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INTRODUCTION — The approach to treatment of postpartum hemorrhage (PPH) differs somewhat depending on the cause and whether hemorrhage occurs after a vaginal birth or after a cesarean delivery. Furthermore, the approach varies depending on whether the bleeding is discovered during or after the operation.
This topic will discuss the approach to the patient with hemorrhage associated with cesarean delivery. As with hemorrhage after vaginal delivery, the key to management is to identify the cause of bleeding and to initiate appropriate intervention. Increasingly, hospitals have adopted policies, protocols and guidelines to deal with massive obstetric hemorrhage. A physician practicing obstetrics should be aware of the existence and content of such protocols.
An overview of issues related to diagnosis and management of postpartum hemorrhage and the approach to the patient with PPH after vaginal delivery are reviewed separately:
ETIOLOGY — Causes of PPH after cesarean delivery include uterine atony, placenta accreta/increta/percreta, bleeding from the uterine incision or extensions of this incision, retained placenta, and bleeding from vaginal or cervical tears or uterine rupture. Uterine atony can be isolated or associated with one or more of the other causes of hemorrhage. Cervical and vaginal lacerations typically occur after a long labor with complete or nearly complete dilatation. They can develop spontaneously, during a trial of forceps or vacuum extraction, or during cesarean delivery when the operator attempts to dislodge a fetal head wedged deep in the pelvis. Serious hemorrhage from the uterine incision is generally caused by lateral extension, which can result from excessive traction when creating the incision or from tears resulting from delivery of the fetus through an incision that is too small.
DIAGNOSTIC EVALUATION — After delivery of the placenta, the volume and source(s) of bleeding are routinely assessed. As discussed above, excessive bleeding may be related to poor myometrial tone and/or associated with lacerations, incisions, or focal areas of endometrial abnormality.
The diagnosis of uterine atony is made if the uterus does not become firm after uterine massage and administration of uterotonic agents. Bleeding from lateral extension of the uterine incision from cesarean is readily ascertained by inspection of the incision. Similarly, inspection of the endometrial cavity will reveal any retained placental fragments. Placenta accreta should be suspected if the placenta does not separate readily, but can be present even if placental delivery appeared to be complete. Placenta accreta usually manifests as hemorrhage from an implantation site in the lower uterine segment. The presence of cervical and lower genital tract lacerations may not be noted until excessive vaginal bleeding postoperatively prompts lower genital tract examination. Ideally, the perineum should be inspected in the operating room to determine if there is active vaginal bleeding and, if bleeding lacerations are present, they should be repaired.
INTRAOPERATIVE INTERVENTIONS — A variety of interventions can be useful to control PPH. Clinicians should use their clinical judgment in deciding whether to expend time attempting one or more of these interventions in a patient with severe hemorrhage who is better served by hysterectomy.
Uterine artery and utero-ovarian artery ligation — Bilateral ligation of the uterine vessels (O'Leary stitch) to control PPH has become a first-line procedure for controlling uterine bleeding at laparotomy [2,3]. It is preferable to internal iliac artery ligation because the uterine arteries are more readily accessible, the procedure is technically easier, and there is less risk to major adjacent vessels and the ureter (see 'Internal iliac artery ligation' below).
Uterine artery ligation is primarily indicated when bleeding is due to laceration of the uterine or ovarian artery, but can also temporarily decrease bleeding from other etiologies. Although it will not control bleeding from uterine atony or placenta accreta, it may decrease blood loss while other interventions are being attempted.
After identification of the ureter, we pass a large curved needle with a #0 chromic catgut or polyglycolic acid suture through the lateral aspect of the lower uterine segment as close to the cervix as possible, then back through the broad ligament just lateral to the uterine vessels. The suture is tied to compress these vessels. If this does not control bleeding, the vessels of the utero-ovarian arcade are similarly ligated just distal to the cornua by passing a suture ligature through the myometrium just medial to the vessels, then back through the broad ligament just lateral to the vessels, and then tying to compress the vessels (figure 1).
