- Email: [email protected]
Uterine artery ligation to control postpartum hemorrhage
Int. .I. Gynoecol. Obstet., 1987, 25: 363-367 International Federation of Gynaecology & Obstetrics
UTERINE ARTERY LIGATION
363
TO CONTROL POSTPARTUM
HEMORRHAGE
K. FAHMY Department of Obstetrics ond Gynoecology, Benho Faculty of Medicine, Benho (Egypt) (Received March 17th, 1986) (Revised and accepted January 23rd, 1987)
Abstract Bilateral uterine artery ligation was performed for 32 patients in order to control intractable postpartum hemorrhage in 25 of them (currative ligation) and as prophylaxis against postpartum hemorrhage in seven (elective ligation). Mass ligation was used for 29 patients and isolation ligation for three. Among the 25 patients for whom curative ligation was performed, successful hemostasis was achieved in 20 patients (8OYo) and the technique failed in ftve (200/o). This failure was due to a clotting defect in three and placenta previa accreta in two patients. Twenty-four patients (960/o) survived and one died as a result of a clotting defect. Among five patients followed up, normal menstruation occurred with pregnancy in three of them. Keywords: Uterine artery ligation; Postpartum hemorrhage. Introduction Postpartum hemorrhage is one of the most common, and most deadly, of all hemorrhagic threats to the parturient [8]. When postpartum hemorrhage is from a nontraumatic cause and classic conservative measures fail to control it, obstetricians usually resort to hysterectomy, a radical and sometimes unsuccessful procedure [6] with the undesirable side-effect of reproductive sterility. 0020-7292/87/$03.50 0 1987 International Federation of Gynaecology & Obstetrics Published and Printed in Ireland
Bilateral uterine artery ligation has been reported by multiple authors as a simple, safe, effective and life-saving alternative to hysterectomy in the management of uncontrollable postpartum hemorrhage [l-5,7,8]. Previous reports on 122 uterine artery ligations had a success rate of 87.7% (107 cases) [3]. In spite of these encouraging reports, the technique is still not used as frequently as it should in the management of uncontrollable postpartum hemorrhage. The only logical explanation for this appears to be unfounded fears on the part of the practitioner with respect to complications, insecurity regarding the exact position of the ureters and most importantly a lack of experience with surgical tehnique [7]. Hypogastric artery ligation, although at times a life-saving procedure for the control of pelvic hemorrage, is not recommended for postpartum uterine hemorrhage. It takes much longer time to perform than uterine vessel occlusion, requires more dissection, is occasionally associated with troublesome complications, and is more difficult to perform because of anatomic considerations [71. Materials and methods Uterine artery ligation was performed upon 32 patients in the Maternity Hospital, Kuwait, from March 1975 to March 1980 by the author. the operation was done to control intractable postpartum hemorrhage which was not responding to classical lines Int J Gynoecol Obstet 25
364
Fahmy
of management (curative ligation) in 25 patients and as a prophylactic procedure, or safeguard against the possible occurrence of postpartum hemorrhage (elective ligation) in seven patients who had cesarean section for severe concealed or mixed accidental hemorrhage. Among the 25 curative ligations, three 18 were para one to were primigravidae, four and four were para five or more. Three patients were preterm (28-36 weeks of gestation) deliveries, 21 were term gestation (37 weeks or more), and one patient was 10 days postpartum after a term delivery with retained placental parts and puerperal sepsis. There were seven of vaginal delivery; five of those were spontaneous, one was a vacuum extraction, and one was an assisted breech. Eighteen deliveries were by cesarean section. Cesarean section was performed for severe antepartum hemorrhage in eight patients, for previous section in three patients and for other obstetrics indications in the remaining seven. Postpartum hemorrhage occurred as a result of uterine atony in ten patients and from contracted uterus in two cases. Both of the latter cases had placenta accreta as well as two or more previous cesarean sections. Bleeding was from the lower uterine segment in five cases, resulting from placenta previa in two of those cases and from placenta accreta in the other three, who had with previous cesarean section. Bleeding occurred from a lower segment cesarean section incision in one case. Clotting defect due to severe portpartum hemorrhage developed in seven patients. Clotting defect was diagnosed by clinical observation of non-clotting of the shedded blood and venous blood taken in a test tube, after 12 min, and by reduced platelet count. In some cases, clotting defect was diagnosed by the detection of fibrin degradation products by immunological test. All seven patients on whom prophylactic was performed had cesarean ligation sections for severe concealed or mixed antepartum hemorrhage. Four of these patients Int J Gynaecol Obstet 25
