Home About us Editorial board Ahead of print Browse Articles Search Submit article Instructions Subscribe Contacts Login 
  • Users Online: 677
  • Home
  • Print this page
  • Email this page

Previous article Browse articles Next article 
J Res Med Sci 2022,  27:63

Prophylactic hypogastric arterial ligation before cesarean hysterectomy for controlling complications in pregnant women with placenta adherent abnormality: A randomized controlled clinical trial

1 Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Community and Family Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Surgery, School of Medicine Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission30-Aug-2021
Date of Decision28-Feb-2022
Date of Acceptance07-Mar-2022
Date of Web Publication27-Aug-2022

Correspondence Address:
Dr. Zahra Niakan
Isfahan University of Medical Sciences, Isfahan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrms.jrms_763_21

Rights and Permissions

Background: Placenta adherent abnormality (PAA) is abnormal attachment of the placenta to the myometrium. This abnormal placenta binding has severe clinical consequences for the mother and the fetus. We investigated the outcomes of hypogastric arterial ligation (HAL) before hysterectomy compared to hysterectomy alone in pregnant women with PAA. Materials and Methods: In this randomized controlled clinical trial, 70 patients were randomly allocated to HAL along with hysterectomy and hysterectomy alone groups (35 in each Group). The total amount of intraoperative blood loss, the need for intraoperative blood products transfusion, frequency of deep vein thrombosis, duration of surgery, duration of hospitalization, and visceral trauma were compared between 2 Groups. Results: Finally, 64 patients completed the study protocol with mean age of 33.84 ± 4.25 years. The study groups were comparable in terms of basic baseline demographic and clinical characteristics. Visceral trauma was less frequently occurred in HAL group compared to hysterectomy alone (0% vs. 15.6%; P = 0.02). Intraoperative blood loss (1525 ± 536.41 cc vs. 2075 ± 889.36 cc; P = 0.001) and were significantly lower in HAL group compared to hysterectomy alone. Duration of operation (179.06 ± 36.28 vs. 197.66 ± 39.47; P = 0.05) and hospitalization (4.97 ± 2.20 vs. 6.10 ± 2.39; P = 0.03) also were significantly lower in HAL group. Conclusion: Our findings suggest that prophylactic HAL has a protective effect on the reduction of blood loss and less visceral trauma in pregnant women with PAA.

Keywords: Deep vein thrombosis, hemorrhage, hypogastric, hysterectomy, placenta accrete

How to cite this article:
Movahedi M, Niakan Z, Shahshahan Z, Hooshmand Meibodi AR, Babak A, Saeidi M. Prophylactic hypogastric arterial ligation before cesarean hysterectomy for controlling complications in pregnant women with placenta adherent abnormality: A randomized controlled clinical trial. J Res Med Sci 2022;27:63

How to cite this URL:
Movahedi M, Niakan Z, Shahshahan Z, Hooshmand Meibodi AR, Babak A, Saeidi M. Prophylactic hypogastric arterial ligation before cesarean hysterectomy for controlling complications in pregnant women with placenta adherent abnormality: A randomized controlled clinical trial. J Res Med Sci [serial online] 2022 [cited 2023 Mar 28];27:63. Available from: https://www.jmsjournal.net/text.asp?2022/27/1/63/354868

  Introduction Top

Placenta adherent abnormality (PAA), as the most problematic issue in obstetric surgery, has substantially over the past 30 years, with one estimate increasing from 4 to 14.4/10,000 deliveries.[1],[2] PAA is divided into accreta, increta, and percreta based on invasion of the placental to the myometrium and visceral organs such as the bladder and intestine.[3],[4]

An attempt to separate it following delivery of the fetus may cause severe bleeding (as the most common complication), deep vein thrombosis (DVT), multiple organ dysfunction, and failure such as acute respiratory distress syndrome, renal failure, and even maternal death.[1],[5],[6],[7]

