The surgical management of postpartum haemorrhage

The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy

Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.

Perspective of the comparative effectiveness of non-pharmacologic managements on postpartum hemorrhage using a network meta-analysis

OBJECTIVE

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and is both unpredictable and inevitable. While uterotonic drugs are routinely recommended, there is ongoing debate on the ideal intervention to control uterine bleeding. This review aims to compare the use of non-pharmacologic treatments with peripartum hysterectomy in cases of life-threatening uncontrolled obstetric hemorrhage. The review's objective is to use a network meta-analysis to help prevent maternal deaths and rank the treatments according to success rates.

METHODS

We searched MEDLINE (PubMed), Embase, and the Cochrane Library, from January 2014 until December 2018. A second search was carried out in April 2019 before the final data analysis. Network meta-analysis allows for the calculation of the effect size between treatment groups through indirect treatment comparison.

RESULTS

We confirmed that balloon-assisted management is the best intervention for uncontrolled postpartum bleeding with pharmacologic treatment. This is followed by uterine artery embolization and surgical procedures, which can help avoid the need for a hysterectomy. The balloon tamponade demonstrated lower failure rate than the surgical procedure with odds ratio (OR) of 0.44 and 95% confidence intervals (CIs) 0.50-30.54. Uterine artery embolization had a lower risk for hysterectomy than the surgical procedure group (OR, 0.74; 95% CI, 0.22-2.50).

CONCLUSION

For the quick treatment of postpartum bleeding, balloon tamponade is the best method for uncontrolled postpartum bleeding with pharmacologic treatment, followed by uterine artery embolization and surgical procedures.

Improved Treatment of Postpartum Hemorrhage: Design, Development, and Bench-Top Validation of a Reusable Intrauterine Tamponade Device for Low-Resource Settings

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide, and effective interventions for addressing PPH are urgently needed. Uterine balloon tamponade (UBT) is a technique to control PPH. Commercially available UBT devices are expensive and frequently require imaging technology to ensure placement. Condom-catheter uterine tamponade (C-UBT) is a technique appropriate for low-resource settings. Testing of the C-UBT is needed to better understand and optimize this technique for use in a variety of clinical settings including low-resource contexts. We describe here the design, development, and bench-top validation of a reusable C-UBT device optimized for low-resource settings. The device was tested in three differently sized uterine models using a variety of condom balloon configurations. Intrauterine wall pressure application was measured to evaluate the device capacity to apply pressure of at least 90 mmHg, estimating the mean arterial pressure within the uterine vasculature. Bench-top experimental validation of pressure exerted in uterine models demonstrated the device's capability of reaching hemostatic pressure in uterine volumes ranging from 170 to 1740 mL. Device adaptability and versatility were shown through its ability to reach the target pressure of 90 mmHg in different uterine sizes by varying balloon parameters, including condom thickness and condom configuration. The results of this study show the potential of a low-cost, reusable C-UBT device optimized to treat PPH in a variety of clinical settings, including low-resource contexts.

Subinvolution of placental bed vessels: case report and review of the literature

Subinvolution of placental bed vessels, a well-recognized cause of postpartum and postabortal hemorrhage, is defined with prolonged or excessive uterine hemorrhage beginning after the delivery or abortion. Although physiological changes in uteroplacental parts of spiral arteries are well known, the sequence of events in involution of these vessels is not yet clearly understood. In this article we present two cases of subinvolution of placental bed vessels in which we were able to demonstrate the presence of extravillous trophoblast in and around the placental bed vessels. The disease is supposed to be the result of abnormal interaction between maternal uterine cells and fetal trophoblast.

Placement of a cervical cerclage in combination with an intrauterine balloon catheter to arrest postpartum hemorrhage

Placement of a cervical cerclage postpartum allows retention of a uterine tamponade balloon in women with a dilated cervix. This novel indication for a cervical cerclage may be a useful adjunct to intrauterine balloon catheter in management of postpartum uterine hemorrhage.

Uterine packing during cesarean section in the management of intractable hemorrhage in central placenta previa

OBJECTIVE

To determine the safety and effectiveness of uterine packing in the management of intractable hemorrhage during cesarean section for central placenta previa.

METHODS

This retrospective study was conducted on 70 pregnant women with central placenta previa from May 2005 to March 2010. Patients with uterine packing in the control of massive hemorrhage during cesarean section were identified. The indications, uterine packing procedures, estimated blood loss, postoperative complications, and packing material used were reviewed.