had a Couvelaire uterus, while the other three manifested marked shock, with lack of adequate blood transfusion. One patient was primigravida, three were para one to four and three were para five or more. Three patients were 28-36 weeks pregnant and four were 37-40 weeks pregnant. In all seven patients no postpartum hemorrhage occurred. Of the 32 uterine artery ligations, mass ligation as described by O’Leary and O’Leary [6,7] was done in 29 patients and isolation ligation [I] was performed on three patients. All patients were given contraceptive pills after the operation. Only five of the patients, one who delivered vaginally and four who delivered by cesarean section, came for follow-up. Technique of mass ligation In mass uterine artery ligation [6,7], the surgeon stands on the left side of the patient. To ligate the left uterine artery, the uterus is elevated upwards and to the right. Then a large Mayo needle, with a number one chromic catgut suture, is passed into and through the myometrium from anterior to posterior, 2-3 cm medial to the left uterine vessels. It is then passed from posterior to anterior through the avascular area in the left broad ligament, lateral to left uterine vessels, and the suture is tied. To ligate the right uterine vessels, the uterus is elevated upwards and to the left. The needle is then passed, from anterior to posterior, in the avascular area of the right broad ligament, lateral to the right uterine vessels. It is then passed through the myometrium from posterior to anterior, 2-3 cm medial to the right uterine vessels and tied. If ligation is done during cesarean section, there is no need for bladder mobilization and the suture can be placed below the level of the uterine incision under the reflected peritoneal flap. If the operation is not done in conjunction with cesarean section, there is
Urine artery ligation to control postpartum hemorrhage
no need for a peritoneal incision and the bladder can simply be retracted downward. There is also no need to palpate the vessels. Absorbable suture should be used and the figure of eight suture should be avoided. The effect of ligation is to produce an immediate blanching of the uterus to a pinkish hue with myometrial fibrillary contractions. In some cases, the whole uterus will contract. Occasionally, the uterus does not become firm after ligation, only somewhat less soft. If the uterus exhibits no change, however, this is of no significance as bleeding is controlled even if the uterus remains flabby [7]. After uterine artery ligation, the uterus is compressed with a warm pack to expel any collected blood. It is then covered with warm packs and the abdominal wound covered with a sterile towel. The patient’s legs are then flexed and the thighs obduced and vaginal cleaning performed under observation for 10 m for bleeding. If the surgeon is satisfied that uterine bleeding has been adequately controlled, the abdomen may then be closed. Results The results of ligation in this study are shown in Table I. Successful hemostasis was Table 1.
Table II.
Causes of ligation failure (5 cases).
Causes of failure
No.
Remarks
Clotting defect
3
Placenta previa accreta
2
Severe accidental hemorrhage (I), total hysterectomy Atonic PPH and cesarean incision bleeding (l), total hysterectomy Lax, distended lower segment (1) vertical mattress sutures in lower segment Previous cesarean (1). total hysterectomy No previous cesarean (1) total hysterectomy
Total
5
achieved in 20 of 25 curative ligations (8OOro).The causes of ligation failure are shown in Table II. The rate survival is shown in Table III; 24 of 25 patients with curative ligations survived (%qo). Clinical data on the eight cases with clotting defect are shown in Table IV. Menstruation occurred in the five patients who did not fail to come for follow-up after uterine artery ligation. It started 45 to 60 days after ligation and was of moderate amount and duration. Three of these patients became pregnant 6, 12 and 24 months following surgery. The course of pregnancy was normal in all cases.
Results of curative ligation.
Result
No.
Important remarks
Tabk III.
Survival in 25 curative ligations.
Successful hemostatis
20
Clotting defect (5) Severe accidental APH and cesarean (3) Placenta previa centralis and cesarean (1) Retained placental parts 10 days postpartum, sepsis, evacuation (1) Total hysterectomy done (4). two with clotting defect, two with placenta previa accreta. Vertical mattress sutures in lower segment in (1) with clotting defect
Result
No.
