Postpartum hemorrhage: Solutions to 2 intractable cases
A stepwise approach to bleeding caused by persistent uterine atony and placental abnormalities
IN THIS ARTICLE
Absorbable gelatin sponge
Venous bleeding or oozing from the uterine incision that is unresponsive to suturing can often be contained by placing a piece of absorbable gelatin sponge (Gelfoam; Pfizer, New York City) over the bleeding site. Cut the sponge to fit the size of the bleeding site and hold it in place for 10 to 15 seconds. Leave the sponge in place once bleeding is controlled.
Topical thrombin
When application of gelatin sponge alone does not bring about hemostasis, try topical thrombin (Thrombin-JMI; Jones Pharma, Bristol, Va). This product is supplied as a kit that includes the active ingredient in powder form plus a diluent. The powder is diluted at a strength of 1,000 U/mL, and the mixture is sprayed onto a gelatin sponge and placed at the site of the bleeding. Do not inject thrombin solution! Complete resorption of the gelatin sponge occurs in 4 to 6 weeks.
Gelatin matrix thrombin solution
Another useful topical agent is FloSeal (Baxter Healthcare, Deerfield, Ill), which is supplied as a bovine-derived gelatin matrix that is mixed with a bovine thrombin solution to create a foam matrix, which is then applied directly to the bleeding site. Unlike thrombin-soaked gelatin sponge, FloSeal can be applied directly to arterial bleeding. Because this product requires the presence of fibrinogen within the patient’s blood, its utility is limited in patients with hypofibrinogenemia.
Fibrin sealant
This topical agent (Tisseel; Baxter Healthcare) is useful even in patients with coagulopathy. It is a mixture of thrombin and concentrated fibrinogen. The product is packaged as 2 separate components with diluents. These diluted components are injected in a dual syringe device and mixed in a Y-connector tube and then applied in a thin layer directly to the site of bleeding. The mixture solidifies within 3 to 5 minutes after application. This product can also be used to reapproximate tissues.
Recombinant factor VIIa
This promising systemic agent (NovoSeven; Novo Nordisk US, Princeton, NJ) binds to tissue factors that are exposed at sites of vessel injury.15 It can be administered in cases of life-threatening hemorrhage and is helpful even in the presence of dilutional or consumptive coagulopathy. A dose of 70–90 μg/kg is administered IV and can be repeated in 10 to 15 minutes if bleeding is not controlled.16 The high cost of this potentially life-saving product may preclude community hospital blood banks from stocking it routinely.
The Bakri balloon is a large Silastic balloon with a capacity of 500 mL that is designed to provide intrauterine tamponade for bleeding caused by atony, placenta previa, or focal placenta accreta. It has also been used to control hemorrhage associated with cervical ectopic pregnancy.5
A port with a lumen on the device makes it possible to assess the state of hemorrhage. The balloon is placed through the cervix and into the uterus after vaginal delivery, or in reverse fashion during cesarean delivery. It is then filled with saline to apply pressure to the bleeding surfaces of the endometrium.
Once the balloon is inflated, observe the catheter port for signs of continued hemorrhage. If bleeding remains brisk, further intervention will be necessary to control the hemorrhage. If bleeding slows appreciably, the balloon tamponade is likely to be successful and the patient can be observed.
Leave the balloon in place for 24 to 36 hours, then deflate it incrementally. If bleeding recurs when you deflate the balloon, reinflate it and leave it in place longer.
STEP 3: Control the blood supply to the uterus
If packing or tamponade is unsuccessful, the next step is radiographic uterine artery embolization or surgical ligation of the uterine blood supply with O’Leary sutures,6 followed by utero-ovarian vessel ligation, if necessary.7
Uterine artery embolization is an effective method of decreasing blood flow to the uterus. Only facilities with readily available interventional radiology services can perform the procedure, however, and the patient must be stable enough for transfer to the radiology suite. Because most cases of postpartum hemorrhage involve profuse blood loss, radiographic embolization is limited to cases of slow but continuing uterine blood loss.
Surgical ligation of the uterine blood supply is particularly useful. It requires a laparotomy incision after vaginal delivery but is easily performed at the time of cesarean delivery:
- Create the bladder flap and mobilize the bladder inferiorly
- Place a suture approximately 1 to 2 cm inferior to the level at which a low transverse uterine incision would be placed during cesarean delivery. This is done by pulling the broad ligament laterally using the thumb and index and middle fingers, and placing size 0 chromic suture, anterior to posterior, through the myometrium at the lateral margin of the uterus
- Pass the suture through the broad ligament, posterior to anterior, staying well medial to the course of the ureter
- Tie the suture to occlude the uterine vessels
- Repeat on the opposite side.
