| | Surgical aspects of postpartum haemorrhage published online 28 August 2008. Postpartum haemorrhage (PPH) refers to excessive bleeding from the genital tract after birth. Failure of medical treatment to control bleeding would necessitate surgical measures to arrest haemorrhage, to save lives. Algorithms such as HAEMOSTASIS have been proposed as aids to the systematic and stepwise management of primary PPH. Clinicians need to be aware of various surgical techniques that could be employed to arrest haemorrhage, the appropriateness of a chosen surgical intervention to the specific clinical situation and the timing of instituting the intervention. Surgical measures to arrest PPH include repair of genital tract trauma, evacuation of retained products of conception, uterine balloon tamponade, exploratory laparotomy and uterine compression sutures, systematic pelvic devascularization, uterine artery embolization, subtotal and total abdominal hysterectomy. Consideration should also be given to the experience and the skill of the operator, as well as to the familiarity with the chosen surgical procedure. Introduction  Approximately half a million women are estimated to die each year as a result of pregnancy and childbirth1; another eight million or more suffer life-long health consequences from the complications of pregnancy.2 Obstetric haemorrhage accounts for up to 25% of maternal deaths in the developing world and postpartum haemorrhage (PPH) is the most common type of obstetric haemorrhage.3 According to the recent Confidential Enquiries into Maternal and Child Health (CEMACH) report, 17 women in the UK died as a result of postpartum haemorrhage during the last triennium (2003–2005).4 Almost three-fifths of these women received less than optimal care, which included failures in the identification and management of intra-abdominal bleeding, uterine atony and placenta percreta. This report also highlighted that women who had caesarean-section deliveries had more than 18-times higher odds of requiring a peripartum hysterectomy to control bleeding than women who had not had any caesarean section deliveries. It has been suggested that more than 60 women undergo a peripartum hysterectomy for each woman who dies from haemorrhage.4 Overall, the World Health Organization (WHO) estimates that, worldwide, about 140,000 women die each year from obstetric haemorrhage.5 Massive PPH often requires surgical measures to control bleeding to save lives. Analyses into maternal deaths have highlighted ‘too little done too late’ on many occasions. Failure to appreciate the clinical picture, underestimating blood loss, inappropriate or delayed treatment, lack of effective multidisciplinary team working and failure to seek senior help are some of the issues that have been highlighted. Clinicians need to be aware of various surgical measures that could be employed to arrest haemorrhage, the appropriateness of a chosen surgical intervention to the specific clinical situation as well the timing of instituting the intervention. Consideration should also be given to the experience and the skill of the operator, as well as to the familiarity with the chosen surgical procedure. Effective team working, networking to pool scarce resources and the presence of ‘rapid PPH response teams’, can help improve outcome. Postpartum haemorrhage: definition and causes PPH refers to a blood loss of more than 500 mL after the delivery of the fetus (or 1000mL during a caesarean section). This ‘arbitrary’ value has been set as a general guidance and other clinical parameters should be considered when instituting treatment. For example, patients with a low body mass index (BMI) might have a low blood volume (70mL/kg) and women who are anaemic might have fewer physiological reserves to withstand blood loss. Hence, these patients might not be able to tolerate even 500mL of blood loss and, therefore, will decompensate much sooner. The rate of blood loss should also be considered, as a woman who bleeds rapidly is likely to deplete her blood volume in a few minutes if bleeding continues at the same rate. Massive PPH refers to the loss of 30–40% (generally over 2 litres) of the patient's blood volume, resulting in changes in the haemodynamic parameters. In such cases, if timely and appropriate treatment is not instituted, the maternal morbidity and mortality would be very high. Primary PPH that occurs within 24 hours of delivery is often due to uterine atony, genital tract trauma, coagulopathy or retained products of conception. Secondary PPH that occurs after 24 hours of delivery (often 5–6 hours after delivery) is most likely to be due to infection (endometritis) that is secondary to retained products of