UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Postpartum hemorrhage: Management approaches requiring laparotomy

Author
Michael A Belfort, MBBCH, MD, PhD, FRCSC, FRCOG
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG

INTRODUCTION

Postpartum hemorrhage (PPH) is an obstetric emergency with many potentially effective interventions for management (table 1). In patients with PPH who have had a vaginal birth or whose cesarean delivery has been completed, medical and minimally invasive approaches are the preferred treatment approaches; laparotomy is generally a last resort that is performed when less invasive interventions have failed. During cesarean delivery, uterotonic drugs and manual uterine massage and compression are still the initial treatments for bleeding due to atony, but uterine compression sutures and other operative interventions for control of hemorrhage are performed sooner since the abdomen is already open.

This topic will discuss treatment approaches to PPH that require laparotomy. Medical and minimally invasive management of patients with PPH is reviewed separately (see "Postpartum hemorrhage: Medical and minimally invasive management"). An overview of issues related to PPH: incidence, pathogenesis, risk factors, clinical presentation and diagnosis, general principles of planning and management, morbidity and mortality, and recurrence, is also available separately. (See "Overview of postpartum hemorrhage".)

EVALUATION OF THE ABDOMEN

Laparotomy to assess and treat suspected pelvic bleeding is, in the author's opinion, best performed through a vertical midline incision to provide exposure of both the pelvis and abdomen. In patients at or post cesarean delivery, the existing incision is used, and extended if needed to provide adequate exposure.

A self-retaining retractor, such as a Balfour or Bookwalter, provides adequate lateral exposure. A posterior rupture is not readily visualized upon entering the abdomen so the entire uterus needs to be inspected carefully.

At laparotomy, the abdominal cavity is irrigated to remove blood and clots and inspected for the source of bleeding. The source of bleeding is usually readily apparent if pelvic, but may not be immediately recognized when it is retroperitoneal (including vaginal and vulvar hematomas), confined to the uterine cavity after vaginal delivery or after closure of the uterine incision at cesarean, or under surgical drapes. These sites should be actively evaluated in patients with compensated shock (normal blood pressure with increasing heart rate).