Bilateral ligation of the arteries and veins (uterine and utero-ovarian) is successful in controlling hemorrhage in over 90 percent of patients [3,4]. Uterine necrosis and placental insufficiency in a subsequent pregnancy have not been described as complications [4,5]. However, there is a single case report of ovarian failure and development of intrauterine synechiae after postpartum ligation of the uterine, utero-ovarian, and ovarian arteries for PPH related to atony .
Internal iliac artery ligation — Bilateral ligation of the internal iliac arteries (hypogastric arteries) has been used to control uterine hemorrhage by reducing pulse pressure of blood flowing to the uterus . The technique is difficult, especially with a large uterus, a small transverse incision, a pelvis full of blood, and a surgeon who rarely operates in the pelvic retroperitoneal space . For these reasons, uterine artery ligation has largely replaced this procedure. The procedure is described separately. (See "Management of hemorrhage in gynecologic surgery".)
Uterine compression sutures — Uterine compression sutures are an effective method for reducing uterine blood loss related to atony. Procedure-related complications, such as uterine necrosis, erosion, and pyometra, have been reported, but are rare [9-14]. Uterine synechiae have been reported on postpartum hysteroscopy or hysterosalpingogram, although some of these women may have been curetted as well . Limited follow-up of women who have had a uterine compression suture suggests that there are no adverse effects on future pregnancy .
The specific placement of compression sutures is determined by the operator at the time of laparotomy, and their location requires operator judgment. Generally, longitudinal sutures should be easier to place and should be safer than transverse sutures, but this may not always be the case. If uterine atony persists after administration of uterotonic drugs, compression sutures should be placed promptly, as delaying placement by more than an hour increases the likelihood that hysterectomy will be needed .
The B-Lynch suture is the most common technique for uterine compression; several variations of this technique have been described and no technique has been proven significantly more effective than another .
B-Lynch suture — The B-Lynch suture envelops and compresses the uterus, similar to the result achieved with manual uterine compression . In case reports and small series, it has been highly successful in controlling uterine bleeding from atony when other methods have failed [18-22]. The technique is relatively simple to learn, appears safe, and preserves future reproductive potential. It should only be used in cases of uterine atony; it will not control hemorrhage from placenta accreta.
A large Mayo needle with #1 or #2 chromic catgut is used to enter and exit the uterine cavity laterally in the lower uterine segment (figure 2). A large suture is used to prevent breaking and a rapid absorption is important to prevent a herniation of bowel through a suture loop after the uterus has involuted.
The suture is looped over the fundus and reenters the lower uterine cavity through the posterior wall. The suture then crosses to the other side of the lower uterine segment, exits through the posterior wall, and is looped back over the fundus to enter the anterior lateral lower uterine segment opposite and parallel to the initial bites. The free ends are pulled tightly and tied down securely to compress the uterus, assisted by bimanual compression.
The technique has been used alone and in combination with balloon tamponade. This combination has been called the "uterine sandwich". (See "Intrauterine balloon tamponade for control of postpartum hemorrhage".)
Other techniques — Other techniques have been reported in small case series and represent modifications of the B-Lynch suture [20,23-30]. Hayman described placement of two to four vertical compression sutures from the anterior to posterior uterine wall without hysterotomy (figure 3) [23,24]. A transverse cervicoisthmic suture can also be placed if needed to control bleeding from the lower uterine segment. Pereira described a technique in which a series of transverse and longitudinal sutures of a delayed absorbable multifilament suture are placed around the uterus via a series of bites into the subserosal myometrium, without entering the uterine cavity (figure 4) . Two or three rows of these sutures are placed in each direction to completely envelope and compress the uterus. The longitudinal sutures begin and end tied to the transverse suture nearest the cervix. When the transverse sutures are brought through the broad ligament, care should be taken to avoid damaging blood vessels, ureters, and fallopian tubes. The myometrium should be manually compressed prior to tying down the sutures to facilitate maximal compression. The multiple squares/rectangles technique of Cho is another variation (figure 5) [27,31].
