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Liu LY, Nathan L, Sheen JJ, Goffman D. Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage. Int J Womens Health 2023; 15:905-926. [PMID: 37283995 PMCID: PMC10241213 DOI: 10.2147/ijwh.s366675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/03/2023] [Indexed: 06/08/2023] Open
Abstract
Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.
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Affiliation(s)
- Lilly Y Liu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Lisa Nathan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Ju Sheen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Dena Goffman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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2
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Rostovtsev AV, Aleksandrovich YS, Ryazanova OV, Akimenko TI, Pshenisnov KV. Pharmacological Management of Postpartum Haemorrhage. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2022. [DOI: 10.21292/2078-5658-2022-19-6-97-105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- A. V. Rostovtsev
- St. Petersburg State Pediatric Medical University; Maternity Hospital no. 13
| | | | - O. V. Ryazanova
- D. O. Ott Research Institute of Obstetrics, Gynecology and Reproductology
| | - T. I. Akimenko
- St. Petersburg State Pediatric Medical University; City Pokrov Hospital
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3
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Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W, Ramasauskaite D, Lloyd I, Chandraharan E, Miller S, Burke T, Ossanan G, Andres Carvajal J, Ramos I, Hincapie MA, Loaiza S, Nasner D. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet 2022; 157 Suppl 1:3-50. [PMID: 35297039 PMCID: PMC9313855 DOI: 10.1002/ijgo.14116] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Maria Fernanda Escobar
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,Tygerberg Hospital, Cape Town, South Africa
| | - Eythan R Barnea
- Society for Investigation or Early Pregnancy (SIEP), New York, New York, USA
| | - Wanda Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Diana Ramasauskaite
- Center of Obstetrics and Gynecology, Vilnius University Medical Faculty, Vilnius, Lithuania
| | - Isabel Lloyd
- Department of Obstetrics and Gynecology, Universidad de Panamá, Panama City, Panamá.,Hospital Santo Tomas, Panama City, Panamá
| | - Edwin Chandraharan
- Department of Obstetrics and Gynecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Thomas Burke
- Division of Global Health and Human Rights, Massachusetts General Hospital, Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, USA
| | - Gabriel Ossanan
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Javier Andres Carvajal
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Isabella Ramos
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Maria Antonia Hincapie
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Sara Loaiza
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Daniela Nasner
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
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- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia
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Rouzi AA, Sulaimani M. Damage-Control Surgery for Maternal Near-Miss Cases of Placenta Previa and Placenta Accreta Spectrum. Int J Womens Health 2021; 13:1161-1165. [PMID: 34858065 PMCID: PMC8631974 DOI: 10.2147/ijwh.s334743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/18/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose There is paucity of reports on damage control surgery use in near-miss cases associated with placenta previa, and placenta accreta spectrum. The objective is to report the outcome of damage control surgery for the obstetrical hemorrhage in near-miss cases of placenta previa and placenta accreta spectrum. Materials and Methods The records of all women who had damage control surgery defined as abdominopelvic packing, followed by a period of medical stabilization in the intensive care unit for near-miss placenta previa and placenta accreta spectrum at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between November 1, 2007, and March 1, 2020, were identified and reviewed. Results During the study period, seven women met the inclusion criteria. There were three women with placenta previa, three women with placenta previa accreta, and one woman with placenta accreta. Five women had cesarean section followed by laparotomy, hysterectomy, and damage control surgery, one woman had a cesarean hysterectomy and damage control surgery, and one woman had hysterectomy and damage control surgery. Estimated “near-miss” intraoperative bleeding ranged from 2 to 7 liters for the seven women (median 5 L; IQR 3.5, 6), which was managed by massive blood transfusion. Complications included disseminated intravascular coagulation (3 women), intestinal obstruction (1 woman), acute renal failure (1 woman), and vesicovaginal fistula (1 woman). Hospital stay ranged from 8 to 44 days (median 37; IQR 21, 39). Conclusion Damage control surgery can be life-saving. It should be in the armamentarium of the health care providers managing women with placenta previa, and placenta accreta spectrum.
