Postpartum Hemorrhage Treatment & Management

Updated: Jul 21, 2017
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
  • Print
Treatment

Medical Therapy

The treatment of patients with PPH has 2 major components: (1) resuscitation and management of obstetric hemorrhage and, possibly, hypovolemic shock and (2) identification and management of the underlying cause(s) of the hemorrhage. For the purpose of discussion, these components are discussed separately; however, remember that successful management of PPH requires that both components be simultaneously and systematically addressed.

Next:

Management of obstetric hemorrhage

Patients with PPH require aggressive measures to restore and maintain the circulating blood volume (and thereby perfusion pressure) to vital structures. All medical units involved in the care of pregnant women must have a protocol for the management of severe obstetric hemorrhage. [30] Management of massive obstetric hemorrhage outlines such a protocol for a pregnant woman in either the antepartum or postpartum period. [31] Implement the protocol in a manner similar to a cardiac arrest protocol, with the same attention to detail and documentation. Just as with other advanced life support protocols, conduct periodic reviews and practice drills.

The diagnosis of PPH is established by observing the amount of bleeding and the patient’s clinical status. The amount of blood lost and the patient’s level of consciousness and vital signs are continually assessed. Once the diagnosis is made, immediately notify appropriate staff members. The magnitude and underlying cause of the bleeding to some degree dictate which specialized personnel are called, but a minimum of 1 obstetrician and 1 anesthetist is necessary. Skilled midwives or nurses can be indispensable. Notifying blood transfusion services is essential because the timely availability of blood products is likely to be critical. As in a cardiac arrest, designate an experienced person to document critical information and times. Ensure the availability of an operating room. The speed with which PPH occurs, becomes life-threatening, and can be successfully managed with relatively simple interventions sometimes makes it difficult to decide when to institute the full protocol.

A randomized double-blind, placebo-controlled trial by the WOMAN Trial Collaborators reported that tranexamic acid significantly reduced death due to bleeding in women with postpartum hemorrhage when compared to the placebo group (155 [1.5%] of 10,036 patients vs 191 [1.9%] of 9985 patients in the placebo group). The study also found that the effects of tranexamic acid was greater when given within 3 hours of giving birth (89 [1·2%] vs 127 [1·7%] in the placebo group. Adverse events did not differ significantly in the two groups. [32]

Fluid resuscitation

Fluid resuscitation of women experiencing obstetric hemorrhage is sometimes overly conservative. Possible reasons for this include (1) blood loss being generally underestimated both in volume and rapidity, (2) women initially compensating well for losses because of their good health and the hypervolemia of pregnancy, (3) concerns that overresuscitation leads to pulmonary edema, and (4) failure to appreciate the dynamics of fluid shifts in the body.

Immediately commence resuscitation. Raising the legs improves venous return and is consistent with the positioning used to diagnose and treat the underlying causes of bleeding. Administer oxygen and obtain intravenous access. All intravenous lines started on the labor ward for other reasons must be placed with cannulas of sufficient gauge if PPH develops. Twice as much fluid can be infused through a 14-gauge intravenous line compared with an 18-gauge intravenous line over the same time period. [33] During labor, place at least 1 intravenous line in women at risk for PPH; consider a second line in patients at very high risk.

Perform the initial resuscitation with large volumes of crystalloid solution, either normal saline (NS) or Lactated Ringer’s solution (LRS), through peripheral intravenous sites. Central venous access is not required for the vast majority of patients with PPH, but do not delay establishing such access if necessary. Draw blood for baseline measurements at this time. NS is a reasonable solution in the labor ward setting because of its low cost and compatibility with most drugs and blood transfusions. The risk of hyperchloremic acidosis is very low in the setting of PPH. If large amounts (>10 L) of crystalloid are being infused, a change to LRS can be considered.

Dextrose-containing solutions, such as 5% dextrose in water or diluted NS in 5% dextrose in water, have no role in the management of PPH. Remember that the loss of 1 L of blood requires replacement with 4-5 L of crystalloid because most of the infused fluid is not retained in the intravascular space but instead shifts to the interstitial space. This shift, along with oxytocin use, may result in peripheral edema in the days following PPH. Healthy kidneys easily excrete this excess fluid. Use wide-open initial infusion rates, with the goal of infusing the required replacement volume over minutes rather than hours. PPH of up to 1500 mL in a healthy pregnant woman can usually be managed by crystalloid infusion alone if the cause of bleeding is arrested. Blood loss in excess of this usually requires the addition of a PRBC transfusion.

Because a large portion of crystalloid fluid volume is lost to the interstitial space, the use of colloids in resuscitation has been examined. These solutions are largely retained within the intravascular space and include albumin, dextran, hydroxyethyl starch, and modified fluid gelatin. A meta-analysis in the Cochrane Library comparing resuscitation with colloid solutions versus crystalloid favored the use of crystalloids with respect to mortality. [34, 35]

For albumin or plasma protein fraction compared with NS, 18 trials reported data on mortality in 641 patients. The pooled relative risk from these trials was 1.52 (95% confidence interval, 1.08-2.13). The NS groups had a 1% mortality rate, versus an 11% mortality rate in the colloid group.

For dextran compared to NS, 8 trials compared reported data on mortality in 668 patients. The pooled relative risk was 1.24 (95% confidence interval, 0.94-1.65). Two other recent meta-analyses on the same topic reached the same conclusions.

Large volumes of colloid solutions (>1000-1500 mL/d) can have an adverse effect on hemostasis. No colloid solution has been demonstrated to be superior to NS, and, because of the expense and the risk of adverse effects with colloids, crystalloid is recommended. Given these findings, the authors recommend against the use of colloid solutions in resuscitation outside the setting of an RCT.

