Postpartum Hemorrhage Solutions to 2 Intractable Cases
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Michael L. Stitely, MD To ligate the uterine vessels, place a Assistant Professor, suture through the myometrium at the Department of Obstetrics and lateral margin of the uterus 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 bleeding caused by bleeding or oozing persistent uterine atony 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 oxytocin or uterotonics. In A 21-year-old nulliparous patient at 41 this article, we focus on uncommon as- ❙ When the bladder 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 uterotonic drugs Three prostaglandins are among the Postpartum hemorrhage remains a lead- uterotonic drugs available to clinicians ing cause of maternal death in the United for treating uterine atony (TABLE 1): States, and most cases are the direct con- Carboprost tromethamine, a synthetic 64 OBG MANAGEMENT • April 2007 For mass reproduction, content licensing and permissions contact Dowden Health Media. derivative of prostaglandin 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 Prostaglandin E2, 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 blood 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, Misoprostol 1,000 μg rectally Avoid in patients with renal and diarrhea. or hepatic failure Misoprostol, a synthetic analogue of prostaglandin E1, 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 medications 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 cervix 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 coagulopathy. 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, placenta 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 pregnancy.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.