Obstetrical hemorrhage is the leading cause of maternal death, and its treatment frequently involves surgical procedures. In the most serious cases, regardless of the etiology, the priority is to stop the bleeding and obtain the conditions to definitively repair the injury that generates the bleeding. Multiple options for achieving hemostasis have been described, but most of them require extensive training or technological resources that are not available in all hospitals. Internal manual aortic compression is a procedure that is widely used in the management of massive pelvic bleeding; it was first described more than 50 years ago in obstetrics but is rarely used by obstetricians today.
We describe in detail the technique for internal manual aortic compression and highlight the simplicity and effectiveness of the procedure, especially as an initial measure, to avoid the metabolic consequences of massive blood loss. We hope that internal manual aortic compression is taken into account by each obstetrician when caring for a pregnant woman with massive bleeding.
Problem
Obstetrical hemorrhage is the world’s leading cause of maternal death. The treatment of many of its etiologies converges in surgical management, where the surgeon first faces the need to stop the bleeding and replace blood that was lost. Stopping bleeding is a priority, as effective repair of the injury may require more time. Regardless of the condition that generates obstetrical bleeding, effective vascular control includes the affected vascular pedicles and their anastomotic components, which are factors that determine the ideal aortic occlusion above its terminal division. According to experience, up to 50% of placenta accreta spectrum (PAS) cases are not diagnosed in prenatal studies. The identification of PAS within the cesarean delivery and other causes of massive bleeding may limit multidisciplinary care or referral of patients to specialized centers. It is almost certain that all hospitals that provide obstetrical care will face the intraoperative finding of PAS or another cause of massive bleeding at some point, and it will be a priority to have a simple and effective means for its control. There is a lack of training in managing massive hemorrhages and limited availability of specialists in vascular surgery or interventional radiology in hospitals with obstetrical patients at risk. This makes it clear that obstetricians must be able to handle simple and effective procedures to control bleeding. Hemostatic techniques on uterine or iliac vessels are usually known to achieve hemostasis. However, these techniques do not have universal hemostatic effects, and they require specific skills to be reliable. In addition, most of these options require extensive pelvic dissection or exclusive technological resources.
Internal manual aortic compression (IMAC) is a practical, immediate and straightforward method to stop pelvic bleeding. IMAC is equivalent to aortic clamping or the use of endovascular balloon occlusion, but it does not require extensive training, instruments, or equipment.
Our Solution
We describe the IMAC technique during the management of massive postpartum hemorrhage below.
We emphasize the simplicity of the procedure and its effectiveness, especially as an initial and temporal measure, to avoid the metabolic consequences of massive blood loss (metabolic acidosis, coagulopathy, and others).
The steps could be practiced during a simple cesarean delivery, as training for procedure carries no risk for a patient.
First, the uterus is exteriorized outside the pelvic cavity.
Second, the surgeons move the intestines toward the cephalic sector and cover them with a surgical field. Then, the sacral promontory and aortic pulse are identified by palpation.
A surgical pad is then placed over the aorta just above its bifurcation. Manual pressure is used to compress the aorta between the surgical pad (folded in the surgeon’s hand) and the vertebral body ( Figure ).
