From salvage hysterectomy to damage control: uterine artery ligation with tamponade for AFE with refractory hemorrhage in a 10-year analysis.

BACKGROUND

Amniotic fluid embolism (AFE) is a leading cause of maternal mortality and peripartum hysterectomy. Damage-control surgery offers a theoretical path to uterine preservation, but evidence in AFE is lacking.

OBJECTIVE

To evaluate a paradigm shift from radical hysterectomy to a uterus-preserving damage-control strategy for AFE with refractory postpartum hemorrhage.

METHOD: In this single-center retrospective analysis (2015-2025), patients were categorized into a Radical Surgery Era (2015-2019, n = 5) and a Damage Control Era (2020-2025, n = 6). The latter received a standardized protocol: bilateral uterine artery ligation plus intrauterine tamponade (Bakri balloon or gauze). Descriptive statistics were used.

RESULTS

Among 284,143 deliveries, 11 AFE cases were identified (incidence 3.87/100,000). Maternal survival was comparable (Damage Control 5/6, 83.3% vs. Radical 4/5, 80%). Uterine preservation increased from 0% (0/5) to 66.7% (4/6). Median estimated blood loss was lower (2450 vs. 4000 mL), with no increase in transfusion requirements or ICU stay. Bakri balloon tamponade (2/2) showed more consistent hemostasis and coagulation recovery than gauze packing (2/4).

CONCLUSIONS

A standardized damage-control protocol for AFE-uterine artery ligation with tamponade-is feasible and effective. It preserves maternal survival, significantly increases uterine preservation, and does not increase hemorrhage or resource use. Balloon tamponade appears preferable, supporting fertility preservation in AFE management.