Blood transfusion

Order blood transfusions if blood loss is ongoing and thought to be in excess of 2000 mL or if the patient’s clinical status reflects developing shock despite aggressive resuscitation. Data from various sources suggest that 1 in 16-40 women experiencing PPH requires a blood transfusion if active third-stage management is used, whereas approximately 1 in 9 requires a transfusion if expectant management is used. Newer studies tend to have lower transfusion rates than older studies. [9]

Whole blood is no longer available in most settings, and, for many reasons, PRBCs are initially used with other blood components and given only if indicated. Most medical units have access to uncrossmatched O-type Rh-negative PRBCs for catastrophic bleeding. In PPH, uncrossmatched ABO- and Rh-compatible blood is usually available because a blood group and antibody screen has already been performed. Have full crossmatched blood available for transfusion within 30 minutes. Clinicians must be aware of the capabilities of their blood bank regarding timing, type, and amount of blood products available in emergencies. Good communication with the blood transfusion service is essential, and the nature of the emergency and the potential amount of blood products required must be stressed.

The goal is to rapidly transfuse 2-4 U of PRBCs to replace lost oxygen-carrying capacity and to restore circulating volume. Administer the blood transfusion through a set with an integrated filter, and use a blood warmer if the infusion rate (>100 mL/min) or the total volume infused is high. A rapid infusion set with an integrated warmer or a pressure cuff may be used to increase the infusion rate. PRBCs are very viscous, reducing the infusion rate. This problem may be overcome by adding 100 mL of NS to each unit. Do not use LRS for this purpose because the calcium contained in the solution may cause clotting.

The risks of transfusion are well known and are covered elsewhere (eg, see Transfusion Reactions or Transfusion and Autotransfusion), but they include infection, transfusion reaction, and development of atypical antibodies. Several other complications may be noted in large-volume transfusions. The risk of hypothermia is minimized by the use of blood warmers. Dilutional coagulopathy may be observed and is discussed below. Hyperkalemia and acidosis related to the use of stored blood are theoretical risks but are seldom clinically important if perfusion of vital organs is maintained. Monitor electrolyte and acid-base status if the situation is ongoing. Hypocalcemia due to citrate intoxication is also seldom observed. [36]

Patients may refuse a transfusion of blood products based on religious or other grounds. A patient's refusal of blood products must be respected and must not be equated with a desire for no intervention or be seen as an excuse for suboptimal care. Several options, including the use of autotransfusion, can be considered for the management of these patients. Ensure that a care plan is in place (see Transfusion and Autotransfusion). An article by Hughes et al reviewed the issues and management options in patients who refuse transfusion. Clinicians should bear in mind that the refusal may not extend to all related products. Products that use recombinant technologies such as human erythropoietin and activated factor VIIa are usually acceptable. [37]

Coagulopathy

Women experiencing PPH do not usually have a preexisting disorder of hemostasis; however, initial blood work includes a coagulation screen and platelet count. In previously healthy women, dilutional coagulopathy is not usually observed until approximately 80% of the original blood volume has been replaced. Regularly monitor hemostatic test results in all women who require a massive transfusion. If findings are abnormal in conjunction with ongoing bleeding or oozing from puncture sites, mucous surfaces, or wounds, additional blood products are required. Infuse fresh frozen plasma (FFP), beginning with 4 U and following with additional units to normalize the coagulation test findings. Many authorities recommend the addition of 1 U of FFP for every 5 U of PRBCs for patients who require continued transfusion.

Thrombocytopenia is likely after 1.5-2 times the blood volume has been replaced. Keep the platelet count more than 50 X 109/L by using platelet transfusion. Each unit of platelets increases the platelet count by approximately 10 X 109/L. (Platelets are usually given in packs of 5-6 U.) If bleeding is continuing and the platelet count is less than 50 X 109/L, administer 10-12 U initially. If surgical intervention is necessary, maintain the platelet count at more than 80-100 X 109/L. Platelet preparations contain some RBCs, and the administration of anti-D immunoglobulin (RhoGAM, WinRho) is recommended for Rh-negative women after the crisis has passed. [38]

If coagulation test results are abnormal from the onset of PPH, strongly consider an underlying cause (eg, abruptio placenta, HELLP syndrome, fatty liver of pregnancy, intrauterine fetal demise, amniotic fluid embolus, septicemia, preexisting disorder). Take specific steps to treat the underlying cause and the hemostatic abnormality.

DIC may also develop if shock has led to marked hypoperfusion of tissues, causing damage and release of tissue thromboplastins. In such cases, laboratory test results reveal that the D-dimer levels are elevated and fibrinogen levels are very low, with a prolonged thrombin time. The management of DIC is identical to that for a patient with dilutional coagulopathy. Restoration and maintenance of circulating volume along with blood product replacement is essential.

Cryoprecipitate may be useful along with FFP because of the markedly depressed fibrinogen levels. Cryoprecipitate provides a more concentrated form of fibrinogen and other clotting factors (VIII, XIII, von Willebrand factor) and is faster to prepare in the blood bank. It is commonly given in 6- to 12-U doses and may also be helpful immediately before any surgical intervention in patients with abnormal coagulation test results. The use of heparin and antifibrinolytic therapy is not recommended in women with DIC of obstetric origin.

Interest in and experience with recombinant activated factor VIIa (RFVIIa) in massive hemorrhage situations is growing. This experience has extended to severe postpartum hemorrhage and results have been encouraging. [39] RFVIIa has been used when conventional medical management has been unsuccessful and also when varying degrees of surgical management, up to and including hysterectomy have failed. Therapy is very expensive and some suggest that use in less severe cases may be potentially harmful. [40] RFVIIa may also be useful in cases of severe PPH complicated by DIC. [41] Further study is required before recombinant activated factor VII is put into widespread use.

Seek the advice of a hematologist in cases of massive transfusion or coagulopathy.

