Embolization of the hypogastric artery after surgical ligation: A case series of two patients.

INTRODUCTION

The increasing incidence of obstetric complications, such as post-partum hemorrhage in the case of placenta accreta spectrum, calls for innovative and adapted therapeutic approaches. This presentation highlights the effectiveness of arterial embolization of the hypogastric artery, properly known as the internal iliac artery, in managing obstetric bleeding, even after initial surgical ligation. An approach never described in the literature.

PRESENATION OF CASES

1st Case: A 38-year-old patient, in her fourth pregnancy with two previous caesarean sections, was admitted for moderate metrorrhagia at 19 weeks gestation. Ultrasound showed a monofetal pregnancy at 17 WG with a 6 cm placental abruption and an anterior placenta with accretion signs. An emergency subtotal hysterectomy with triple Tsirulsikov arterial ligation was performed after transfusion. Due to persistent bleeding, bilateral hypogastric artery ligation and abdominal packing were added, but without improvement. The patient was referred for embolization after hemodynamic stabilization. The procedure was carried out successfully and no complications were reported. 2nd Case: A 35-year-old patient with vaginal bleeding from placenta accreta at 25 WG required hemostasis hysterectomy. Despite the procedure, bleeding continued, leading to bilateral hypogastric artery ligation and pelvic packing. The patient was hemodynamically stabilized and transferred for hypogastric artery ligation, which was successfully performed without complication.

DISCUSSION

The role of interventional radiology in managing postpartum hemorrhage (PPH) is well established, with substantial literature supporting the benefits of uterine artery embolization as a lifesaving and often uterine-sparing procedure in PPH. While its indication for prevention is well-known, what about post-operatively? Our experience indicates that consulting a radiologist specializing in pelvic embolization can yield satisfactory outcomes despite technical difficulties.

CONCLUSION

Embolization of the hypogastric arteries as well as embolization followed by surgical ligation of these arteries have been well described in the literature, the originality in our case reports is the embolization performed after surgical ligation which has not been described before according to our knowledge and which despite its technical difficulty can be a satisfactory alternative for the control of post-partum hemorrhage.