CASE 1: Uterine atony leads to heavy bleeding
A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnionitis. After placental separation, profound uterine atony is noted, and the patient begins to hemorrhage. The atony is unresponsive to bimanual massage, intravenous oxytocin, and intramuscular methylergonovine.
What can be done to stanch the flow?
Postpartum hemorrhage remains a leading cause of maternal death in the United States, and most cases are the direct consequence of uterine atony. As such, they generally respond to the timely administration of IV oxytocin or uterotonics. In this article, we focus on uncommon aspects of postpartum hemorrhage—such as bleeding that persists despite these basic maneuvers, as happened in Case 1.
STEP 1: Identify source of bleeding, administer uterotonic drugs
Three prostaglandins are among the uterotonic drugs available to clinicians for treating uterine atony (TABLE 1):
Carboprost tromethamine, a synthetic derivative of prostaglandin F, acts as a smooth-muscle constrictor. It can be injected intramuscularly or directly into the myometrium. Avoid carboprost tromethamine in patients with reactive airway disease, because it can cause bronchial smooth muscle to constrict.
Prostaglandin E2, also known as dinoprostone, is available as a 20-mg vaginal suppository that should be administered rectally for postpartum hemorrhage to prevent the dose from being washed away by excessive blood flow. Dinoprostone is approved by the Food and Drug Administration (FDA) as an abortifacient and works by causing contraction of the smooth muscle of the uterus. Limitations include its high prevalence of side effects, including nausea, vomiting, fever, and diarrhea.
Misoprostol, a synthetic analogue of prostaglandin E1, is FDA-approved for prevention of gastric ulcers. It is highly potent, stable at room temperature, inexpensive, and rapidly absorbed through oral, vaginal, and rectal routes of administration.1 For treatment of postpartum uterine atony, place a dose of 1,000 μg (five 200-μg tablets) rectally. Uterine tone should improve within 3 minutes.2
For a list of other drugs and devices recommended for the labor and delivery suite, see TABLE 2.
Uterotonic drugs: Instructions and cautions
|DRUG||DOSAGE AND ROUTE||PRECAUTIONS|
|Oxytocin||10 U IM or 10–40 U in 1,000 mL of a balanced salt solution by IV infusion||Avoid infusing large doses 10–20 mL/min) for long periods due to antidiuretic effects of oxytocin|
|Methylergonovine||0.2 mg IM||Avoid if hypertension is present; avoid IV administration|
|Carboprost tromethamine||0.25 mg IM||Avoid in patients with asthma, cardiac, renal, or hepatic disease|
|Dinoprostone||20 mg rectally or intravaginally||Avoid in patients with cardiac, renal, or hepatic disease|
|Misoprostol||1,000 μg rectally||Avoid in patients with renal or hepatic failure|
Tools for the well-prepared labor and delivery unit
|Uterotonic drugs (see TABLE 1)||Pharmacotherapy for uterine atony|
|Gauze rolls and sterile Mayo stand cover||Uterine packing|
|Bakri balloon||Intrauterine tamponade|
|Long size 1 chromic suture on larged curved needles||B-Lynch sutures (see FIGURE 1)|
|Long straight free needles and size 0 chromic suture||Hemostatic square sutures (see FIGURE 2)|
|Topical hemostatic agents: Gelfoam, thrombin, Tisseel, FloSeal||Topical hemostasis|
STEP 2: Apply direct pressure to the uterine cavity
If uterotonic medications fail to control bleeding and improve uterine tone, apply direct pressure to the uterine cavity by packing it with gauze3,4 or inserting a Bakri tamponade balloon device (Cook Women’s Health, Spencer, Ind).5
Uterine packing. The goal is to place direct pressure on all surfaces of the uterine cavity. This can be accomplished easily when the cervix has been fully dilated after vaginal delivery. Unfurl multiple rolls of moistened Kerlix gauze and evenly pack and cover the entire uterine cavity. Be sure to place the initial rolls of gauze high in the fundus, or blood may accumulate undetected behind the packing.
We begin by placing a sterile Mayo stand cover into the uterus, then apply packing inside the stand cover. This technique facilitates removal of the gauze and minimizes trauma to the endometrium (the packing does not stick to the uterine cavity when it is removed). Be sure to tie the ends of the gauze rolls together when using more than 1 roll.
Remove the packing 24 to 36 hours after placement. We remove the gauze in an operating room in case additional maneuvers are needed to control recurrent hemorrhage.