Remarks
Alive
24
Dead
1
Successful ligation (20) Failed ligation and total hysterectomy done (3) Failed ligation and vertical mattress suture in lower segment done (1) Para 1+ 0 severe accidental hemorrhage and clotting defect Ligation failed and total hysterectomy done
Total
25
Failure
Total
365
5
25
Int J Gynaecol Obstet 25
366
Fahmy
Clinical data in cases with clotting defect (8 Table IV. cases). Comcomitant therapy blood transfusion, plasma expanders, fibrinogen, aprotonin, epsilon amino caproic acid. Clinical data
No. of patients
Parity 2-4 5 Gestation (weeks): 36 37-40 10 days PP Mode of delivery Normal Cesarean Indications of cesarean Severe APH Previous two cesareans Deep old cervical tear
1 5 2
2 5
1 7
5
1
Site of PPH Upper segment Lower segment
3 2
Renrlts Alive Dead
7 1
Discussion In 1952, Waters [8] reported that ligation of the uterine arteries is anatomically sound, physiologically rational and surgically possible, and that its hemostatic effect is due to the fact that it shuts off 90% of the blood supply to the pregnant uterus. This explains the success of uterine artery ligation in some cases of postpartum hemorrhage with clotting defect and some cases of placenta previa [1,4,8]. Failure of uterine artery ligation to control postpartum hemorrhage was found to be due to placenta previa of major degree, especially its accreta, to lower segment bleeding due to uterine atony or injury, to a clotting defect, or to slippage of the surgical Int J Gynaecol Obstet 25
knot [1,3,7]. In our study, ligation was successful in 80% of cases and failed in 20% (5 cases) due to clotting defect in three cases and placenta accreta in two. It is important to remember, however, that some cases of postpartum hemorrhage due to placenta previa or accreta may be successfully managed by uterine artery ligation [2,3,7].It is impossible to predict which of such cases will respond, but nothing will be lost by attempting ligation in every case. Moreover, uterine artery ligation might succeed in cases of hypo- or afibrinogenemia [2,4,7]. Complications to uterine artery ligation are rare. Two cases of broad ligament hematoma have been reported by O’Leary and O’Leary 171, one of which was due to the inexperience of the surgeon: hematoma could have been avoided by selecting the avascular area of the broad ligament for passage of the needle and by more careful ligation. One case of arterio-venous fistula was reported by Howard [5]. Such a complication can be avoided by the use of absorbable sutures, by avoiding the figure of eight suture and by including a substantial amount of the myometrium at the ligation site. There were no long-term adverse effects following bilateral uterine artery ligation in the present study, or in the large series repeated by O’Leary and O’Leary [7]. Recanalization appears to be the rule [7]. Menstrual flow is not altered as shown in our patients and as reported by O’Leary and O’Leary [6,9]. Moreover, pregnancy can occur after uterine artery ligation as it has in three of the cases reported here. There is no reported percentage of pregnancy after uterine artery ligation, even in the large series of 90 patients reported by 0’ Leary and O’Leary [7]. The advantages of uterine artery ligation over hysterectomy are quite obvious and need no comment. Uterine artery ligation should not, however, be seen as a panacea for carelessness, mismanagement of postpartum hemorrhage or for poor practice of
Urine artery ligation to control postpartum hemorrhage
obstetrics [8]. Moreover, it should not be used as a routine method in place of the effective, well-timed conservative meaSures that succeed in most cases of postpartum hemorrhage [7], neither should its use be delayed until the patient is in a condition of irreversible shock [3]. References Fahmy K: Uterine artery ligation in the management of postpartum hemorrhage due to fibrinogen deficiency. Int Surg 50: 139, 1%8. Fahmy K: Uterine artery ligation in the management of intractable postpartum hemorrhage. J Kwt Med Assoc I: 40, 1%7. Fahmy K: Mass uterine artery ligation to control uterine hemorrhage in obstetrics. J Kwt Med Assoc 9: 73, 1975.
