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Introduction
Postpartum hemorrhage (PPH) is one of the three major killers of mothers all over the world (others being infection and hypertension). The World Health Organization (WHO) estimates it is responsible for nearly one-quarter of all maternal deaths1. PPH occurs in 2–10% of deliveries1 and the incidence of major obstetric hemorrhage is estimated to be 5 per 1000 births2. PPH has been classified into two types based on the timing of onset of bleeding. Primary PPH is defined as bleeding from the genital tract of 500 ml or more in the first 24 hours following delivery of the baby, while secondary PPH occurs between 24 hours up to 12 weeks postpartum. Although a cut off of 500 ml is used for the purpose of definition, in clinical practice – any bleeding after delivery sufficient to cause hemodynamic alterations in the maternal vital parameters is significant. Primary PPH is responsible for the majority of cases of maternal deaths or severe morbidity. PPH may result from failure of the uterus to contract adequately (tone), vaginal or cervical lacerations (genital tract trauma), uterine rupture, retained placental fragments (tissue) or maternal bleeding disorders (thrombin). Evidence has accumulated that a systematic and stepwise approach tothe management of major obstetric hemorrhage improves maternal outcomes3.
Systematic approach to management of PPH
Chandraharan and Arulkumaran proposed a logical sequence of management options for major PPH based on the mnemonic ‘HAEMOSTASIS’ (H – ask for help, A – assess vitals and resuscitate, E – establish etiology and ensure availability of blood and uterotonics, M – massage uterus, O – oxytocin and prostaglandins, S – shift to theaetr, T – tamponade test, A – apply compression sutures, S – systematic pelvic devascularization, I – interventional radiology/internal iliac artery ligation, S – subtotal/total hysterectomy)3. Varatharajan et al reviewed the outcomes of management of massive PPH using such algorithm to validate this logical management pathway to reduce blood transfusions, hysterectomies, admissions to intensive care units (ICU) and maternal deaths3. The decremental pattern of more complex interventions used demonstrated that the algorithm provided a logical management pathway to reduce blood transfusions, hysterectomies, admissions to intensive care units, and maternal deaths.
PPH should be recognized early and prompt action should follow. The two main aspects of management of PPH which should go hand in hand are (1) resuscitation and (2) identification and treatment of the underlying cause4,5. In case of atonic PPH, medical methods and bimanual compression should be instituted in a stepwise method followed by surgical techniques if necessary. The uterotonic agents commonly used are oxytocin, ergometrine, misoprostol and prostaglandin F2α. Other effective measures include antifibrinolytic tranexamic acid and anti-shock garments. Effective treatment of PPH often requires simultaneous multidisciplinary interventions. Ideally the team should consist of senior obstetrician, senior midwife, anesthetist, hematologist/blood bank personnel, theater staff and porters. However, all of these may not be present in periphery (setting of primary care). In such a case, any available healthcare staff needs to be involved and transport facilities alerted to possibility of the need for emergency transfer to higher level of care.
Uterus sparing surgical or radiological interventions
Uterus sparing surgical interventions have long been practiced as an alternative to hysterectomy in the management of severe PPH not responding to medical treatment. Once severe PPH has been recognized, if bimanual uterine compression and pharmacological measures fail to control the hemorrhage, surgical methods to control the bleeding are recommended without delay. Intrauterine balloon tamponade is an appropriate first-line surgical intervention for most women where uterine atony is the only or main cause of hemorrhage. It is simple, inexpensive and can be used by trained operators in areas with limited resources. If tamponade fails to arrest bleeding, the following conservative surgical interventions form the next line of management depending on clinical circumstances and available expertise – hemostatic brace suturing (such as B-Lynch or modified compression sutures), bilateral ligation of uterine arteries, bilateral ligation of hypogastric (internal iliac) arteries or selective radiological arterial embolization. A systematic review of the various techniques concluded that there was no evidence to suggest that any one method is better for the management of severe PPH than the rest6. With recent studies indicating good fertility outcomes following conservative surgical or radiological treatment of PPH7, it has been proposed that a second (or even a third) uterine sparing procedure be performed in case of a failed first procedure before considering hysterectomy in a hemodynamically stable patient. Hysterectomy represents the last resort in the management of PPH owing to uterine cause when all other options of management have been exhausted. In situations where there is no facility for radiological intervention, an early recourse to hysterectomy may be warranted after failure of brace sutures, internal iliac ligation or tamponade in presence of significant ongoing bleeding.
