|Year : 2022 | Volume
| Issue : 3 | Page : 263-267
Management of postpartum hemorrhage – Current strategies
Sushil Kumar, Aditi Sandip Gaiwal
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences, (Deemed to be University), Navi Mumbai- 410209, Maharashtra, India
|Date of Submission||30-Aug-2022|
|Date of Acceptance||30-Aug-2022|
|Date of Web Publication||29-Sep-2022|
Dr. Sushil Kumar
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences, (Deemed to be University), Navi Mumbai- 410209, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar S, Gaiwal AS. Management of postpartum hemorrhage – Current strategies. MGM J Med Sci 2022;9:263-7
| Introduction|| |
Postpartum hemorrhage (PPH) is defined as the blood loss of 500ml or more, within 24 hours of birth, according to World Health Organisation or blood loss >500 mL within 24 hours after vaginal delivery or >1000 mL after cesarean delivery and is the leading cause of maternal mortality globally. However, in developing countries like India, where the incidence of anemia is higher, blood loss of as much as 250ml may also constitute a clinical problem. A further increase in the risk of PPH is due to several changes in obstetric practice and maternal demographics in recent years; these include an increase in the rate of cesarean delivery, a larger proportion of multiple gestation births, and more pregnant women of advanced maternal age in addition to complications like placenta accrete spectrum, uterine rupture, and traumatic PPH. Even though, there is a remarkable improvement in India’s maternal mortality ratio (MMR) from 113 in 2016–18 to 103 in 2017–19, such efforts still need to be made to attain the targeted global MMR of less than 70 per 100,000 live births by the year 2030ad that is a major challenge. Hysterectomy is the final option in cases of refractory PPH when other methods fail to arrest bleeding.
With recent advances in interventional radiology, surgical techniques, and ready availability of blood products, there are effective and safe alternatives to hysterectomy particularly in patients who desire future conception. This article discusses the current evidence-based management of postpartum hemorrhage.
| Management of postpartum hemorrhage|| |
In an event of severe bleeding during or after delivery, a specific protocol should be initiated which allows precise and quick communication among members of various departments, hence a multidisciplinary approach involving the senior obstetrician, anaesthesiologist, pediatrician, blood transfusion specialist, intensivist, hematology consultant, laboratory staff and transport services of blood and blood products should be made stating that PPH is in the process.
Once PPH has been recognized, intensive monitoring and mechanical and pharmacological measures should be taken to initiate uterine contractions, such as uterine massage, bimanual uterine compression, drugs like uterotonics, tranexamic acid, IV fluids, and if needed calcium should be given. Uterotonics like oxytocin, PGF2 alfa, methyl ergometrine, or misoprostol may be tried in that order. Misoprostol has an advantage in a rural setting as it is a stable compound at room temperature and may be given sublingually for rapid action.
Simultaneously, a package containing a pre-decided number of blood and blood product units should be sent by emergency transport to the obstetric surgical suite. An “emergency package” consisting of 4 units of packed red blood cells (RBCs), 4 units of fresh frozen plasma (FFP), 1 platelet (PLT) concentrate (SDP), 2 g of fibrinogen concentrate, and rFVIIa at a dose of 60 mg/kg body weight. Labile blood products are to be given in fixed ratios of 1:1, as this combination has shown to improve survival in trauma., Hence, a standard protocol not only reduces the amount of blood loss but also the incidence of hysterectomy. What we have described above is an optimal or desirable protocol that may not be available in most of the obstetrical units in toto.
| Mechanical methods|| |
The various types of balloons used for producing a tamponade effect are Foley’s catheter, Rusch balloon, Bakri balloon, Sengstaken-Blackmore oesophageal catheter, or sterile glove and condom. A study by Choi Wah Kong et al, compared the use of intrauterine balloon tamponade (IUBT) and compression sutures in the management of severe PPH, which concluded that IUBT and compression sutures had similar overall success rates in terms of control of hemorrhage, need for additional procedures, blood loss, and need for hysterectomy to control severe PPH, specifically, for cases caused by uterine atony, but the former performed better in placenta praevia cases.Our own experience is that Balloon tamponade is convenient and works in almost 90% of cases of PPH following normal delivery while Compression suture is more convenient to use in PPH during cesarean section with almost similar affectivity.
Uterine packing with ‘Mini Sponge device’
A mini sponge tamponade device consisting of a strong mesh pouch and a tubular applicator was devised by Maria et al. in Oregon. These compressed mini-sponges, placed transcervical, rapidly absorbed blood and expanded within seconds, and filled the uterus exerting sustained pressure uniformly to bleeding sites. The sponges are removed after 24 hours. Ultrasound assessment is used to confirm control of bleeding from the uterus. Although the mini sponge tamponade was found highly effective in the control of PPH, its uses have been limited.
