Michael L. Stitely, MD To ligate the uterine vessels, place a Assistant Professor, suture through the at the Department of and lateral margin of the and then Gynecology, West Virginia University through the broad ligament. Tie the suture School of Medicine, Morgantown, WVa ends to occlude the vessels. Robert B. Gherman, MD Director of Maternal–Fetal Medicine, Prince George’s Hospital Center, Cheverly, Md

The authors report no fi nancial relationships relevant to this article.

®

Dowden Health Media Swift Andrew ObstetricCopyrightFor emergencies personal use only © Postpartum hemorrhage IN THIS ARTICLE Solutions to 2 intractable cases ❙ Five agents to control venous A stepwise approach to caused by bleeding or oozing persistent and placental abnormalities Page 66

❙ B-Lynch technique CASE 1 Uterine atony leads sequence of uterine atony. As such, they of compression to heavy bleeding generally respond to the timely adminis- Page 70 tration of IV or . In ❙ When the bladder A 21-year-old nulliparous patient at 41 this article, we focus on uncommon as- weeks’ gestation delivers vaginally after a pects of postpartum hemorrhage—such wall is involved prolonged second stage and chorioamnio- as bleeding that persists despite these ba- Page 75 nitis. After placental separation, profound sic maneuvers, as happened in Case 1. uterine atony is noted, and the patient be- gins to hemorrhage. The atony is unrespon- sive to bimanual massage, intravenous oxy- STEP 1 tocin, and intramuscular methylergonovine. Identify source of bleeding, What can be done to stanch the fl ow? administer drugs Three are among the Postpartum hemorrhage remains a lead- uterotonic drugs available to clinicians ing cause of in the United for treating uterine atony (TABLE 1): States, and most cases are the direct con- tromethamine, a synthetic

64 OBG MANAGEMENT • April 2007

For mass reproduction, content licensing and permissions contact Dowden Health Media. derivative of F, acts as a TABLE 1 smooth-muscle constrictor. It can be in- Uterotonic drugs: Instructions and cautions jected intramuscularly or directly into the DRUG DOSAGE AND ROUTE PRECAUTIONS myometrium. Avoid carboprost trometh- amine in patients with reactive airway Oxytocin 10 U IM or 10–40 U in Avoid infusing large doses disease, because it can cause bronchial 1,000 mL of a balanced (10–20 mL/min) for long smooth muscle to constrict. salt solution by IV infusion periods due to antidiuretic effects of oxytocin , also known as dino- prostone, is available as a 20-mg vaginal Methylergonovine 0.2 mg IM Avoid if hypertension is suppository that should be administered present rectally for postpartum hemorrhage to Avoid IV administration prevent the dose from being washed Carboprost 0.25 mg IM Avoid in patients with away by excessive fl ow. Dinopro- tromethamine asthma, cardiac, renal, stone is approved by the Food and Drug or hepatic disease Administration (FDA) as an abortifa- Dinoprostone 20 mg rectally or Avoid in patients with cient and works by causing contraction intravaginally cardiac, renal, or hepatic of the smooth muscle of the uterus. Limi- disease tations include its high prevalence of side effects, including nausea, vomiting, fever, 1,000 μg rectally Avoid in patients with renal and diarrhea. or hepatic failure Misoprostol, a synthetic analogue of , is FDA-approved for TABLE 2 prevention of gastric ulcers. It is highly potent, stable at room temperature, in- Tools for the well-prepared labor and delivery unit expensive, and rapidly absorbed through ITEM APPLICATION oral, vaginal, and rectal routes of admin- istration.1 For treatment of postpartum Uterotonic drugs (see TABLE 1) Pharmacotherapy for uterine atony uterine atony, place a dose of 1,000 μg Gauze rolls and sterile Mayo Uterine packing (fi ve 200-μg tablets) rectally. Uterine tone stand cover 2 should improve within 3 minutes. Bakri balloon Intrauterine tamponade For a list of other drugs and devices Long size 1 chromic suture B-Lynch sutures recommended for the labor and delivery on larged curved needles (see FIGURE 1, page 70) suite, see TABLE 2. Long straight free needles Hemostatic square sutures and size 0 chromic suture (see FIGURE 2, page 70)