conception. Surgical measures for postpartum haemorrhage Surgical measures to control PPH (Box 1) include repair of genital lacerations, evacuation of retained products of conception, the ‘tamponade test’, exploratory laparotomy with a view for compression uterine sutures, systematic pelvic devascularization, subtotal or total abdominal hysterectomy and rarely, repair of a ruptured uterus. Box 1 Surgical measures for postpartum haemorrhage •Repair of genital lacerations: perineal trauma including episiotomy, broad ligament haematoma, paravaginal haematoma (supra and infra-levator), vaginal and cervical lacerations •Exploratory laparotomy and direct uterine massage, intramyometrial injection of prostaglandins, use of compression uterine sutures (B-Lynch or modified), systematic pelvic devascularization (uterine, quadruple and internal artery ligation) •Subtotal or total abdominal hysterectomy •Repair of a ruptured uterus •Evacuation of retained products of conception Indications for surgical management of postpartum haemorrhage In cases of genital tract trauma and retained products of conception, the need for surgical measures to control PPH is straightforward. However, for PPH due to uterine atony or coagulopathy, the appropriate timing for surgical intervention is not clearly defined. A management algorithm – HAEMOSTASIS (Box 2) – has been proposed to aid stepwise management of atonic PPH.6 It has been suggested that patient should be moved to the theatre, with a view for surgical measures, if bleeding continues despite three 250-μg doses of Haemabate (15-methyl prostaglandin 2-alpha or PGF2α).6 The general condition of the patient, her haemodynamic stability, the amount and rate of bleeding, the effectiveness of conservative measures, the likely cause of PPH and the skill and experience of the clinician, as well as the availability of resources, should be considered in the decision-making process. A woman presenting with postpartum collapse due to a massive PPH might require an emergency exploratory laparotomy and radical surgical procedures like hysterectomy to save her life. Conversely, in a young woman, conservative medical or surgical measures could be attempted, to preserve future fertility, if she is haemodynamically stable. Box 2 Management algorithm for atonic postpartum haemorrhage: HAEMOSTASIS6 H:Ask for HELP and Hands on the uterus (uterine massage) A:Assess and resuscitate (vital signs, IV fluids, blood and blood products) E:Establish aetiology, ensure availability of blood and ecbolics (oxytocin) M:Massage uterus O:Oxytocics – Oxytocin infusion/prostaglandins– IV/per rectal/IM/intramyometrial S:Shift to theatre – bimanual compression/anti-shock garment T:Tissue and Trauma (exclude/manage)/proceed to Tamponade balloon/uterine packing A:Apply compression sutures – B-Lynch/modified compression sutures (2–5) S:Systematic pelvic devascularization – uterine/ovarian/quadruple/internal iliac I:Interventional radiology (and if appropriate, uterine artery embolization) S:Subtotal/total abdominal hysterectomy Surgical management of genital tract trauma Perineal trauma It is estimated that over 85% of women who have a vaginal birth will sustain some degree of perineal trauma, and of these 60–70% will experience suturing.7, 8 Episiotomy itself can increase the risk of PPH by up to 5-fold.9 Extensions of the episiotomy incision can occur, especially in instrumental and traumatic vaginal deliveries such as shoulder dystocia. Careful inspection under good light with adequate analgesia as well as exposure is important to correctly identify the apex of the episiotomy incision and to place the first suture above the apex. First-degree perineal tears involve the skin (or vaginal mucosa) and these should be repaired by continuous sutures using an absorbable suture material such as polyglactin 910 (Vicryl®). Bleeding due to second-degree tears (including episiotomy) should be controlled by repair of the vaginal mucosa, perineal muscles and skin. Recent evidence suggests that continuous suturing techniques for perineal closure are associated with less short-term pain than interrupted methods. Moreover, if the continuous technique is used for all layers (vagina, perineal muscles and skin), instead of perineal skin only, the reduction in pain is even greater.10 A per rectal examination should be carried out after the repair to exclude inadvertent inclusion of rectal mucosa. If this is the case, it is often possible to pull on the suture with the index finger, through the anal canal and cut it with a pair of scissors. Rarely, it might be necessary to use a vaginal approach. Failure to do this could result in rectovaginal fistula. Third- and fourth-degree perineal tears, which