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Affiliation(s)
- Abdulrahim A Rouzi
- Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed Sulaimani
- Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia
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Abstract
Peripartum hemorrhage is a leading cause of maternal morbidity and mortality. Anesthesiologists must be familiar with conditions associated with hemorrhage that are unique to labor and delivery and not seen elsewhere in their practice. Regardless of etiology, early recognition and timely treatment of obstetric hemorrhage is necessary to prevent significant blood loss. Massive transfusion protocols are crucial to successful resuscitation, and providers should also consider use of cell salvage, uterine artery embolization, and anti-fibrinolytics. Because more than half the deaths due to hemorrhage are preventable, multidisciplinary care bundles should be used on every labor and delivery unit.
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Affiliation(s)
- Joy L Hawkins
- University of Colorado School of Medicine, 12631 East 17th Avenue, Mail Stop 8202, Aurora, CO 80045, USA.
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Successful Perioperative Management with Damage Control Surgery in a Patient with Massive Postpartum Hemorrhage of More Than 20,000 mL. Case Rep Anesthesiol 2020; 2020:8872925. [PMID: 32607258 PMCID: PMC7315259 DOI: 10.1155/2020/8872925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 11/17/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) in obstetrics is related to postpartum hemorrhage and has been a leading cause of maternal death. We here report a successful treatment, via damage control surgery (DCS), of a life-threatening massive hemorrhage of more than 20,000 mL due to DIC. A 30-year-old female was admitted to our hospital because of atonic bleeding. Since she was having a uterine rupture, an emergency hysterectomy was performed. Because of the severe DIC (fibrinogen, 65 mg/dL; platelet count, 6.0 × 109/L), oozing persisted after the hysterectomy; thus, intraperitoneal gauze packing was performed as DCS. Afterwards, the coagulopathy was corrected, and the gauze was removed on the second postoperative day (POD 2). The patient was discharged without complications on POD 16. The present case demonstrated that performing DCS and waiting for improvement of the coagulation system can be one of the treatment options for management of patients with severe DIC.
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Carvajal JA, Ramos I, Kusanovic JP, Escobar MF. Damage-control resuscitation in obstetrics. J Matern Fetal Neonatal Med 2020; 35:785-798. [PMID: 32102586 DOI: 10.1080/14767058.2020.1730800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Severe obstetric hemorrhage is a catastrophic event and represents the main cause of maternal morbidity and mortality worldwide. The elevated mortality rate due to hemorrhage is associated with metabolic complications and organ hypoperfusion that may trigger a state of irreversible coagulopathy. Thus, the use of conventional measures to control bleeding frequently generates a vicious cycle in which the patient continues bleeding (prolonging surgical times). Damage-control surgery has proven to be feasible and effective in the context of obstetric hemorrhage. It combines surgical and resuscitative measures that generate successful results in the control of refractory bleeding, ultimately decreasing mortality in patients being in critical condition.
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Affiliation(s)
- Javier A Carvajal
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Isabella Ramos
- Faculty of Health Sciences, ICESI University, Cali, Colombia
| | - Juan P Kusanovic
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Department of Obstetrics and Gynecology, Hospital Sótero del Río, Santiago, Chile.,Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - María F Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
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Lozada MJ, Goyal V, Levin D, Walden RL, Osmundson SS, Pacheco LD, Malbrain MLNG. Management of peripartum intra-abdominal hypertension and abdominal compartment syndrome. Acta Obstet Gynecol Scand 2019; 98:1386-1397. [PMID: 31070780 PMCID: PMC7313226 DOI: 10.1111/aogs.13638] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/09/2019] [Accepted: 05/02/2019] [Indexed: 12/24/2022]
Abstract
Normal pregnancy leads to a state of chronically increased intra-abdominal pressure. Obstetric and non-obstetric conditions may increase intra-abdominal pressure further, causing intra-abdominal hypertension and abdominal compartment syndrome, which leads to maternal organ dysfunction and a compromised fetal state. Limited medical literature exists to guide treatment of pregnant women with these conditions. In this state-of-the-art review, we propose a diagnostic and treatment algorithm for the management of peripartum intra-abdominal hypertension and abdominal compartment syndrome, informed by newly available studies.
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Affiliation(s)
- M. James Lozada
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Varun Goyal
- Department of Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Danielle Levin
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Sarah S. Osmundson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Luis D. Pacheco
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Manu L. N. G. Malbrain
- Intensive Care Unit, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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