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Postpartum hemorrhage (PPH) is defined as a blood loss of more than 500 ml following vaginal delivery and more than 1 l following cesarean section. The definitive procedure for severe PPH is hysterectomy. Due to its high morbidity and impact on fertility, it is undesirable in majority of patients. Fertility preserving procedures include internal iliac artery ligation (IIAL), uterine artery ligation (UAL), and selective uterine artery embolization (UAE). The former two surgical procedures require laparotomy. Moreover, there are high failure rates and morbidity of IIAL. Bilateral UAL has been shown to carry high success rates and relatively low complication rates. UAE is a less invasive technique that has success rates similar to UAL [1]. The advantage of utilisation of UAE early in the management protocol of severe refractory PPH has been well documented. In case of failure, surgical techniques (arterial ligation/hysterectomy) can be undertaken without any hindrance. In contrast, if the surgical ligation procedures are performed without consideration of UAE, the application of latter becomes extremely challenging (as in the present case) should the ligation procedures fail [2]. Thus, there should be low threshold for UAE in the setting of severe refractory PPH.  To the best of our knowledge, there are no reports of UAE through the ligated internal iliac artery and as such, our case emphasises that even arterial ligation does not preclude UAE, if the patient continues to worsen.

Uterine Artery Embolization Following Internal Iliac Arteries Ligation in a Case of Post-Partum Hemorrhage: A Technical Challenge