Objective
The purpose of this study was to analyze the potential of abdominopelvic ultrasonography at the initial examination in women with severe postpartum hemorrhage.
Study Design
One hundred twenty-five women were included in the study. The therapeutic approaches that were performed to stop the bleeding were evaluated for each category of ultrasonographic finding.
Results
Seventy-one women (56.8%) had normal ultrasonography; 30 women (24%) had echogenic endometrial lining; 17 women (13.6%) had echogenic intrauterine mass, and 7 women (5.6%) had abdominopelvic free fluid effusion. Medical therapies allowed the bleeding to stop in 90.1% of women with normal ultrasonography, in 66.6% of women with echogenic endometrial lining, and in 29.4% of women with echogenic intrauterine mass. Pelvic embolization and surgery were performed less frequently in women who had normal ultrasonography results (9.9%) than in women with abnormal ultrasonography results (46.8%; P < .0001).
Conclusion
A normal abdominopelvic ultrasonography is associated with a favorable outcome and can be considered to be a predictor for the effectiveness of conservative, noninvasive therapeutic approaches.
Severe postpartum hemorrhage is responsible for 25% of maternal deaths worldwide and remains the major cause of emergency peripartum hysterectomy. A better understanding of pathophysiologic mechanisms, improvements in the monitoring of pregnancy, and medical supervision of childbirth has led to a substantial decrease in maternal morbidity and mortality rates, mainly in western countries.
Postpartum hemorrhage is defined as a blood loss of >500 mL that occurs within the 24 hours after delivery. The first-line therapies for postpartum hemorrhage include manual removal of uterine-retained products, systematic exploration of the lower genital tract, and administration of uterotonic drugs such as oxytocin. According to these recommendations, postpartum hemorrhage should be considered serious when second-line uterotonic drugs, such as sulprostone, are required. Postpartum hemorrhage is classified as severe when second-line uterotonic drugs fail to stop the bleeding within 1 hour or when invasive, interventional, or surgical procedures are needed. The estimated incidence of severe postpartum hemorrhage is approximately 1 per 1000 deliveries.
Ideally, the treatment of severe postpartum hemorrhage should be decided after multidisciplinary evaluation. In this regard, resuscitation techniques, pelvic embolization, and emergency surgery should be available on a 24-hour-a-day basis. In many countries, women with severe postpartum hemorrhage may benefit from pelvic embolization, thus preserving future fertility, but surgery often is performed at many facilities because interventional radiologic evaluation is not available.
Our institution, which is a tertiary care center for the treatment of women with severe postpartum hemorrhage, provides open access that is available 24 hours a day, 7 days a week. Women with postpartum hemorrhage for whom persistent bleeding has been observed despite first-line therapies (that included systematic genital tract exploration, manual removal of possible retained products) and after a failure of second-line uterotonics administration are transferred from outside facilities. At admission to our institution, beside clinical examination and blood tests, abdominopelvic ultrasonography is performed routinely in all women. The same protocol is also applied to inpatients. Although ultrasonography plays a pivotal role for the evaluation of the severity and cause of severe postpartum hemorrhage and is the best way to determine the therapeutic approach, its potential in this specific situation has, to our knowledge, not been evaluated to date.
Accordingly, the goal of this study was to estimate the potential for the routine use of abdominopelvic ultrasonography in women with severe postpartum hemorrhage and to determine whether this examination may be used for anticipating patient outcome.
Materials and Methods
The electronic database (MiddleCare; Lincoln, Boulogne-Billancourt, France) of our institution was queried to identify all women who had been treated for severe postpartum hemorrhage between April and December 2007. Patient data, including results of ultrasonographic examinations, were recorded at the time of admission. The study was performed in accordance with the guidelines of our institutional review board; the requirement for informed consent was waived. All data were treated anonymously.
According to local and referring institutions protocol, all women had had manual removal of uterine-retained products and clinical examination of the lower genital tract and had received uterotonic drugs. Patients were referred from outside institutions when locally available treatments had failed to stop the bleeding. At admission or initial evaluation in the intensive care unit, severity of blood loss was evaluated by physical examination after invasive monitoring and correction of hemodynamic disorders were undertaken.
Abdominopelvic ultrasonographic examination was performed by an obstetrician with a Logic unit (General Electric-MedicalSystems, Zipf, Austria), using a commercially available 3.5-MHz probe. In the absence of emergency hysterectomy that had been performed before interhospital transfer, images were obtained in the axial, sagittal, and coronal planes of the uterus. The entire abdominopelvic cavity was further scrutinized to search for heterogeneous free fluid effusion. The results of ultrasonographic examinations were classified into 4 categories in the following standardized fashion: normal findings in the presence of an empty uterine cavity and the absence of free fluid effusion ( Figure 1 ); presence of echogenic endometrial lining with a thickness of <15 mm; presence of echogenic intrauterine mass with a thickness of >15 mm, without heterogeneous free fluid effusion ( Figure 2 ); and presence of heterogeneous free fluid effusion in the Douglas pouch, Morisson’s pouch or parietocolic gutters ( Figure 3 ). Doppler imaging was used to determine whether intrauterine masses had blood flow.