RESULTS

A total of 70 patients were identified among 1,121 women with placenta previa during the study period. Sixty-five cases were successful in the control of intraoperative bleeding using uterine packing. Two patients with severe placenta accreta had hemorrhage during cesarean section, and packing with gauze in the uterine cavity was not able to control the bleeding, thereby resulting in cesarean hysterectomy. One case demonstrated failure in packing because of disseminated intravascular coagulation occurring before hospital admission. The remaining two patients had massive vaginal bleeding after uterine packing in cesarean section and underwent laparotomy or hysterectomy 4 h postoperative.

CONCLUSION

Uterine packing is a safe and effective technique in the control of intractable hemorrhage in cesarean section. It is a reasonable alternative to further surgical intervention in patients with intractable obstetric hemorrhage, especially in developing countries.

Management of post-partum haemorrhage

Management of post-partum haemorrhage (PPH) involves the treatment of uterine atony, evacuation of retained placenta or placental fragments, surgery due to uterine or birth canal trauma, balloon tamponade, effective volume replacement and transfusion therapy, and occasionally, selective arterial embolization. This article aims at introducing pregnancy- and haemorrhage-induced changes in coagulation and fibrinolysis and their relevant compensatory mechanisms, volume replacement therapy, optimal transfusion of blood products, and coagulation factor concentrates, and briefly cell salvage, management of uterine atony, surgical interventions, and selective arterial embolization. Special attention, respective management, and follow-up are required in women with bleeding disorders, such as von Willebrand disease, carriers of haemophilia A or B, and rare coagulation factor deficiencies. We also provide a proposal for practical instructions in the treatment of PPH.

[Obstetric bleeding: an update]

Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.

Successful Treatment of Post-Cesarean Hemorrhage Related to Placenta Praevia Using an Intrauterine Balloon

The authors report a positive experience in controlling severe postpartum hemorrhage after cesarean section performed for placenta praevia by using an inflated intrauterine balloon and avoiding any further invasive surgery.

Use of Sengstaken-Blakemore tube in massive postpartum hemorrhage: a series of 17 cases

BACKGROUND

To evaluate the efficacy and identify the indications of intrauterine tamponade with a Sengstaken-Blakemore tube in acute postpartum hemorrhage.

METHODS

Retrospective study was performed in 17 female patients with massive postpartum hemorrhage despite appropriate medical treatment, and requiring surgery (embolization techniques were not available in our hospital). Patients were treated by inserting a Sengstaken-Blakemore tube in the uterus through the vagina in case of vaginal delivery or through the hysterotomy incision in case of cesarean section. The esophageal balloon was inflated with 250 ml of isotonic saline solution. Patients underwent regional or general anesthesia. A preventive treatment with broad-spectrum antibiotics was systematically administered.

RESULTS

Tamponade treatment prevented surgery in 88% of patients, hemorrhage was controlled in 71% of cases (reducing the need for embolization by 80%), and waiting for a transfer for embolization was made possible for 18% of patients.

CONCLUSION

Intrauterine tamponade with a Sengstaken-Blakemore tube appears as a simple, low-cost, readily available and effective means of treating life-threatening postpartum hemorrhage. The only apparent contraindication is the discovery of an infection during delivery.

Surgical uterine devascularization for placenta accreta: immediate and long-term follow-up

BACKGROUND

To report immediate and long-term outcome in patients with surgical uterine devascularization for placenta accreta.

METHODS

Six patients with placenta accreta were treated conservatively during a cesarean section by a bilateral uterine and ovarian surgical devascularization procedure. Menstrual flow, imaging monitoring and further pregnancy were retrospectively reported.

RESULTS

Blood transfusion was necessary in five cases and a hysterectomy was performed in one patient with placenta previa accreta. All patients resumed menstruation without oral contraception but one of them reported temporary clinical symptoms of estrogen insufficiency. A chronic placental retention occurred in three patients with incomplete placenta removal. One patient with both bilateral uterine and ovarian arterial ligations had a subsequent pregnancy complicated by a recurrent placenta accreta that was subsequently treated conservatively.

CONCLUSIONS

Surgical uterine devascularization for placenta accreta may be useful for uterine conservation. However, reproductive capacity may be altered by placental chronic retention and further pregnancies may be complicated by recurrent placenta accreta.