361
Fuchs K: Afibrinogenemia treated by ligation of the uterine artery. Gynaecologia 148: 1959. Howard LR: Iatrogenic arteriovenous sinus of a uterine artery and vein. Report of a case. Obstet Gynecol 31: 255, 1%8. O’Leary J, O’Leary JA: Uterine artery ligation in the control of intractable postpartum hemorrhage. Am J Obstet Gynecol 94: 920: 1966. O’Leary J, O’Leary JA: Uterine artery ligation or control of post-cesarean section hemorrhage. Obstet Gynecol43: 948, 1974. Waters EC: Surgical management of postpartum hemorrhage with particular reference to ligation of uterine arteries. Am J Obstet Gynecol54: 1143, 1952. Address for reprints: K. Fahmy Department of Obstetrics and Gynaecology Renha Faculty of Medicine Benha. Egypt
Int J Gynaecoi Obstet 25
UTERINE ARTERY LIGATION
363
TO CONTROL POSTPARTUM
HEMORRHAGE
K. FAHMY Department of Obstetrics ond Gynoecology, Benho Faculty of Medicine, Benho (Egypt) (Received March 17th, 1986) (Revised and accepted January 23rd, 1987)
Abstract Bilateral uterine artery ligation was performed for 32 patients in order to control intractable postpartum hemorrhage in 25 of them (currative ligation) and as prophylaxis against postpartum hemorrhage in seven (elective ligation). Mass ligation was used for 29 patients and isolation ligation for three. Among the 25 patients for whom curative ligation was performed, successful hemostasis was achieved in 20 patients (8OYo) and the technique failed in ftve (200/o). This failure was due to a clotting defect in three and placenta previa accreta in two patients. Twenty-four patients (960/o) survived and one died as a result of a clotting defect. Among five patients followed up, normal menstruation occurred with pregnancy in three of them. Keywords: Uterine artery ligation; Postpartum hemorrhage. Introduction Postpartum hemorrhage is one of the most common, and most deadly, of all hemorrhagic threats to the parturient [8]. When postpartum hemorrhage is from a nontraumatic cause and classic conservative measures fail to control it, obstetricians usually resort to hysterectomy, a radical and sometimes unsuccessful procedure [6] with the undesirable side-effect of reproductive sterility. 0020-7292/87/$03.50 0 1987 International Federation of Gynaecology & Obstetrics Published and Printed in Ireland
Bilateral uterine artery ligation has been reported by multiple authors as a simple, safe, effective and life-saving alternative to hysterectomy in the management of uncontrollable postpartum hemorrhage [l-5,7,8]. Previous reports on 122 uterine artery ligations had a success rate of 87.7% (107 cases) [3]. In spite of these encouraging reports, the technique is still not used as frequently as it should in the management of uncontrollable postpartum hemorrhage. The only logical explanation for this appears to be unfounded fears on the part of the practitioner with respect to complications, insecurity regarding the exact position of the ureters and most importantly a lack of experience with surgical tehnique [7]. Hypogastric artery ligation, although at times a life-saving procedure for the control of pelvic hemorrage, is not recommended for postpartum uterine hemorrhage. It takes much longer time to perform than uterine vessel occlusion, requires more dissection, is occasionally associated with troublesome complications, and is more difficult to perform because of anatomic considerations [71. Materials and methods Uterine artery ligation was performed upon 32 patients in the Maternity Hospital, Kuwait, from March 1975 to March 1980 by the author. the operation was done to control intractable postpartum hemorrhage which was not responding to classical lines Int J Gynoecol Obstet 25
364
Fahmy
of management (curative ligation) in 25 patients and as a prophylactic procedure, or safeguard against the possible occurrence of postpartum hemorrhage (elective ligation) in seven patients who had cesarean section for severe concealed or mixed accidental hemorrhage. Among the 25 curative ligations, three 18 were para one to were primigravidae, four and four were para five or more. Three patients were preterm (28-36 weeks of gestation) deliveries, 21 were term gestation (37 weeks or more), and one patient was 10 days postpartum after a term delivery with retained placental parts and puerperal sepsis. There were seven of vaginal delivery; five of those were spontaneous, one was a vacuum extraction, and one was an assisted breech. Eighteen deliveries were by cesarean section. Cesarean section was performed for severe antepartum hemorrhage in eight patients, for previous section in three patients and for other obstetrics indications in the remaining seven. Postpartum hemorrhage occurred as a result of uterine atony in ten patients and from contracted uterus in two cases. Both of the latter cases had placenta accreta as well as two or more previous cesarean sections. Bleeding was from the lower uterine segment in five cases, resulting from placenta previa in two of those cases and from placenta accreta in the other three, who had with previous cesarean section. Bleeding occurred from a lower segment cesarean section incision in one case. Clotting defect due to severe portpartum hemorrhage developed in seven patients. Clotting defect was diagnosed by clinical observation of non-clotting of the shedded blood and venous blood taken in a test tube, after 12 min, and by reduced platelet count. In some cases, clotting defect was diagnosed by the detection of fibrin degradation products by immunological test. All seven patients on whom prophylactic was performed had cesarean ligation sections for severe concealed or mixed antepartum hemorrhage. Four of these patients Int J Gynaecol Obstet 25
