Compressive Uterine Sutures to Treat Postpartum Bleeding Secondary to Uterine Atony

OBJECTIVE

To demonstrate the usefulness of a new method of applying compressive sutures to treat postpartum bleeding secondary to uterine atony.

METHODS

Multiple sutures were applied longitudinally and transversally around the uterus of 7 women with postpartum uterine atony and postpartum bleeding.

RESULTS

The procedure was successful in all cases.

CONCLUSION

Compressive sutures of the uterus were effective in treating uterine atony with postpartum bleeding.

LEVEL OF EVIDENCE

III.

B-Lynch Brace Suturing in primary post-partum hemorrhage during cesarean section

Primary atonic post-partum hemorrhage during lower segment cesarean section, which was not controlled by ecbolics--oxytocin, methylergometrine, 15-methyl-prostaglandinF2alpha--was managed by applying a B-Lynch Brace Suture. The test of potential efficacy was the control of hemorrhage by bimanual uterine compression. Six primigravida patients at their term gestation, who underwent emergency cesarean section, all except one under spinal anesthesia, received this type of suture. Interestingly, in every case hemorrhage was controlled successfully with the compression suture. None of them received blood or blood products transfusions or developed disseminated intravascular coagulopathy. Postoperative recovery was good and all patients are in follow-up to assess their future reproductive activity. B-Lynch Brace Suturing is an invaluable procedure for the control of atonic primary post-partum hemorrhage following cesarean delivery.

Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII

BACKGROUND

Postpartum hemorrhage is one of the most common causes of maternal mortality and morbidity worldwide. The aims of treatment are to maintain the circulation and to stop the bleeding. The latter is achieved by either medical or surgical management. In intractable bleeding, emergency hysterectomy is usually required.

CASE

A 30-year-old nullipara presented with major postpartum hemorrhage due to uterine atony and vaginal lacerations. The patient developed hemorrhagic shock, resulting in prolonged prothrombin time, prolonged activated partial thromboplastin time, and low levels of factor VIII and fibrinogen. Treatments with uterotonic drugs, suturing, ligation of internal iliac arteries, subtotal hysterectomy, packing of the pelvis, and blood transfusion failed to control diffuse pelvic and vaginal bleeding. Recombinant activated factor VIIa (60-microg/kg intravenous bolus injection) was given as a final attempt to control the bleeding. The bleeding was successfully controlled within 10 minutes after administration. No side effects were noted.

CONCLUSION

Recombinant factor VIIa may be an alternative hemostatic agent in a patient with life-threatening postpartum hemorrhage unresponsive to conventional therapy.

Selective arterial embolization of the uterine arteries in the management of intractable post-partum hemorrhage

BACKGROUND

To evaluate the efficacy and safety of selective arterial embolization in the management of intractable post-partum hemorrhage.

METHODS

Thirty-five consecutive women with severe post-partum hemorrhage (primary, n=25; secondary, n=10) were treated by selective embolization of the uterine arteries. The main cause of immediate post-partum hemorrhage was atonic uterus. Retained placental fragments with endometritis was the main cause of delayed hemorrhage. In all cases, hemostatic embolization was performed because of intractable hemorrhage. Hysterectomy had been performed in two cases before embolization but it had also failed to stop the bleeding.

RESULTS

Angiography revealed extravasation in ten cases, spasm of the internal iliac artery in four cases, false aneurysm in two cases and arteriovenous fistula in one case. After embolization, immediate cessation or dramatic diminution of bleeding was observed in all cases. Two patients required repeated embolization the following day. No major complication related to embolization was found. In one patient with placenta accreta, delayed hysterectomy was necessary. Normal menstruation resumed in all women but two who had hysterectomy. One woman became pregnant after embolization.

CONCLUSION

Selective emergency arterial embolization is an effective means of controlling severe post-partum hemorrhage. This procedure avoids high risk surgery and maintains reproductive ability.

[Intrapartum hemorrhages in the maternity ward of the Yalgado Ouédraogo University Hospital Center of Ouagadougou, Burkina Faso]

On 12,175 childbirth registered in 4 years, 200 cases of delivery haemorrhage have been observed giving a rate of 1.6% of these accumulated childbirth. 60 patients (30.5%) have been evacuated from region of the country. The main etiology were: placental retention (54.5%), uterine inertia (24.5%) and coagulation disorders (21%). Blood was not available for emergency transfusion of 72 patients (54.1%) 26 deplorable cases of death raised the rate of lethality by 13%. Instant research of risk factors on all parturients, recycling of all personal on elementary first aid and life saving, also an improvement of sanitary references will enable to lower incidences related to haemorrhage by delivery.

