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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 abnor-

mally 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 beendescribed 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 cesar-

ean 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 ourhospital 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 andthe cervical ostium. Toclearly identify the relationship between the

location of the placenta and the uterine scar, magnetic resonance

imaging was performed. It showed features characteristic of com-

plete placenta previa including outward bulging of the lower

uterine segment. The demarcation between the placenta and

uterine muscle layer was unclear, with heterogeneous signal in-

tensity 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 operativebloodloss. 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 in-

fant weighting 2920 g with 1-minute and 5-minute Apgar scores of

8 and 9, respectively, was delivered through a longitudinal hyster-

otomy 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 catheterwas then inserted through the rear end of the abdominal aorta and

loop ligation was performed (Figure 1). After meticulously dissect-

ing the uterine ligaments and vessels, a rapid hysterectomy was

performed, and the cervical vault was repaired. The surgical pro-

cedure 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. Patho-

logic 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 deliveryand in cases wherethe placenta adheres

to or implants into the uterine scar[4]. These patients have a highrisk 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 utero-

tonic drugs, intrauterine packing (e.g., Bakri balloon), external

compression with uterine sutures (e.g., B-Lynch and hemostatic

* 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).

Contents lists available atScienceDirect

Taiwanese Journal of Obstetrics & Gynecology

j o u r n a l h o m e p a g e : w w w . t j o g - o n l i ne . c o m

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.

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

mailto:245180977@qq.comhttp://www.sciencedirect.com/science/journal/10284559http://www.tjog-online.com/http://dx.doi.org/10.1016/j.tjog.2014.08.006http://dx.doi.org/10.1016/j.tjog.2014.08.006http://dx.doi.org/10.1016/j.tjog.2014.08.006http://dx.doi.org/10.1016/j.tjog.2014.08.006http://dx.doi.org/10.1016/j.tjog.2014.08.006http://dx.doi.org/10.1016/j.tjog.2014.08.006http://www.tjog-online.com/http://www.sciencedirect.com/science/journal/10284559http://crossmark.crossref.org/dialog/?doi=10.1016/j.tjog.2014.08.006&domain=pdfmailto:245180977@qq.com

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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 necessitatinghysterectomy [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 ach-

ieved 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 pro-

phylactic 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 whomCH forplacenta 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 ar-

tery 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% oc-

clusion. 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 ob-

stetric 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 oc-

clusion in patients with placenta previaaccreta/increta.In their study,

15 patients with preoperative internal abdominal artery BC [intra-

abdominal 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 andfor 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 cross-

clamping of the IAA during CH to minimize operative blood loss

in placenta previa increta/percreta. The aorta was cross-clampedusing 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 tempo-

rary 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. Quet 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),

Figure 1. (AeD) Operative photographs showing the retroperitoneal dissection that was initially performed to se parate 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.

M.-l. Long et al. / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 323e325324

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medium level (L2, above the renal artery), and low level (L4, above

the common iliac artery) were between 25 minutes and 30 mi-

nutes. 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 puncturesite 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 temporaryloop ligation of the abdominal aorta during CH.

However, further studies in a larger number of cases are needed toevaluate the safety and efcacy of this procedure.

Conicts of interest

The authors have no conicts of interest relevant to this article.

References

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