involve the anal sphincters and the rectal mucosa, respectively, should be sutured under direct supervision of a senior obstetrician to improve long-term outcome. Anterior vaginal tears often bleed profusely and, if these are close to the urethral orifice, it is advisable to insert a catheter during repair to avoid accidental inclusion of urethra during repair. Anterior vaginal tear can occur secondary to previous female genital cutting (formerly known as female genital mutation or FGM). A suggested technique for repair is shown in Figure 1. Multiple vaginal lacerations can cause ‘diffuse oozing’ of blood and, if the vagina is too friable, this can cause difficulty with surgical repair, as the sutures might cut through. In such cases, a vaginal pack can be inserted to control haemorrhage; this is generally removed after 12–24 hours. However, it is very important to exclude any arterial bleeders prior to inserting a pack; if these are present, they should be ligated. To avoid friction and trauma during removal, the pack can be ‘lubricated’ with flavin or povidone iodine. Alternatively, the pack can be inserted inside sterile plastic bags or drapes; the latter can help avoid ‘frictional trauma’ during removal. Rotational instrumental vaginal deliveries can result in ‘spiral vaginal tears’, which need to be repaired under good anaesthesia and light, in the theatre. A ‘stay suture’ is first placed as high as possible and then an attempt should be made to proceed upwards to reach the apex of the tear, using the stay suture to apply a downward traction, thus exposing the tear above. Upper vaginal or cervical tears These should be repaired by an experienced clinician because of the anatomical structures that are in close proximity; these include bladder neck and upper urethra (anteriorly), ureters (laterally), rectum and loops of bowel in the Pouch of Douglas (posteriorly). Upper vaginal tears can pose difficulty with regard to exposure and access. Placing a stay suture as high as possible and using this to pull downwards, so as to access the tear above this, is a useful technique. Such a ‘climb-up’ technique, using each suture to exert a downward traction and thereby exposing the tear above the suture to place further sutures, can help to insert interrupted sutures to the apex of the tear, which would otherwise have been difficult. If surgical repair is not possible, or is deemed risky in view of a strong possibility of inadvertent damage to surrounding structures, selective arterial embolization can be considered, after transfemoral arteriogram. Cervical tears are not common after delivery. Small tears (<2cm), which do not bleed, need no surgical intervention. Larger tears (>2cm) and those that bleed profusely (regardless of the size) need suturing. The cervix should be explored with the help of two round (or ‘ovum’) forceps, which are moved sequentially, usually in a clockwise direction. Such a ‘circumferential approach’ helps to visualize the entire lip of the cervix and to exclude anterior, posterior, lateral and oblique tears. Lateral cervical tears can be exposed by retracting anterior and posterior walls of the vagina with two Sim's specula. A lateral vaginal wall retractor on the side of the tear is very useful in providing additional space required for placing sutures in a ‘restricted’ area. Two round (or ‘ovum’) forceps are used to hold the anterior and posterior lips of the cervix, respectively, and to exert a downward traction. This will help expose the apex and bleeding can be arrested by placing figure-of-eight sutures. Cervical tears extending above the internal os may be associated with intraperitoneal bleeding and, hence, can warrant a laparotomy. Haematoma It is estimated that up to 50% of parturients develop vulval or infra-levator haematomas, which are minor and self-limiting.11 Management of these haematomas, which are often less than 5cm in size, is by a conservative approach. Ice packs, pressure dressings, analgesia and antibiotics are recommended. However, a woman may bleed rapidly and profusely into a dead space, leading to the development of a large haematoma that might result in significant haemodynamic instability. Expanding haematomas, or those that are over 5cm in size, often require surgical measures. Large vulval or infra-levator haematomas (>5cm) Principles of management include incision and drainage, identifying and ligating bleeding vessels and prevention of ‘re-filling’. Surgical incision to evacuate a vulval or infra-levator haematoma should be made through the vaginal mucosa, to avoid visible scarring on the perineal skin, if possible. After evacuation of clots and blood, the cavity should be examined for any bleeding points and