Intrauterine irrigation with prostaglandin F2-alpha for management of severe postpartum hemorrhage

BACKGROUND

Severe postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. The use of prostaglandin F2-alpha to control severe postpartum hemorrhage may avert surgery for the control of bleeding.

METHODS

After ruling out the possibility of genital tract injuries, 18 patients with severe postpartum hemorrhage caused by uterine atony were enrolled in the study. None of the patients responded to treatment with oxytocin, methylergonovine, or uterine massage. A Foley catheter was introduced into the uterine cavity and the balloon was inflated with 5 ml sterile saline solution. The catheter was connected to an infusion line of 500 ml saline solution containing 20 mg prostaglandin F2-alpha. The solution was infused at a rate of 3-4 ml/minute for the first 10 min, and then reduced to 1 ml/minute for a period of 12 24 hours.

RESULTS

In 17 patients (94.4%) bleeding ceased within several minutes of initiation of intrauterine prostaglandin F2-alpha infusion, the uterus was firmly contracted and uterine bleeding did not recur. In one patient with placenta increta bleeding continued and hysterectomy was performed. None of the patients had any side effects.

CONCLUSIONS

Intrauterine irrigation with low concentrations of prostaglandin F2-alpha is a simple, rapid and effective treatment for severe postpartum hemorrhage and facilitates constant and continuous hemostasis. Moreover, the minute dosage used eludes potentially complicating side effects.

Bimanual uterine compression as a major technique in controlling severe postpartum hemorrhage from uterine atony

A 27-year old woman, primigravida, 33 weeks' gestation, presented with complaints of labor pain and absent fetal movement. A dead fetus in utero, abruptio placentae, and labor pain were diagnosed. Severe postpartum hemorrhage from uterine atony and disseminated intravascular cogulopathy was noted after spontaneous delivery of the baby and placenta. Bimanual uterine compression for 40 minutes was performed as a major procedure accompanied by uterotonic drugs, correction of hypovolemic shock and coagulopathy by crytalloid, blood, fresh frozen plasma. The patient had no complications when seen at 6 weeks' postpartum follow-up.

Vaginal ligature of uterine arteries during postpartum hemorrhage

Immediate postpartum hemorrhage due to uterine inertia is usually treated by injection of oxytocics. In some situations, bleeding continues and distends the uterine cavity, in turn disturbing the hemostasis that accompanies uterine retraction. Uterine bleeding must be rapidly reduced while the coagulation defect is corrected. The authors propose the vaginal ligature of uterine arteries, which can be performed in the delivery room, as an alternative to hysterectomy.

[Treatment of post-partum atonic hemorrhage with prostaglandin F2 alpha analogs]

In the authors' group of patients with haemorrhage during childbirth, in 1990-1994 a total of 28 atonic haemorrhages were recorded, 15 of them were controlled by uterotonic treatment, in the remaining 13 cases haemostasis using PG F2 alpha was applied after ruling out post-partum injury. Some patients were given moreover saline infusions. According to initial results and consistent with the literature analogues of PG F2 alpha are effective uterotonic preparations of a new generation. With regard to their simple and rapid administration they are becoming the drug of first aid in the treatment of acute atonic haemorrhage.

[Analysis of risk factors of postpartum hemorrhage in rural women]

Sixty variables during pregnancy, labor and delivery of 951 rural women were analyzed to identify the risk factors of postpartum hemorrhage. The result showed that uterine atony (RR = 13.30, 95% CI = 8.23-21.50) and its related factors were the major risk factors of postpartum hemorrhage. The related factors included prolonged labor (3.49, 1.98-6.15), prolonged second stage of labor (2.72, 1.54-4.78), pregnancy induced hypertension (mild 2.35, 1.11-4.99; > or = moderate 3.04, 1.38-6.70), neonatal weight > or = 3.500 g (2.55, 1.66-3.91). Another category of postpartum hemorrhage risk factors were placental factors (6.32, 2.35-17.01), the third stage of labor > or = 10 minutes (2.65, 1.74-4.01), parity > or = 2 (2.61, 1.69-4.01) and maternal age > or = 30 (2.19, 1.13-4.24). The authors recommends that the stress should be put on the management of labor and delivery, to prevent and management of postpartum hemorrhage, through training the birth attendants to promote their ability to prevent and manage uterine atony and correct management of labor and delivery.