Response to resuscitation

Pay close attention to the patient’s level of consciousness, pulse, blood pressure, and urine output during the course of the management of massive hemorrhage. A urine output of 30 mL/h or more likely indicates adequate renal perfusion. Closely monitor the CBC count, coagulation, and blood gas values in addition to acid-base status. Pulse oximetry is useful for evaluating tissue perfusion and oxygen saturation. Frequent auscultation of the lung fields helps detect pulmonary edema or the development of adult respiratory distress syndrome. For patients in critical condition with ongoing bleeding, the placement of a central venous line may be helpful for resuscitation. Arterial line placement also may aid in monitoring blood pressure and allowing easy access for blood work. Few patients experiencing PPH require such invasive monitoring; however, consultation with appropriate specialists and placement in an intensive care setting are preferred for those who do.

Previous
Next:

Management of massive obstetric hemorrhage

The following is a plan for managing massive obstetric hemorrhage, adapted from Bonner. [31] The word order is a useful mnemonic for remembering the basic outline.

  • Organization
    1. Call experienced staff (including obstetrician and anesthetist).
    2. Alert the blood bank and hematologist.
    3. Designate a nurse to record vital signs, urine output, and fluids and drugs administered.
    4. Place operating theater on standby.
  • Resuscitation
    1. Administer oxygen by mask.
    2. Place 2 large-bore (14-gauge) intravenous lines.
    3. Take blood for crossmatch of 6 U PRBCs, and obtain a CBC count, coagulation screen, urea level, creatinine value, and electrolyte status.
    4. Begin immediate rapid fluid replacement with NS or Ringer lactate solution.
    5. Transfuse with PRBCs as available and appropriate.
  • Defective blood coagulation
    1. Order coagulation screen (International Normalized Ratio, activated partial thromboplastin time) if fibrinogen, thrombin time, blood film, and D-dimer results are abnormal.
    2. Give FFP if coagulation test results are abnormal and sites are oozing.
    3. Give cryoprecipitate if abnormal coagulation test results are not corrected with FFP and bleeding continues.
    4. Give platelet concentrates if the platelet count is less than 50 X 109/L and bleeding continues.
    5. Use cryoprecipitate and platelet concentrates before surgical intervention.
  • Evaluation of response
    1. Monitor pulse, blood pressure, blood gas status, and acid-base status, and consider monitoring central venous pressure.
    2. Measure urine output using an indwelling catheter.
    3. Order regular CBC counts and coagulation tests to guide blood component therapy.
  • Remedy the cause of bleeding
    1. If antepartum, deliver the fetus and placenta.
    2. If postpartum, use oxytocin, prostaglandin, or ergonovine.
    3. Explore and empty the uterine cavity, and consider uterine packing.
    4. Examine the cervix and vagina, ligate any bleeding vessels, and repair trauma.
    5. Ligate the uterine blood supply (ie, uterine, ovarian, and/or internal iliac arteries).
    6. Consider arterial embolization.
    7. Consider hysterectomy.
Previous
Next:

Management of the underlying cause of PPH

Initial assessment

The patient’s risk factors and the events leading to the diagnosis of PPH may suggest an underlying etiology, but knowledge that most cases are caused by uterine atony and the need to be systematic argues for a planned, stepwise approach to assessment and management. The status of the patient, the severity of the bleeding, and the response to initial management steps determine if and when the protocol for massive obstetric hemorrhage is instituted.

Uterine atony

Two well-designed trials indicate that oxytocin should be the drug of choice for both prophylaxis and treatment of post partum hemorrhage caused by uterine atony. [42]

Assess uterine size and tone by placing a hand on the uterine fundus and massaging the uterus, which serves to express any clots that have accumulated in the uterus or vagina. If the uterus is found to be boggy and not well contracted, commence vigorous massage and therapeutic oxytocin. Oxytocin can be administered as a 5-U intravenous bolus, as 20 U in 1 L of NS intravenously run as fast as possible, or as 10 U intramyometrially with a spinal needle if no immediate intravenous access is available. [6]

Emptying the bladder may aid in ongoing assessment and facilitate uterine contraction and subsequent therapeutic maneuvers. Wearing a waterproof gown, elbow-length gloves, and eye protection is prudent during the management of PPH. Sterile technique is used.

If the uterus remains atonic, commence bimanual massage. A hand is placed on the fundus, and the second hand is placed anterior to the cervix in the vagina. Prepare the perineum and vagina. The vaginal hand may be covered in povidone-iodine solution (Proviodine) or a lubricant to allow it to enter the vagina with less difficulty. Take care to minimize the chance of causing or worsening trauma in the lower genital tract. Trauma to the vaginal sidewalls and cervix may be palpated as the hand is gently introduced into the vagina, and blood clots may be evacuated from the vagina, cervix, and lower uterine segment.

The vaginal hand is placed in the anterior fornix, and the abdominal hand is placed on the posterior aspect of the fundus. The uterus is raised from the pelvis, pivoted anteriorly, and compressed between the two hands. The compression expels clots and decreases bleeding. Massaging the uterus between the hands aids in promoting and sustaining contraction. Bimanual massage results in a decrease in bleeding, even if the uterus remains relatively atonic, thus allowing resuscitation a chance to begin to catch up with blood loss.

Use other uterotonic agents if the uterus remains atonic despite oxytocin administration and bimanual massage. The traditional second-line agent for uterine atony has been ergonovine (or ergotrate) given as an initial dose of 100 or 125 mcg intravenously or intramyometrially or 200 or 250 mcg intramuscularly. The maximum total dose is 1.25 mg. Hypertension is a relative contraindication. In some regions, the availability of ergot preparations has become problematic. Every effort should be made to secure supplies of this inexpensive and useful agent.

Many authorities now recommend the use of intramuscular carboprost as the second-line agent when it is available. The recommended dose is 250 mcg intramuscularly or intramyometrially, not to exceed 2 mg (8 doses). Asthma is a relative contraindication. Carboprost has been shown to be 80-90% effective in stopping PPH in cases refractory to oxytocin and ergonovine. Intramuscular administration of these agents is not recommended if the patient demonstrates evidence of shock because absorption would be compromised.

