Postpartum hemorrhage: Solutions to 2 intractable cases
A stepwise approach to bleeding caused by persistent uterine atony and placental abnormalities
IN THIS ARTICLE
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.
Uterotonic drugs: Instructions and cautions
DOSAGE AND ROUTE
10 U IM or 10–40 U in 1,000 mL of a balanced salt solution by IV infusion
Avoid infusing large doses 10–20 mL/min) for long periods due to antidiuretic effects of oxytocin
0.2 mg IM
Avoid if hypertension is present; avoid IV administration
0.25 mg IM
Avoid in patients with asthma, cardiac, renal, or hepatic disease
20 mg rectally or intravaginally
Avoid in patients with cardiac, renal, or hepatic disease
1,000 μg rectally
Avoid in patients with renal or hepatic failure
Tools for the well-prepared labor and delivery unit
Uterotonic drugs (see TABLE 1)
Pharmacotherapy for uterine atony
Gauze rolls and sterile Mayo stand cover
Long size 1 chromic suture on larged curved needles
B-Lynch sutures (see FIGURE 1)
Long straight free needles and size 0 chromic suture
Hemostatic square sutures (see FIGURE 2)
Topical hemostatic agents: Gelfoam, thrombin, Tisseel, FloSeal
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.
These 5 topical or systemic agents can control venous bleeding and oozing
Absorbable gelatin sponge
Venous bleeding or oozing from the uterine incision that is unresponsive to suturing can often be contained by placing a piece of absorbable gelatin sponge (Gelfoam; Pfizer, New York City) over the bleeding site. Cut the sponge to fit the size of the bleeding site and hold it in place for 10 to 15 seconds. Leave the sponge in place once bleeding is controlled.
When application of gelatin sponge alone does not bring about hemostasis, try topical thrombin (Thrombin-JMI; Jones Pharma, Bristol, Va). This product is supplied as a kit that includes the active ingredient in powder form plus a diluent. The powder is diluted at a strength of 1,000 U/mL, and the mixture is sprayed onto a gelatin sponge and placed at the site of the bleeding. Do not inject thrombin solution! Complete resorption of the gelatin sponge occurs in 4 to 6 weeks.
Gelatin matrix thrombin solution
Another useful topical agent is FloSeal (Baxter Healthcare, Deerfield, Ill), which is supplied as a bovine-derived gelatin matrix that is mixed with a bovine thrombin solution to create a foam matrix, which is then applied directly to the bleeding site. Unlike thrombin-soaked gelatin sponge, FloSeal can be applied directly to arterial bleeding. Because this product requires the presence of fibrinogen within the patient’s blood, its utility is limited in patients with hypofibrinogenemia.
This topical agent (Tisseel; Baxter Healthcare) is useful even in patients with coagulopathy. It is a mixture of thrombin and concentrated fibrinogen. The product is packaged as 2 separate components with diluents. These diluted components are injected in a dual syringe device and mixed in a Y-connector tube and then applied in a thin layer directly to the site of bleeding. The mixture solidifies within 3 to 5 minutes after application. This product can also be used to reapproximate tissues.
Recombinant factor VIIa
This promising systemic agent (NovoSeven; Novo Nordisk US, Princeton, NJ) binds to tissue factors that are exposed at sites of vessel injury.15 It can be administered in cases of life-threatening hemorrhage and is helpful even in the presence of dilutional or consumptive coagulopathy. A dose of 70–90 μg/kg is administered IV and can be repeated in 10 to 15 minutes if bleeding is not controlled.16 The high cost of this potentially life-saving product may preclude community hospital blood banks from stocking it routinely.
The Bakri balloon is a large Silastic balloon with a capacity of 500 mL that is designed to provide intrauterine tamponade for bleeding caused by atony, placenta previa, or focal placenta accreta. It has also been used to control hemorrhage associated with cervical ectopic pregnancy.5
A port with a lumen on the device makes it possible to assess the state of hemorrhage. The balloon is placed through the cervix and into the uterus after vaginal delivery, or in reverse fashion during cesarean delivery. It is then filled with saline to apply pressure to the bleeding surfaces of the endometrium.