Vacuum suction hemostatic device
Vacuum-assisted Haemostatic device has been a recent innovation for the control of PPH. The rationale is that negative pressure in the uterus makes the uterus smaller (similar to uterine retraction after uterotonics) which closes the spiral arteries and sinuses of the uterus immediately after delivery of the baby. The first article on the successful use of this device was published by Purwosunni in 2016.9 Pannicker from India also published an article on vacuum devices in 2017. Pannicker also devised a suction device for the control of PPH. The device is being used in low-resource centers around India with success rates.
Haslinger used the ‘Bakri balloon’ along with a vacuum device and had a success rate of 86% in cases of uterine atony. However, the use of the Bakri balloon along with the suction device makes it a more expensive procedure for primary health centers
Compression of the aorta and prophylactic abdominal aortic balloon occlusion
Manual compression of the aorta may help to control the bleeding for a short time until uterotonics help in contracting the uterus or until the help arrives. The fist is placed at the umbilicus level and pushed toward the spine to obliterate the aorta. This way the vessels originating from the aorta will be obliterated thus obliterating the blood supply to the uterus. Prophylactic abdominal aortic balloon occlusion (PAABO) reduces blood loss immediately after cesarean section, especially in cases of Placenta accrete syndrome. Intra aortic balloon catheter is placed in the abdominal aorta below the renal arteries, the balloon is inflated after the baby’s cord is clamped and removed after surgery is over and hemostasis is achieved.
| Radiological management|| |
It is recognized that trans-arterial embolization (TAE) is an effective therapeutic strategy for PPH of various causes., It has the advantage of being a fast, repeatable procedure and can be performed without general anesthesia along with preservation of the uterus and making future menstruation and fertility possible. Completion angiography of bilateral common iliac arteries or aortography is recommended to cover all possible bleeding foci. A femoral artery approach under local anesthesia by the Seldinger technique is used for conventional catheterization of the internal iliac arteries. The most commonly used embolic material is gelatine sponge particles, which are mixed with diluted contrast medium to produce a slurry, which is injected into the arteries until stasis or occlusion of blood flow is seen during angiography. They cause temporary occlusion for 3–6 weeks and recanalization of the target arteries which has an additional advantage for future fertility. It can be done as an elective or emergency procedure.Prophylactic balloon catheter placement can be done in major vessels like uterine arteries, internal iliac artery as well as the aorta, in cases where postpartum hemorrhage is anticipated as in cases of the adherent placenta, anemia, grand multiparity, previous caesareans, etc. However, it can also be used as an emergency procedure and can maintain the hemodynamic stability of the patient and reduce bleeding when a hysterectomy is planned. The major drawback however is the 24-hour availability of interventional radiologists with appropriate facilities and teams. We have used these procedures in cases of placenta accrete spectrum cases, and post-partum hemorrhage with disseminated intravascular coagulation (DIC) with success. However, our study is limited to 10 patients only.
| Surgical procedures used for controlling postpartum hemorrhage|| |
For surgical management, the options available are uterine compression sutures, ligation of pelvic arteries, and hysterectomy.
Uterine compression sutures
Uterine compression sutures are used primarily for the management of atonic PPH, these include B-Lynch brace sutures, first introduced by B-Lynch et al. in 1997 are easy and popular with obstetricians around the world. In the current issue of the journal Dr. Priya Bagade wrote an article on “Efficacy of B-Lynch compression suture for control of intractable hemorrhage during cesarean section”. It is a large study from a tertiary care teaching hospital. The author has analyzed 34 cases of hemorrhage during cesarean section and found the ‘B-Lynch suture’ effective in all cases. There were no known complications either. We have been able to control PPH during cesarean section in almost 80% of cases and 20% required an obstetric hysterectomy. We too have not experienced any case of uterine infection or uterine necrosis. The controversies are on the use of suture material during the procedure. I met Dr. B Lynch at a conference in Pune (India) in 2014–15 and asked him about his choice of suture material. He said he was using ‘Chromic Catgut’ probably because it dissolves faster and maybe the chances of necrosis of the uterus would be lower. However, at the moment most of us are using Vicryl(Polygalactin suture) as it has more strength and does not break while tying. Since the uterus involutes quickly after delivery, the compression sutures of any material shall become loose in a couple of days thus avoiding prolonged ischemia of the uterus. There are other compression sutures described in the literature - Hayman simple brace sutures, Cho multiple square sutures, Perieranon-penetrating multiple transverse and longitudinal sutures, Ouahba four transverse sutures, etc. Shigeki et al, compared the efficacy and safety of various uterine compression sutures and concluded that these sutures achieved hemostasis while preserving fertility in many women, however, obstetricians should understand the fundamental characteristics of each suture, thus the choice ultimately depends on several factors such as bleeding site, severity, disorders causing PPH, and most importantly, the experience of the surgeon. Uterine compression sutures-related complications like pyometra, uterine inflammation resulting in chronic endometritis, systemic sepsis, ischemic uterine necrosis, uterine suture erosion, and uterine synechiae have been reported by several studies.