                               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jun 2017. | This topic last updated: Jun 30, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Taylor A, Sharma M, Tsirkas P, et al. Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial. BJOG 2005; 112:340.
  2. Breen M. Temporary treatment of severe postpartum hemorrhage. Int J Gynaecol Obstet 2012; 118:253.
  3. Luotonen J. [Management of epistaxis]. Duodecim 1987; 103:101.
  4. Doumouchtsis SK, Nikolopoulos K, Talaulikar V, et al. Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG 2014; 121:382.
  5. Mason BA. Postpartum hemorrhage and arterial embolization. Curr Opin Obstet Gynecol 1998; 10:475.
  6. Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997; 176:938.
  7. Sentilhes L, Gromez A, Clavier E, et al. Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage. Obstet Gynecol 2009; 113:992.
  8. Søvik E, Stokkeland P, Storm BS, et al. The use of aortic occlusion balloon catheter without fluoroscopy for life-threatening post-partum haemorrhage. Acta Anaesthesiol Scand 2012; 56:388.
  9. Bazin M, Bonnin M, Bolandard F, et al. [Post-partum haemorrhage in delivery room: anaesthetists' practioner in Auvergne]. Ann Fr Anesth Reanim 2011; 30:397.
  10. Harma M, Harma M, Kunt AS, et al. Balloon occlusion of the descending aorta in the treatment of severe post-partum haemorrhage. Aust N Z J Obstet Gynaecol 2004; 44:170.
  11. Shih JC, Liu KL, Shyu MK. Temporary balloon occlusion of the common iliac artery: new approach to bleeding control during cesarean hysterectomy for placenta percreta. Am J Obstet Gynecol 2005; 193:1756.
  12. Matsubara S, Kuwata T, Usui R, et al. Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta. Acta Obstet Gynecol Scand 2013; 92:372.
  13. Minas V, Gul N, Shaw E, Mwenenchanya S. Prophylactic balloon occlusion of the common iliac arteries for the management of suspected placenta accreta/percreta: conclusions from a short case series. Arch Gynecol Obstet 2015; 291:461.
  14. Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet 1985; 160:250.
  15. Buckley B. Interventional radiology in abnormal placentation. RANZCOG O & G Magazine 2010; 12:56. https://www.google.com/search?q=Buckley+B.+Interventional+radiology+in+abnormal+placentation.+RANZCOG+O+%26+G+Magazine+2010%3B+12%3B56.&sourceid=ie7&rls=com.microsoft:en-US:IE-Address&ie=&oe=&gws_rd=ssl (Accessed on July 01, 2017).
  16. Dubreuil-Chambardel L. Traite des variations du system arteriel variations des arteres du pelvis et du membre inferieur, Masson et Cie, Paris 1925.
  17. Joshi VM, Otiv SR, Majumder R, et al. Internal iliac artery ligation for arresting postpartum haemorrhage. BJOG 2007; 114:356.
  18. Rebarber A, Lonser R, Jackson S, et al. The safety of intraoperative autologous blood collection and autotransfusion during cesarean section. Am J Obstet Gynecol 1998; 179:715.
  19. Rainaldi MP, Tazzari PL, Scagliarini G, et al. Blood salvage during caesarean section. Br J Anaesth 1998; 80:195.
  20. Liumbruno GM, Meschini A, Liumbruno C, Rafanelli D. The introduction of intra-operative cell salvage in obstetric clinical practice: a review of the available evidence. Eur J Obstet Gynecol Reprod Biol 2011; 159:19.
  21. Liumbruno GM, Liumbruno C, Rafanelli D. Intraoperative cell salvage in obstetrics: is it a real therapeutic option? Transfusion 2011; 51:2244.
  22. Oei, SG, WInger, CB, Kerkkamp, HE, et al. Cell salvage: how safe in obstetrics? Int J Obstet Anesth 2000; 9:143.
  23. Clausen C, Lönn L, Langhoff-Roos J. Management of placenta percreta: a review of published cases. Acta Obstet Gynecol Scand 2014; 93:138.
  24. Faranesh R, Romano S, Shalev E, Salim R. Suggested approach for management of placenta percreta invading the urinary bladder. Obstet Gynecol 2007; 110:512.
  25. Chandraharan E, Rao S, Belli AM, Arulkumaran S. The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta. Int J Gynaecol Obstet 2012; 117:191.
  26. Miller DT, Roque DM, Santin AD. Use of Monsel solution to treat obstetrical hemorrhage: a review and comparison to other topical hemostatic agents. Am J Obstet Gynecol 2015; 212:725.
  27. O'Leary JL, O'Leary JA. Uterine artery ligation in the control of intractable postpartum hemorrhage. Am J Obstet Gynecol 1966; 94:920.
  28. O'Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med 1995; 40:189.
  29. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994; 171:694.
  30. Sentilhes L, Trichot C, Resch B, et al. Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage. Hum Reprod 2008; 23:1087.
  31. Roman H, Sentilhes L, Cingotti M, et al. Uterine devascularization and subsequent major intrauterine synechiae and ovarian failure. Fertil Steril 2005; 83:755.
  32. Kayem G, Kurinczuk JJ, Alfirevic Z, et al. Uterine compression sutures for the management of severe postpartum hemorrhage. Obstet Gynecol 2011; 117:14.
  33. Gottlieb AG, Pandipati S, Davis KM, Gibbs RS. Uterine necrosis: a complication of uterine compression sutures. Obstet Gynecol 2008; 112:429.
  34. B-Lynch C. Partial ischemic necrosis of the uterus following a uterine brace compression suture. BJOG 2005; 112:126.
  35. Joshi VM, Shrivastava M. Partial ischemic necrosis of the uterus following a uterine brace compression suture. BJOG 2004; 111:279.