The recommended approach to abnormally invasive placenta (AIP) is total hysterectomy following delivery of the fetus.[8] Blood loss during hysterectomy might be severe during operation especially in placenta percreta cases.[9] Thought, the literature has been described that nonsurgical measures such as administration of tranexamic acid and the use of cell-saver equipment during surgery[10],[11],[12],[13] and also surgical measures such as hypogastric (internal iliac) artery ligation (HAL), intraoperative balloon occlusion of the aorta, common iliac, internal iliac, and uterine arteries[14],[15],[16] are both effective to reduce blood loss and facilitate surgery. However, there is no clear consensus on effective measures that should be used at the time of cesarean hysterectomy (CH) to prevent massive blood loss and reduce the principal uterine vascularity during surgery.[14],[17]

To date, the most of studies attempt to control postpartum hemorrhage (PPH)[18],[19],[20] or these therapeutic modality have been limited to case reports and case–control comparisons.[14],[21],[22] Furthermore, it has been shown that balloon occlusion of the internal iliac artery (IIA) by interventional radiology was found to be ineffective for reducing blood loss and decreasing blood transfusion rates.[15],[22],[23],[24],[25],[26] Papillon-Smith et al. study recently revealed that the prophylactic placement of HAL during CH for PAA disorders had advantage such as lower complication rate, shorter total procedure time, and less blood loss compared to those Undergoing endovascular balloons.[17]

It looks like the most efficient procedures in reducing blood flow are the methods performing during operation, not postoperation. Hence, we design this randomized clinical trial study, as the first study in Iran and scare studies over the world to investigate the prophylactic effect of HAL method compared to hysterectomy alone on the blood loss, transfusion rates, and other complications of CH in pregnant women with confirmed diagnosis of PAA.

  Materials and Methods Top

This single blind parallel-randomized controlled clinical trial study was conducted in the Gynecology Department of Alzahra Hospital, Isfahan, Iran, during October 2018 to September 2019. This study was approved by the Ethics Committee of Isfahan University of Medical (Code: IR.MUI.MED.REC.1397.156). Furthermore, the protocol of the study was registered to the Iranian Registry of Clinical Trials (IRCT; Code: IRCT20190123042467N1). All participants and their families were fully informed about how the study was conducted, the possible benefits, and its side effects then provided written and informed consent. The inclusion criteria were pregnant women with the placental adherent abnormality diagnosed by two experienced specialists using color Doppler ultrasonography or the pregnant women who were candidate for hysterectomy during cesarean section according to the physician's discretion with gestational age ≥24 weeks.

The exclusion criteria were HAL after hysterectomy to control bleeding, discontinue the intervention due to possible injuries to the participants, and women with a false-positive diagnosis of PAA by color Doppler ultrasound.

Sample size was determined in the current study to be 33, considering type one error rate (α = 0.05), statistical power 80% (1-β = 0.80) for detecting standardized effect size 0.7 for blood loss during operation as study main outcome. We recruited 35 patients in each group and allocation was done using simple randomization by generated random numbers by SPSS software. Allocation concealment was done by a nurse who was not a research team member using encrypted envelopes (A and B). Due to the nature of the intervention, it was not possible to blind the researcher, but the patient and the person who performed the statistical analyzes were blind to assigned groups.

Interventions and study outcomes evaluation

Women underwent HAL and then CH as intervention group, while control group underwent CH alone. Participants in both groups underwent general anesthesia with the same operating room conditions. In study (HAL) group, before hysterectomy, a right-angle clamp was placed under the IIA's anterior division after the posterior branches had branched from the main trunk (3.5 cm after the origin of IIA). To prevent damage to the external iliac vein, located in the lower lateral part of the IIA, the right-angle clamp was moved inward from under the IIA. In contrast, the endpoint of the clamp was held upward. After getting on the other side beneath the hypogastric artery, the suture material was grasped and pulled backward in the same direction. The ureter, external iliac artery, and other important anatomic landmarks are re-checked, and finally, the suture is tied carefully. An experienced gynecologist performed all HAL procedures. A vascular surgeon was on standby during the surgery for safety. All participants were given postoperative low molecular weight heparin (enoxaparin, 40–60 mg) daily during 10 days and the DVT pump was used in the recovery room, whenever the patient was not weight-bearing until discharge from hospital, to avoid thromboembolism. The amount of intraoperative blood loss, as a primary outcome, was calculated from the volume of blood in the suction canisters and the weighed laps (obtained from the pre and postoperative difference in weight of the towels and drapes placed beneath the patients).[27],[28] As the secondary outcomes, the need for intraoperative blood products transfusion, frequency of DVT, duration of surgery, duration of hospitalization (days), and visceral trauma were assessed. Duplex ultrasonography was used to investigate the existence of DVT in case of clinical suspicion. The number of blood products transfusion and the extent of visceral trauma were measured by direct counting. A timer recorded the duration of surgery and the duration of hospitalization was obtained by reading participants' medical records. The history of previous deliveries and gynecological procedures was gathered from medical documents of subjects. Full investigations in the form of complete blood picture investigated individualized.