STEP 2 Topical hemostatic agents: Topical hemostasis Apply direct pressure Gelfoam, thrombin, Tisseel, FloSeal to the uterine cavity If uterotonic fail to control bleeding and improve uterine tone, ap- Be sure to place the initial rolls of gauze ply direct pressure to the uterine cavity high in the fundus, or blood may accu- by packing it with gauze3,4 or inserting a mulate undetected behind the packing. Bakri tamponade balloon device (Cook We begin by placing a sterile Mayo Women’s Health, Spencer, Ind).5 stand cover into the uterus, then apply Uterine packing. The goal is to place di- packing inside the stand cover. This tech- rect pressure on all surfaces of the uterine nique facilitates removal of the gauze and cavity. This can be accomplished easily minimizes trauma to the endometrium when the has been fully dilated af- (the packing does not stick to the uterine ter vaginal delivery. Unfurl multiple rolls cavity when it is removed). Be sure to tie of moistened Kerlix gauze and evenly the ends of the gauze rolls together when pack and cover the entire uterine cavity. using more than 1 roll. CONTINUED

www.obgmanagement.com April 2007 • OBG MANAGEMENT 65 Postpartum hemorrhage

These 5 topical or systemic agents can control venous bleeding and oozing Absorbable gelatin sponge ing. Because this product requires the Venous bleeding or oozing from the uterine presence of fi brinogen within the patient’s incision that is unresponsive to suturing blood, its utility is limited in patients with can often be contained by placing a piece hypofi brinogenemia. of absorbable gelatin sponge (Gelfoam; Pfi zer, New York City) over the bleeding Fibrin sealant site. Cut the sponge to fi t the size of the This topical agent (Tisseel; Baxter bleeding site and hold it in place for 10 to Healthcare) is useful even in patients with 15 seconds. Leave the sponge in place . It is a mixture of thrombin once bleeding is controlled. and concentrated fi brinogen. The product is packaged as 2 separate components Topical thrombin with diluents. These diluted components When application of gelatin sponge are injected in a dual syringe device and alone does not bring about hemostasis, mixed in a Y-connector tube and then try topical thrombin (Thrombin-JMI; Jones applied in a thin layer directly to the site Pharma, Bristol, Va). This product is sup- of bleeding. The mixture solidifi es within plied as a kit that includes the active ingre- 3 to 5 minutes after application. This dient in powder form plus a diluent. The product can also be used to reapproxi- powder is diluted at a strength of 1,000 mate tissues. U/mL, and the mixture is sprayed onto a gelatin sponge and placed at the site of the Recombinant factor VIIa bleeding. Do not inject thrombin solution! This promising systemic agent (NovoSev- Complete resorption of the gelatin sponge en; Novo Nordisk US, Princeton, NJ) binds occurs in 4 to 6 weeks. to tissue factors that are exposed at sites of vessel injury.15 It can be administered in Gelatin matrix thrombin solution cases of life-threatening hemorrhage and FAST TRACK Another useful topical agent is FloSeal is helpful even in the presence of dilutional (Baxter Healthcare, Deerfi eld, Ill), which is or consumptive coagulopathy. A dose of Recombinant supplied as a bovine-derived gelatin matrix 70–90 μg/kg is administered IV and can be factor VIIa can help that is mixed with a bovine thrombin solu- repeated in 10 to 15 minutes if bleeding is control hemorrhage tion to create a foam matrix, which is then not controlled.16 The high cost of this po- applied directly to the bleeding site. Unlike tentially life-saving product may preclude even in the presence thrombin-soaked gelatin sponge, FloSeal community hospital blood banks from of dilutional can be applied directly to arterial bleed- stocking it routinely. or consumptive coagulopathy Remove the packing 24 to 36 hours of hemorrhage. The balloon is placed after placement. We remove the gauze in through the cervix and into the uterus af- an operating room in case additional ma- ter vaginal delivery, or in reverse fashion neuvers are needed to control recurrent during cesarean delivery. It is then fi lled hemorrhage. with saline to apply pressure to the bleed- The Bakri balloon is a large Silastic balloon ing surfaces of the endometrium. with a capacity of 500 mL that is designed Once the balloon is infl ated, observe to provide intrauterine tamponade for the catheter port for signs of continued bleeding caused by atony, previa, hemorrhage. If bleeding remains brisk, or focal placenta accreta. It has also been further intervention will be necessary to used to control hemorrhage associated control the hemorrhage. If bleeding slows with cervical ectopic .5 appreciably, the balloon tamponade is A port with a lumen on the device likely to be successful and the patient can makes it possible to assess the state be observed. CONTINUED

