1273 The effectiveness of bilateral hypogastric artery ligation for obstetric hemorrhage in three different underlying conditions and its impact on future fertility Orhan Unal, Bulent Kars, Esra Esim Buyukbayrak, A. Yasemin Karageyim Karsidag, & Cem Turan Department of Obstetrics and Gynecology, Dr. Luti Kirdar Kartal Education and Research Hospital, Istanbul, Turkey Journal of Maternal-Fetal and Neonatal Medicine, 2011; 24(10): 1273-1276 Copyright © 2011 Informa Uk,Ltd. ISSN 1476-7058 print/ISSN 1476-4954 online DOI: 10.3109/14767058.2011.574751 Correspondence: Dr Bulent Kars, Department of Obstetrics and Gynecology, Dr. Luti Kirdar Kartal Education and Research Hospital, Istanbul, Turkey. E-mail: bulent1972kars@yahoo.com Objective. To evaluate the effectiveness of bilateral hypogastric artery ligation (BHAL) according to the underlying cause and future fertility in these women. Method. Fifty-eight women who underwent BHAL operation in our department between 1997 and 2008 were further divided into three subgroups in accordance with the underlying disease. Group 1: Severe preeclampsia with coagulapathy (n:24). Group 2: Postpartum hemorrhage (PPH) due to uterine atony (n:24). Group 3: Massive hemorrhage due to inadequate surgical control of bleeding and/ or uterine rupture (n:10). Effectiveness of BHAL according to the underlying cause and future fertility after BHAL were evaluated. Results. Success rate of BHAL was found to be 87.9% (51 out of 58 patients). Complication rates of the groups were 25%, 12.5%, and 10%, respectively. There was one maternal death in each group. Mean hospital stay, blood and blood products transfusion need were similar for all groups. Thirty women out of 58 had desired future fertility, and 17/30 (56.7%) of them became preg- nant within less than 1 year. Conclusion. BHAL is a safe, effective, life-saving procedure in controlling massive PPH. It preserves future fertility and must be the first choice operation for PPH in young women whichever the underlying condition is. Keywords: Hypogastric artery ligation, future fertility, success rate Introduction Postpartum hemorrhage (PPH) remains a major cause of maternal mortality and morbidity in spite of outstanding improvements in management [1]. his is unfortunate because 90% of maternal deaths ater PPH are indeed preventable. he classical deinition of PPH is that estimated total blood loss is greater than 500 ml at vaginal delivery and it is greater than 1000 ml at cesarean delivery [2]. To some others, however, it is deined as a 10-point decrease in hematocrit between admission and postpartum [2], or a need for blood transfusion [3]. here is a controversy due to the limitations at clinical estimation of blood loss during delivery. PPH afects approximately 5–15% of women ater giving birth [2–4]. Causes of PPH include uterine atony, obstetric lacerations, retained placental tissue, and coagulation defects [5]. Among these causes, uterine atony is the most common cause of life threatening PPH [5]. In some conditions such as women not responding to medical treatment or treatment of a speciic underlying disorder like repairment of uterine rupture or a supralevator hematoma evacu- ation, surgical management plans including lapatomy with liga- tion of the uterine vessels, or bilateral hypogastric arteries, or even hysterectomy is taken into consideration [5]. Bilateral ligation of hypogastric artery (BHAL) is an alterna- tive life-saving operation for a woman who wishes to continue childbearing. BHAL is mainly indicated in PPH due to uterine atony rather than due to obstetric traumas [6]. However, there are reports of successful BHAL results in cases of uterine rupture and placenta accreta [7,8], but knowledge about the eiciency of BHAL in cases other than uterine atony is still insuicient in the literature. here are several reports that have examined and described the surgical technique in the literature, but data regarding future fertility following the procedure is rare [6,7,9–13]. he aim of this retrospective cohort study is to evaluate the insuicient points related to BHAL in the literature which are efectiveness according to diferent underlying causes and future fertility in these women. Materials and methods A cohort of 58 women to whom BHAL was performed between January 1997 and January 2008 in our tertiary centre was studied retrospectively. he patients were identiied by using operating theatre registers and record oice sources. Case notes were reviewed for clinical details and outcome of surgery. Women enrolled in the study cohort were further divided into three subgroups in accordance with the underlying disease. Group 1: Pregnant women who had severe preeclampsia and/ or hemolysis–elevated liver enzymes–low platelets (HELLP) syndrome with coagulopathy (n:24). Group 2: Pregnant women with PPH due to uterine atony (n:24). Group 3: Pregnant women who had massive hemorrhage due to inadequate surgical control of bleeding and/or uterine rupture (n:10). he surgical technique involves identiication of the bifurca- tion of the common iliac artery, which the ureter crosses. We entered the retroperitoneum posteriorly, entering the broad ligament medial to the infundibulopelvic ligament and lateral to the external iliac artery. he ureter was then retracted medially and aerolar tissue surrounding the artery was carefully dissected