Statistical analysis

Statistical analysis was done by SPSS software for Windows version 25 (SPSS Inc., Chicago, IL). Numerical data were reported as mean ± standard deviation and categorical data as frequency and percentage. The normality of data was assessed by Kolmogorov–Smirnov test. Nonnormally positive skewed data were subjected to logarithmic transformation for normalizing data. Continuous and categorical baseline variables were compared between two groups using independent samples t-test or Mann–Whitney U-test and Chi-squared, respectively. Furthermore, the continuous and categorical study outcomes were compared by using independent sample t-test and Chi-squared (or Fisher exact t-test when appropriate). For evaluating the interaction between intervention and type of PAA, we use two-way multivariate analysis of variance (two-way MANOVA).

  Results Top

Of 70 participants who initially entered in this study, 6 persons excluded (declined to participate), and finally 64 women were included in the analysis [Figure 1]. The characteristics of these women were described in [Table 1].
Figure 1: Consort flow diagram of the patients' recruitment into the study

Click here to view
Table 1: Maternal demographic and basic clinical characteristics of study participants in two study groups (n=32/each group)

Click here to view

The mean age of participants was 33.84 ± 4.25 years (range 24–44 years). All diagnoses were made in the second and third trimesters, at a mean gestational age of 24.5 ± 1.7 weeks (range 18–36 weeks). The mean gestational age at CH was 33.2 ± 0.9 weeks. Mean overall gravida was 3.42 ± 1.47. Mean duration of operation was 188.36 ± 38.76 min. The initial hemoglobin level was 11.48 ± 2.63.

Among the 64 patients, the most frequent indication for PAA was found to be placenta percreta, accreta, and increta, respectively. There were no significant differences between 2 groups in terms of maternal age, gestational age, gravidity and parity, caesarean section and curettage history and PAA [Table 1].

The mean values of blood loss during operation (P = 0.01), duration of operation (P = 0.05), time of hospitalization (P = 0.03) were significantly lower in women who underwent the prophylactic HAL technique during CH compared with women who underwent hysterectomy. The number of intraoperative transfused packed red blood cells although was not statistically different between 2 groups (P = 0.11); it was clinically lower in prophylactic HAL group than control group. There was no visceral trauma during operation in study HAL group compared to control group (0 vs. 15.6%) (P = 0.02); there were bladder (3 persons) and intestine (2 persons) injuries in control group [Table 2].
Table 2: Comparison of study outcomes between two study groups (n=32/each)

Click here to view

We used MANOVA for comparing the mean values of study outcomes in cross categories of interventions and type of PAA (interaction between intervention and PAA). We did not find significant interaction for each study outcome, indicating that the intervention effects did not depend on type of PAA [Table 3].
Table 3: The comparison of mean values of complications in cross categories of interventions and type of placenta adherent abnormality

Click here to view

  Discussion Top

According to the best of our knowledge, this is the second randomized trial evaluating the efficacy of bilateral HAL, as an intervention to decrease the blood loss during CH for PAA. We found that bilateral HAL on the amount of blood loss during CH for PAA is beneficial. As, the gynecologist of our study described that, the bilateral HAL intervention decreased perceived difficulty and improved vision due to less bloody and decreased problematic of surgical procedure compared to control group that associated with significantly lower visceral trauma in women undergoing HAL (P = 0.02) and shorter operative duration time (179.06 ± 36.28 vs. 197.66 ± 39.47), however, is not statistically significant (P = 0.05).