Balloon tamponade to control haemorrhage following transanal rectal surgery

BACKGROUND

Bleeding following transanal rectal surgery can be difficult to manage.

CASE

We report a case where a Minnesota tube was used to achieve haemostasis in a patient with severe bleeding after transanal excision of a large dysplastic polyp.

Massive obstetric hemorrhage

Massive obstetric haemorrhage is a major cause of maternal death and morbidity; abruption of the placenta, placenta praevia and postpartum haemorrhage being the main causes of haemorrhages. A delay in the correction of hypovolaemia, diagnosis and treatment of defective coagulation and/or surgical control of bleeding are the avoidable factors in most maternal deaths caused by haemorrhage. The main goal is to maintain effective circulating intravascular volume by prompt and adequate replacement of blood, crystalloids or fresh-frozen plasma through more than one intravenous line (it might be necessary to pump blood under pressure) with constant monitoring of the pulse rate and the arterial blood pressure. The rapid correction of hypovolaemia with crystalloids and red cells is the first priority, followed by blood component therapy. Oxytocin and prostaglandin will correct uterine atony, and appropriate surgical intervention is required for traumatic bleeding. Ligation of the uterine arteries, ovarian arteries and hypogastric arteries will usually control uterine bleeding and arterial embolization is also effective. Hysterectomy should also be considered in severe cases. All gynecologists should be able to perform without delay the operative maneuvers which are necessary to control the bleeding, including hypogastric artery ligation, or even emergency hysterectomy. This topic may have received little attention because it is perceived as being associated with maternal morbidity rather than mortality in developed countries; it is only recently that the extent and importance of postnatal maternal morbidity has been recognized.

Major postpartum hemorrhage: survey of maternity units in the United Kingdom

BACKGROUND

To determine current clinical practice among different maternity units in the United Kingdom for the management of major postpartum hemorrhage.

METHODS

A postal questionnaire was sent to 258 maternity units in the UK. It was developed to identify the definition of major postpartum hemorrhage, and to identify the medical and surgical interventions used for postpartum hemorrhage, as considered by each unit, and the type and use of thromboprophylaxis following surgery for major hemorrhage after delivery.

RESULTS

A total of 212 (82%) returned the questionnaire, but 13 units indicated that the questionnaire was not applicable to them, leaving 199 (82%) for analysis. There was a lack of agreement between the different units regarding the definition and interventions for major postpartum hemorrhage. The majority of the units use oxytocin, ergometrine and carboprost as a 'first-line' for the treatment of postpartum hemorrhage. Hysterectomy was the most common surgical procedure (89% of units had performed at least one hysterectomy for major hemorrhage in the last 5 years). There was a lack of agreement regarding the use and choice of thromboprophylaxis following surgery for major hemorrhage.

CONCLUSIONS

Current management of major postpartum hemorrhage varies considerably. There is an urgent need to identify protocols that will reduce the need for hysterectomy in women with major hemorrhage who are unresponsive to conventional medical therapy.

The surgical management of post-partum haemorrhage

Life-threatening post-partum haemorrhage (PPH) occurs with a frequency of 1 per 1000 deliveries in the developed world. In the 1994-1996 Triennial Confidential Enquiry into Maternal Deaths in the United Kingdom primary PPH was responsible for five deaths. In this chapter we discuss briefly the assessment and initial medical management of the patient with primary PPH but concentrate on the surgical management where medical treatment has failed. The surgical management discussed includes both traditional or long-established management strategies together with newer, less radical surgical options, such as embolization techniques, uterine compression sutures and methods involving uterine tamponade, which are less hazardous to perform and have the advantage of preserving reproductive function. The recommendations of the reports from the Confidential Enquiries into Maternal Deaths in the UK are summarized at the end of the chapter.

Major postpartum haemorrhage

Postpartum haemorrhage remains in the top five causes of maternal deaths in both developed and developing countries. Persistent blood loss of more than 1000 ml should prompt predetermined measures to achieve resuscitation and haemostasis. A protocol including guidelines is given and volume replacement is discussed. The range of medical and surgical interventions that may be considered for the modern management of major haemorrhage unresponsive to oxytocin and ergometrine are presented. The review discusses in depth the use of misoprostol, recombinant activated factor VII, the uterine tamponade procedures, artery ligation, and uterine haemostatic suturing techniques. It also evaluates the place of interventional radiology and hysterectomy in modern obstetrics.