Pune: A study by a team of city doctors on aortic clamping for limiting blood loss during caesarean hysterectomy has been published in the International Journal of Gynaecology and Obstetrics, the official journal of the apex body of the International Federation of Gynaecology and Obstetrics (FIGO).
The doctors who published the study suggested a modified technique of temporary aortic clamping which can significantly reduce blood loss and further complications.
The study was conducted by a team of doctors from Pune’s King Edward Memorial Hospital (KEM) which includes Dr Vivek Joshi, director and consultant-obstetrics and gynaecology department, along with Dr Suhas Otiv, consultant, obstetrics and gynaecology, Dr Yogesh Sovani, consultant, urology and Dr Prasad Kulat, junior consultant, obstetrics and gynaecology.
The placenta normally detaches itself from the uterus after delivery of the baby. However, due to previous surgeries on the uterus, like a caesarean-section, the placenta becomes pathologically stuck to the uterus and, in some cases, invades outside the uterus (placenta percreta).
Dr Joshi said that in such cases the uterus has to be removed. He said, “A caesarean hysterectomy refers to removal of the uterus at the time of caesarean delivery and is a technically challenging procedure especially in placenta percreta due to massive bleeding which may occur during surgery. Currently, the technique used is the temporary aortic clamping which is an effective technique used during this procedure refers to clamping of the aorta which is the main artery coming from the heart and which supplies blood all the way down.”
Explaining the suggestions made by the team in the study, Dr Joshi said, “We clamp it just above the bifurcation of the common iliac arteries, so that blood supply to kidneys, intestine, spinal cord and other organs is preserved, but the blood supply to the pelvis is blocked. Earlier the clamping was done all round the artery, but this could injure the lumbar vessels leading to paralysis of the lower limbs. We modified the technique wherein the same clamp is put from above covering only two sides and avoids posterior dissection of the aorta. Since the blood supply to other parts is maintained and blood supply to pelvis is blocked, the blood loss is limited significantly making the procedure safe and effective. This is becoming important as more C-section procedures are being performed especially in the last decade or so which is causing an increase in the incidence of placenta percreta.”
{{/usCountry}}Explaining the suggestions made by the team in the study, Dr Joshi said, “We clamp it just above the bifurcation of the common iliac arteries, so that blood supply to kidneys, intestine, spinal cord and other organs is preserved, but the blood supply to the pelvis is blocked. Earlier the clamping was done all round the artery, but this could injure the lumbar vessels leading to paralysis of the lower limbs. We modified the technique wherein the same clamp is put from above covering only two sides and avoids posterior dissection of the aorta. Since the blood supply to other parts is maintained and blood supply to pelvis is blocked, the blood loss is limited significantly making the procedure safe and effective. This is becoming important as more C-section procedures are being performed especially in the last decade or so which is causing an increase in the incidence of placenta percreta.”
{{/usCountry}}Dr Joshi added that aortic clamping has reduced the blood loss from 3000-4000 ml to just about 650 ml. It would also reduce ICU admissions of such patients as complications are reduced. The simple technique of clamping can be mastered with practice by obstetricians under the supervision of a vascular surgeon, he said.
The conclusion is based on a case study series of 15 women with placenta percreta who underwent a caesarean section with total hysterectomy at the hospital. The doctors had tried this technique of temporary clamping of the infra-renal aorta for reducing blood loss during hysterectomy. These fifteen women with placenta percreta underwent classical caesarean section followed by total hysterectomy with temporary clamping of the aorta. The procedure was associated with median estimated intraoperative blood loss of 650 ml. In addition, none of these women had ureteric injury or needed post-operative intensive care. Dr Joshi said, “Aortic clamping for 28-70 minutes was not associated with any intraoperative vascular complications or postoperative ischemic lesions in the lower limbs, kidneys, or bowel. After the initial successful results, we increased the procedures and till today we have used this technique in 26 women with similar outcomes. We feel that this should become a standard for management of such conditions.”