Clinical Review

Postpartum hemorrhage: Solutions to 2 intractable cases

Author and Disclosure Information

A stepwise approach to bleeding caused by persistent uterine atony and placental abnormalities


 

References

CASE 1: Uterine atony leads to heavy bleeding

A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnionitis. After placental separation, profound uterine atony is noted, and the patient begins to hemorrhage. The atony is unresponsive to bimanual massage, intravenous oxytocin, and intramuscular methylergonovine.

What can be done to stanch the flow?

Postpartum hemorrhage remains a leading cause of maternal death in the United States, and most cases are the direct consequence of uterine atony. As such, they generally respond to the timely administration of IV oxytocin or uterotonics. In this article, we focus on uncommon aspects of postpartum hemorrhage—such as bleeding that persists despite these basic maneuvers, as happened in Case 1.

STEP 1: Identify source of bleeding, administer uterotonic drugs

Three prostaglandins are among the uterotonic drugs available to clinicians for treating uterine atony (TABLE 1):

Carboprost tromethamine, a synthetic derivative of prostaglandin F, acts as a smooth-muscle constrictor. It can be injected intramuscularly or directly into the myometrium. Avoid carboprost tromethamine in patients with reactive airway disease, because it can cause bronchial smooth muscle to constrict.

Prostaglandin E2, also known as dinoprostone, is available as a 20-mg vaginal suppository that should be administered rectally for postpartum hemorrhage to prevent the dose from being washed away by excessive blood flow. Dinoprostone is approved by the Food and Drug Administration (FDA) as an abortifacient and works by causing contraction of the smooth muscle of the uterus. Limitations include its high prevalence of side effects, including nausea, vomiting, fever, and diarrhea.

Misoprostol, a synthetic analogue of prostaglandin E1, is FDA-approved for prevention of gastric ulcers. It is highly potent, stable at room temperature, inexpensive, and rapidly absorbed through oral, vaginal, and rectal routes of administration.1 For treatment of postpartum uterine atony, place a dose of 1,000 μg (five 200-μg tablets) rectally. Uterine tone should improve within 3 minutes.2

For a list of other drugs and devices recommended for the labor and delivery suite, see TABLE 2.

TABLE 1

Uterotonic drugs: Instructions and cautions

DRUGDOSAGE AND ROUTEPRECAUTIONS
Oxytocin10 U IM or 10–40 U in 1,000 mL of a balanced salt solution by IV infusionAvoid infusing large doses 10–20 mL/min) for long periods due to antidiuretic effects of oxytocin
Methylergonovine0.2 mg IMAvoid if hypertension is present; avoid IV administration
Carboprost tromethamine0.25 mg IMAvoid in patients with asthma, cardiac, renal, or hepatic disease
Dinoprostone20 mg rectally or intravaginallyAvoid in patients with cardiac, renal, or hepatic disease
Misoprostol1,000 μg rectallyAvoid in patients with renal or hepatic failure

TABLE 2

Tools for the well-prepared labor and delivery unit

ITEMAPPLICATION
Uterotonic drugs (see TABLE 1)Pharmacotherapy for uterine atony
Gauze rolls and sterile Mayo stand coverUterine packing
Bakri balloonIntrauterine tamponade
Long size 1 chromic suture on larged curved needlesB-Lynch sutures (see FIGURE 1)
Long straight free needles and size 0 chromic sutureHemostatic square sutures (see FIGURE 2)
Topical hemostatic agents: Gelfoam, thrombin, Tisseel, FloSealTopical hemostasis

STEP 2: Apply direct pressure to the uterine cavity

If uterotonic medications fail to control bleeding and improve uterine tone, apply direct pressure to the uterine cavity by packing it with gauze3,4 or inserting a Bakri tamponade balloon device (Cook Women’s Health, Spencer, Ind).5

Uterine packing. The goal is to place direct pressure on all surfaces of the uterine cavity. This can be accomplished easily when the cervix has been fully dilated after vaginal delivery. Unfurl multiple rolls of moistened Kerlix gauze and evenly pack and cover the entire uterine cavity. Be sure to place the initial rolls of gauze high in the fundus, or blood may accumulate undetected behind the packing.

We begin by placing a sterile Mayo stand cover into the uterus, then apply packing inside the stand cover. This technique facilitates removal of the gauze and minimizes trauma to the endometrium (the packing does not stick to the uterine cavity when it is removed). Be sure to tie the ends of the gauze rolls together when using more than 1 roll.

Remove the packing 24 to 36 hours after placement. We remove the gauze in an operating room in case additional maneuvers are needed to control recurrent hemorrhage.

Pages

Recommended Reading

Early Fetal Growth Rate Helps Predict Macrosomia
MDedge ObGyn
Outcomes Improved With Low Threshold for GDM Diagnosis
MDedge ObGyn
Data Watch: Gestational Diabetes Follows Its Own Road
MDedge ObGyn
Alpha Fetoprotein Adjustment in Diabetes May Be Insufficient
MDedge ObGyn
Oral Drugs Show Promise in Gestational Diabetes
MDedge ObGyn
Podocyturia May Signal Preeclampsia Risk Early
MDedge ObGyn
Delivery Urged at 36 Weeks With Placenta Previa
MDedge ObGyn
Classical Incision Advised In Some Circumstances
MDedge ObGyn
Aspiration Benign, Helpful For Investigating Breast Mass
MDedge ObGyn
MRgFUS Could Be New Wave in Breast Ca Ablation
MDedge ObGyn