these should be ligated. Multiple ‘figure-of-eight’ sutures can be tried to achieve haemostasis, using absorbable sutures. If there is persistent oozing and there is no demonstrable bleeding point, a vaginal pack could be inserted as a ‘tamponade’. Alternatively, a Foley's catheter balloon could be inserted into the cavity of the haematoma and the bulb inflated with saline (about 30mL) to apply constant pressure. These are removed after 12–24 hours. Prophylactic antibiotics and continuous bladder drainage using an indwelling Foley's catheter, to avoid urinary retention due to pain and possible pressure on the urethra by the vaginal pack, should be considered. Supra-levator haematomas As the name implies, collection of blood occurs above the levator ani muscles (i.e. pelvic floor). These are likely to be missed as there may not be any visible signs of bleeding or haematoma; they should be suspected in the presence of upper vaginal tears. Clinically, the patient may be haemodynamically very unstable and there may be a disparity between the perceived amount of ‘visible’ blood loss and the clinical condition of the patient. Approximately half of these supra-levator haematomas present immediately after delivery with lower abdominal pain and signs and symptoms of shock. Others may present later, sometimes after the first 24 hours. Conservative management is recommended if the patient is stable and if the supra-levator haematoma remains the same size, without any evidence of rapid expansion.12 Intravenous fluids and blood transfusion might be required to correct hypovolumia and a vaginal pack may be helpful for tamponade. Patient should be monitored carefully and antibiotics should be prescribed to prevent secondary infection, which could lead to an abscess. Imaging techniques (transabdominal and transvaginal ultrasound scan) can be helpful to determine the site and size of haematomas, as well as to assess any changes in the size. An increase in size might be suggestive of continued bleeding, whereas a gradual reduction in size could indicate resolution. Surgical management is indicated if there is evidence of increase in the size of the haematoma or if the haemodynamic status of the patient deteriorates. Exploratory laparotomy should be performed with a view to ligating the bleeding vessel, if possible. However, in the presence of enlarging supra-levator or broad-ligament haematomas, this might not be always possible. In such cases, ligation of the anterior division of the internal iliac artery should be considered, as this can reduce the pulse pressure in the distal branches by about 85% and the overall blood flow by approximately 50%.13 Alternatively, selective arterial embolization could be attempted, following transfemoral angiography to identify the bleeder. This procedure might help avoid a laparotomy, and its associated risks, in an already compromised patient. However, expertise (an interventional radiologist) and resources are required. Rarely, pelvic pressure packing might be considered if bleeding continues despite of surgical measures to control bleeding. Broad-spectrum antibiotics should be prescribed to avoid infections and the pack could be removed in 24–36 hours. Such an approach might also help to correct accompanying coagulopathy secondary to massive blood loss. Surgical management of postpartum haemorrhage due to uterine causes Uterine atony not responding to conservative measures, uterine rupture or tears, unintended extensions of caesarean section incisions, morbidly adherent placentae and retained products of conception would require surgical measures to control bleeding. The type of intervention would depend on the aetiology and on the haemodynamic condition of the patient. Uterine atony not responding to conservative measures Uterine tamponade can be attempted to apply pressure to the placental site and to arrest bleeding with the aid of uterine packs or various balloons, if bleeding persists despite of conservative measures. These balloons include bulbs of the Foley's catheter, Sengstaken–Blakemore oesophageal catheter (SBOC), Rusch urological hydrostatic balloon or the specially designed ‘Bakri SOS’ balloon. It might be necessary to instil about 300 to 400mL of saline or sterile water to distend the balloon of the catheter in order to exert the desired counterpressure to stop bleeding from the uterine sinuses. A ‘tamponade test’ has been described, which has a positive predictive value of 87% for the successful management of PPH.14 If the tamponade arrests the bleeding (i.e. the ‘tamponade test’ is positive), then the chances of the patient requiring any further surgical intervention are remote. However, if uterine tamponade fails to