Hémorragies du post-partum immédiat : techniques et indications de la chirurgie

[Can we predict intrauterine balloon tamponade failure according to the mode of delivery?]

OBJECTIVE

The intrauterine balloon tamponade (IUBT) is one of the major tool to manage the postpartum hemorrhage (PPH). Previous studies identified factors predicting IUBT failure regardless the mode of delivery. Our aim was to determine if IUBT predictive failure can be determined regarding the mode of delivery.

MATERIALS AND METHODS

This was a retrospective cohort study among women who had IUBT secondary to severe PPH after vaginal or cesarean delivery from 2012 until 2021 at Lille (France). We compared 2 groups: success or failure of the IUBT, which was defined as the need of additional invasive procedures (uterine embolization or surgical procedure).

RESULTS

We included 238 women, 83 who underwent cesarean and 155 vaginal delivery. The overall success of the IUBT was 78% (80% for vaginal delivery and 75% for cesarean delivery). In the vaginal delivery group with failed IUBT, coagulopathies were significantly more frequent (84.2 vs. 33.3% P=<0.001) with higher estimated blood loss at the use of the IUBT (1865.8 vs. 1580.8mL, P=0.015) compared with the vaginal delivery group with success of IUBT. In the cesarean delivery group, none factor was significant between the two groups.

CONCLUSION

It is possible to identify predictors of IUBT failure in case of vaginal delivery. In contrast, in case of cesarean delivery, there is no apparent predictive facto. It could be interesting to validate our findings in a multicentric study.

Uterine compression sutures with additional hemostatic procedures for the management of postpartum hemorrhage

AIM

The aim of the study was to evaluate the efficacies and possible short-term complications in women receiving uterine compression sutures only and those with additional hemostatic procedures for the management of postpartum hemorrhage.

METHODS

It was a retrospective study carried out from year 2009 to 2019 at a tertiary obstetric hospital and included 79 women who underwent uterine compression sutures (B-Lynch sutures, Hayman's sutures and Cho's sutures) for primary postpartum hemorrhage. Thirty-six of these women had additional hemostatic procedures (uterine artery ligation or embolization) performed for bleeding control.

RESULTS

Of the 43 women who were primarily treated with uterine compression sutures only, the success rate to preserve the uterus was 97.7% (42/43). In women with uterine compression sutures and additional hemostatic procedures performed, the success rate was 75% (27/36). Among these two groups of women without peripartum hysterectomy, there were no significant differences in the incidence of secondary postpartum hemorrhage (14.8% vs. 11.9%; P = 0.729), postoperative endometritis (14.8% vs. 14.3%; P > 0.99) and retained products of conception (3.7% vs. 9.5%; P = 0.641) during their 6-week postpartum checkup. Three women were diagnosed to have hematometra. No pyometra or uterine necrosis was noted.

CONCLUSION

Uterine compression sutures with additional hemostatic procedures are effective to control postpartum hemorrhage and prevent hysterectomy. The short-term complication rate is low. Long-term monitoring is needed to identify rare but potentially dangerous complications.

Hypogastric artery ligation in postpartum haemorrhage: a ten-year experience at a tertiary care centre

This study investigated patients who underwent bilateral hypogastric artery ligation (BHAL) due to postpartum haemorrhage (PPH). Patients who underwent BHAL because of PPH following a conservative treatment were included in this study. Placental abnormalities were referred to as placenta accreta. A total of 130 BHAL procedures took place at the study hospital as a result of PPH. Of these, 39 (30%) were referred to the hospital. The rate of BHAL requirement was 62 out of 10,000 births. Among the 130 patients, the most frequent indication for BHAL was placenta accreta (58.5%). Haematological parameters were poorer among the referral patients. Four of the exitus patients (80%) were referral patients. The mortality rate among the referral patients was 10.25%, whereas this rate was only 1.01% among the patients who gave birth at the hospital. PPH is a life-threatening condition that requires immediate medical attention. BHAL, with its fertility-preserving features, is a good option that can be employed in all PPH patients. BHAL not only preserves patients' fertility, but it also gives them a higher chance of survival.IMPACT STATEMENTWhat is already known on this subject? PPH is a life-threatening condition. Due to the worldwide increase in caesarean sections, placenta accreta has also increased. BHAL is a vital treatment method for PPH.What do the results of this study add? Placenta accreta is one of the most common causes of PPH. Traditional hysterectomy rates can be reduced by replacing this treatment with BHAL in this group of patients. Without early intervention in PPH, a patient's mortality risk can increase by up to 10 times. As research and surgeons' experience grows, PPH can be controlled with treatments with less complex modalities without the need for BHAL.What are the implications of these findings for clinical practice and/or further research? The need for BHAL should be kept in mind when addressing PPH, especially in cases of placenta accreta. The need for hypogastric artery ligation, which is a more aggressive treatment for the surgical correction of the pathology, can be reduced as surgeons' experience increases. Early intervention and/or referral in cases of PPH is of great importance.

