Video Clips on DVD
- 4-1
PowerPoint Discussion of Protocols and Review of Management of Postpartum Hemorrhage
- 4-2
Techniques and Equipment Required to Manage Uterine Inversion
- 4-3
Technique of Balloon Tamponade for Postpartum Hemorrhage
- 4-4
Technique for How Best to Perform a Cesarean Hysterectomy
* Acknowledgement: To Dr. Nader Susseinzadeh for his contribution of Video 4-4.
Postpartum hemorrhage (PPH) is the leading cause of maternal deaths worldwide and a major cause of maternal death in the United States. The reported incidence ranges from 5% to 10% of all deliveries depending on the definition used. Postpartum hemorrhage is defined as an estimated blood loss of ≥500 mL after vaginal delivery or ≥1000 mL following cesarean section. It is also classified as primary (onset within 24 hours after delivery of the baby) or secondary (onset >24 hours postpartum). Hemorrhage is also classified as mild if the blood loss is ≤1500 mL, severe if >1500 mL, and massive if >2500 mL. The incidence of severe postpartum hemorrhage (0.5% to 1%) is increasing because of recent changes in obstetric demographics (see Chapter 1 ). Severe postpartum hemorrhage is a life-threatening emergency that develops in association with one or more of the factors listed in Table 4-1 .
|
In general, uterine atony is the most frequent cause of PPH. Risk factors for uterine atony are summarized in Table 4-2 . Persistent vaginal bleeding after delivery of the fetus and the placenta is the first sign of PPH. The bleeding can be in the form of slow and continuous oozing or it can be profuse vaginal bleeding. The bleeding is also associated with maternal tachycardia with narrow pulse pressure and reduced urine output. In severe or unrecognized cases, PPH leads to hypovolemic shock ( Table 4-3 ).
|
| Signs | Symptoms |
|---|---|
| Systolic pressure ≤90 mm Hg | Anxiety |
| Diastolic pressure ≤50 mm Hg | Confusion |
| Heart rate ≥110 bpm | Lethargy |
| Narrow pulse pressure | Air hunger |
| Cold and clammy | Tachypnea |
| Pale looking | Dizziness |
| Oliguria/anuria |
Case 1: Uterine Atony
A 20-year-old G1 was admitted at 38 weeks’ gestation for induction of labor because of severe preeclampsia. Cervical examination revealed vertex presentation at −2 station, and the cervix was long and closed. IV magnesium sulfate was started as a 6-g loading dose over 20 minutes followed by 2 g/hr as maintenance. Because of severe hypertension, the patient received two doses of 5 mg IV hydralazine. Laboratory testing revealed a hematocrit of 39% and hemoglobin (Hgb) of 13 g/dL, the platelet count was 140,000/mm 3 , with normal serum creatinine (0.8 mg/dL), normal liver enzymes, and normal fibrinogen, prothrombin, and partial thromboplastin time. Cervical ripening was started at 6 pm with misoprostol at 25-mg vaginal suppositories every 4 hours. At 3 pm the next day, cervical exam revealed 2 cm dilation, 70% effacement with presenting part at −1 station. Oxytocin induction was started and 3 hours later membranes were ruptured when she was 4 cm dilated. The oxytocin dose was progressively increased and she reached full dilation at midnight. At that time she started pushing and after 3 hours of pushing, the vertex was at 3+ station with subsequent delivery by vacuum of a 3800-g infant with good Apgar scores.
Following delivery of the placenta, the patient was noted to have moderate amount of vaginal bleeding. Oxytocin 40 IU was added to the IV and ran wide open. Pelvic examination revealed no retained products of conception, but the uterus was noted to be soft but full with clots of blood. Uterine massage was initiated for about 10 minutes, but she continued to bleed. Inspection of the vagina revealed no cervical or vaginal laceration. Because of continued vaginal bleeding, 800 µg of misoprostol was inserted per rectum. Vital signs obtained at that time revealed a blood pressure of 110/70 mm Hg, pulse of 110 beats per minute (bpm) and a respiratory rate of 22/min. The patient was also noted to be pale. Blood was obtained and sent for complete blood count (CBC) and crossmatch of 2 units of packed red blood cells (PRBCs), and patient received a bolus of 500 mL of lactated Ringer’s.