66 OBG MANAGEMENT • April 2007 Postpartum hemorrhage

Leave the balloon in place for 24 to If this procedure does not reduce the 36 hours, then defl ate it incrementally. hemorrhage substantially, perform a high If bleeding recurs when you defl ate the uterine artery ligation. This technique is balloon, reinfl ate it and leave it in place identical to the inferior vessel ligation, longer. but is performed approximately 5 cm su- perior to the fi rst ligation site. If these steps fail to reduce bleeding STEP 3 signifi cantly, ligate the utero-ovarian blood Control the blood supply supply bilaterally in similar fashion. to the uterus If packing or tamponade is unsuccessful, the next step is radiographic uterine ar- STEP 4 tery embolization or surgical ligation of Place uterine the uterine blood supply with O’Leary compression sutures sutures,6 followed by utero-ovarian ves- The uterus can be externally compressed sel ligation, if necessary.7 by the strategic placement of sutures. Uterine artery embolization is an effective The B-Lynch technique. This method8 method of decreasing blood fl ow to the begins with placement of a long size 1 uterus. Only facilities with readily avail- chromic suture on a large curved needle able interventional radiology services can through the anterior lateral aspect of perform the procedure, however, and the the myometrium just below the repaired patient must be stable enough for trans- uterine incision during a cesarean deliv- fer to the radiology suite. Because most ery (FIGURE 1, page 70). (It is placed in the cases of postpartum hemorrhage involve same anatomic location in the absence of profuse blood loss, radiographic emboli- a hysterotomy.) The suture then exits just zation is limited to cases of slow but con- above the uterine incision. tinuing uterine blood loss. The suture is directed over the ante- Surgical ligation of the uterine blood rior surface of the myometrium, over the supply is particularly useful. It requires a fundus, and down the posterior wall of FAST TRACK laparotomy incision after vaginal deliv- the uterus, before reentering the myome- Radiographic ery but is easily performed at the time of trium at the inferior posterior lateral edge cesarean delivery: of the uterus and crossing horizontally embolization of the 1. Create the bladder fl ap and mobilize to the opposite edge. The suture is then uterine artery is best the bladder inferiorly brought up over the posterior myometri- suited to cases of 2. Place a suture approximately 1 to 2 um, over the fundus, and back across the slow but continuing cm inferior to the level at which a low anterior myometrium. It then reenters the transverse uterine incision would be anterior myometrium just above the uter- blood loss placed during cesarean delivery. This ine incision and exits just below it. The 2 is done by pulling the broad ligament free ends are tied together under tension laterally using the thumb and index while a surgical assistant manually com- and middle fi ngers, and placing size presses the uterus. 0 chromic suture, anterior to poste- To determine the degree of blood rior, through the myometrium at the loss, visually inspect the vagina. If the lateral margin of the uterus technique has been successful, close the 3. Pass the suture through the broad abdomen and give the patient a utero- ligament, posterior to anterior, stay- tonic for 24 hours. Also, monitor urine ing well medial to the course of the output, hemoglobin, and hematocrit care- ureter fully and inspect the vagina frequently for 4. Tie the suture to occlude the uterine blood loss. vessels The square-suture technique, described 5. Repeat on the opposite side. by Cho and colleagues,9 is also useful