control the haemorrhage (i.e. the ‘tamponade test’ is negative), then the patient often needs further surgical intervention. Exploratory laparotomy and direct uterine massage, intramyometrial injection of prostaglandins and compression sutures can be tried. Compression sutures include the ‘B-Lynch’ suture15, horizontal and vertical brace sutures16 and various modifications, including Cho's multiple square technique.17 The main aim of these compression sutures is to control bleeding from the placental site, by apposing the anterior and posterior uterine walls together. Box 3 shows the surgical steps involved in B-Lynch suture, which is illustrated in Figure 2. The B-Lynch suturing technique enables exploration of the uterine cavity at the time of laparotomy and does not significantly interfere with drainage of inflammatory exudate, blood and debris. By contrast, Cho's multiple square technique (Figure 3) is likely to restrict drainage of uterine effluent, and cases of pyometra have been reported.18 The simplest technique is the placing of vertical compression sutures on either side. This has the advantage of not needing to open the uterus, helps to achieve better tension and enables one to place between two and five vertical sutures from the inferior aspect of the lower segment going over the fundus where the knots are placed (Figure 3a). Box 3 Technique of B-Lynch suture •A 90-mm, round-bodied, hand-held needle on which a (No. 1 or 0) Vicryl® suture is mounted is used to puncture the uterus 3cm from the right lateral border •The mounted (No. 1 or 0) Vicryl® suture is threaded through the uterine cavity to emerge at the upper incision margin 3cm above and approximately 4cm from the lateral border (because the uterus widens from below upwards) •The (No. 1 or 0) Vicryl® suture now visible is passed over to compress the uterine fundus approximately 3–4cm from the right cornual border •The (No. 1 or 0) Vicryl® suture is fed posteriorly and vertically to enter the posterior wall of the uterine cavity at the same level as the upper anterior entry point •The (No. 1 or 0) Vicryl® suture is pulled under moderate tension assisted by manual compression exerted by the first assistant. The length of the (No. 1 or 0) Vicryl® suture is passed back posteriorly through the same surface marking as for the right side, the suture lying horizontally •The (No. 1 or 0) Vicryl® suture is fed through posteriorly and vertically over the fundus to lie anteriorly and vertically, compressing the fundus on the left side as occurred on the right. The needle is passed in the same fashion on the left side through the uterine cavity and out approximately 3cm anteriorly and below the lower incision margin on the left side •The two lengths of (No. 1 or 0) Vicryl® suture are pulled taught assisted by bimanual compression to minimize trauma and to achieve or aid compression. During such compression, the vagina is checked that the bleeding is controlled •As good haemostasis is secured and, while the uterus is compressed by an experienced assistant, the principal surgeon throws a knot (double) If bleeding persists, systematic pelvic devascularization can be attempted, which includes ligation of uterine, tubal branch of the ovarian as well as internal iliac arteries, respectively. Uterine artery ligation should be carried through a ‘clear window’ in the broad ligament, just immediately lateral to the uterine vessels, after mobilizing the bladder (and, hence, the ureter) downwards. A needle should be passed through the myometrium about 2cm from the lateral border of the uterus in an antero-posterior direction, to emerge behind uterus. Leaving a 2-cm margin will prevent the suture cutting through the myometrium when the knot is tied. The needle should then be brought through the clear window in the broad ligament (postero-anteriorly) and a ‘double knot’ tied. A similar procedure should be carried out on the opposite side. If bleeding persists, a ‘quadruple ligation’ could be attempted, which involves ligation of both tubal branches of ovarian artery in the mesosalpinx, in addition to ligating uterine vessels (Figure 4). Bilateral internal iliac artery ligation could be attempted if bleeding persists despite conservative measures (including compression sutures) or if there is bleeding from the base of the broad ligament, lateral pelvic wall, angle of the vagina or laceration of the cervix. It is also useful in cases where bleeding continues despite of a peripartum hysterectomy and – rarely – in uterine rupture, whereby the uterine artery might have been torn close to its origin in the internal iliac artery. This procedure should be performed by a surgeon who is familiar with the anatomy of the lateral pelvic