Once the balloon is inflated, observe the catheter port for signs of continued hemorrhage. If bleeding remains brisk, further intervention will be necessary to control the hemorrhage. If bleeding slows appreciably, the balloon tamponade is likely to be successful and the patient can be observed.
Leave the balloon in place for 24 to 36 hours, then deflate it incrementally. If bleeding recurs when you deflate the balloon, reinflate it and leave it in place longer.
STEP 3: Control the blood supply to the uterus
If packing or tamponade is unsuccessful, the next step is radiographic uterine artery embolization or surgical ligation of the uterine blood supply with O’Leary sutures,6 followed by utero-ovarian vessel ligation, if necessary.7
Uterine artery embolization is an effective method of decreasing blood flow to the uterus. Only facilities with readily available interventional radiology services can perform the procedure, however, and the patient must be stable enough for transfer to the radiology suite. Because most cases of postpartum hemorrhage involve profuse blood loss, radiographic embolization is limited to cases of slow but continuing uterine blood loss.
Surgical ligation of the uterine blood supply is particularly useful. It requires a laparotomy incision after vaginal delivery but is easily performed at the time of cesarean delivery:
- Create the bladder flap and mobilize the bladder inferiorly
- Place a suture approximately 1 to 2 cm inferior to the level at which a low transverse uterine incision would be placed during cesarean delivery. This is done by pulling the broad ligament laterally using the thumb and index and middle fingers, and placing size 0 chromic suture, anterior to posterior, through the myometrium at the lateral margin of the uterus
- Pass the suture through the broad ligament, posterior to anterior, staying well medial to the course of the ureter
- Tie the suture to occlude the uterine vessels
- Repeat on the opposite side.
If this procedure does not reduce the hemorrhage substantially, perform a high uterine artery ligation. This technique is identical to the inferior vessel ligation, but is performed approximately 5 cm superior to the first ligation site.
If these steps fail to reduce bleeding significantly, ligate the utero-ovarian blood supply bilaterally in similar fashion.
STEP 4: Place uterine compression sutures
The uterus can be externally compressed by the strategic placement of sutures.
The B-Lynch technique. This method8 begins with placement of a long size 1 chromic suture on a large curved needle through the anterior lateral aspect of the myometrium just below the repaired uterine incision during a cesarean delivery (FIGURE 1). (It is placed in the same anatomic location in the absence of a hysterotomy.) The suture then exits just above the uterine incision.
The suture is directed over the anterior surface of the myometrium, over the fundus, and down the posterior wall of the uterus, before reentering the myometrium at the inferior posterior lateral edge of the uterus and crossing horizontally to the opposite edge. The suture is then brought up over the posterior myometrium, over the fundus, and back across the anterior myometrium. It then reenters the anterior myometrium just above the uterine incision and exits just below it. The 2 free ends are tied together under tension while a surgical assistant manually compresses the uterus.
To determine the degree of blood loss, visually inspect the vagina. If the technique has been successful, close the abdomen and give the patient a uterotonic for 24 hours. Also, monitor urine output, hemoglobin, and hematocrit carefully and inspect the vagina frequently for blood loss.
FIGURE 1 Compress the uterus with the B-Lynch technique
Pass long size 1 chromic suture through the anterior uterine wall just below and above the usual site of a low-transverse incision, wrap the suture around the anterior and posterior uterine walls, and pass through the posterior wall opposite the entry point. Wrap the suture again and finish near the entry point on the anterior wall. Tie the ends tightly with the uterus under compression.The square-suture technique, described by Cho and colleagues,9 is also useful (FIGURE 2). It involves placement of size 1 chromic catgut suture using a free, long, straight Keith needle in the following steps:
- Pass the suture through the myometrium, anterior to posterior
- Pass the suture through the myometrium again, posterior to anterior, approximately 4 to 6 cm medial to the exit point of the first pass
- Place the suture 4 to 6 cm inferior and pass it through the myometrium yet again, anterior to posterior
- Pass the suture through the myometrium, posterior to anterior, 4 to 6 cm lateral to the last exit point
- Tie the 2 free ends together under tension while a surgical assistant compresses the uterus in the anterior-to-posterior direction.
Place 3 to 5 of these sutures across the surface of the uterus until the resulting compression relieves the hemorrhage. Before closing the abdomen, inspect the vagina carefully to confirm the success of the procedure.