Uterine massage was initiated again because of continued heavy vaginal bleeding. Approximately 15 minutes later, the blood pressure was 90/50 mm Hg, the pulse was 130 bpm, and respiratory rate was 26/min. The rate of IV infusion was increased to 200 mL/hr. Approximately 15 minutes later, the patient was complaining of dizziness and was noted to be lethargic. Repeat vital signs revealed blood pressure of 80/40 mm Hg, the pulse was 140 bpm, and respiratory rate was 28/min. The patient received 0.25 mg of 15-methyl prostaglandin F 2 α IM, and anesthesia was called to help in the management. Another IV access was established, PRBCs were started, and large boluses of fluid were administered. Blood was sent for coagulation studies and for 2 more units of PRBCs. Because of continued blood loss, another dose of 0.25 mg of 15-methyl prostaglandin F 2 α was given, and the decision was made for surgery. The results of initial CBC revealed a hematocrit of 26%, an Hgb of 7 g/dL, and a platelet count of 100,000/mm 3 .
Exploratory laparotomy performed approximately 80 minutes postpartum revealed an intact, boggy uterus that was full of clots. A diagnosis of uterine atony was confirmed. The patient had bilateral uterine artery ligation followed by bilateral uterotubal artery ligation. Despite this, the uterus remained atonic. A third dose of 0.25 mg of 15-methyl prostaglandin F 2 α was administered in the uterine fundus. Results of coagulation studies arrived while patient was in the OR and revealed presence of disseminated intravascular coagulopathy (DIC) with a hematocrit of 21% and Hgb of 5.4 g/dL. Two additional units of PRBCs were given, and anesthesia called for 4 more units of PRBCs, 4 units of fresh frozen plasma (FFP), and 10 units of platelets. Because of continued uterine atony, the decision was made for B-Lynch sutures (uterine compression sutures), which was performed.
During surgery, blood pressures were <90 mm Hg systolic and ≤50 mm Hg diastolic. Following the B-Lynch sutures, uterine blood loss was reduced, and the abdomen was closed. The patient remained intubated and was transferred to the intensive care unit (ICU) for postoperative management. Her postoperative course was complicated by DIC (requiring 12 more units of PRBCs, 8 units of FFP, and 10 units of platelets), acute renal failure (requiring four sessions of dialysis), pulmonary edema, and acute respiratory distress syndrome (ARDS). Because of neurologic symptoms (visual changes and upper extremity weakness) the patient had magnetic resonance imaging (MRI), which revealed findings consistent with hypoxic ischemic changes. She remained in the ICU for 10 days and then discharged home 7 days later. At time of discharge, she had moderate renal dysfunction with memory loss and continued motor weakness in upper extremities.
Discussion
This patient had prolonged induction of labor requiring large doses of uterotonic agents. In addition, she was in labor for a total of 30 hours including prolonged second stage. Moreover, she received large doses of magnesium sulfate for more than 24 hours. Thus she was at high risk for uterine atony (see Table 4-2 ). Consequently, the managing providers should have anticipated this complication and been prepared for prompt diagnosis, availability of blood products, adequate staff for close monitoring, and calling for additional help very early in the process. As a result, she developed unrecognized massive blood loss for which she received “too little” replacement of fluids and blood and “too late” replacement of blood products and surgical intervention.