Efficacy of uterine sparing procedures for management of major PPH
A systematic review regarding conservative management of PPH identified 396 publications, and after exclusions, 46 studies were included in the review6. There were no randomized controlled trials. The cumulative outcomes showed success rates of 90.7% (95% confidence interval [CI] 85.7–94.0%) for arterial embolization, 84.0% (95% CI 77.5–88.8%) for balloon tamponade, 91.7% (95% CI 84.9–95.5%) for uterine compression sutures and 84.6% (95% CI 81.2–87.5%) for iliac artery ligation or uterine devascularization (p = 0.06). There was no evidence to suggest that any one method was better for the management of severe PPH6.
Uterine tamponade
After an adequate examination under anesthesia to exclude retained tissue or trauma, if intractable bleeding continues despite use of all drugs, a tamponade should be attempted. Uterine tamponade is performed by passing a balloon through the cervix into the uterine cavity. Either commercially available balloons such as Bakri, Sengstaken Blackmore tube or Rusch balloon or, in resource poor settings, a condom tied on a Foley catheter may be used. The balloon should be filled with 100–500 ml of warm saline to obliterate the uterine cavity. A close watch should be kept on any ongoing blood loss through the catheter lumen as well as through the cervix. If the bleeding stops with tamponade, the need for further surgery is avoided and the catheter may be removed after few hours once the patient’s condition is stable. However, if significant bleeding continues, a laparotomy is indicated. A Scottish confidential audit of severe maternal morbidity identified 64 cases where balloon tamponade was used for the management of major PPH and hysterectomy was averted in 50 (78%) women8.
Uterine brace sutures
B-Lynch suture9 and modifications
This involves a pair of vertical brace sutures (with catgut or vicryl) around the uterus to appose the anterior and posterior walls, and to apply continuing compression to stop bleeding. A stitch is passed through the anterior wall of the uterus at the level of the uterine incision, over the right cornu horizontally through the lower posterior wall, over the left cornu, back through the anterior wall at the right side of the uterine incision and tied in front. The procedure is carried out in lithotomy position to enable access to the vagina to facilitate objective assessment of control of bleeding. Before a B-Lynch suture is applied, it is advised that the surgeon should apply firm compression over the uterus for few minutes to demonstrate that such compression is effective and reduces the blood loss. Various modifications of the B-Lynch technique have been described in literature. The Scottish confidential audit of severe maternal morbidity identified 52 cases where hemostatic brace suturing was used for the management of major PPH; hysterectomy was averted in 42 (81%) women10. Uterine compression sutures are simple, safe and cost effective uterine preserving procedures which can be adopted in emergency situations even by obstetricians with limited training and skill for more complex procedures. The disadvantages of the technique include complications of infection, uterine necrosis and Asherman’s syndrome which have been described by various case reports.
Systematic pelvic devascularization
Uterine artery ligation
The uterus receives 90% of its blood supply from the uterine arteries and hence ligation of these arteries may help reduce the ongoing blood loss. Since bilateral uterine artery ligation is technically easier and safer than internal iliac artery ligation, it is usually performed as the initial procedure when attempting systematic devascularization of the uterus4. Infundibulopelvic vessel ligation
The procedure involves ligation of utero-ovarian vessel anastomosis to reduce uterine blood supply.
Internal iliac artery ligation
Internal iliac artery ligation helps the control of uterine and vaginal bleeding as the vagina is supplied by the vaginal branch of internal iliac. Bilateral ligation results in 85% reduction in pulse pressure and 50% reduction in blood flow in the arteries distal to the ligation. This has the effect of slowing down the circulation which favours clot formation11. Input from vascular surgeons is recommended to improve the safety and efficacy of the operation. The reported success rates of this procedure vary between 40 and 80% and by this stage patient may have significant degree of compromise and coagulopathy4. However, this surgical technique can often prove difficult and requires a high degree of surgical skill and training, and may be associated with ureteric or iliac vein injury.
Interventional radiology
Arterial embolization
This procedure is available in select centers with trained interventional radiologists and the necessary set up. Vascular access is gained via the femoral arteries under local anesthesia and fluoroscopic control. The catheter is advanced above the bifurcation of aorta and bleeding point identified by contrast injection. The feeder artery is then embolized with polyvinyl alcohol or gelatin sponge particles which are reabsorbed in about 10 days. The advantages of the procedure include preservation of uterus and a high success rate. A 2002 review summarized case series totaling 100 women and reported 97% success with selective arterial embolization for obstetric hemorrhage12. The Scottish confidential audit of severe maternal morbidity identified 14 cases where arterial embolization was used for the management of major PPH; hysterectomy was averted in 10 (71%) women10. The drawbacks of embolization include the necessity of availability of a skilled interventional radiologist and radiology setup; and occasional complications such as postprocedure fever, infection, uterine necrosis and vascular perforation13.
