**7.7 Role of abdominal packing after peripartum hysterectomy**

The scientific evidence suggests that abdominal packing can effectively control bleeding after peripartum hysterectomy in cases of intractable hemorrhage. Abdominal packing techniques include pads or roller gauze and balloon packs and abdominal packs retrieved within 24–48 hours. Studies have shown that abdominal packing can be successful in controlling bleeding after peripartum hysterectomy, even in cases where bleeding persists after the hysterectomy. However, there are potential

risks associated with abdominal packing, such as infection and embolization of nontargeted vessels. The decision to use abdominal packing should be individualized based on the patient's clinical presentation and medical history [31, 32].

In a study that included more than a million deliveries consisting of 718 peripartum hysterectomies and 53 abdominal packing operations (about 1 per 14 hysterectomies), the success rate of abdominal packing was 62%, and the mortality rate was 24%. Other patients required other measures of interventions. The study concluded that abdominal packing was considerably helpful to physicians in means of being an option as a lifesaving procedure. The mean time for preserving the packing was 39 hours postpartum [31].

Some surgeons depend on modifications to abdominal packing procedures in the literature. In a six-patient case study, authors wrapped hot fluid-soaked and squeezed packing material circularly around a Bakri-type balloon and stabilized it, applying gentle pressure around the whole pelvic vasculature using the vaginal route. The estimated amount of bleeding was limited compared to the conventional packing procedure, and the method was useful in five patients [33].

#### **7.8 Role of uterine compression sutures**

The scientific evidence suggests that uterine compression sutures can effectively avoid cesarean hysterectomy in cases of intractable postpartum hemorrhage. Uterine compression sutures involve the placement of sutures around the uterus to compress the bleeding vessels and reduce bleeding. Several studies have evaluated the efficacy and safety of uterine compression sutures in preventing cesarean hysterectomy and reducing morbidity and mortality associated with postpartum hemorrhage. The benefits of uterine compression sutures include preservation of fertility, avoidance of hysterectomy, and ease of application. However, there are also potential risks associated with uterine compression sutures, such as infection, uterine rupture, and decidual cast formation [34].

Studies have shown that uterine compression sutures with additional hemostatic procedures can effectively control postpartum hemorrhage and prevent hysterectomy [35]. The B-Lynch suture technique and modified Pereira suture have also been reported to be effective alternatives to cesarean hysterectomy [36]. However, these methods are only recommended as first-line interruptions and will cause of losing valuable time during the management of patients with severe PAS and ones who already lost a considerable amount of blood.

#### **7.9 Prophylactic intraoperative uterine artery embolization (UAE)**

Prophylactic intraoperative uterine artery embolization during cesarean hysterectomy is a technique used to reduce the risk of intraoperative bleeding and complications in cases where cesarean delivery and subsequent hysterectomy are anticipated to be challenging or associated with a high risk of bleeding. The procedure involves the selective occlusion of the uterine arteries using embolic materials to decrease blood flow to the uterus.

The role of prophylactic intraoperative UAE is to limit blood loss during the surgical procedure by reducing blood flow to the uterus. By temporarily blocking the uterine arteries, the blood vessels that supply the uterus, the procedure aims to minimize the risk of excessive bleeding, which can be particularly challenging in cases of placenta accreta, increta, or percreta, where the placenta is abnormally attached to

the uterine wall [37]. Several studies have evaluated the efficacy and safety of UAE in preventing cesarean hysterectomy and reducing morbidity and mortality associated with PAS [38]. The benefits of UAE include decreased blood loss, reduced morbidity, and preservation of fertility in some cases. However, there are also potential harms associated with UAE, such as the risk of embolization of nontargeted vessels, uterine necrosis, and infection [39].