www.obgmanagement.com April 2007 • OBG MANAGEMENT 69 Postpartum hemorrhage

FIGURE 1 (FIGURE 2). It involves placement of size 1 Compress the uterus with the B-Lynch technique chromic catgut suture using a free, long, straight Keith needle in the following steps: 1. Pass the suture through the myome- trium, anterior to posterior 2. Pass the suture through the myome- trium again, posterior to anterior, ap- proximately 4 to 6 cm medial to the exit point of the fi rst pass 3. Place the suture 4 to 6 cm inferior and pass it through the myometrium yet again, anterior to posterior 4. Pass the suture through the myome- trium, posterior to anterior, 4 to 6 cm lateral to the last exit point 5. Tie the 2 free ends together under tension while a surgical assistant compresses the uterus in the anterior- to-posterior direction. Place 3 to 5 of these sutures across Pass long size 1 chromic suture through the anterior uterine wall just below and above the usual the surface of the uterus until the result- site of a low-transverse incision, wrap the suture around the anterior and posterior uterine walls, and pass through the posterior wall opposite the entry point. Wrap the suture again and fi nish ing compression relieves the hemorrhage. near the entry point on the anterior wall. Tie the ends tightly with the uterus under compression. Before closing the abdomen, inspect the vagina carefully to confi rm the success of FIGURE 2 the procedure. Compression option: Both the B-Lynch and square-suture Square-suture technique techniques are intended to preserve the patient’s fertility. If the patient has com- pleted childbearing, consider prompt instead.

STEP 5 Perform hysterectomy If compression sutures and devasculariza- tion of the uterus fail to control the hem- orrhage, hysterectomy is the next step.

CASE 2 Attached placenta exacerbates bleeding

A 36-year-old gravida 4 para 3 with 3 prior cesarean deliveries presents at 36 weeks’ gestation with heavy . A sonogram performed earlier in the pregnan- cy revealed an anterior placenta previa. The patient undergoes emergent cesarean de-

livery for continued brisk bleeding, but the Flewell

Using size 1 chromic catgut suture on a free, long, straight Keith needle, stitch the anterior and placenta fails to detach from the uterus. Rob posterior uterine walls together in 3 to 5 small squares. The ends of each square are then tied

tightly while an assistant compresses the uterus from anterior to posterior. How would you proceed? Images: CONTINUED

70 OBG MANAGEMENT • April 2007 Postpartum hemorrhage

Temporary abdominal closure is damage control for hemorrhagic catastrophes

ot all hospitals have the facilities or blood-bank tion of acidosis and coagulopathy. Once the acidosis capacity to manage hemorrhagic catastro- and coagulopathy are reversed, take the patient back Nphes, so temporizing measures to stabilize the to the operating room for removal of the packing and patient may be necessary, followed by transfer to a abdominal closure. tertiary center. If intensive care facilities are unavailable, the Temporary abdominal closure is a useful strategy patient can be transferred to a tertiary care center for uncontrollable intra-abdominal hemorrhage or following temporary closure. coagulopathy. It involves packing the bleeding site with sterile laparotomy pads and sealing it with an occlusive dressing. To begin, place a sterile x-ray cassette cover into the peritoneal cavity to cover any exposed bowel. Then place moist sterile towels over the cassette cover and any exposed subcutaneous tissue. Place 2 suction drains on top of the towels. Cover the towels and drains with an occlusive adhesive dressing such as an Ioban (3M Healthcare, St Paul, Minn). Attach the drains to wall suction to achieve temporary abdominal closure (see photo).17 Transfer the patient to an intensive care unit for warming, fl uid and blood replacement, and correc- Photo courtesy Alison Wilson, MD

STEP 1 hemostatic square-suture technique or Attempt to separate the Bakri balloon may be helpful. FAST TRACK placenta from the uterus In a case series, Nishijima and col- If only a small area Gently attempt to manually develop a leagues10 described successful removal of separation plane between the placenta the adherent placenta in 2 patients un- of the placenta and uterus. If this proves impossible at der direct visualization by inverting the is fi rmly adherent all surfaces of the placenta, the accreta is uterus through a large midline uterine to the uterus, an global, and hysterectomy is warranted in incision. 11 attempt to remove most cases. Kayem and colleagues described li- If placenta accreta or percreta is strong- gation of the umbilical cord close to the or excise it ly suspected before delivery, avoid attempts placental insertion, with the placenta left is reasonable to deliver the placenta and proceed to hys- in the uterus. They reviewed the records terectomy or planned retention. of all patients with the diagnosis of pla- centa accreta during 2 time frames: • when management involved immedi- STEP 2 ate hysterectomy Perform hysterectomy • when management was conservative or planned retention with the placenta left in utero. If a separation plane can be developed During conservative management, 3 between the placenta and uterus, and of 20 patients underwent hysterectomy— only a small area is fi rmly adherent, the 1 at the patient’s request, 1 at the time of accreta is focal. An attempt to remove delivery due to hemorrhage, and 1 for or excise the focally adherent placenta bleeding on postoperative day 26 due to is reasonable. The attachment site can endometritis. The rates of disseminated be oversewn to control bleeding, and the intravascular coagulation and transfusion