[Epidemiologic study on the risk factors of postpartum hemorrhage]

The 1:2 matched case-control retrospective study of postpartum hemorrhage (PPH) was undertaken in Suizhou, Hubei Province from 1 January 1990 to 31 December 1991. The subjects consisted of 109 women who had a PPH (blood loss equal to or more than 500 ml) and 218 women whose blood loss at delivery was less than 200 ml. The results showed that multiparity, age younger than 20 or older than 36, long second and third stages of labour, abortion, low income, lack of obstetric care, etc, were identified as risk factors statistically.

[Uterine defibrillation in uterine inertia. Report of 2 cases]

The uterine atony are the most common cause of postpartum hemorrhage. Manual compression and pharmacologic methods are usually used with a successful result. When pharmacologic methods fail to control hemorrhage from atony, surgical measures should be undertaken to arrest the bleeding before it becomes life-threatening. We presents the utilization of electrical uterine defibrillation in two cases with acute hemorrhage confirming the effectivity of the proceeding.

Inadvertent administration of prostaglandin E1 instead of prostaglandin F2 alpha in a patient with uterine atony and hemorrhage

A woman underwent cesarean delivery for premature labor, breech presentation, and ruptured membranes. Placenta accreta associated with uterine atony and severe hemorrhage was diagnosed. Prostaglandin E1 instead of prostaglandin F2 alpha was inadvertently administered in an effort to control the hemorrhage. The resulting complications included profound hypotension, disseminated intravascular coagulation, and ventricular tachycardia.

[An immunochemical analysis of the function of the hemato-encephalic barrier in acute fetal hypoxia and asphyxia neonatorum]

The neurospecific protein alpha 1-globulin has been assayed in serum in order to evaluate the blood-brain barrier in newborns with acute intrapartum hypoxia. The study involved 35 term newborns with birth asphyxia of variable severity. The alpha 1-globulin levels correlated with severity of condition at birth, duration of intrauterine exposure to hypoxia and the presence of obstetric complications and clinical severity of cerebral circulatory disorders. A normal early adaptation and effective therapy reduced serum alpha 1-globulin levels 4-8-fold on the 3rd postnatal day and 6-16-fold on the 5th day. Deterioration of neurological symptoms was parallelled by a significant increase in protein levels (to 6400 ng/ml) at day 5. This evidence may confirm the fact that permeability of the blood-brain barrier is impaired by intrapartum hypoxia.

[Prevention of hypotonic hemorrhage in the placental and early puerperal period with prostenone]

To prevent afterbirth and early postpartum hemorrhages the authors used prostenone in 46 (the main group) and oxytocin in 20 females (control group). Intraplacental blood pressure and coagulation parameters were studied. With prostenone, the mean amount of the blood loss turned to be significantly lower (137 +/- 13 ml) than with oxytocin (208 +/- 17 ml). Administration of prostenone led to a significant elevation of prothrombin index alone and tolerance to heparine. As there was an insignificant difference between the parameters in the main and control groups, the mechanism of prostenone's effect on the myometrium required further studies.

[Sulprostone in the prevention and therapy of hemorrhage due to postpartal uterine atony]

Sulprostone (Nalador-Schering) was used on 25 cases of bleeding caused by post-partum atonia that did not respond to conventional uterotonic treatment. The good results obtained led to the use of the drug whenever it was necessary to prevent haemorrhage independent of the risk factors that might cause its onset.

[Dynamics of the development of disseminated intravascular coagulation syndrome in dystocia]

A comprehensive investigation of the hemostasis system permitted to follow the dynamics of disseminated intravascular hemocoagulation syndrome in patients with dystocia. In patients with spastic contractility and myometrial hypertonicity hypercoagulation stage of the aforementioned syndrome was preserved, in those with uterine inertia a transitory stage persisted, those with hypotonicity demonstrated hypocoagulation stage of the syndrome development. It was concluded that the prevention of acute syndrome stages depended on the rapid recovery of coordinated uterine contractility.

Maternal arterial desaturation with 15-methyl prostaglandin F2 alpha for uterine atony

Over a six-month period, five women with severe uterine atony and postpartum hemorrhage developed marked maternal arterial oxygen desaturation within five to ten minutes of the administration of 15-methyl prostaglandin F2 alpha. The average fall from baseline was 10.4 +/- 5.4%, to a mean arterial oxygen saturation of 88.8 +/- 5.45%. The desaturation was accompanied by acute increases, averaging 20.7 +/- 5.9%, in the intrapulmonary shunt.