Balloon tamponade — Devices such as the Bakri tamponade balloon and the BT-Cath have been used successfully to tamponade bleeding from the uterine cavity after vaginal delivery. For each device, the balloon is filled until bleeding is controlled; continued excessive bleeding indicates that tamponade is not effective. The technique has been used alone and in combination with uterine compression sutures ("uterine sandwich")
Balloon tamponade after cesarean delivery is performed while the surgeon has direct vision of the uterus, but there are few published reports describing outcomes. These data and the use of these devices are described separately. (See "Intrauterine balloon tamponade for control of postpartum hemorrhage".)
Hysterectomy — Hysterectomy is the last resort, but should not be delayed in women who require prompt control of uterine hemorrhage to prevent death. (See "Peripartum hysterectomy".)
Post-laparotomy inspection — At the completion of the laparotomy, the operative field should be inspected carefully for hemostasis. Microvascular bleeding usually can be controlled using topic hemostatic agents. (See "Management of hemorrhage in gynecologic surgery".)
The bladder should be inspected and the ureters identified. If there is a possibility of bladder laceration, then 200 mL of saline mixed with 5 mL of indigo carmine can be infused into the bladder through the Foley catheter. Integrity of the bladder is confirmed by failure of the colored fluid to leak through the serosa.
The ureter should generally be identified before abdominal closure either by transillumination through the broad ligament or direct visual identification during retroperitoneal dissection (figure 6 and figure 7). It courses horizontally along the peritoneum 1 to 5 cm dorsal to the ovarian vessels and can be identified readily as it passes ventral to the bifurcation of the common iliac artery. (See "Surgical female pelvic anatomy".)
The ureters should be inspected to confirm that they are not damaged. Their integrity can be assessed by injecting two ampules (10 mL) of indigo carmine intravenously. A ureter that has been severed will release blue urine into the pelvis in 10 to 15 minutes. If a ureter has been ligated, cystoscopy or direct visualization of the ureters through a cystotomy will demonstrate that urine is only passing through one of the two ureteral orifices. Passage of a ureteral stent can also be employed to localize the site of obstruction. (See "Diagnostic cystourethroscopy for gynecologic conditions".)
Management of diffuse oozing — Topical hemostatic agents can be helpful for management of diffuse light bleeding. (See "Management of hemorrhage in gynecologic surgery", section on 'Manage diffuse bleeding'.)
Aortic compression — Severe bleeding may pose a threat of exsanguination within a few minutes. In these cases, the surgeon should palpate the aorta a few centimeters superior to the sacral promontory and compress the aorta just proximal to the bifurcation. This will markedly slow the volume of bleeding and affords a better opportunity for finding and controlling the source of hemorrhage.
Uterine tourniquet — Tourniquets have been used to control bleeding at myomectomy, and for other types of pelvic hemorrhage, and may be useful as a temporizing measure in PPH . (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Tourniquets and clamps'.)
Intraoperative cell salvage — Intraoperative blood salvage with a leukocyte filter and autotransfusion is another option, but its use is investigational in the obstetrical setting [33-36]. Although there is a theoretical concern that reinfusing amniotic fluid may cause amniotic fluid embolism, this has been documented only once . Salvaged blood also may be contaminated by fetal erythrocytes. This is not a major concern as Rh(D) alloimmunization in an Rh(D) negative mother can be prevented by administration of anti-D immunoglobulin and ABO incompatibility reactions are unlikely to be serious because the volume of fetal blood contamination is small and A and B antigens/antibodies are not fully developed at birth. In addition, these risks are probably less than or similar to those from allogeneic transfusion.
Pelvic packing — Patients with continued severe hemorrhage after hysterectomy can enter a lethal downward spiral characterized by hypothermia, coagulopathy, and metabolic acidosis [38,39]. Criteria proposed for this "in extremis" state include pH <7.30, temperature <35 degrees Celsius, combined resuscitation and procedural time >90 minutes, nonmechanical bleeding, and transfusion requirement >10 units packed RBCs . To abort the cycle, the bleeding area is tightly packed  and the wound dressed, but left open, and the patient is transferred to an intensive care unit for continuous monitoring, replacement of appropriate blood products, and correction of physiologic derangements ("damage control"). This approach halts the downward spiral and lessens the risk of abdominal compartment syndrome. Compartment syndrome is more difficult to define postpartum since postcesarean intraabdominal pressure appears to be higher than in the general surgical population, especially in women with elevated body mass index and hypertensive disorders . (See "Abdominal compartment syndrome".)
