Question

Order of ligation of devascularization in PPH (Postpartum Hemorrhage)

• A. Uterine artery, pudendal artery, vaginal artery
• B. Uterine artery, internal iliac, obturator artery
• C. Uterine artery, ovarian artery, internal iliac artery
• D. Uterine artery, ovarian artery, vaginal artery

Hint:

Recall the stepwise surgical approach to devascularization starting with the primary uterine blood supply and then addressing collateral vessels.

Answer 1

The Correct Option is C

Step 1: Understand devascularization in PPH. Surgical devascularization is performed when medical management of PPH (postpartum hemorrhage) fails and the surgeon wishes to preserve the uterus. It involves stepwise ligation of arteries supplying the uterus.

Step 2: Know the stepwise order of ligation.

1. Uterine artery ligation (O'Leary stitch): Bilateral ligation of the uterine arteries at the level of the lower uterine segment. This is the first step and addresses the primary blood supply to the uterus.
2. Ovarian artery ligation: The utero-ovarian arcade is similarly ligated if uterine artery ligation fails to control bleeding. This targets collateral flow from the ovarian vessels.
3. Internal iliac (hypogastric) artery ligation: Ligation of the anterior division of the internal iliac artery reduces pulse pressure in pelvic vessels by approximately 85%, reducing hemorrhage. This step is reserved for refractory PPH.

Step 3: Eliminate wrong options. The pudendal, obturator, and vaginal arteries are not part of the standard stepwise devascularization protocol for PPH.

Conclusion: The correct order is uterine artery, ovarian artery, then internal iliac artery.