wall (Figure 5) and who is experienced and skilled in this technique. Input from gynaecological oncology colleagues is very valuable and should be sought whenever feasible. Injury to adjacent veins, ureters and inadvertent ligation of the external iliac artery, with consequent devascularization of the lower limbs, are the possible complications. Ligation of posterior division of the internal iliac artery can cause ischaemia and intermittent claudication of the gluteal region. There are two common approaches to the internal iliac artery: (1) via the posterior aspect of the round ligament, by opening the leaves of the broad ligament; and (2) a direct approach by incising the peritoneum directly over the bifurcation of common iliac vessels. Surgeon preference and familiarity, as well as presence or absence of the uterus (i.e. a direct approach following postpartum hysterectomy), would dictate the chosen approach. An extra-peritoneal approach could also be used to access the internal iliac vessels. Once the peritoneum is opened, the ureters should be identified (crossing the pelvic brim, just in front of the bifurcation of common iliac vessels, and lying on the medial flap of the peritoneal leaf) and reflected. The use of a sling to hold the ureter away from the operative field can help protect from inadvertent injury. After separating the loose areolar tissue, the bifurcation should be exposed and both internal and external iliac arteries should be clearly identified. The internal iliac vein should be separated from the artery and a plane developed between the artery and the vein, so that a right-angled clamp can be passed in between the two, through this space. Alternatively, a right-angled, blunt-ended needle can be passed through this space. Silk or Vicryl® sutures should be threaded and the vessel should be doubly ligated, about 0.5cm apart, approximately 1cm below the bifurcation so as to avoid ligating the main trunk of the internal iliac artery. As the knot is tightened, it is good practice to check the femoral pulse to exclude inadvertent ligation of external iliac artery. The same procedure should be repeated on the opposite side. To avoid kinking of the ureters, the peritoneum should be closed with interrupted (2-0 Vicryl®) sutures. Subtotal or total abdominal hysterectomy should be attempted as the last resort to save life. However, as mentioned earlier, this might need to be considered earlier if the patient is haemodynamically unstable. Safety should not be compromised for preservation of future fertility, although it can be devastating – especially for primigravid women – to have to undergo a hysterectomy.18 The decision to perform a hysterectomy should be made by the most senior obstetrician and it is good practice to convey this decision to the patient (if possible) or her relatives, as well as to anaesthetic colleagues. Subtotal hysterectomy is safer, quicker and easier to perform than total abdominal hysterectomy, and is indicated in cases in which the source of bleeding is from the upper segment. Hence, it is not useful in cases of placenta praevia or when cervical or upper vaginal tears contribute to PPH; in such cases, a total abdominal hysterectomy is warranted to arrest haemorrhage. The procedure is similar to a standard gynaecological abdominal hysterectomy. However, pregnancy can pose additional challenges (Box 4). Okogbenin et al, reflecting on 15 years of experience of obstetric hysterectomy in a tertiary centre, reported a maternal mortality rate of 12.5% and a urinary-tract injury rate of 7.5% after this procedure.19 A more recent 25-year review reported a maternal mortality rate of 11.6%.20 This emphasizes the importance of understanding the technical difficulties when performing a peripartum hysterectomy, of seeking senior help early and also of resorting to this option before it becomes too late to save the life of the patient. Box 4 Points to consider during peripartum hysterectomy •The normal pelvic/genital tract anatomy might be distorted •Vascular pedicles are thicker and more oedematous than in the non-pregnant state •The vascular pedicles should be double clamped to avoid slippage of ligatures. Small pedicles should be secured and knots tied when they are in the correct anatomical plane, without torsion or twisting of the pedicle •The bladder might be adherent to the lower segment, especially in previous caesarean sections. This could increase the risk of bladder injury and, hence, the bladder should be adequately mobilized •The presence of uterine tears or extensions of the uterine angles might increase the risks of ureteric injuries, during placement of sutures •The ovarian pedicle might be shortened due to enlargement