Question

Order of ligation of devascularization in PPH (Postpartum Hemorrhage)

• A. Uterine artery, pudendal artery, vaginal artery
• B. Uterine artery, internal iliac, obturator artery
• C. Uterine artery, ovarian artery, internal iliac artery
• D. Uterine artery, ovarian artery, vaginal artery

Hint:

Recall the stepwise surgical approach to devascularization starting with the primary uterine blood supply and then addressing collateral vessels.

Answer 1

The Correct Option is C

Topic: Surgical management of Postpartum Hemorrhage (PPH) -- Devascularization.

When conservative medical measures fail (oxytocin, ergometrine, misoprostol, tranexamic acid), surgical devascularization is performed in a stepwise manner to preserve the uterus:

Step 1 -- Uterine artery ligation (O'Leary stitch):
Bilateral ligation of uterine arteries just below the level of lower uterine segment. Cuts off the dominant blood supply.

Step 2 -- Ovarian artery ligation:
Ligates the utero-ovarian arcade (collateral supply from ovarian vessels via the anastomosis with uterine artery).

Step 3 -- Internal iliac (hypogastric) artery ligation:
Ligation of the anterior division reduces pelvic arterial pulse pressure by $\sim$85%. Pioneered by Howard Kelly for cervical cancer bleeding, later applied to PPH.

The sequence follows the anatomical hierarchy of uterine blood supply:
\[\text{Uterine a.} \rightarrow \text{Ovarian a.} \rightarrow \text{Internal iliac a.}\]

If all fail: Hysterectomy (definitive).

\[\boxed{\text{Uterine artery, Ovarian artery, Internal iliac artery}}\]