Bimanual examination for clot evacuation: a retrospective cohort study of women with postpartum haemorrhage after vaginal delivery

BACKGROUND

Bimanual clot evacuation (BCE) is a simple clinical manoeuvre that may reduce need for surgical intervention in the management of severe postpartum haemorrhage (PPH). We sought to determine whether performing BCE in cases of severe PPH after vaginal birth reduces the need for surgical intervention.

METHODS

A retrospective chart review of women who delivered vaginally with a severe PPH between January 1, 2011 and December 31, 2014 in a single tertiary women's hospital in Sydney, Australia was conducted. Severe PPH was classified as a blood loss ≥1000mls. The need for surgical management (including operating theatre uterine exploration or evacuation, intrauterine balloon tamponade, repair of significant trauma, uterine or internal iliac artery ligation, B-Lynch suture insertion or hysterectomy) was the primary outcome measure, as expressed by need for operating theatre utilisation.

RESULTS

From a cohort of 438, 149 women (34.0%) had BCE, of whom 29 (19.5%) required surgical management compared to 103 of 289 women with no BCE (35.6%); an odds ratio (OR) of 0.38 for BCE (confidence interval 0.20-0.72; p = 0.003). Early BCE (< 1 h of delivery) was associated with a further reduction in surgery (OR 0.24; confidence interval 0.08-0.70; p = 0.009) compared to late BCE (> 1 h of delivery). There was no reduction in estimated blood loss (p = 0.86) or blood transfusion (p = 0.71) with BCE.

CONCLUSION

Our study suggests BCE reduces theatre utilisation in the context of severe PPH following vaginal delivery. Prospective trials are needed to determine whether BCE should be endorsed as a treatment modality for PPH post-vaginal delivery.

[Complete cost of surgery for postpartum haemorrhage]

OBJECTIVE

Reduction of maternal mortality is a major priority in the public health domain. One of the main causes of maternal mortality is postpartum haemorrhage. Because economic pressures favour the use of less expensive strategies, it is becoming now critical to know exactly the cost of the surgical procedures involved in the treatment of postpartum haemorrhage, in order to provide future guidelines in Implementing reforms in hospital.

MATERIALS AND METHODS

Evaluation was made on multiple data collected in the Gynecology-Obstetrics and Central Sterile Supplies departments of a tertiary care Hospital. Analysis of the production costs was made based on the actual costs. The receipts were figured on the basis of applicable reimbursement in France in 2005, taking into account the financial decisions of the producers.

RESULTS

From January 2004 to December 2005, 262 patients were treated for postpartum hemorrhage and patients files were available for review in 255 cases. Of these, surgery was performed in 52 cases. The costs of surgery in the postpartum care ranged from 275.04 euro per manual exploration of the uterine cavity (n=8), 302.48 euro per exploration with valve (n=26), 601.55 euro per vascular ligation (n=3), 725.53 euro per vaginal packing or unpacking (n=10) to 875.06 euro per hysterectomy (n=5). Cleaning and sterilizing of surgical instruments represented a substantial burden, ranging from 7.5% to 11.4% of the total cost of surgery.

DISCUSSION AND CONCLUSION

The costs of surgery for postpartum haemorrhage have been calculated to provide future guidelines for the directions and follow-up of these activities in light of the T2A-EPRD and poles of activity. The actual costs could be used to determine the bases of one or more French DRGs (PMSI) "postpartum hemorrhage" evolution.

Hémorragie de la délivrance « menaçant la vie » et utilisation du facteur VII recombinant activé rFVIIa NovoSeven®

Postpartum haemorrhage remains a dangerous obstetrical complication, which is the main cause of maternal mortality in developing countries. The diagnosis must be immediate and its management is both medically and surgically in life-threatening haemorrhage. We present a case of a thirty-three-year-old woman who asked a pregnancy interruption for premature rupture of membranes at 21(th) gestational week for her second pregnancy; she underwent a caesarean section at term for her first pregnancy. She delivered vaginally and developed a postpartum haemorrhage with hemorrhagic shock which was resistant to medical, surgical and radiological management. We decided to use recombinant activated factor VII (rFVIIa, NovoSeven) as a final attempt to rescue the patient. During surgery, two intravenous bolus injections (60, 120 mug/kg) were successfully given with a control of bleeding and haemoglobin. The patient developed later a splenic thrombosis that can be related to either rFVIIa or to the hypovolemic shock or to the sepsis. Recombinant activated factor VII is an interesting and promising haemostatic agent in the management of life-threatening postpartum haemorrhage unresponsive to conventional treatment.