Misoprostol may also become a valuable agent in the treatment of PPH. One small case series reported that a dose of 1000 mcg given rectally was effective in causing sustained uterine contraction in 14 cases refractory to oxytocin, ergonovine, or both. [43, 44] Recent trials are examining whether the more rapid onset of sublingual/buccal misoprostol will improve its efficacy in the setting of acute PPH. [45] At this time, however, misoprostol remains a third-line agent in the management of PPH. [46] The low cost of the drug and its heat stability (does not require refrigeration) makes it especially appealing for use in the developing world. More trials are pending.

Winikoff et al examined sublingual (SL) misoprostol for PPH when oxytocin is not feasible to administer. Oxytocin is considered the standard of care for treating postpartum hemorrhage, but because of refrigeration requirements and the need for intravenous administration, it is not always clinically viable, particularly in primitive clinical settings. Active bleeding was controlled within 20 min for 440 (90%) women administered misoprostol 800 mcg SL (n=488) and 468 (96%) administered oxytocin 40 units IV (n=490) (relative risk [RR], 0.94; 95% confidence interval [CI], 0.91-0.98). Additional blood loss of 300 mL or greater after treatment occurred for 147 (30%) of women receiving misoprostol and 83 (17%) receiving oxytocin (RR, 1.78; 95% CI, 1.40-2.26). The authors concluded that in circumstances where it is not feasible to use oxytocin for postpartum hemorrhage, misoprostol is a suitable alternative. [47]

A study by Quibel et al found that adding misoprostol with prophylactic routine oxytocin did not have an effect on the rate of postpartum hemorrhage risk and increased the rate of adverse events. The study reported that the rate of postpartum hemorrhage was 8.4% (68/806) in the misoprostol and 8.3% (66/797) in the placebo group (P=.98). In the misoprostol group there was a significant increase in adverse events with fever being the highest occurrence (30.4% in the misoprostol group vs 6.3% in the placebo group). The study was stopped after early results showed that misoprostol was associated with adverse events. [48]

A study by Diop et al that compared the efficacy of misoprostol and oxytocin when delivered by auxiliary midwives at maternity huts in Senegal via Uniject concluded that misoprostol could be more appropriate for community-level prophylaxis of postpartum hemorrhage. [49]

The investigational agent carbetocin has been compared with oxytocin for prevention of postpartum hemorrhage. Attilakos et al compared the effectiveness of carbetocin and oxytocin when given for postpartum hemorrhage after cesarean delivery in a double-blind, randomized trial. The primary outcome measure was women who required additional pharmacologic oxytocic interventions. Results showed that significantly more women required additional oxytocics in the oxytocin group compared with the carbetocin group. [50]

Retained tissue

If the uterus continues to contract poorly or to relax when bimanual compression and massage are stopped despite the administration of uterotonics, perform manual exploration. Some authorities advocate earlier exploration; however, this is difficult without general anesthesia unless the patient is in severe shock or an epidural is already in place. Nitrous oxide (Entonox) may be useful in facilitating manual exploration if general anesthesia is not available.

Ensure that resuscitation is well underway by this time, and, if not already started, institute the massive hemorrhage protocol. If possible, keep the vaginal hand in situ throughout because it minimizes patient discomfort, the risk of iatrogenic trauma, and, possibly, the risk of subsequent infection. If the placenta was not delivered before the onset of PPH, an attempt is now made to deliver it with cord traction and uterine countertraction. Care must be taken because the risk of uterine inversion is greater if the uterus remains poorly contracted. Perform manual removal if the placenta is not easily delivered or the cord is avulsed.

Perform manual removal with a level of analgesia that matches the clinical urgency of the situation. The hand is passed through the cervix and into the lower segment. Care is taken to minimize the profile of the hand as it enters, keeping the thumb and fingers together in the shape of a cone in order to avoid damage. Control of the uterine fundus with the other hand is essential. If the placenta is encountered in the lower segment, it is removed. If the placenta is not encountered, the placental edge is sought. Once found, the fingers gently develop the space between the placenta and uterus and shear off the placenta. The placenta is pushed to the palmar aspect of the hand and wrist, and, once it is entirely separated, the hand is withdrawn. Do not stop uterotonics while the manual removal is being performed. Restart bimanual massage, and have an assistant examine the placenta for completeness.

If the placenta has been previously delivered, then exploration of the uterus is still indicated at this time. The hand is introduced in the same manner, with control of the uterine fundus with the other hand. Any clots are removed. The cavity is gently explored with attention to any defects suggestive of uterine rupture. Rupture in the absence of a previous scar is uncommon. Rupture or dehiscence of a previous lower segment scar does not usually bleed heavily. The presence of a uterine rupture dictates that a laparotomy be performed.

A partial uterine inversion can be detected as the hand is introduced, just as a complete uterine inversion would have been detected as the hand was placed in the vagina. If the condition is encountered, return the uterus to its normal position by pressure on the inverted fundus from within the uterus. If retained placental tissue is encountered, it is sheared off the uterine wall and delivered. Adherent placental fragments may be left in situ or removed by gentle curettage. The risks of curettage include uterine perforation and increased bleeding caused by laceration of uterine vessels. This may be somewhat minimized by the use of a large, dull curette. Fragments left in situ may be removed by curettage sometime after the crisis has passed, although an increased risk of infection probably ensues.