  36. Reyftmann L, Nguyen A, Ristic V, et al. [Partial uterine wall necrosis following Cho hemostatic sutures for the treatment of postpartum hemorrhage]. Gynecol Obstet Fertil 2009; 37:579.
  37. El-Hamamy E. Partial ischemic necrosis of the uterus following a uterine brace compression suture. BJOG 2005; 112:126.
  38. Pechtor K, Richards B, Paterson H. Antenatal catastrophic uterine rupture at 32 weeks of gestation after previous B-Lynch suture. BJOG 2010; 117:889.
  39. Gizzo S, Saccardi C, Patrelli TS, et al. Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature. Fertil Steril 2013; 99:2097.
  40. Poujade O, Grossetti A, Mougel L, et al. Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage. BJOG 2011; 118:433.
  41. 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.
  42. Ferguson JE, Bourgeois FJ, Underwood PB. B-Lynch suture for postpartum hemorrhage. Obstet Gynecol 2000; 95:1020.
  43. Allam MS, B-Lynch C. The B-Lynch and other uterine compression suture techniques. Int J Gynaecol Obstet 2005; 89:236.
  44. Sentilhes L, Gromez A, Razzouk K, et al. B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization. Acta Obstet Gynecol Scand 2008; 87:1020.
  45. Smith KL, Baskett TF. Uterine compression sutures as an alternative to hysterectomy for severe postpartum hemorrhage. J Obstet Gynaecol Can 2003; 25:197.
  46. Fuglsang J. Later reproductive health after B-Lynch sutures: a follow-up study after 10 years' clinical use of the B-Lynch suture. Fertil Steril 2014; 101:1194.
  47. Cowan AD, Miller ES, Grobman WA. Subsequent pregnancy outcome after B-lynch suture placement. Obstet Gynecol 2014; 124:558.
  48. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol 2002; 99:502.
  49. Ghezzi F, Cromi A, Uccella S, et al. The Hayman technique: a simple method to treat postpartum haemorrhage. BJOG 2007; 114:362.
  50. Pereira A, Nunes F, Pedroso S, et al. Compressive uterine sutures to treat postpartum bleeding secondary to uterine atony. Obstet Gynecol 2005; 106:569.
  51. Ouahba J, Piketty M, Huel C, et al. Uterine compression sutures for postpartum bleeding with uterine atony. BJOG 2007; 114:619.
  52. Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000; 96:129.
  53. Nelson GS, Birch C. Compression sutures for uterine atony and hemorrhage following cesarean delivery. Int J Gynaecol Obstet 2006; 92:248.
  54. Hackethal A, Brueggmann D, Oehmke F, et al. Uterine compression U-sutures in primary postpartum hemorrhage after Cesarean section: fertility preservation with a simple and effective technique. Hum Reprod 2008; 23:74.
  55. Zheng J, Xiong X, Ma Q, et al. A new uterine compression suture for postpartum haemorrhage with atony. BJOG 2011; 118:370.
  56. Nanda S, Singhal SR. Hayman uterine compression stitch for arresting atonic postpartum hemorrhage: 5 years experience. Taiwan J Obstet Gynecol 2011; 50:179.
  57. Alouini S, Coly S, Mégier P, et al. Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment. Am J Obstet Gynecol 2011; 205:335.e1.
  58. Hess JR, Lawson JH. The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma 2006; 60:S12.
  59. Sagraves SG, Toschlog EA, Rotondo MF. Damage control surgery--the intensivist's role. J Intensive Care Med 2006; 21:5.
  60. Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am 1997; 77:761.
  61. Abdel-Razeq SS, Campbell K, Funai EF, et al. Normative postpartum intraabdominal pressure: potential implications in the diagnosis of abdominal compartment syndrome. Am J Obstet Gynecol 2010; 203:149.e1.
  62. Dildy GA, Scott JR, Saffer CS, Belfort MA. An effective pressure pack for severe pelvic hemorrhage. Obstet Gynecol 2006; 108:1222.
  63. Finan MA, Fiorica JV, Hoffman MS, et al. Massive pelvic hemorrhage during gynecologic cancer surgery: "pack and go back". Gynecol Oncol 1996; 62:390.
  64. Ghourab S, Al-Nuaim L, Al-Jabari A, et al. Abdomino-pelvic packing to control severe haemorrhage following caesarean hysterectomy. J Obstet Gynaecol 1999; 19:155.
  65. Awonuga AO, Merhi ZO, Khulpateea N. Abdominal packing for intractable obstetrical and gynecologic hemorrhage. Int J Gynaecol Obstet 2006; 93:160.
  66. Howard RJ, Straughn JM Jr, Huh WK, Rouse DJ. Pelvic umbrella pack for refractory obstetric hemorrhage secondary to posterior uterine rupture. Obstet Gynecol 2002; 100:1061.
  67. Robie GF, Morgan MA, Payne GG Jr, Wasemiller-Smith L. Logothetopulos pack for the management of uncontrollable postpartum hemorrhage. Am J Perinatol 1990; 7:327.
  68. Hallak M, Dildy GA 3rd, Hurley TJ, Moise KJ Jr. Transvaginal pressure pack for life-threatening pelvic hemorrhage secondary to placenta accreta. Obstet Gynecol 1991; 78:938.
  69. Dildy, GA, Scott, JR, Saffer, CS, Belfort, MA. Pelvic pressure pack for catastrophic postpartum hemorrhage. Obstet Gynecol 2000; 95:S7.
  70. Deffieux X, Vinchant M, Wigniolle I, et al. Maternal outcome after abdominal packing for uncontrolled postpartum hemorrhage despite peripartum hysterectomy. PLoS One 2017; 12:e0177092.
  71. Dildy GA, Belfort MA, Adair CD, et al. Initial experience with a dual-balloon catheter for the management of postpartum hemorrhage. Am J Obstet Gynecol 2014; 210:136.e1.
  72. Charoenkwan K. Effective use of the Bakri postpartum balloon for posthysterectomy pelvic floor hemorrhage. Am J Obstet Gynecol 2014; 210:586.e1.