72 OBG MANAGEMENT • April 2007 Postpartum hemorrhage

were lower during conservative manage- FIGURE 3 ment. Two women who underwent con- Bladder wall involvement servative management had subsequent successful . One of these pa- A tients had 2 subsequent pregnancies, both complicated by placenta accreta that was again managed conservatively.

Long-term morbidity of conservative management is unclear Because of the small number of cases reported, long-term morbidity and mor- tality rates due to hemorrhage or infec- This ultrasonographic image shows placenta percreta in- tion are unknown. Therefore, conserva- volving the posterior bladder wall. tive management should be undertaken with extreme caution! Patients who have B completed childbearing should be man- aged by hysterectomy. In some cases, conservative manage- ment of placenta accreta may serve as a temporizing measure to allow for trans- fer to a higher level of care when imme- diate postpartum hysterectomy is not safe or feasible.

When the bladder is involved Placenta percreta that has eroded through the entire lower When placenta percreta involves the uterine segment and into the bladder. Photo from Stoehr E, Stitely M. Placenta percreta diagnosed antenatally with urinary bladder, conservative manage- magnetic resonance imaging. The Female Patient. 2005; ment may be the only safe option be- 30:37–39. Used with permission. FAST TRACK cause of the irreparable harm that could When placenta occur to the lower urinary tract during hysterectomy.12 (Imagine the urinary Manage blood replacement percreta involves tract injuries that could occur during Few community hospitals keep a large the bladder, hysterectomy for the patients in FIGURE reserve of blood products in stock. A retention of the 3A and B!) massive obstetric hemorrhage can rap- placenta may be the In these cases, conservative man- idly deplete blood-bank stores and ne- agement involves delivering the cessitate transferring the patient or ob- only safe option through a classical uterine incision, li- taining products from other hospitals or gating the umbilical cord close to the facilities. For this reason, the blood bank placental insertion, and closing the should be notifi ed of postpartum hemor- uterine incision. Avoid attempts to re- rhage as soon as possible, and the pos- move the placenta. Give the patient a sibility of using emergency-release, type- broad-spectrum prophylactic antibiotic specifi c blood should be discussed with such as amoxicillin/clavulanic acid for blood-bank medical personnel. 10 days.11 Assess the patient weekly for 6 weeks with ultrasonography, clinical When to transfuse red blood cells examination, and a white blood cell Administer packed red blood cells (RBCs) count with differential (to assess for if the hemorrhage is profuse and ongo- signs of infection). It may take 6 to 10 ing or if the patient is hemodynamically months for the placenta to be entirely unstable. Each unit of packed RBCs in- reabsorbed. creases the hematocrit by approximately

www.obgmanagement.com April 2007 • OBG MANAGEMENT 75 Postpartum hemorrhage

3% and raises the hemoglobin level by ap- Monitor urine output to gauge the ad- proximately 1 g. equacy of volume replenishment. If coagulopathy is suspected, or the Consider contacting a referral cen- patient has received more than 6 to 8 U ter about patient transfer or additional of packed RBCs, consider transfusing blood products if bleeding is ongoing or fresh frozen plasma. coagulation defects persist. ■

