The authors report no financial relationships relevant to this article.
CASE: Postcesarean hemorrhage fails to respond to early maneuvers.
A 25-year-old G1P0 undergoes cesarean section at our hospital for fetal distress. She has no history of coagulopathy, and no intraoperative complications are noted during the procedure. Upon her arrival in the postanesthesia care unit, however, vaginal bleeding is observed. She is given 40 U of oxytocin in 1 L of lactated Ringer solution, two intramuscular doses of 0.2 mg of methylergonovine maleate, and 1,000 μg of misoprostol to treat the postpartum bleeding. Nevertheless, she loses almost 1 L of additional blood from her vagina and is returned to the operating room for exploration and resuscitation for hypotensive shock. What are the next steps?
Management of obstetrical hemorrhage often begins with conservative measures, circumstances permitting. It is common practice to give 20–40 U of oxytocin in 1 L of lactated Ringer solution after delivery of the placenta and to perform uterine massage as part of initial management of uterine atony, along with careful evaluation and repair of any laceration or hematoma. In addition, ultrasonography (US) can help detect any retained uterine products.
Medical management usually involves the use of various uterotonics, such as methylergonovine maleate, 15-methylprostaglandin F2α, dinoprostone, and misoprostol. If uterotonics fail, techniques of tamponade include uterine packing with gauze material or use of the Foley intrauterine catheter, Sengstaken–Blakemore tube, and Bakri balloon.1-3
Surgical management is often the last resort, and is limited by the clinician’s experience. Some surgical methods include uterine or hypogastric artery ligation, or both. Newer techniques include a variation of uterine compression sutures such as the B-Lynch suture or multiple-square suturing. The B-Lynch provides continuous compression of the uterus, thereby decreasing blood loss.4 Multiple-square suturing joins the anterior and posterior walls of the uterus, also compressing the uterus.
Hysterectomy should be a last resort, with the knowledge that bleeding may continue after the procedure, in which case pelvic packing becomes an alternative. Unfortunately, pelvic packing of the intraperitoneal cavity often has little effect on endometrial hemorrhage or retroperitoneal bleeding.2-5
Resuscitation calls for blood products. Our resuscitation regimen includes recent clinical recommendations from military medical units in Iraq and Afghanistan and from domestic trauma centers. These guidelines propose that 1 U of fresh frozen plasma be administered with every 1 or 2 U of packed red blood cells (RBCs) until the clinical situation stabilizes or coagulopathy is excluded. Because of massive blood loss in this case, however, fluid replacement continues throughout the procedure—totaling 6 U of packed RBCs, 6 U of fresh frozen plasma, and 5 U of cryoprecipitate with additional crystalloid.6-8
A decision is made to undertake surgical exploration. We open a Pfannenstiel incision and enter the peritoneal cavity, encountering scant dark red blood without gross intraperitoneal bleeding. The uterus is intact with apparent endometrial hemorrhage. Uterine vessels are not easily visualized because they are obscured by retroperitoneal blood and an engorged uterus. The uterus has increased in size severalfold during hemorrhage and occupies the entire pelvic cavity, making dissection difficult for emergent hysterectomy.
As the uterus is exteriorized, Péan clamps are placed on the cornua for retraction, and the round ligaments are transected and ligated bilaterally. Ecchymoses along the peritoneum suggest that retroperitoneal bleeding is occurring in addition to the endometrial blood loss.
What can be done about the retroperitoneal bleeding?
Although laparotomy and hysterectomy are last resorts in postpartum hemorrhage, the use of retroperitoneal packing during these procedures may hasten life-saving hemostasis. In pelvic trauma, a technique of retroperitoneal packing has significantly reduced mortality.9 The same technique of retroperitoneal packing is ideally suited for such devastating circumstances as life-threatening postpartum hemorrhage.
Retroperitoneal packing is a lesson gleaned from trauma surgery and has profound application in cases of severe postpartum hemorrhage.
CASE CONTINUED
Hemorrhage is stanched. Blood loss continues, and the patient remains in hypotensive shock. Vital signs are critical:
- systolic blood pressure, 40 mm Hg
- heart rate, 160 bpm
- minimal urine output
- hemoglobin level, 4 g/dL.
Hemorrhage is obvious from the appearance of the pelvis, and continuing blood loss suggests disseminated coagulopathy. Total abdominal hysterectomy cannot be safely or quickly performed.
To quickly prevent further blood loss, we pack the retroperitoneum using a technique adapted from trauma surgery and first described by Smith and colleagues.9 We make a 5-cm incision into the space of Retzius just cephalad to the pubic symphysis (FIGURES 1 and 2). This incision is separate and inferior to the earlier laparotomy incision.