Surgical management of Postpartum Hemorrhage

Postpartum hemorrhage is the leading cause of maternal mortality. Thereby its appropriate management is of great importance. Here I discuss the surgical management of Postpartum Hemorrhage which is done when medical management fails.

1. S urgical M anagement o f P ost P artum H emorrhage H arsh S rivastava R oll no- 31 M oderator- D r S oniya V ishwkarma

2. Case Scenario A 29-year-old woman ( G 2 P 1 A L 1 ) underwent an elective cesarean delivery at a gestational age of 37 weeks for complete placenta previa (type IV) in the Obstetrics department of UPUMS, Saifai. During the procedure, the placenta was delivered by manual removal without difficulty. There was no evidence of placenta accreta. Prophylactic oxytocin (3 units) was given to prevent uterine atony. Hemostasis was achieved, and the uterus was well contracted. However, 2 hours after the uneventfully completed initial surgery, heavy vaginal bleeding was observed that was controlled with additional oxytocin (10 units IV), misoprostol (1000 µg per rectum) and manual compression . After another 2 hours, bleeding started again. Curettage revealed no retained placental tissue. The clinical picture was compatible with uterine atony. What are the next steps in the management?

3. Overview of Surgical Techniques Uterine packing Balloon Tamponade Uterine Compression Sutures Uterine artery Ligation Internal Iliac artery Ligation Arterial Embolization Hysterectomy Pelvic Umbrella Pack

4. Uterine Packing Gauze size- 5m x 8 cm . Antiseptic soaked gauze is placed high up in the fundal area . Then rest of the uterine cavity is packed. A separate pack is used to fill the vagina. Antibiotic is given and the plug is removed after 24 hours. Principle- stimulates uterine contractions and exerts direct hemostatic pressure on the open sinuses. Done under General Anesthesia . This is the first step to do when medical management has failed. Also done when the patient has to be transported to the tertiary care center .

5. Balloon Tamponade Bakri balloon , Foley catheter, Condom catheter or Sengstaken -Blakemore tube may be used. The required capacity should be between 200-500 mL , so Foley catheter may be insufficient. Once inserted into the uterus, the balloon has to be inflated with normal saline until the bleeding stops or for 4-6 hours . Principle- stimulates uterine contractions and exerts direct hemostatic pressure on the open sinuses. Preferred method over packing due to the ease of use. First surgical intervention for most women with atonic PPH. This can avoid hysterectomy in 78% cases .

6. Tohamy Said, S. (n.d.). Major Obstetric Hemorrhage and Disseminated Intravascular Coagulation (Content last reviewed: 15th December 2018). In D. James, P. Steer, C. Weiner, B. Gonik , & S. Robson (Eds.), High-Risk Pregnancy: Management Options (pp. 1985-2013). Cambridge: Cambridge University Press.

7. Uterine Compression Sutures These include: B-Lynch suture Hayman suture Cho square hemostatic suture Hackethal suture

8. B-Lynch suture Developed by Christopher B-Lynch in 1997. In an open uterus, the suture compresses the upper segment but the lower segment remains open. Number 2 chromic catgut suture is used. Bi manual compression is first tried to assess the potential chance of success of the B‐Lynch suturing technique. Referred to as “ Brace suture ”. Principle- Tamponade of the uterus. Success rate is about 80% and can avoid hysterectomy.

9. B‐Lynch, C., Coker, A., Lawal, A.H., Abu, J. and Cowen, M.J. (1997), The B‐Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG: An International Journal of Obstetrics & Gynaecology, 104: 372-375. https://doi.org/10.1111/j.1471-0528.1997.tb11471.x

10. Hayman suture This was developed by Hayman et al to overcome the drawbacks of B-Lynch suture : Hysterotomy is necessary. Difficult to remember in an emergency. Uterine compression is achieved by using two longitudinal threads and transfixing the entire uterine wall. The needle transfixes the whole thickness of both uterine walls at the lower uterine segment level, with the thread being passed over to compress the fundus, and the thread tied at the fundus . Referred to as “ Simple Brace suture ”. Number 2 Polyglycolic acid or Vicryl sutures are used.

11. Matsubara, S, Yano, H, Ohkuchi , A, Kuwata , T, Usui, R, Suzuki, M. Uterine compression sutures for postpartum hemorrhage : an overview. Acta Obstet Gynecol Scand 2013; 92: 378– 385.

12. Cho square hemostatic suture Cho et al stated, “the purpose of the technique is to approximate the uterine walls until no space is left in the uterine cavity .” A needle transfixes the uterus from anterior to posterior (point a) and then from posterior to anterior (point b). The same is done (points c and d) to approximate the anterior and posterior uterine walls in a “ square ” manner. In an atonic uterus, four to five square sutures should be made. Although easier than B-Lynch sutures, it may completely occlude the blood supply to the uterine muscle within the square, leading to ischemic necrosis and subsequent complications Referred to as “ Multiple square suture ”. Number 1 Chromic Catgut sutures are used.