In agreement with our finding, previous studies retrospectively[17],[21],[29] or prospectively[30] reviewed the medical records of all patients diagnosed with PAA; the estimated blood loss was significantly decreased in the study group compared with the control group. Whereas, in some studies,[31],[32],[33] the mean blood loss with or without IIA ligation (IIAL) was not significantly different. Kuhn et al.'s study[33] showed that IIAL was not effective in reducing bleeding in cases diagnosed with placenta percreta, which may partially due to the method of study that blood loss was estimated and not quantified, as well as small sample size of the study. Another reason that other studies[31],[32] have been raised that is in some cases massive blood flow was observed from external iliac artery to anastomosis lines, and even anastomoses with inferior epigastric and inferior mesenteric arteries contributed blood buildup of uterus again through uterine artery, which would explain the failure of IIAL in controlling the bleeding in AIP.

In line with previous study[34] which indicated more surgical trauma followed by abdominal hysterectomy operation, our finding declares that the visceral trauma in women undergoing HAL is significantly lower than the control group. This may be due to less bloody leading to the better sight of anatomical location of viscera and deep vascular structures in study group that makes it easier to do CH and leads to less tissue and visceral trauma. However, it should be noted that the risks are related to experience and technique, with principal concerns being injury to the nearby external iliac vein or inadvertent ligation of the posterior division.

As, the superiority of undergoing prophylactic HAL previously have been demonstrated compared to preoperative placement of balloon-occlusive devices during CH for PAA.[17] Furthermore, the Chitragari et al. meta-analysis study reported that HAL is safer than hypogastric arterial embolization and coverage for ischemic complications.[35] On the other hand, the alternative method of decreasing arterial pelvic perfusion is vessel ligation, that is recognized as an integral component in the surgical management of major obstetrical hemorrhage.[36] This technique also has the advantage of being inexpensive, available in low-resource settings, and can be performed in under 10 min by an experience surgeon.[17]

Altogether, it seems that HAL is an effective prophylactic method in decreasing hemorrhage during a hysterectomy in women with PAA and other emergency conditions like postpartum hemorrhage.[37]

The strength of the study lies in being the first randomized control trial in Iran, to compare between the ligation and nonligation of IIA in cases of PAA undergoing CH. While, the most of previous studies were retrospective or prospective (based on medical document) which their nature may have introduced information bias.

Furthermore, we obtained a large sample size of women with various PAA (accreta, increta, and percreta) in this study, whereas most studies investigated just one spectrum the of PAA.

Another strength of our study is that all patients undergoing CH by an expert gynecologist with the definite experience, talent, and speed at the same hospital. This will minimize interoperator skill variability between groups to avoid performance bias that provides a more valid assessment of the procedure being evaluated.

  Conclusion Top

According to the findings of this study, it could be concluded that HAL is a safe and effective prophylactic technique that should be considered as a therapeutic option for controlling blood loss during hysterectomy performed for pregnant women with PAA. More studies with larger populations are required to confirm our data.


The proposal of the study was reviewed and approved by the ethics committee of Isfahan University of Medical Sciences, Isfahan, Iran (Code: IR.MUI.MED.REC.1397.156). We would like to thank of Isfahan University of Medical Sciences for its assistance in conduct of the current study. We also thank of Isfahan Al-Zahra Hospital staff for their assistances in this project.

Financial support and sponsorship

This article is extracted from the M.D. dissertation of Zahra Niakan which has been financially supported by Isfahan University of Medical Sciences, Isfahan, Iran.

Conflicts of interest

There are no conflicts of interest.