Blood studies are also indicated References 1. Khan RU, El-Refaey H, Sharma S, Sooranna D, Staf- Send blood to the laboratory for mea- ford M. Oral, rectal, and vaginal pharmacokinetics of surement of prothrombin time (PT), misoprostol. Obstet Gynecol. 2004;103:866–870. partial thromboplastin time (PTT), and 2. O’Brien P, El-Refaey H, Gordon A, Geary M, Rodeck CH. Rectally administered misoprostol for the treat- fi brinogen. If the hospital is not equipped ment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: a descriptive study. Obstet to measure fi brinogen, perform a rapid- Gynecol. 1998;92:212–214. 13 clot observation test by fi lling a plain, 3. Hsu S, Rodgers B, Lele A, Yeh J. Use of packing in obstetric hemorrhage of uterine origin. J Reprod Med. red-top tube with blood and observing it 2003;48:69–71. for clotting. If a clot forms in 8 to 10 min- 4. Maier RC. Control of postpartum hemorrhage with utes and remains intact, the test is normal. uterine packing. Am J Obstet Gynecol. 1993;169:317– 321. When the fi brinogen level is less than 150 5. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-bal- mg/dL, the blood will not clot or the clot loon for . Int J Gynaecol Obstet. 2001;74:139–142. will dissolve in 30 to 60 minutes. 6. O’Leary JL, O’Leary JA. Uterine artery ligation for This rapid test can guide the decision control of postcesarean section hemorrhage. Obstet to infuse fresh frozen plasma. Each unit Gynecol. 1974;43:849–853. 7. Abd Rabbo SA. Stepwise uterine devascularization: of fresh frozen plasma raises the fi brino- a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uter- gen level by 10 mg/dL. The goal is to keep us. Am J Obstet Gynecol. 1994;171:694–700. the fi brinogen level above 100 mg/dL. 8. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hyster- Platelet count often ectomy? Five cases reported. Br J Obstet Gynaecol. declines during hemorrhage 1997;104:372–375. 9. Cho JH, Jun HS, Lee CN. Hemostatic suturing tech- FAST TRACK When blood loss is ongoing, try to keep nique for uterine bleeding during cesarean delivery. the platelet count above 50 x 103/μL. Obstet Gynecol. 2000;96:129–131. Each unit of packed 10. Nishijima K, Shukunami K, Arikura S, Kotsuji F. An op- Each unit of platelets will increase the erative technique for conservative management of pla- red blood cells platelet count by 5–10 x 103/μL. How- centa accreta. Obstet Gynecol. 2005;105:1201–1203. 11. Kayem G, Davy C, Goffi net F, Thomas C, Clément D, increases the ever, platelets are rapidly destroyed after Cabrol D. Conservative versus extirpative manage- transfusion, so continue to assess hemo- ment in cases of placenta accreta. Obstet Gynecol. hematocrit by about 2004;104:531–536. globin level, hematocrit, platelet count, 3% and raises 12. Valayatham V, Rao S, Nath R, Raju S, Maxwell D, and coagulation parameters. Also, check Oteng-Ntim E. A case of placenta percreta with blad- der involvement managed conservatively. J Obstet the hemoglobin level calcium and electrolyte levels, and cor- Gynaecol. 2005;25(4):397–398. by about 1 g rect levels after the transfusion of every 13. Poe MF. Clot observation test for clinical diagnosis of 4 U of blood. clotting defects. Anesthesiology. 1959;20:825–829. 14. Rebarber A, Lonser R, Jackson S, Copel JA, Sipes S. Cell-saver technology is an option for The safety of intraoperative autologous blood collec- tion and autotransfusion during cesarean section. Am management of postpartum hemorrhage, J Obstet Gynecol. 1998;179:715–720. once the surgical fi eld has been cleared of 15. Zeeman GG. Obstetric critical care: a blueprint for amniotic fl uid.14 improved outcomes. Crit Care Med. 2006; 34(Suppl): S208–S214. Volume replacement can be accom- 16. Pepas LP, Arif-Adib M, Kadir RA. Factor VIIa in pu- plished with concurrent administration erperal hemorrhage with disseminated intravascular coagulation. Obstet Gynecol. 2006;108:757–761. of crystalloid or other volume expanders, 17. Schreiber MA. Damage control surgery. Crit Care Clin. such as hetastarch (Hespan) or albumin. 2004;20:101–118.

76 OBG MANAGEMENT • April 2007