had a Couvelaire uterus, while the other three manifested marked shock, with lack of adequate blood transfusion. One patient was primigravida, three were para one to four and three were para five or more. Three patients were 28-36 weeks pregnant and four were 37-40 weeks pregnant. In all seven patients no postpartum hemorrhage occurred. Of the 32 uterine artery ligations, mass ligation as described by O’Leary and O’Leary [6,7] was done in 29 patients and isolation ligation [I] was performed on three patients. All patients were given contraceptive pills after the operation. Only five of the patients, one who delivered vaginally and four who delivered by cesarean section, came for follow-up. Technique of mass ligation In mass uterine artery ligation [6,7], the surgeon stands on the left side of the patient. To ligate the left uterine artery, the uterus is elevated upwards and to the right. Then a large Mayo needle, with a number one chromic catgut suture, is passed into and through the myometrium from anterior to posterior, 2-3 cm medial to the left uterine vessels. It is then passed from posterior to anterior through the avascular area in the left broad ligament, lateral to left uterine vessels, and the suture is tied. To ligate the right uterine vessels, the uterus is elevated upwards and to the left. The needle is then passed, from anterior to posterior, in the avascular area of the right broad ligament, lateral to the right uterine vessels. It is then passed through the myometrium from posterior to anterior, 2-3 cm medial to the right uterine vessels and tied. If ligation is done during cesarean section, there is no need for bladder mobilization and the suture can be placed below the level of the uterine incision under the reflected peritoneal flap. If the operation is not done in conjunction with cesarean section, there is
Urine artery ligation to control postpartum hemorrhage
no need for a peritoneal incision and the bladder can simply be retracted downward. There is also no need to palpate the vessels. Absorbable suture should be used and the figure of eight suture should be avoided. The effect of ligation is to produce an immediate blanching of the uterus to a pinkish hue with myometrial fibrillary contractions. In some cases, the whole uterus will contract. Occasionally, the uterus does not become firm after ligation, only somewhat less soft. If the uterus exhibits no change, however, this is of no significance as bleeding is controlled even if the uterus remains flabby [7]. After uterine artery ligation, the uterus is compressed with a warm pack to expel any collected blood. It is then covered with warm packs and the abdominal wound covered with a sterile towel. The patient’s legs are then flexed and the thighs obduced and vaginal cleaning performed under observation for 10 m for bleeding. If the surgeon is satisfied that uterine bleeding has been adequately controlled, the abdomen may then be closed. Results The results of ligation in this study are shown in Table I. Successful hemostasis was Table 1.
Table II.
Causes of ligation failure (5 cases).
Causes of failure
No.
Remarks
Clotting defect
3
Placenta previa accreta
2
Severe accidental hemorrhage (I), total hysterectomy Atonic PPH and cesarean incision bleeding (l), total hysterectomy Lax, distended lower segment (1) vertical mattress sutures in lower segment Previous cesarean (1). total hysterectomy No previous cesarean (1) total hysterectomy
Total
5
achieved in 20 of 25 curative ligations (8OOro).The causes of ligation failure are shown in Table II. The rate survival is shown in Table III; 24 of 25 patients with curative ligations survived (%qo). Clinical data on the eight cases with clotting defect are shown in Table IV. Menstruation occurred in the five patients who did not fail to come for follow-up after uterine artery ligation. It started 45 to 60 days after ligation and was of moderate amount and duration. Three of these patients became pregnant 6, 12 and 24 months following surgery. The course of pregnancy was normal in all cases.
Results of curative ligation.
Result
No.
Important remarks
Tabk III.
Survival in 25 curative ligations.
Successful hemostatis
20
Clotting defect (5) Severe accidental APH and cesarean (3) Placenta previa centralis and cesarean (1) Retained placental parts 10 days postpartum, sepsis, evacuation (1) Total hysterectomy done (4). two with clotting defect, two with placenta previa accreta. Vertical mattress sutures in lower segment in (1) with clotting defect
Result
No.