Ligation of pelvic arteries
Stepwise uterine devascularisation involves ligation of the uterine artery, ovarian artery, and internal iliac artery, the purpose is to reduce the blood flow to the uterus for cessation of bleeding in PPH before hysterectomy. The uterine artery, a branch of the anterior division of the internal iliac artery, contributes to 90% of the blood supply to the uterus in pregnancy; is ligated by the O’ Leary technique. The ovarian artery arises from the aorta and forms the utero-ovarian anastomoses, thus contributing to the rest of the blood supply to the uterus, which is ligated at the infundibulopelvic ligament. The internal Iliac artery, when ligated causes abolition of the arterial pulse pressure, thus the trip hammer effect of arterial pulsations is terminated, the net pressure being equivalent to that of a vein, thus allowing the clots to remain in situ leading to hemostasis.Tsirulnikov triple ligation, proposed in 1979, involved bilateral ligation of the uterine artery, utero-ovarian anastomoses, and arteries of the round ligament reported a success rate of 100% in a series of 24 patients..
Emergency Peripartum Hysterectomy (EPH), total or subtotal, is a hysterectomy performed in the event of life-threatening hemorrhages as a last resort following the failure of all conservative measures of achieving hemostasis. The operation is considered one of the most major complications in modern obstetrics and carries a high maternal mortality and morbidity risk. The common indications include abnormal placentation, uterine atony, uterine rupture, and trauma. However, a balance between spending excessive time on alternative techniques that are proving ineffective, ultimately leading to delay and further hemorrhage and probably DIC (Disseminated intravascular Coagulation), and moving to the definitive and life-saving hysterectomy needs to be made. However, there are times when even hysterectomy may not be able to control hemorrhage, especially in cases of adherent Placenta.
Abdominal packing post hysterectomy
When bleeding continues after a hysterectomy, very limited options remain. Intra-abdominal packing is a damage control surgery, consisting of applying sterile abdominal pads directly over the bleeding sites following which the abdomen is closed under tension for maintenance of pressure on the packs, which are removed later by re-laparotomy between 24-48hours. It is supposed to prevent the worsening of the DIC and acidosis that usually accompany massive bleeding till resuscitation measures can be taken. It is associated with a decrease in mortality and morbidity in women presenting with uncontrolled intra-abdominal bleeding. Various methods of packing like pelvic umbrella packs and parachute packs have been used successfully to control bleeding.
| Recombinant factor vii|| |
Recombinant activated factor VII (rFVIIa) was first developed for the management of bleeding in patients with hemophilia A or B and inhibitors. It plays a major role in the initiation of hemostasis. After an injury to the vessel wall, tissue factor (TF) is exposed to circulating blood leading to the formation of TF–FVIIa complexes on the TF-bearing cells and factor X (FXa) is activated leading to the conversion of prothrombin to thrombin. An increasing number of case reports where ‘off-label’ use of rFVIIa has been successful in the treatment of massive PPH which did not respond to conventional methods. Breborowicz et al. reported that rFVIIa was useful in controlling bleeding after hysterectomy as well as avoiding hysterectomy in some cases. The criteria for administration included adequate haematocrit, platelet count is >50x109/l, fibrinogen >1 gm/l, pH>7.2 and temperature >340C. The dose is 90 μg/Kg IV over 3–5 minutes, repeated only if necessary. However, vascular thrombosis is one of the life-threatening complications of the drug and must be used with extreme caution. The drug is expensive and is beyond the financial means of most of our patients. Thus, the current recommendation is that it can be used after the failure of conventional methods.
To conclude I would like to admit that PPH is one of the most serious emergencies encountered during delivery. No obstetrician can master all the techniques mentioned above. Besides this, the interventional radiology setup is not available in the majority of hospitals. It would be better if the obstetrician use a few techniques he or she has mastered. I do admit that at times, the bleeding is so severe that even the experienced obstetrician loose nerves. Timely professional help, availability of blood products, expertise in one or two conservative surgical procedures, and obstetric hysterectomy may save the majority of the patients.
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Conflicts of interest
There are no conflicts of interest.
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