  References Top

Goh WA, Zalud I. Placenta accreta: Diagnosis, management and the molecular biology of the morbidly adherent placenta. J Matern Fetal Neonatal Med 2016;29:1795-800.  Back to cited text no. 1
Papillon-Smith J, Singh SS, Ziegler C. Internal iliac artery rupture caused by endovascular balloons in a woman with placenta percreta. J Obstet Gynaecol Can 2016;38:1024-7.  Back to cited text no. 2
Garmi G, Salim R. Epidemiology, etiology, diagnosis, and management of placenta accreta. Obstet Gynecol Int 2012;2012:873929.  Back to cited text no. 3
Protocols for High-Risk Pregnancies: An Evidence-Based Approach, 7th ed. Editor(s): John T. Queenan MD, Catherine Y. Spong MD, Charles J. Lockwood MD, MHCM, First published: 29 November 2020. Print ISBN:9781119635260 |Online ISBN:9781119635307 |DOI:10.1002/9781119635307. © 2021 John Wiley & Sons Ltd.  Back to cited text no. 4
Bansal CL, Gupta J, Asthana D, Kayal A. Placenta percreta in first trimester leading to disseminated intravascular coagulopathy (DIC): A rare case report. J Clin Diagn Res 2015;9:D03-4.  Back to cited text no. 5
Judy AE, Lyell DJ, Druzin ML, Dorigo O. Disseminated intravascular coagulation complicating the conservative management of placenta percreta. Obstet Gynecol 2015;126:1016-8.  Back to cited text no. 6
Gupta P, Khare V, Kumar D, Ahmad A, Banerjee G, Singh M. Comparative evaluation of disc diffusion and E-test with broth micro-dilution in susceptibility testing of amphotericin B, voriconazole and caspofungin against clinical Aspergillus isolates. J Clin Diagn Res 2015;9:C04-7.  Back to cited text no. 7
Committee on Practice Bulletins-Obstetrics. Practice bulletin No. 183: Postpartum hemorrhage. Obstet Gynecol 2017;130:e168-86.  Back to cited text no. 8
Marcellin L, Delorme P, Bonnet MP, Grange G, Kayem G, Tsatsaris V, et al. Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta. Am J Obstet Gynecol 2018;219:193.e1-9.  Back to cited text no. 9
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): An international, randomised, double-blind, placebo-controlled trial. Lancet 2017;389:2105-16.  Back to cited text no. 10
Xu J, Gao W, Ju Y. Tranexamic acid for the prevention of postpartum hemorrhage after cesarean section: A double-blind randomization trial. Arch Gynecol Obstet 2013;287:463-8.  Back to cited text no. 11
McDonnell NJ, Kennedy D, Long LJ, Gallagher-Swann MC, Paech MJ. The development and implementation of an obstetric cell salvage service. Anaesth Intensive Care 2010;38:492-9.  Back to cited text no. 12
Elagamy A, Abdelaziz A, Ellaithy M. The use of cell salvage in women undergoing cesarean hysterectomy for abnormal placentation. Int J Obstet Anesth 2013;22:289-93.  Back to cited text no. 13
Knuttinen MG, Jani A, Gaba RC, Bui JT, Carrillo TC. Balloon occlusion of the hypogastric arteries in the management of placenta accreta: A case report and review of the literature. Semin Intervent Radiol 2012;29:161-8.  Back to cited text no. 14
Chen M, Lv B, He G, Liu X. Internal iliac artery balloon occlusion during cesarean hysterectomy in women with placenta previa accreta. Int J Gynaecol Obstet 2019;145:110-5.  Back to cited text no. 15
Ballas J, Hull AD, Saenz C, Warshak CR, Roberts AC, Resnik RR, et al. Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: A management paradox. Am J Obstet Gynecol 2012;207: 5.e1-5.  Back to cited text no. 16
Papillon-Smith J, Hobson S, Allen L, Kingdom J, Windrim R, Murji A. Prophylactic internal iliac artery ligation versus balloon occlusion for placenta accreta spectrum disorders: A retrospective cohort study. Int J Gynaecol Obstet 2020;151:91-6.  Back to cited text no. 17
İçen MS, Findik FM, Akin Evsen G, Ağaçayak E, Yaman Tunç S, Evsen MS, et al. Hypogastric artery ligation in postpartum haemorrhage: A ten-year experience at a tertiary care centre. J Obstet Gynaecol 2021;41:536-40.  Back to cited text no. 18
Boynukalin FK, Boyar H, Gormus H, Aral AI, Boyar N. Bilateral hypogastric artery ligation in emergency setting for intractable postpartum hemorrhage: A secondary care center experience. Clin Exp Obstet Gynecol 2013;40:85-8.  Back to cited text no. 19