Menstrual and fertility outcomes after radiological or conservative surgical interventions for major PPH
A systematic review evaluated the menstrual and fertility outcomes following radiological or conservative surgical interventions for severe PPH7. In all 28 studies were included in the review. Seventeen studies (675 women) reported on the fertility outcomes after uterine artery embolization, five studies (195 women) reported on the fertility outcomes after uterine devascularization, and six studies (125 women) reported on the fertility outcomes following uterine compression sutures. Overall, 553 out of 606 (91.25%) women resumed menstruation within 6 months of delivery. One hundred and eighty-three out of 235 (77.87%) women who desired another pregnancy achieved conception. The authors concluded that uterus sparing radiological and surgical techniques for the management of severe PPH do not appear to adversely affect the menstrual and fertility outcomes in most women. However, the number of studies and the quality of the available evidence was of concern. Yet another systematic review compared the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus), fertility rate (subsequent pregnancies or the return of regular menstrual cycles), complication rate of the procedure, and the outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications14. Data on restoration of menses and pregnancy rates after these procedures were limited by the short-term follow-up and by the paucity of studies, especially for vascular ligation. Pelvic vessel embolization and compressive sutures were associated with high rates of restoration of regular menses and successive pregnancies, although the former was burdened by an increased rate of placental disorders and fetal growth restriction, and the latter by an increased risk of cesarean deliveries and PPH recurrence.
Blanc et al.15 suggested that uterine compression sutures exposed patients to the risk of subsequent abnormalities of the uterine cavity and development of uterine synichae. Other reports also linked amenorrhea and uterine synichae to pelvic arterial embolization. Postprocedure endometritis (inflammation and scarring) and endometrial ischemia secondary to embolization were thought to be the possible mechanisms responsible for development of such adhesions. In the study by Senthilis et al.16, out of the 15 women who complained of amenorrhea or decreased flow of menstruation, severe intrauterine synichae were found in all (n = 8) who decided to undergo ambulatory hysteroscopy. Except for two women in whom placenta acreta was the cause of PPH, severe intrauterine synechia were successfully treated by operative hysteroscopy. The occurrence of severe synechiae was significantly associated with a higher rate of placenta accreta/percreta and postpartum fever >38.5°C. Complications of infections and synechiae have also been described after compression sutures, but overall data appear reassuring regarding long-term fertility outcomes7. Although these complications are uncommon and may be amenable to surgical management, nevertheless women should be made aware of the possibility of uterine synechiae following the procedure and follow-up hysteroscopy advised in those who experience decreased flow or amenorrhea beyond 2–3 months following the procedure.
Almost all studies included in the systematic review had uncomplicated full-term deliveries in the majority of women who became pregnant following conservative management of PPH7. In a few studies which reported occasional complications in pregnancy such as fetal growth restriction or pre-eclampsia their incidence was not in excess of that in the general population. The overall literature presents conflicting evidence about risks of abnormal placentation and recurrent PPH following fertility sparing procedures for PPH. While some studies have reported increased risk of placenta acreta or percreta and PPH following pelvic embolization or uterine devascularization, others have failed to find a similar association. The numbers studied are too small to draw any definite conclusions and speculate whether the risk of abnormal placentation/PPH may be related to underlying uterine tendency to bleed or a result of reporting bias. Although there is lack of certainty about these associations, it is clinically prudent to be vigilant for these complications in women who conceive following such procedures.
A recent case series of five pregnancies and births in women who had previously required Bakri balloon temponade in the management of PPH was reported by Georgiou17. In these cases, normal regular menses returned following cessation of breast feeding at 7 weeks to 5 months, and subsequent pregnancies occurred within 15–29 months. There were no reported interval pregnancies such as miscarriages, ectopic pregnancies or terminations of pregnancy. Ultrasound appearances of the uterine cavity following the resumption of menses in the index pregnancy were described as normal. No antenatal complications with respect to fetal growth and development were noted except the presence of a succenturiate placenta in one case. Four of the five cases established labor spontaneously. All cases delivered vaginally and although PPH recurred in one of the patients, this was successfully managed with uterotonics. In conclusion, with respect to balloon tamponade, minimal effect on menses, fertility and future pregnancies was demonstrated in these reported cases.
Conclusion
Uterus sparing surgical or radiological methods for management of major PPH are safe and effective and should be attempted before resorting to hysterectomy depending on availability of local resources and expertise. Although the quality of available evidence is not very high and there is lack of randomized studies on the subject, it appears that none of the techniques such as balloon temponade, embolization, hypogastric artery ligation, uterine artery ligation (whether or not associated with utero-ovarian ligament ligation) and compression sutures adversely affects menstruation or fertility outcomes in most women.
References
