Kerala obstetrician’s device saves mothers from bleeding to death

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The “Paily Aortic Clamp” has shown good results in several centers in low-resource settings

The “Paily Aortic Clamp” has shown good results in several centers in low-resource settings

An aortic clamp developed by a state obstetrician to control torrential bleeding during the surgical management of placenta accreta Spectrum (PAS), a serious obstetric complication and a significant cause of maternal mortality, has proven to be very useful in contain blood loss and save maternal lives, without any incidence of vascular injury.

The “Paily Aortic Clamp”, developed by VP Paily, Senior Obstetrics Consultant and Master Trainer for the Federation of Obstetrics and Gynecology of Kerala, is currently being used in several centers across the state and in a few centers outside Kerala , with good results.

A retrospective review of 33 women with varying grades of PAS, who underwent caesarean section hysterectomies as elective or emergency procedures using Paily’s Aortic Clamp, appears in the March 2022 issue of International Journal of Gynecology and Obstetrics.

With the increase in the number of caesarean sections (C-sections) in public and private hospitals, PAS is becoming a major concern and is a significant cause of maternal mortality and morbidity. A previous C-section scar is the most typical risk factor for PAS because the placenta adheres deeply to the scar tissue and the uterine wall, sometimes spreading to nearby organs, such as the bladder.

This means that the placenta will not eject naturally after childbirth and any attempt to remove it will result in torrential bleeding (especially if it occurs unexpectedly during childbirth). Even when rescued, the woman suffers catastrophic morbidity, including loss of the uterus, bladder damage, and fistula formations.

The condition should be identified early during antenatal ultrasounds and the woman should be referred to a tertiary care center for a planned cesarean hysterectomy, to be performed at 34-25 weeks.

The management of PAS is therefore a nightmare for obstetricians around the world because, in addition to the risk of catastrophic blood loss, there is also the high likelihood of urological damage and massive transfusion requirements encountered during non-conservative surgery.

In high-resource settings, PAS disorders are cared for by multidisciplinary teams of expert gynecological and vascular surgeons, supported by anesthesiologists, resuscitators, radiologists and urologists.

In large tertiary centers, vascular surgeons attempt to reduce bleeding by using intravascular balloon occlusion at the lower end of the abdominal aorta or common iliac arteries.

But the application of Paily’s aortic clamp in low-resource settings, where access to unlimited amounts of blood to transfuse and the services of a vascular surgeon might not be available, says Dr. Paily, who has conducted countless demonstrations across the state on PAS Support using the Aortic Clamp.

The Paily Aortic Clamp is an easy aid that obstetricians themselves can use to control bleeding. It can be applied quickly, without retroperitoneal dissection to manage bleeding.

“We started promoting this method in 2011-2012 and now all state government medical colleges and many private hospitals are also using it to prevent torrential bleeding in PAS. Many cases of near misses that we analyzed in our recent maternal near-miss reviews showed that the clamp had been very handy,” he says.

The clamp, once attached, leaves a bloodless field for the surgeon attempting a complex pelvic dissection in a high-grade PAS. Dr. Paily says that in an emergency involving PAS, clamping works well as a “lifesaving intervention” because it can be applied more quickly than cross clamping or aortic balloon occlusion.

Of the 33 PAS cases examined in the study, none developed evidence of aortic wall rupture and had positive surgical outcomes with no clamp-related adverse events.

Dr. Paily, however, insists that only obstetrician-gynecologists with reasonable expertise should attempt to manage PAS using the aortic clamp and that the team should have a urologist to repair any accidental injury.

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