massive hemorrhage for which uterine
vessels ligation had been performed. At the time of presentation, she was conscious her BP was 130/85mmhg, the temperature was
39Ä?, PR 130bpm, Respiratory rate 21 cycles per minute. By physical exam she looked plae, lungs were bilaterally clear to auscultation,
the heart was tachycardic but regular rhythm, the abdomen was distended, bowel sounds were audible, incision was clean, uterine
size on the fifth day of cesarean section was 31cm and tendered. In lab exams Hb was 4.5gr/dl, HCT-14%, WBC-13000, CRP-34.
Ultrasound showed a foreign body inside the uterus (RPOC). CT scan wasnâ??t diagnostic due to lack of experts. With the diagnosis
of postoperative infection, she was admitted and broad-spectrum antibiotics were started. Despite taking antibiotics, her condition
didnâ??t improve. She remained febrile and in spite of taking uterotonics her uterusâ??s size remained the same. On the fifth day of her
hospitalization due to no improvement, she underwent laparotomy. Opening the abdomen massive adhesions were observed and
after removing some adhesions, it was found that the uterus was so big flabby and necrotic with foul smell, the ovaries were both
gangrenous. It was evident that along with the ligation of the uterine and uteroovarian arteries the broad ligament was completely
ligated from the base that caused ligation of all vessels of uterine and ovary. Subtotal hysterectomy was performed and abdomen was
washed with serum NS and then closed. After the operation her condition started to improve, her temperature got normal and her
lab exams improved. She totally received three points of fresh blood and Hb finally got 11gr/dl. She was discharged home on the third
day of post-laparotomy with oral antibiotics. After one week she showed up for follow up with good condition.
Conclusion: This case confirms that for management of postpartum hemorrhage there are many surgical techniques. So, we suggest
that proper ligation of uterine and uteroovarian arteries and in case of no control performing primary hysterectomy can prevent
the most serious outcomes of all vessels ligation like uterine necrosis, sepsis, and patientâ??s death. Logical picking up of the surgical
technique according to patientâ??s condition can prevent sequellas postoperatively.
E-mail: huma_alizai@yahoo.com