The administration of short-term, broad-spectrum antibiotics following manual removal, manual exploration, or instrumentation of the uterus in this context is commonly advocated. Evidence is very limited, but a single small, randomized trial supports the practice. [51]

Immediately resume bimanual massage and compression following exploration and evacuation of the uterus. Continue infusion of oxytocin, and administer repeat doses of other uterotonics if the uterus fails to contract and maximal doses have not already been given. The uterus may contract well, and bleeding abates with massage, followed by uterine relaxation and increased bleeding when compression and massage are stopped. Prolonged massage at this point may allow the uterus to contract and retract if it can be kept empty of clots and if perfusion can be improved with adequate resuscitation. Any period of decreased bleeding allows fluid and blood component replacement to exceed blood loss and help improve the patient’s status.

Surgical management is necessary if the uterus does not remain contracted and bleeding persists despite all efforts. Packing of the uterus may be an option until the operating room is ready or if surgery is not an immediately available option. Uterine packing fell into disfavor during the 1960s as being nonphysiological, concealing ongoing blood loss, and increasing the risk of infection; however, reports since then have been favorable in very select circumstances when all previously mentioned maneuvers have failed. [52] The uterus and vagina must be tightly packed with continuous, layered, 2- or 4-inch gauze under direct visualization using a speculum and/or retractors or a purpose-built uterine packer. [53] At times, packing may serve as a definitive treatment. In these cases, the packing is usually removed in 24-48 hours in a setting where recurrent bleeding can be managed if it occurs.

Intrauterine catheters for tamponade of bleeding have also been used. In the past, large bulb Foley catheters or Sengstaken-Blakemore tubes have been used. [54] More recently, experience has been gained using catheters specifically designed for postpartum hemorrhage. One such device is the SOS Bakri tamponade balloon (Bakri, 2001). In low resource settings, condoms and surgical gloves have been used successfully to control bleeding. [55] Anti-shock garments are also being evaluated in low resource settings for both the definitive treatment of uterine atony as well as a method to allow time to bring other treatments to bear [56]

Manual examination helps to exclude a cervical or vaginal laceration, but direct visualization confirms that bleeding is coming from the uterus and excludes the possibility of missing trauma to the lower genital tract. If packing is meant to be definitive treatment, then ongoing assessment of uterine size, blood loss, and patient status must be maintained. Continue uterotonics and commence broad-spectrum antibiotics. Remove the pack in 24-36 hours in a setting that allows for appropriate management if bleeding recurs. Packing may also be used as a temporizing measure before arterial embolization (see Selective arterial embolization). Isolated reports of successful uterine tamponade with balloon devices have also been published. [57]

Genital tract trauma

Genital tract trauma is the most likely cause if bleeding persists or is present despite a well-contracted uterus. Use appropriate analgesia along with good lighting and positioning, which facilitates excellent exposure. If not already initiated, moving the patient to an operating room is reasonable at this time. Experienced assistants and an excellent circulating nurse are essential.

Directly visualize and inspect the cervix with the aid of ring forceps. The anterior lip is grasped, and the cervix is inspected by using a second ring forceps placed at the 2-o’clock position, followed by progressively "leap-frogging" the forceps ahead of one another until the entire circumference has been inspected. Small, nonbleeding lacerations of the cervix do not need to be sutured. Suture any laceration that is bleeding significantly or appears to have the potential to bleed significantly. Each side of the laceration can be grasped with a ring forceps back from the torn edge, and gentle traction can be used to aid exposure.

Use an absorbable, continuous interlocking stitch, and use tapered (rather than cutting) needles for all repairs except for the perineal skin. Ensure that the stitch begins above the apex of the tear, as with vaginal lacerations and episiotomies. If the apex cannot be visualized, place the stitch as high as possible and then use it to apply gentle traction to bring the apex into view. Polyglycolic sutures have largely replaced catgut; however, the latter may be somewhat less likely to tear the friable tissues of the cervix and vaginal vault and may thus be useful in repairing lacerations in these areas. The laceration must be observed for bleeding after the torn edges of the cervix are approximated. The ring forceps can be replaced and left on for some time if oozing persists.

Lacerations of the vaginal vault must be well visualized and their full extent realized prior to repair. Lacerations high in the vaginal vault and those extending up from the cervix may involve the uterus or lead to broad ligament or retroperitoneal hematomas. The proximity of the ureters to the lateral vaginal fornices, and the base of the bladder to the anterior fornix, must be kept in mind when repair is undertaken in these areas. Poorly placed stitches can lead to genitourinary fistulas. An absorbable, continuous interlocking stitch is used. The stitch must start and finish beyond the apices of the laceration. Great care must be taken because the tissue is usually very friable. Take a good amount of tissue, and ensure that the needle reaches the full depth of the tear. Ongoing bleeding and hematoma formation are possible if small bites are taken.

Again, the laceration must be observed for bleeding after the repair is complete. Pressure or packing over the repair may achieve hemostasis or allow for better placement of further hemostatic stitches. Cervical and vaginal vault lacerations that continue to ooze or those that are associated with hematomas may be amenable to selective arterial embolization (see Selective arterial embolization).

Traumatic hematomas are rare and may be related to lacerations or may occur in isolation. They include vulvar and paravaginal hematomas in the lower genital tract and broad ligament and retroperitoneal hematomas adjacent to the uterus. Patients with lower genital tract hematomas usually present with intense pain and localized, tender swelling. Broad ligament hematomas may be palpated as masses adjacent to the uterus. All may result in significant blood loss that mandates resuscitation.

Lower genital tract hematomas are usually managed by incision and drainage, although expectant management is acceptable if the lesion is not enlarging. [58] Any bleeding vessels are tied off, and oozing areas may be oversewn. Place a Foley catheter because urinary retention can occur because of pain and tissue distortion. Vaginal packing may be useful following drainage and repair of a paravaginal hematoma. Remove the pack in 24-36 hours. Embolization may be used in both vaginal and vulvar hematomas that are unresponsive to surgical management.