of the uterus. Failure to appreciate this could result in the clamp being placed laterally, compromising ovarian function or rarely this may result in an unintended oophorectomy. •There may be a difficulty in identifying the cervix, especially if hysterectomy follows a caesarean section done at full dilatation. The tissues might be very friable and this can pose added difficulties •When a hysterectomy has been decided on, and if the patient is bleeding profusely, applying clamps (Green–Armytage or sponge forceps) to the edges of uterine incision or ruptured muscle; long (Spencer Wells) clamps at the cornua may help reduce further blood loss. Similarly, a tourniquet could be applied near the lower segment to compress uterine vessels. Surgical management for placental abnormalities In cases of profuse PPH due to placenta praevia, horizontal and vertical compression sutures could be tried in the lower segment. In authors' experience, these full-thickness sutures placed in the lower segment are more effective than B-Lynch sutures in this situation. A curved, round-body needle (110mm), as used for suturing the liver, or a straight needle can be passed through the anterior and posterior uterine walls. The needle is then re-inserted through the posterior wall to re-emerge through the anterior wall, so that the knot can be tied. These compression sutures could also be tried in placenta accreta or increta to achieve haemostasis. If the bleeding is profuse, multiple figure-of-eight sutures should be applied rapidly to the placental bed prior to the B-Lynch sutures. Alternatively, a balloon catheter could be inserted and the bulb inflated with 300–400mL of saline to provide a tamponade effect on the placental bed. In cases of placenta percreta that invades the adjacent organs (e.g. the bladder), the umbilical cord can be clamped and cut as close to the placenta as possible and the patient managed conservatively. Hysterectomy, with or without internal iliac artery ligation or uterine artery embolization, is the alternative management option. Uterine rupture Lower-segment uterine rupture, which commonly occurs in a previously scarred uterus, is often amenable to repair. However, rupture of the upper segment that occurs following a previous classical caesarean section or in a multiparous woman, may necessitate a peripartum hysterectomy to arrest haemorrhage. It is important to achieve rapid haemostasis as the woman could lose a significant proportion of her blood volume within minutes. Resuscitation should be vigorous and occur simultaneously to surgical measures to arrest haemorrhage. During laparotomy, pressure on the abdominal aorta might help reduce uterine blood flow. Clamps should be applied swiftly to the ragged edges, as well as to the cornua, to reduce the amount of bleeding while hysterectomy is in progress. A ‘uterine artery tourniquet’ may be applied by creating windows in the broad ligament on either side and passing a rubber tube (or tubing of an intravenous set) circumferentially around the uterus and tightening under tension. Surgical management of postpartum haemorrhage secondary to retained products Retained products of conception can cause primary and secondary PPH. In the former, evacuation of retained products should be carried out under anaesthesia. A blunt curette should be used to avoid ‘Asherman's syndrome’ resulting from vigorous curettage that can damage the basal layer of the decidua, which is more likely to occur with a sharp curette. Secondary PPH is often due to a co-existing infection (endometritis) and this should be treated with broad-spectrum antibiotics. If there is clinical suspicion or sonographic evidence of retained products (usually >2cm in size), these should be surgically evacuated. Conclusion Surgical measures play an important role in the overall management of PPH due to uterine atony, placental abnormalities, genital tract and uterine trauma as well as retained products of conception. The timing of surgery and the type of intervention would depend on the aetiology of PPH, degree of efficacy of conservative measures, haemodynamic instability and the skill and experience of the clinician. It is paramount for practising obstetricians to be familiar with various surgical aspects of managing PPH and also to understand their limitations and to seek help from those appropriately skilled to reduce maternal morbidity and mortality. Practice points•Approximately 85% of women who have a vaginal birth will sustain some degree of perineal trauma, and of these 60–70% will experience suturing. •Massive PPH often requires surgical measures to control bleeding in order to save lives. •The odds of requiring a peripartum hysterectomy to control