The author uses a sufficient number of gauze bandages (eg, Kerlix) tied end-to-end to pack the pelvis tightly and tamponade the hemorrhage. The free end of the gauze train is extracorporealized through the main incision. The peritoneum, muscle, and fascia are closed in the usual fashion, but with the gauze protruding from one end of the incision. The subcutaneous and cutaneous layers are left open and packed with additional gauze.
Different surgeons practice slight variations of this procedure [41,43-52]. One variation is to fill a sterile plastic bag (eg, drawstring bag used to cover x-ray film) or cloth container with gauze and place it against the pelvic bleeders. The drawstrings are pulled through the vagina and attached to a weight, which provides traction so that the pack exerts pressure against the pelvic floor.
The need for ≥2 units packed RBCs per hour for three hours is a sign of significant ongoing bleeding and need for surgical intervention or arterial embolization by an interventional radiologist.
Otherwise, the patient is returned to the operating room to undergo definitive surgical care in 48 hours. Packing should not be removed until coagulation defects have been corrected. If the packing has controlled bleeding, it generally is removed at this time. If it is removed too soon, bleeding will resume, whereas if it is removed too late, pelvic infection or abscess may ensue.
Under general anesthesia, the wound is opened and the gauze is removed with gentle traction. The pelvis is irrigated with saline to clear loose clots and other debris, but aggressive exploration of the pelvis is not performed if no pooling of blood is noted. The wound is then reapproximated in the usual manner.
Recombinant activated factor VIIa — Human recombinant factor VIIa has been approved by the United States Food and Drug Administration for treatment of individuals with bleeding related to hemophilia A and B inhibitors, acquired inhibitors, and congenital factor VII deficiency. It has also been used successfully off-label for control of bleeding in other situations, such as intractable bleeding associated with postpartum uterine atony, placenta accreta, or uterine rupture [53,54]. This therapy appears promising when standard therapy fails [54,55].
Doses of 16.7 to 120 mcg/kg as a single bolus injection over a few minutes every two hours until hemostasis is achieved have been effective, and usually control bleeding within 10 to 40 minutes of the first dose [53,56]. However, the appropriate dose of rFVIIa may be quite different, depending on the levels of other coagulation factors present. As an example, a case report of bleeding despite administration of rFVIIa for PPH attributed the failure to the patient's low fibrinogen level (<60 mg/dL) . The authors suggested aggressive therapy with standard blood components should be undertaken before giving rFVIIa. (See "Therapeutic uses of recombinant coagulation factor VIIa".)
The drug is very expensive (about $1 per mcg) and may increase the risk of thromboembolism, thus it should be reserved for cases of intractable hemorrhage and coagulopathy.
POSTOPERATIVE UTERINE HEMORRHAGE — Hemorrhage may not be appreciated before the abdomen has been closed or before the patient has been moved out of the operating room. It may manifest as excessive vaginal bleeding or as hypotension, tachycardia, and/or low urine output from hypovolemia.
If excessive vaginal bleeding is present, the cervix and vagina should be inspected and lacerations repaired under adequate . If the uterus is boggy, the diagnosis of uterine atony is made.
The initial management of uterine atony after cesarean delivery is similar to that after vaginal delivery and consists of:
If excessive bleeding persists, uterine artery embolization is an option for stable patients in whom volume status can be maintained until the procedure can be completed (approximately two hours). Laparotomy is indicated in patients with massive bleeding and those who are unstable since is unlikely that replacement of blood products will match blood loss in these patients.
These procedures are discussed in detail separately. (See "Management of postpartum hemorrhage at vaginal delivery".)
PPH more than 24 hours postpartum is termed secondary PPH. Causes and management are discussed separately. (See "Overview of postpartum hemorrhage", section on 'Secondary postpartum hemorrhage'.)
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