18JCEI / 2014; 5 (1): 18-23 Journal of Clinical and Experimental Investigations doi: 10.5799/ahinjs.01.2014.01.0352 ORIGINAL ARTICLE / ÖZGÜN ARAŞTIRMA Approach to cases with postpartum haemorrhage: Retrospective analysis of 41 cases Postpartum hemoraji vakalarına yaklaşım: 41 olgunun retrospektif analizi Adnan İncebıyık1, Aysun Camuzcuoğlu2, Neşe Gül Hilali1, Ahmet Küçük2, Hasan Hüsnü Yüce2, Harun Aydoğan2, Hakan Camuzcuoğlu1, Mehmet Vural1 ABSTRACT ÖZET Objective: To assess treatment approaches and out- Amaç: Kliniğimizde tedavi edilen 41 postpartum hemoraji comes in 41 cases with postpartum haemorrhage (PPH). (PPH) olgusunun tedavi yöntemleri ve sonuçlarını değer- Methods: Screening the electronic database of the hos- lendirmek pital identified 41 cases admitted to the obstetrics clinic Yöntemler: Hastanemiz elektronik kayıt sisteminden 1 with a diagnosis of PPH (ICD codes: O72, O72, O72.2) Ocak 2010 ile 30 Haziran 2013 tarihleri arasında “Interna- between January 1, 2010, and June 30, 2013. The clinical tional Classification of Diseases” hastalık kodlarına göre findings and the results of the surgical and medical treat- Postpartum kanama (O72, O72.1, O72.2) tanısı ile obs- ments used were noted in all the patients. tetri servisine yatışı yapılan hastalar taranarak 41 hasta Results: Forty-one cases with PPH were detected who kaydına ulaşıldı. Tüm hastaların tedavi sırasındaki klinik had been managed at the clinic during a 3-year pe- durumları ve uygulanan cerrahi ve medikal tedavi sonuç- riod. Normal spontaneous vaginal delivery (26 patients; ları not edildi. 63.4%) was the most common type of delivery. Uterine Bulgular: Üç yıllık dönem içerisinde PPH nedeniyle has- atony was the most common cause of PPH in 30 patients tanemizde tedavi altına alınan 41 olgu saptandı. Doğum (73.2%). Medical therapy was the most common thera- şekli olarak en çok 26 hasta (%63,4) ile normal doğum peutic approach in PPH caused by uterine atony (16 pa- saptanırken, 12 hastada (%29,3) sezaryen, 3 hastada tients; 53.3%), followed by total abdominal hysterectomy (%7,3) ise vakum yardımıyla vajinal doğum yaptırıldığı (TAH) plus bilateral hypogastric artery ligation (9 patients; görüldü. PPH neden olma bakımından en sık rastlanı- 30.0%), uterine packing sutures plus bilateral hypogastric lan klinik durum 30 hastada (%73,2) görülen uterin atoni artery ligation (BHAL) (4 patients; 13.3%) and intrauterine olarak tespit edildi. Atoni nedeniyle gelişen PPH’de en balloon tamponade (IUBT) (one patient; 2.4%). Only one sık uygulanan tedavi şekli 16 hastada (%53,33) görülen of 3 patients with uterine rupture underwent a hysterec- medikal tedavi iken ardından 9 hasta (%30,00) total ab- tomy. Three patients in whom placental adhesion anoma- dominal histerektomi + bilateral hipogastrik arter ligasyo- lies were detected were treated by a combination of man- nu (BHAL), 4 hasta (%13,33) uterin paketleme sütürü + ual removal of the placenta, uterine curettage and IUBT. BHAL ve 1 hastada ise (%2,44) intrauterin balon tampo- Conclusion: The results suggest that care should be nat (İUBT) uygulamasının yapıldığı tespit edildi. Uterin taken regarding PPH in pregnant women, even in those rüptür saptanan 3 olgudan sadece birinde histerektomi without any risk factors. In particular, the third phase of yapıldı. Plasental yapışma anomalisi saptanan 3 hasta labour should be carefully monitored. Medical treatment elle halas, uterin küretaj ve İUBT uygulaması ile tedavi and organ-sparing surgery are generally associated with edildi. positive outcomes in patients with stable haemodynamic Sonuç: Sonuç olarak risk faktörü bulunmayan gebelerde status. J Clin Exp Invest 2014; 5 (1): 18-23 bile PPH açısından dikkatli olunmalı ve özellikle doğum 3. Key words: Surgical treatment, medical treatment, post- evresi dikkatle izlenmelidir. Hemodinamik açıdan durumu partum haemorrhage stabil olan hastalarda medikal tedavi ve organ koruyucu cerrahi genelde olumlu sonuçlar vermektedir. Anahtar kelimeler: Cerrahi tedavi, medikal tedavi, post- partum hemoraji 1 Harran University, Faculty of Medicine, Department of Gynecology and Obstetrics, Şanlıurfa, Turkey 2 Harran University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Şanlıurfa, Turkey Correspondence: Adnan İncebıyık, Harran University School of Medicine, Gynecology and Obstetrics Clinic, Şanlıurfa, Turkey Email: [email protected] Received: 17.09.2013, Accepted: 19.12.2013 Copyright © JCEI / Journal of Clinical and Experimental Investigations 2014, All rights reserved İncebıyık et al. Approach to postpartum haemorrhage 19 INTRODUCTION The treatment methods employed were classi- fied into 2 groups: surgical and medical. Surgical Postpartum haemorrhage (PPH) is traditionally de- treatment was further subclassified