{'fraction_non_alphanumeric': 0.01603206412825651, 'fraction_numerical': 0.0070140280561122245, 'mean_word_length': 4.738505747126437, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Internal iliac artery ligation for arresting postpartum haemorrhage

We read with interest the paper by Joshi et al. on the role of internal iliac artery ligation (IIAL) in the management of postpartum haemorrhage (PPH). We would like to draw attention to certain issues. 1. The authors made no attempt to define PPH or quantify blood loss. We suggest that the World Health Organization protocol should be adopted for accuracy. 2. The authors used oxytocin infusion and carboprost injections in women with atonic PPH. We suggest the use of rectal misoprostol 800-1000 mcg before resorting to IIAL. The low cost of the drug ease of administration and its heat stability make it especially appealing for use in the developing world. 3. In cases of atonic PPH there is no mention of whether uterus was manually explored/evacuated to effect the removal of retained placental tissue and/or clots. The presence of clots in uterus acts as a mechanical factor preventing uterine contraction and thereby leading to more haemorrhage. 4. Prophylactic IIAL was performed in 22 women at high risk of PPH during caesarean section in the absence of any significant uterine bleeding. We strongly discourage the use of prophylactic IIAL as very little is known about the fertility and pregnancy outcomes for women who have undergone IIAL. Although there are some reports of favourable outcome with regards to future fertility following IIAL they were all of small series. 5. IIAL was performed at the outset in women with ruptured uterus which according to the authors helped them to achieve haemostasis during hysterectomy or repair. We suggest using Green Armytage clamp/Allis forceps while repairing the torn edges of the uterus which saves time and improves haemostasis rather than embarking on IIAL. These comments aside the authors should be commended on their results and we agree that when all other measures fail; in the management of women with severe PPH IIAL should be considered promptly. (full text)