Remarks
Alive
24
Dead
1
Successful ligation (20) Failed ligation and total hysterectomy done (3) Failed ligation and vertical mattress suture in lower segment done (1) Para 1+ 0 severe accidental hemorrhage and clotting defect Ligation failed and total hysterectomy done
Total
25
Failure
Total
365
5
25
Int J Gynaecol Obstet 25
366
Fahmy
Clinical data in cases with clotting defect (8 Table IV. cases). Comcomitant therapy blood transfusion, plasma expanders, fibrinogen, aprotonin, epsilon amino caproic acid. Clinical data
No. of patients
Parity 2-4 5 Gestation (weeks): 36 37-40 10 days PP Mode of delivery Normal Cesarean Indications of cesarean Severe APH Previous two cesareans Deep old cervical tear
1 5 2
2 5
1 7
5
1
Site of PPH Upper segment Lower segment
3 2
Renrlts Alive Dead
7 1
Discussion In 1952, Waters [8] reported that ligation of the uterine arteries is anatomically sound, physiologically rational and surgically possible, and that its hemostatic effect is due to the fact that it shuts off 90% of the blood supply to the pregnant uterus. This explains the success of uterine artery ligation in some cases of postpartum hemorrhage with clotting defect and some cases of placenta previa [1,4,8]. Failure of uterine artery ligation to control postpartum hemorrhage was found to be due to placenta previa of major degree, especially its accreta, to lower segment bleeding due to uterine atony or injury, to a clotting defect, or to slippage of the surgical Int J Gynaecol Obstet 25
knot [1,3,7]. In our study, ligation was successful in 80% of cases and failed in 20% (5 cases) due to clotting defect in three cases and placenta accreta in two. It is important to remember, however, that some cases of postpartum hemorrhage due to placenta previa or accreta may be successfully managed by uterine artery ligation [2,3,7].It is impossible to predict which of such cases will respond, but nothing will be lost by attempting ligation in every case. Moreover, uterine artery ligation might succeed in cases of hypo- or afibrinogenemia [2,4,7]. Complications to uterine artery ligation are rare. Two cases of broad ligament hematoma have been reported by O’Leary and O’Leary 171, one of which was due to the inexperience of the surgeon: hematoma could have been avoided by selecting the avascular area of the broad ligament for passage of the needle and by more careful ligation. One case of arterio-venous fistula was reported by Howard [5]. Such a complication can be avoided by the use of absorbable sutures, by avoiding the figure of eight suture and by including a substantial amount of the myometrium at the ligation site. There were no long-term adverse effects following bilateral uterine artery ligation in the present study, or in the large series repeated by O’Leary and O’Leary [7]. Recanalization appears to be the rule [7]. Menstrual flow is not altered as shown in our patients and as reported by O’Leary and O’Leary [6,9]. Moreover, pregnancy can occur after uterine artery ligation as it has in three of the cases reported here. There is no reported percentage of pregnancy after uterine artery ligation, even in the large series of 90 patients reported by 0’ Leary and O’Leary [7]. The advantages of uterine artery ligation over hysterectomy are quite obvious and need no comment. Uterine artery ligation should not, however, be seen as a panacea for carelessness, mismanagement of postpartum hemorrhage or for poor practice of
Urine artery ligation to control postpartum hemorrhage
obstetrics [8]. Moreover, it should not be used as a routine method in place of the effective, well-timed conservative meaSures that succeed in most cases of postpartum hemorrhage [7], neither should its use be delayed until the patient is in a condition of irreversible shock [3]. References Fahmy K: Uterine artery ligation in the management of postpartum hemorrhage due to fibrinogen deficiency. Int Surg 50: 139, 1%8. Fahmy K: Uterine artery ligation in the management of intractable postpartum hemorrhage. J Kwt Med Assoc I: 40, 1%7. Fahmy K: Mass uterine artery ligation to control uterine hemorrhage in obstetrics. J Kwt Med Assoc 9: 73, 1975.
361
Fuchs K: Afibrinogenemia treated by ligation of the uterine artery. Gynaecologia 148: 1959. Howard LR: Iatrogenic arteriovenous sinus of a uterine artery and vein. Report of a case. Obstet Gynecol 31: 255, 1%8. O’Leary J, O’Leary JA: Uterine artery ligation in the control of intractable postpartum hemorrhage. Am J Obstet Gynecol 94: 920: 1966. O’Leary J, O’Leary JA: Uterine artery ligation or control of post-cesarean section hemorrhage. Obstet Gynecol43: 948, 1974. Waters EC: Surgical management of postpartum hemorrhage with particular reference to ligation of uterine arteries. Am J Obstet Gynecol54: 1143, 1952. Address for reprints: K. Fahmy Department of Obstetrics and Gynaecology Renha Faculty of Medicine Benha. Egypt
Int J Gynaecoi Obstet 25