as follows: to- fined as bleeding over 500 ml within 24 hours af- tal abdominal hysterectomy (TAH) or organ-sparing ter normal delivery and bleeding over 1000 ml after surgery. The organ-sparing surgeries were uterine caesarean section [1,2]. Although PPH is generally packing sutures (B-Lynch) plus bilateral hypogas- observed in developing countries, its incidence is in- tric artery ligation (BHAL), repair of lacerations in creasing in developing countries due to increases in the lower genital tract and intrauterine balloon tam- the number of pregnancies at advanced age, induc- ponade (IUBT). The medical therapies were fundal tion of labour, caesarean section rates and multiple massage and the use of uterotonic agents, such as pregnancies in recent years [3,4]. PPH accounts for oxytocin, ergometrine and misoprostol. 30% of maternal mortality worldwide [5]. There is no consensus regarding the true incidence of PPH because there is no available method able to mea- RESULTS sure the amount of bleeding in PPH in an objective Forty-one cases with PPH were detected who had manner. However, in various series, its incidence been managed in the clinic during a 3-year period. has been reported as 5–12% [1,6,7]. The most fre- Thirty-four (82.93%) of the 41 cases were referred quent etiology is uterine atony; other etiological fac- to the clinic with uncontrolled PPH. Table 1 presents tors include injuries of the lower genital tract, uterine the demographic characteristics at admission, and rupture, uterine inversion, retention of products of Table 2 summarizes the labouratory results, num- conception and coagulopathy [2,6,8]. ber of transfusions and length of hospital stay of all Early diagnosis and management can prevent the patients. The most common type of delivery was complications, such as hypovolemic shock, renal normal spontaneous vaginal delivery (26 patients; failure, disseminated intravascular coagulation, 63.4%), followed by caesarean section (12 patients; hepatic dysfunction and acute respiratory distress 29.3%) and vacuum-assisted vaginal delivery (3 pa- syndrome [3,9]. Thus, careful monitoring is impor- tients; 7.3%). tant during the third phase of labour. The most common clinic entity causing PPH The management in PPH may vary depending was uterine atony, which was detected in 30 pa- on the type of delivery, amount of bleeding, source tients (73.2%). Reasons other than uterine atony of bleeding, haemodynamic status of the patient, included injuries of the genital tract, such as vagi- desire for children and skills of the obstetrician [1]. nal or cervical tears (5 patients; 12.2%), placental Management options comprise a wide spectrum adhesion anomalies (3 patients, 7.3%) and uterine from fundal massage to hysterectomy [1,10]. rupture (3 patients; 7.3%). Table 3 presents the In this manuscript, we review the clinical find- treatment methods used in PPH in this case series. ings of 41 patients with PPH at our clinic and the In the PPH caused by atony, medical therapy diagnostic and therapeutic approaches. (16 patients; 53.3%) was the most commonly used treatment method, followed by TAH plus BHAL (9 METHODS patients; 30.0%), B-Lynch brace sutures plus BHAL (4 patients; 13.3%) and IUBT (one patient; 2.4%). This retrospective study was carried out at the De- Of the 3 patients with uterine rupture, rupture partment of Gynecology and Obstetrics at our uni- repair was performed in 2 patients, and TAH plus versity, was planned in accordance with the Second BHAL was performed in one patient as repair was Declaration of Helsinki (revised in 2008) and was not possible. Genital tract injuries observed in 5 pa- approved by the local ethics committee. tients (deep vaginal lacerations with episiotomy in Screening the electronic database of our hos- 3 patients and vaginal lacerations plus an irregular pital identified records of 41 cases admitted to the cervical tear in 2 patients) were treated by repair clinic with a diagnosis of PPH (ICD codes: O72, under general anaesthesia, as well as by applying O72, O72.2) between January 1, 2010, and June vaginal compresses for 24 hours. 30, 2013. In all patients, we reviewed data regard- In 3 patients with postpartum placental reten- ing age at management, number of pregnancies, tion, the placental tissue was manually removed, gestational week, type of delivery, birth weight, aeti- and uterine curettage was performed under general ology of PPH, haemoglobin level, transfusion status anaesthesia. An IUBT was subsequently placed and treatment methods used. because the above-mentioned interventions failed to stop the bleeding. If no bleeding was observed J Clin Exp Invest www.jceionline.org Vol 5, No 1, March 2014 20 İncebıyık et al. Approach to postpartum haemorrhage during