[Acute fibrinopenia in obstetrics]

A review of 10 cases of severe obstetrical haemorrhage is presented. The etiology is not always clear. The most significant biological sign is the early, acute and marked drop of fibrinogen levels, below 1 g in 20 p. cent of the cases and 0.5 g in 50 p. cent. An early and rapid treatment is essential and based on correcting the fibrinopenia; fibrinogen, in fractioned form, at a mean dose of 3 g, reduces the duration of the syndrome and minimize the risks of complications. In the acute phase, heparin therapy must be avoided because it might aggravate the haemorrhage.

Postpartum hemorrhage

Postpartum hemorrhage is usually unexpected, and blood loss can be massive. Excessive bleeding after delivery may result from uterine atony, disruption of the genital tract, placental abnormalities, coagulation disorders and miscellaneous obstetric complications. Prompt treatment is imperative. Treatment options include oxytocics, prostaglandins, uterine exploration, uterine packing and, occasionally, surgery.

Control of postpartum uterine atony by intramyometrial prostaglandin

Five patients with severe postpartum hemorrhage due to uterine atony and unresponsive to oxytocin, ergonovine, and massage were treated with intramyometrial injection of 250 micrograms of prostaglandin (15S)-15-methyl PGF2 alpha-Tham. Four patients received 2 injections (500 micrograms), and 1 patient required 1 injection (250 micrograms). Three (60%) of 5 patients responded successfully with an increase in uterine tone and cessation of uterine hemorrhage, thus obviating the need for hysterectomy. Two patients had no uterine response, possibly because of delayed use of the drug, excessive blood loss, and accompanying shock; they required hysterectomy. Intramyometrial injection of prostaglandin is an effective and safe method of managing severe postpartum hemorrhage unresponsive to oxytocin and ergonovine, but it must be used early during the management of atony to obtain maximum effect. This method should precede surgical management of uterine atony.

Trasylol in the management of abruptio placentae with consumption coagulopathy and uterine inertia

A study was conducted on 40 patients with abruptio placentae complicated by intrauterine death of the fetus, consumption coagulopathy and uterine inertia. All patients had severe hyperfibrinolysis (FDP > 300 microgram/ml). Following correction of shock, amniotomy was performed, intrauterine pressure catheters were placed, and oxytocin infusions were begun in all cases. The diagnosis of uterine inertia was made when the cervix failed to dilate following six hours of this treatment. After diagnosing uterine inertia, 18 patients (group B) did not. All but one patient in group A showed a marked improvement in the associated consumption coagulopathy and a rapid reawakening of uterine activity with progress to spontaneous vaginal delivery. Thirteen patients in group B did not show prepartum improvement in consumption coagulopathy or a resumption of uterine activity. These patients required cesarean section. There were two maternal deaths in group B; the overall complication rate in this group was greater than in group A.

Treatment of postpartum uterine atony with prostaglandin E2 vaginal suppositories

When severe postpartum hemorrhage secondary to uterine atony is unresponsive to medical management, including oxytocic drugs and/or ergonovine and its derivatives, surgical intervention becomes necessary. This case of postpartum uterine atony, with several features suggesting persistent myometrial dysfunction which did not respond to usual medical measures, responded to treatment with intravaginal prostaglandin E2 (PGE2) suppositories. Prostaglandin E2 vaginal suppositories may be useful in the treatment of persistent postpartum uterine atony.

The diagnosis and management of accidental haemorrhage with associated coagulopathy

An approach to the diagnosis and management of accidental haemorrhage with associated coagulation failure is discussed and outlined. It is stressed that special investigations play a minor role in planning management. The main aim should be to achieve rapid delivery, preferably via the vaginal route. About 50% of these cases are associated with uterine atony and inertia. This is probably due to raised local and circulating levels of fibrin/fibrinogen degradation products (FDP). In such cases uterine activity can be restored by the administration of large intravenous doses of Trasylol (Bayer). Life-endangering complications such as acute respiratory and renal failure should be prevented by prophylactic management and by treatment aimed at rapid delivery. The indications for Caesarean section are outlined. The need for careful assessment prior to discharge of these patients and for re-assessment throughout the puerperium is stressed.