13. Matsubara, S, Yano, H, Ohkuchi , A, Kuwata , T, Usui, R, Suzuki, M. Uterine compression sutures for postpartum hemorrhage : an overview. Acta Obstet Gynecol Scand 2013; 92: 378– 385.

14. Hackethal suture A total of 6–16 transverse transfixing 2‐ to 4‐cm‐long sutures (U‐suture) are made. Since there is no simultaneous vertical and horizontal compression, the complication of ischemia, as in Cho square suture, doesn’t appear here. Hackethal et al claimed that “multiple” sutures may provide insurance in case one suture loosens. Referred to as “ Multiple Transverse U‐suture ”. Number 0 Vicryl sutures are used.

15. Hackethal, Andreas & Brueggmann , Doerthe & Oehmke , Frank & Tinneberg , Hans & Zygmunt, Marek & Münstedt , Karsten . (2008). Uterine compression U-sutures in primary postpartum hemorrhage after Cesarean section: Fertility preservation with a simple and effective technique. Human reproduction (Oxford, England). 23. 74-9. 10.1093/ humrep /dem364.

16. Uterine Artery Ligation The ascending branch of the uterine artery is ligated at the lateral border between upper and lower uterine segment. Suture is passed into the myometrium 2 cm medial to the artery. Number 1 chromic suture is used. In atonic PPH, B/L ligation is effective in about 75% cases. Tohamy Said, S. (n.d.). Major Obstetric Hemorrhage and Disseminated Intravascular Coagulation (Content last reviewed: 15th December 2018). In D. James, P. Steer, C. Weiner, B. Gonik , & S. Robson (Eds.),  High-Risk Pregnancy: Management Options  (pp. 1985-2013). Cambridge: Cambridge University Press.

17. Internal Iliac Artery Ligation The anterior division of internal iliac artery is ligated. The areolar sheath covering the internal iliac artery is incised longitudinally, and a right-angle clamp is carefully passed just beneath the artery from the lateral side to the medial side . Care must be taken not to perforate contiguous large veins, especially the internal iliac vein . Non absorbable sutures are used. The most important mechanism of action with internal iliac artery ligation is an 85-percent reduction in pulse pressure in those arteries distal to the ligation and hence clot formation is facilitated . B/L ligation can avoid hysterectomy in 50% patients.

18. B-Lynch, C., Keith, L., & Campbell, W. (2012). Internal Iliac ( Hypogastric ) Artery Ligation.

19. Angiographic Arterial Embolization May be used if surgical access to bleeding pelvic vessels is difficult . Embolization is done under fluoroscopy using gel foam . Success rate is more than 90 % & avoids hysterectomy. Fertility is not impaired , and most women have successful subsequent pregnancies. Ischemic necrosis may happen as a complication.

20. Bleich AT, Rahn DD, Wieslander CK, et al. Posterior division of the internal iliac artery: Anatomic variations and clinical applications. Am J Obstet Gynecol 2007;197:658.e1-658.e5.

21. Hysterectomy If all measures fail , hysterectomy is done. A second obstetrician should be consulted. It may be subtotal or total , depending on the case. https://www.buckshealthcare.nhs.uk/Downloads/Patient-leaflets-Obstetrics-and-Gynaecology/Laparoscopic%20subtotal%20and%20total%20hysterectomy.pdf

22. Pelvic Umbrella Pack Described by Logothetopulos (1926), the umbrella or parachute pack is placed for continuing pelvic hemorrhage following hysterectomy. The pack is constructed of a sterile x-ray cassette bag, filled with gauze rolls knotted together to provide enough volume to fill the pelvis. The pack is introduced transabdominally with the stalk exiting the vagina. Mild traction is applied by tying the stalk to a 1-liter fluid bag which is hung over the foot of the bed. Broad spectrum antimicrobials should be administered, and the umbrella pack is removed vaginally after 24 hours . Regarded as the “ last ditch attempt ”.

23. Cunningham, F. G., Leveno , K. J., Bloom, S. L., Spong , C. Y., Dashe , J. S., Hoffman, B. L., . . . Sheffield, J. S. (2014). Williams obstetrics (24th edition.). New York: McGraw-Hill Education.

24. Resources Cunningham, F. G., Leveno , K. J., Bloom, S. L., Spong , C. Y., Dashe , J. S., Hoffman, B. L., . . . Sheffield, J. S. (2014). Williams obstetrics (24th edition.). New York: McGraw-Hill Education. Steer, Philip & Steer, Philip. (2009). The surgical approach to postpartum haemorrhage . The Obstetrician & Gynaecologist . 11. 231 - 238. 10.1576/toag.11.4.231.27525. 2018. DC Dutta's Textbook Of Obstetrics. 9th ed. New Delhi: Jaypee Brothers Medical Publishers, pp.294-301. Matsubara, S, Yano, H, Ohkuchi , A, Kuwata , T, Usui, R, Suzuki, M. Uterine compression sutures for postpartum hemorrhage: an overview. Acta Obstet Gynecol Scand 2013; 92: 378– 385.

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