bleeding are about 18-times higher in women who have had previous deliveries by caesarean section than in women who have not had caesarean section deliveries. •Ligation of the anterior division of the internal iliac artery can reduce the pulse pressure in the distal branches by about 85% and the overall blood flow by approximately 50%. •Surgical measures to control PPH due to placenta praevia include haemostatic sutures to the placental bed, a tamponade balloon, uterine compression sutures, systematic pelvic devascularization and hysterectomy. Research agenda•Morbidity and fertility data following vertical and horizontal compression sutures versus B-Lynch compression sutures. •The role of prophylactic compression sutures in women who are at increased risk of PPH during caesarean sections. References *1. 1.UNFPA and University of Aberdeen . Maternal mortality update 2004: delivering into good hands. New York: UNFPA; 2005;. 2. 2UNFPA: State of World population . Chapter 4 -Reproductive health: a measure of equity. http://www.unfpa.org/swp/2005/index.htm2005;. *3. 3.World Health Organization (WHO) Department of Reproductive Health and Research . Maternal mortality in 2000: estimates developed by WHO, UNICEF, and UNFPA. Geneva: WHO; 2004;. *4. 4.Liston William. Haemorrhage. In: Saving mothers' lives (2003–2005). Confidential Enquiries into Maternal and Child Health (CEMACH); 2007; http://www.cemach.org.uk/Publications/CEMACH-Publications/Maternal-and-Perinatal-Health.aspx. 5. 5AbouZahr C. Global burden of maternal death. In: British Medical Bulletin editors. Pregnancy: reducing maternal death and disability. British Council. Oxford University Press; 2003;p. 1–13www.bmb.oupjournals.org. *6. 6.Chandraharan E, Arulkumaran S. Management algorithm for atonic postpartum haemorrhage. J Paediatrics Obstet Gynaecol. June 2005;106–112. 7. 7McCandlish R, Bowler U, Van Asten H, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol. 1998;105:1262–1272. MEDLINE 8. 8Sleep J, Grant A, Garcia J, et al. West Berkshire perineal management trial. BMJ. 1984;289:587–690. MEDLINE 9. 9Coombs C, Murphy E, Laros R. Factors associated with postpartum haemorrhage with vaginal birth. Obstet Gynecol. 1991;77:69–76. MEDLINE *10. 10.Kettle C, Hills RK, Ismail KMK. Continuous versus interrupted sutures for repair of episiotomy or second degree tears. Cochrane Database Syst Rev. 2008;(1):. 11. 11Drife J. Management of primary postpartum haemorrhage. Br J Obstet Gynaecol. 1997;104:275–277. MEDLINE 12. 12Lingam K, Hood V, Carty M. Angiographic embolization in the management of pelvic haemorrhage. Br J Obstet Gynaecol. 2000;107:1176–1178. 13. 13Burchell R. Physiology if internal iliac artery ligation. J Obstet Gynaecol Br Commonw. 1968;75:642–651. MEDLINE *14. 14.Condous GS, Arulkumaran S, Symonds I, et al. The tamponade test for massive postpartum haemorrhage. Obstet Gynecol. 2003 Apr;104(4):767–772. *15. 15.B-Lynch C, Coker A, Lawal AH, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage:an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol. 1997;104:372–375. MEDLINE *16. 16.Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum haemorrhage. Obstet Gynecol. 2002;99:502–506. MEDLINE |
CrossRef
*17. 17.Cho JH, Jun HS, Lee CN. Haemostatic suturing technique for uterine bleeding during caesarean delivery. Obstet Gynecol. 2000;96:129–131. MEDLINE |
CrossRef
18. 18Ochoa M, Allaire AD, Stitely ML. Pyometra after haemostatic square suture technique. Obstet Gynecol. 2002;99:506–509. MEDLINE |
CrossRef
19. 19Okogbenin SA, Gharoro EP, Otoide VO, et al. Obstetric hysterectomy: fifteen years' experience in a Nigerian tertiary centre. J Obstet Gynaecol. 2003 Jul;23(4):356–359. MEDLINE |
CrossRef
*20. 20.Rahman J, Al-Ali M, Qutub HO, et al. Emergency obstetric hysterectomy in a university hospital: a 25-year review. J Obstet Gynaecol. 2008 Jan;28(1):69–72.
CrossRef
St George's Hospital Medical School, London, UK  Corresponding author. St George's Healthcare NHS Trust, Blackshaw Road, London SW17 0QT, UK.
PII: S1521-6934(08)00097-7 doi:10.1016/j.bpobgyn.2008.08.001 © 2008 Published by Elsevier Inc. | |
|
FULL TEXT00097-7/journalimage?img=PIIS1521693408000977.gr1.lrg.gif&fig=fig1&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00097-7/journalimage?img=PIIS1521693408000977.gr2.lrg.gif&fig=fig2&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00097-7/journalimage?img=PIIS1521693408000977.gr3.lrg.gif&fig=fig3&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00097-7/journalimage?img=PIIS1521693408000977.gr4.lrg.gif&fig=fig4&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00097-7/journalimage?img=PIIS1521693408000977.gr5.lrg.gif&fig=fig5&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)