Broad ligament and retroperitoneal hematomas are initially managed expectantly if the patient is stable and the lesions are not expanding. [59] Ultrasound, CT scanning, and MRI all may be used to assess the size and progress of these hematomas. Selective arterial embolization may be the treatment of choice if intervention is required in these patients. Use surgical procedures to evacuate the hematoma, and attempt to tie off any bleeding vessels. Consider involving a surgeon with extensive experience operating in the retroperitoneal space.

Coagulopathy

If manual exploration has excluded uterine rupture or retained placental fragments, bleeding from a well-contracted uterus is most commonly due to a defect in hemostasis. A review of the history and risk factors along with coagulation test results clarifies this diagnosis. Proceed with blood product replacement as previously described in order to correct abnormalities of hemostasis. If the coagulation status is normal and bleeding is ongoing despite a well-contracted uterus, then the possibilities of uterine rupture or an inadequately repaired uterine incision (if the patient had a cesarean delivery) must be considered. Revisit any repair to the cervix or vagina before proceeding to surgical management.

Previous
Next:

Surgical Therapy

Ongoing bleeding secondary to an unresponsive and atonic uterus, a ruptured uterus, or a large cervical laceration extending into the uterus requires surgical intervention. Laparotomy for PPH following a vaginal delivery is rare. In a review of emergency peripartum hysterectomies over a 5-year period in Los Angeles, Calif, the rate was 1 in 1000 deliveries, but most of these cases began as cesarean deliveries, usually for placenta previa. [60] A study from Boston, Mass, found a rate of 1.5 in 1000 deliveries with similar risk factors. [61] Canadian and Irish studies put the rate at 0.4 and 0.3 per 1000 deliveries, respectively.

Adequately resuscitate the patient before surgery. This includes optimizing hemoglobin and coagulation status as previously described. Fully inform anesthetic and operating room staff as to the nature of the case. Schedule for a second surgeon to be in attendance, if possible. As mentioned previously, sustained bimanual compression and massage and uterine packing may be used to gain time to mount a surgical response. Military antishock trousers provide the equivalent of an approximately 500- to 1000-mL autotransfusion and potentially gain time during a resuscitation. Only the leg portion of the trousers are inflated in the setting of PPH. Direct compression of the aorta may be performed for a short period while the operating room is prepared.

A recent systematic review examined various techniques used when medical management is unsuccessful. These included arterial embolization, balloon tamponade, uterine compression sutures, and iliac artery ligation or uterine devascularization. At present, no evidence suggests that any one method is more effective for the management of severe PPH. Randomized controlled trials of the various treatment options may be difficult to perform. Balloon tamponade is the least invasive and most rapid approach and may thus be the logical first step. [62]

Laparotomy

The choice between a subumbilical vertical incision and a Pfannenstiel incision for entry into the abdomen is left to the individual surgeon. Both entries have support, and no strong evidence indicates that either is superior in this setting. [63] If concern exists regarding pathology in the upper abdomen or if exposure is thought to be a concern, the vertical incision is recommended. Broad-spectrum antibiotic coverage is advised.

Upon entry, remove any free blood and inspect the uterus and surrounding tissues for evidence of rupture or hematoma. If uterine rupture is found, a rapid decision must be made concerning the viability of repair versus hysterectomy. Bleeding may be reduced in either instance by grasping bleeding points on the torn edges with clamps. The number of layers used for any repair is dictated by the thickness of the tissue and the hemostatic response to suturing. Principles are similar to those of cesarean delivery incision repair. Ensure that bleeding is stopped and not merely internalized because this would result in ongoing vaginal bleeding or hematoma formation. Any repair must be carefully observed for hemostasis before abdominal closure is performed. Uterine exteriorization may improve exposure and decrease operating time, but great care must be taken to not worsen uterine trauma and to keep the uterus warm and well perfused to avoid worsening atony.

Hemostasis must be reassessed after the uterus is returned to the abdominal cavity. Consider placement of a suction drain.

If the uterus is intact upon entry and the bleeding has been caused by atony, then direct bimanual massage and compression may be performed while systemic uterotonics are continued. Direct injection of oxytocin, carboprost, and/or ergonovine may be successful in overcoming atony.

Uterine artery ligation

Uterine artery ligation is a relatively simple procedure and can be highly effective in controlling bleeding from uterine sources. These arteries provide approximately 90% of uterine blood flow. The uterus is grasped and tilted to expose the vessels coursing through the broad ligament immediately adjacent to the uterus. Ideally, place the stitch 2 cm below the level of a transverse lower uterine incision site. A large atraumatic (round) needle is used with a heavy absorbable suture. Include almost the full thickness of the myometrium to anchor the stitch and to ensure that the uterine artery and veins are completely included. The needle is then passed through an avascular portion of the broad ligament and tied anteriorly. Opening the broad ligament is unnecessary. Perform bilateral uterine artery ligation. While the uterus may remain atonic, blanching is usually noted and blood flow is greatly diminished or arrested.

Local oozing may be controlled with direct injection or compression with warm saline packs. In a series of 265 cases, a 95% success rate was reported using this procedure in PPH unresponsive to uterotonics in patients who had cesarean births. [64] Another series of 103 cases had a 100% success rate if a stepwise approach was taken. [65] After initial uterine artery ligation, subsequent stitches were placed 2-3 cm below the initial stitches following bladder mobilization, and, finally, ovary artery ligation was performed if required. Menstrual flow and fertility were not adversely affected.

Ovarian artery ligation

The ovarian artery arises directly from the aorta and ultimately anastomoses with the uterine artery in the region of the uterine aspect of the uteroovarian ligament. Ligation is performed just inferior to this point in a manner similar to that of uterine artery ligation. The amount of uterine blood flow supplied by these vessels may increase following uterine artery ligation. The procedure is easy to perform; however, the potential benefit must be weighed against the time required to perform the ligations.

