Surgical Interventions in Management of Atonic Pph -A Prospective Study

Abstract

Background: Postpartum haemorrhage (PPH) remains a leading direct cause of maternal mortality worldwide, with atonic PPH contributing the largest share despite evidence-based medical protocols. When uterotonics fail, timely surgical interventions are critical, particularly in low- and middle-income settings where interventional radiology is limited.

Methods: This prospective observational study was conducted in the Department of Obstetrics and Gynaecology, Karnataka Institute of Medical Sciences, Hubballi, from June 2023 to May 2024. All women with atonic PPH within 24 hours of delivery, in whom standard medical management (high-dose oxytocin, misoprostol, carboprost, uterine massage, tranexamic acid) failed and surgical intervention was required, were included (n=83). Women with secondary PPH (>24 hours) were excluded. Data on demographics, obstetric risk factors, type and sequence of surgical procedures, intra- and postoperative course, near-miss events (WHO criteria), and maternal deaths were recorded. Statistical analysis was performed using SPSS v26; p<0.05 was considered significant.

Results: Most women were young (mean age 25.2±4.3 years); 54.2% were unbooked and 75.9% delivered by caesarean section. Severe preeclampsia/gestational hypertension (51.8%) was the most frequent risk factor. Uterine artery ligation was performed in 62.7% and bilateral internal iliac artery ligation (BIIAL) in 48.2%; compression sutures (B-Lynch/Hayman) were used in 34.9%. Hysterectomy was required in 22/83 (26.5%) women, predominantly after failure of BIIAL. Uterine artery ligation alone controlled haemorrhage in 48.1% of cases, whereas hysterectomy was strongly associated with maternal mortality (71.4% of deaths; p=0.002) and near-miss status (36.7%; p<0.001). Overall maternal mortality was 8.4% and maternal near-miss occurred in 36.1%.

Conclusion: In this high-risk cohort, a stepwise devascularisation strategy—uterine artery ligation, BIIAL and uterine compression sutures—allowed uterine preservation in nearly three-quarters of women with refractory atonic PPH. However, a substantial proportion still required hysterectomy, which was strongly associated with severe morbidity and mortality, underscoring the need for earlier referral, protocolised escalation, and optimisation of perioperative critical care.