Evsen MS, Sak ME, Soydine HE, Basaranoglu S, Bakir C, Sak S, et al. Internal iliac artery ligation for severe postpartum hemorrhage. Ginekol Pol 2012;83:665-8.  Back to cited text no. 20
Chou MM, Hwang JI, Tseng JJ, Ho ES. Internal iliac artery embolization before hysterectomy for placenta accreta. J Vasc Interv Radiol 2003;14:1195-9.  Back to cited text no. 21
Bodner LJ, Nosher JL, Gribbin C, Siegel RL, Beale S, Scorza W. Balloon-assisted occlusion of the internal iliac arteries in patients with placenta accreta/percreta. Cardiovasc Intervent Radiol 2006;29:354-61.  Back to cited text no. 22
Shrivastava V, Nageotte M, Major C, Haydon M, Wing D. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol 2007;197: 5.e1-5.  Back to cited text no. 23
Salim R, Chulski A, Romano S, Garmi G, Rudin M, Shalev E. Precesarean prophylactic balloon catheters for suspected placenta accreta: A randomized controlled trial. Obstet Gynecol 2015;126:1022-8.  Back to cited text no. 24
Feng S, Liao Z, Huang H. Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: An impact study. Anaesthesia 2017;72:853-8.  Back to cited text no. 25
Clausen C, Stensballe J, Albrechtsen CK, Hansen MA, Lönn L, Langhoff-Roos J. Balloon occlusion of the internal iliac arteries in the multidisciplinary management of placenta percreta. Acta Obstet Gynecol Scand 2013;92:386-91.  Back to cited text no. 26
Quantification of blood loss: AWHONN practice brief number 1. J Obstet Gynecol Neonatal Nurs 2015;44:158-160. doi: 10.1111/1552-6909.12519. Epub 2014 Nov 7. PMID: 25382673.  Back to cited text no. 27
Levine AB, Kuhlman K, Bonn J. Placenta accreta: Comparison of cases managed with and without pelvic artery balloon catheters. J Matern Fetal Med 1999;8:173-6.  Back to cited text no. 28
Köstü B, Ercan Ö, Özer A, Bakacak M, Sakalli H. Prophylactic hypogastric artery ligation in surgery for placental invasion disorders. J Turk German Gynecol Assoc 2016;17:S49.  Back to cited text no. 29
Refaie W, Fawzy M, Shabana A. Prophylactic bilateral internal iliac artery ligation for management of low-lying placenta accreta: A prospective study. Tanta Med J 2014;42:146.  Back to cited text no. 30
  [Full text]  
Iwata A, Murayama Y, Itakura A, Baba K, Seki H, Takeda S. Limitations of internal iliac artery ligation for the reduction of intraoperative hemorrhage during cesarean hysterectomy in cases of placenta previa accreta. J Obstet Gynaecol Res 2010;36:254-9.  Back to cited text no. 31
Hussein AM, Dakhly DM, Raslan AN, Kamel A, Abdel Hafeez A, Moussa M, et al. The role of prophylactic internal iliac artery ligation in abnormally invasive placenta undergoing caesarean hysterectomy: A randomized control trial. J Matern Fetal Neonatal Med 2019;32:3386-92.  Back to cited text no. 32
Kuhn T, Martimucci K, Al-Khan A, Bilinski R, Zamudio S, Alvarez-Perez J. Prophylactic hypogastric artery ligation during placenta percreta surgery: A retrospective cohort study. AJP Rep 2018;8:e142-5.  Back to cited text no. 33
Härkki-Sirén P, Sjöberg J, Toivonen J, Tiitinen A. Clinical outcome and tissue trauma after laparoscopic and abdominal hysterectomy: A randomized controlled study. Acta Obstet Gynecol Scand 2000;79:866-71.  Back to cited text no. 34
Chitragari G, Schlosser FJ, Ochoa Chaar CI, Sumpio BE. Consequences of hypogastric artery ligation, embolization, or coverage. J Vasc Surg 2015;62:1340- 7.e1.  Back to cited text no. 35
Leduc D, Senikas V, Lalonde AB; Clinical Practice Obstetrics Committee. Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can 2009;31:980-93.  Back to cited text no. 36
Cekmez Y, Ozkaya E, Öcal FD, Küçüközkan T. Experience with different techniques for the management of postpartum hemorrhage due to uterine atony: Compression sutures, artery ligation and Bakri balloon. Ir J Med Sci 2015;184:399-402.  Back to cited text no. 37


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


Previous article  Next article
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded109    
    Comments [Add]    

Recommend this journal