Internal iliac (hypogastric) artery ligation

Internal iliac artery ligation can be effective to reduce bleeding from all sources within the genital tract by reducing the pulse pressure in the pelvic arterial circulation. One study indicated that pulse pressure was reduced by 77% with unilateral ligation and by 85% with bilateral ligation. [66] Hypogastric artery ligation is much more difficult to perform, more commonly associated with damage to nearby structures, and less likely to succeed than uterine artery ligation. One study reported a success rate of 42%. In patients who undergo hypogastric artery ligation, uterine artery ligation has usually already failed.

Prerequisites for the procedure include a stable patient, an operator experienced in the procedure, and a desire to maintain reproductive potential. The retroperitoneal space is entered by incising the peritoneum between the fallopian tube and the round ligament. The ureter must be identified and reflected medially with the attached peritoneum. The external iliac artery is identified on the pelvic sidewall and followed proximally to the bifurcation of the common iliac artery. The ureter passes over the bifurcation. The internal iliac artery is identified and followed distally approximately 3-4 cm from its point of origin. The loose areolar tissue is carefully cleared from the artery. A right-angle clamp is passed beneath the artery at this point, with great care to avoid damage to the underlying internal iliac vein.

A recommendation is to pass the clamp from lateral to medial in order to minimize the chance of damage to the adjacent external iliac vessels. Gentle elevation of the artery with a Babcock clamp facilitates this maneuver.

Ligate the artery with heavy absorbable suture, but do not divide it. Palpate the femoral and distal pulses before and after the ligation to ensure that the external or common iliac artery was not inadvertently ligated. If possible, place the ligation distal to the posterior division of the artery because this decreases the risk of subsequent ischemic buttock pain. Identification of the posterior division may be difficult, and ligation 3 cm from the internal iliac artery origin usually ensures that it is not included.

Hysterectomy is required if internal iliac artery ligation is unsuccessful. Patients in whom internal iliac artery ligation has failed have greater morbidity than those in whom the procedure has not been attempted. The likelihood of benefit from the procedure must be balanced against the potential risks. The advent of more effective uterotonic agents, the fact that most cases of intractable hemorrhage are now related to abnormalities of placentation that are diagnosed or suggested before delivery, and the option of embolization have lessened the use of hypogastric artery ligation. The number of surgeons comfortable using this procedure and the opportunities to teach it are rapidly declining.

Hysterectomy

Hysterectomy is curative for bleeding arising from the uterine, cervical, and vaginal fornices. The procedure of peripartum hysterectomy is well described in several texts and articles (eg, Hysterectomy), and the technique differs little from that in nonpregnant patients. [67, 63] While the organ is more vascular, the tissue planes are often more easily developed. Total hysterectomy is preferred to subtotal hysterectomy, although the latter may be performed faster and be effective for bleeding due to uterine atony. Subtotal hysterectomy may not be effective for controlling bleeding from the lower segment, cervix, or vaginal fornices. Take every opportunity to become involved when peripartum hysterectomies are performed.

Selective arterial embolization

Angiographic embolization in the management of PPH was first described more than 30 years ago. [68] As with all of the surgical and most of the medical treatments of PPH, no RCTs regarding its effectiveness have been conducted. This is likely to remain the case for some time given the relative rarity of intractable PPH. Several case series suggest that selective arterial embolization may be useful in situations in which preservation of fertility is desired, when surgical options have been exhausted, and in managing hematomas. [69] Follow-up of women undergoing successful embolization for severe intractable PPH reports that women almost invariably have a return to normal menses and fertility. [70]

The major drawbacks of the procedure are the requirement for 24-hour availability of radiological expertise and the time required to complete the procedure. Patients must be stable to be candidates for this procedure. Complications include local hematoma formation at the insertion site; infection; ischemic phenomena, including uterine necrosis in rare instances; and contrast-related adverse effects. Currently, most PPH cases requiring hysterectomy are related to placenta previa. These patients are commonly diagnosed before delivery and are usually delivered by elective cesarean birth. This planning may allow increased use of invasive radiological services in the management of such cases.

A retrospective study by Park et al indicated that transcatheter arterial embolization (TAE) is safe and effective for secondary PPH. In the study, the procedure was clinically successful in 47 of 52 patients (90.4%) being treated for secondary PPH (caused in 23 cases by retained placenta). Gelatin sponge particles were used in 48 patients, either alone or in combination with permanent embolic materials (eg, microcoils, N-butyl cyanoacrylate); embolization was performed with permanent materials alone in the remaining four patients. Regular menstruation returned in the 44 patients who were followed up (for a mean 12.6-month period), and five patients were known to become pregnant. [71]

B-Lynch and Cho sutures

Recent case series and case reports advocate the use of transmural uterine compression sutures to rapidly control bleeding. The initial reports described the B-Lynch technique, which involves opening the lower segment and passing a suture through the posterior uterine wall and then over the fundus to be tied anteriorly. [72, 73] A similar technique has been described without opening the uterus. A long, straight needle is passed anterior to posterior through the lower uterine segment; the suture is passed over the fundus and then tied anteriorly. [74] Both techniques use bilateral stitches. The most recent variant uses multiple stitches passed transmurally and tied anteriorly at various points over the uterine body. This technique may be focused in the area of the placental bed in cases of abnormal placentation. [75] All of these procedures effectively produce tamponade by compressing together the anterior and posterior walls.

Follow-up reports suggest a normal return to menses and fertility, but the number of cases is small. The techniques have the advantage of being very simple to perform and may be a rapidly effective alternative to hysterectomy. [72]

Bleeding at cesarean delivery

In the past, most cases of intractable PPH followed vaginal delivery and were due to uterine atony; however, more recent case series and national databases show that more cases are now associated with cesarean delivery. Cesarean delivery for placenta previa carries a relative risk of 100 for peripartum hysterectomy, with many patients having a diagnosis of placenta accreta. [76] High-resolution ultrasound with color Doppler may allow antenatal diagnosis of placenta accreta.