Early recognition and prompt treatment are important to reduce adverse maternal outcome in patients with PPH. The first step in management should include planning for its development based on the presence of risk factors, and to call for help when PPH is recognized. Subsequent management should include finding the cause of bleeding with simultaneous assessment of blood loss and maternal vital signs ( Table 4-4 ). It is important to keep in mind that blood loss is usually underestimated or it can be difficult to assess because large amounts of blood can accumulate in the uterus (uterine atony), in the vagina (obese women with cervical or vaginal laceration), or in the peritoneal cavity (extension of vertical cervical laceration). In addition, considering that blood flow to the uterus at term is approximately 600 mL/min, the patient can lose about 50% of her blood volume within 5 to 10 minutes in case of severe uterine atony. Therefore, two short large-bore IV catheters should be secured immediately to help in administration of large amounts of crystalloids, blood, and blood products as needed. This also requires the availability of rapid infusion systems and forced-air warming devices. An arterial line is also very helpful for continuous monitoring of vital signs, arterial gases and CBC, platelet count, and coagulation studies. This requires help from anesthesia staff or staff with expertise in massive volume replacement therapy. Subsequent management can be medical ( Table 4-5 ) or surgical ( Table 4-6 ) depending on etiology and response to initial therapy. Finally, the decision to proceed with prompt hysterectomy should depend on one or more of the following factors: maternal hemodynamic status, age and parity, number of cesarean sections (≥3), and presence of preexisting conditions such as accreta/percreta.
|
|
|
Uterine Atony
Management of uterine atony should include uterine massage (very difficult in obese women), use of uterotonic agents such as continuous infusion of oxytocin (40 IU/L), 0.2 mg of IM methylergonovine (avoid using in women with hypertension or preeclampsia), IM 0.25 mg prostaglandin F 2 λ (Hemabate), or oral or rectal misoprostol (600 mg). If these measures fail, then uterine packing or tamponade with a balloon or a Foley catheter should be performed. Proper positioning of the uterine balloon is crucial to stop bleeding. It is important to emphasize that if uterine atony continues despite the use of massage and uterotonic agents, the patient should be moved to the operating room for proper evaluation (rule out the presence of retained tissues, cervical or vaginal lacerations), and for insertion of the balloon for tamponade. If bleeding continues despite uterine packing or tamponade, the patient should receive immediate laparotomy and then considering the use of one of the uterine compression sutures described later.
Balloon Tamponade of Uterine Cavity
This procedure consists of insertion of a silicone or rubber-shaped balloon in the uterine cavity with subsequent filling of the balloon with a certain volume of normal saline. Balloon tamponade can be used as a temporary measure to slow down the bleeding in preparation for surgery and/or to allow for resuscitation and availability of blood and blood products. It may also be useful during maternal transfer of the patient from a level-1 hospital to a tertiary care facility. In vaginal delivery, the balloon is inserted after complete examination of the uterine cavity, cervix, and vagina to exclude the presence of retained products of conception or lacerations. The balloon should be inserted above the cervical internal os, and is then filled with 300 to 400 mL of warm saline. The balloon is held in place with vaginal packing in case of complete cervical dilation to prevent it from prolapsing into the vagina. It is important to observe for cessation of bleeding after insertion (the tamponade test). If bleeding continues, uterine tamponade will not work. Balloon tamponade can also be used to treat uterine atony following cesarean section. Following balloon tamponade, the patient should be closely monitored with serial measurements of vaginal bleeding, vital signs, and fluid intake and output. Broad-spectrum antibiotics and continuous IV oxytocin should be administered as long as the balloon is in place. The balloon is then gradually deflated over a 24-hour period. Balloon tamponade is successful in approximately 80% of cases.
Balloon tamponade can be achieved with a Foley catheter balloon that usually holds a maximum of 80 mL, which is readily available in any labor and delivery unit. In this case, at least four or five Foley balloons may be needed to be effective in the case of a term uterus. There are also several uterine balloons that are available for uterine tamponade in cases of uterine atony. The SOS Bakri catheter balloon was the first to be introduced for this purpose. It can hold up to 500 mL of fluid. Proper positioning of the balloon for this purpose is described in Figure 4-1A and improper positioning in Figure 4-1B . The BT-Cath catheter is also effective for this purpose ( Fig. 4-2 ). The U.S. Food and Drug Administration (FDA) has approved the Epps balloon for uterine tamponade in cases of postpartum hemorrhage ( Fig. 4-3 ). Note that this balloon has a large uterine bag and a smaller cervical bag that can be used to tamponade bleeding from the cervix. It can also be used for pelvic packing in case of diffuse oozing in the pelvis. For proper inflation and insertion of these balloons, please refer to the DVD.