Whenever possible, delivery of the placenta at cesarean delivery should be performed in an assisted fashion following the administration of a uterotonic agent, preferably oxytocin. This practice leads to less blood loss and less infectious morbidity. [77]

Uterine rupture has also become a more common cause of severe PPH necessitating hysterectomy. The vast majority of these cases occur in patients with a previous cesarean birth. Counsel all women with placenta previa, and especially those with a previous low segment uterine scar, in the antenatal period regarding the risk of severe PPH and the possible need for transfusion and even hysterectomy. Ensure that these patients are cared for in facilities with the resources to manage them successfully if complications arise. [78]

The management of bleeding at cesarean delivery or following uterine rupture is not greatly different from that following vaginal delivery. Aggressive resuscitation is performed with attention to restoration of circulating volume and oxygen-carrying capacity and correction of hemostatic defects. Direct bimanual compression may be used in the case of atony. Retained tissue may be removed under direct visualization. Abnormally adherent tissue is a concern; leave it in situ if it cannot be easily removed.

Direct intramyometrial injection of uterotonics may be undertaken. Vasopressin (0.2 U in 1 mL of NS) may also be injected into the myometrium, with great care taken to avoid intravascular injection. Individual vessels in the placental bed may be ligated. Simple or box stitches may be placed where continuous oozing is present. [75] In cases of placenta previa, the lower uterine segment may be temporarily packed; leaving a pack in the uterus is also an option. The end of the pack is fed through the cervix and into the vagina and is removed 24-36 hours later. Uterine rupture or extension of a uterine incision requires excellent visualization and careful repair with attention to adjacent structures.

The stepwise surgical approach described above may be used if these measures are unsuccessful and preservation of fertility is desired. Strongly consider immediate hysterectomy if further reproduction is not an issue or if bleeding or damage to the uterus appears severe. Embolization may be considered in this setting. Its successful use has been described both intraoperatively to preserve the uterus and after hysterectomy for continued bleeding. Embolization may also be used for continued postoperative vaginal bleeding. [79]

Persistent bleeding following hysterectomy may also be managed by packing with gauze brought out through the vagina or by a pelvic pressure pack composed of gauze in a sterile plastic bag brought out through the vagina and placed under tension. This pack is also known as a parachute, mushroom, or umbrella pack. Place a Foley catheter to monitor urine output and prevent urinary retention. The placement of a suction drain may be useful to monitor losses in cases of ongoing oozing. Always consider coagulopathy in patients with continued slow blood loss.

Previous
Next:

Postoperative Details

Continue resuscitation, and repeat laboratory tests. Monitor vital signs, urine output, and any ongoing losses. Care in an intensive care setting is advantageous, as is close follow-up by the obstetric service. The patient must be monitored for complications (see Complications).

Previous
Next:

Follow-up

Full documentation of the case is imperative, and a careful explanation of events and interventions must be given to the patient and family. Caregivers must be available and approachable for questions. Implications and recommendations for future pregnancies may be discussed during the postoperative stay and reinforced at the postdischarge visit.

Previous
Next:

Summary

PPH is a common complication of childbirth and a leading cause of maternal morbidity and mortality. Clinicians should identify risk factors before and during labor so that care may be optimized for high-risk women. However, significant life-threatening bleeding can occur in the absence of risk factors and without warning. All caregivers and facilities involved in maternity care must have a clear plan for the prevention and management of PPH. This includes sound resuscitation skills and familiarity with all medical and surgical therapies available.

Previous
Next:

Complications

Most patients with PPH are quickly identified and successfully treated before major complications develop. The most common problem is anemia and loss of iron stores, which results in fatigue in the postpartum period. Clinicians and patients are more tolerant of low hemoglobin levels, mild postural lightheadedness, and fatigue because of current concerns over blood transfusion. The risks of transfusion with blood products are well known and have been previously described.

Not surprisingly, many of the complications of severe PPH are related to massive blood loss and hypovolemic shock. Damage to all major organs is possible; respiratory (adult respiratory distress syndrome) and renal (acute tubular necrosis) damage are the most common but are rare. These conditions are best managed by specialists. Renal failure is usually self-limited, and renal function recovers fully. Temporary dialysis is seldom required. Pulmonary edema is uncommon in this previously healthy group; however, it may develop acutely or during the recovery phase because of fluid overload or myocardial dysfunction. Response to standard therapy is usually prompt.

Pregnant women are at increased risk of venous thrombosis and embolic events. Many of the risk factors for PPH are also risk factors for venous thrombosis and embolic events, including operative vaginal delivery, cesarean delivery, and pelvic surgery. Venous stasis due to shock and immobility also contribute, and caregivers should maintain a high index of clinical awareness.

Hypopituitarism following severe PPH (Sheehan syndrome) is due to critical ischemia of the hypertrophied pituitary. This condition should be considered if a failure to lactate occurs. Isolated deficiencies of pituitary tropins and hyperprolactinemia have also been reported.

Evidence suggests that prophylaxis against gastrointestinal ulceration is useful in critically ill patients, especially those requiring ventilation. The recommended agents are sucralfate and histamine 2 blockers. Both are effective at reducing the risk of ulcers. Sucralfate may be associated with a lower incidence of pneumonia. [80]

Several of the complications related to surgical interventions have been described. Complications include sterility, uterine perforation, uterine synechiae (Asherman syndrome), urinary tract injury and genitourinary fistula, bowel injury and genitointestinal fistula, vascular injury, pelvic hematoma, and sepsis. Consider ultrasound of the kidneys following complicated emergency pelvic surgery in order to exclude ureteric obstruction. Patients undergoing uterine exploration, instrumentation, or laparotomy in this context probably benefit from antibiotic coverage at the time of the intervention. Good evidence suggests that all patients having cesarean births should receive prophylactic antibiotics. [81] The duration of antibiotic coverage following surgery in these circumstance is unknown.

Previous