OB Hemorrhage - Surgical Treatment Resources

We performed a systematic review to identify all studies evaluating the success rates of treatment of major postpartum hemorrhage by uterine balloon tamponade, uterine compression sutures, pelvic devascularization, and arterial embolization. We included studies reporting on at least 5 cases. All searches were performed independently by 2 researchers and updated in June 2006. Failure of management was defined as the need to proceed to subsequent or repeat surgical or radiological therapy or hysterectomy, or death. As the search identified no randomized controlled trials, we proceeded to search for observational studies. This identified 396 publications, and after exclusions, 46 studies were included in the systematic review. 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% (81.2%-87.5%) for iliac artery ligation or uterine devascularization (P = 0.06). At present there is no evidence to suggest that any one method is better for the management of severe postpartum hemorrhage. Randomized controlled trials of the various treatment options may be difficult to perform in practice. As balloon tamponade is the least invasive and most rapid approach, it would be logical to use this as the first step in the management

BACKGROUND: It has been estimated that worldwide, over 125,000 women die of postpartum hemorrhage each year. The traditional management of this condition includes the use of oxytocics, such as oxytocin, ergometrine, and prosta- glandins, before proceeding to ligation of the internal iliac arteries and even hysterectomy. The B-Lynch technique is a surgical procedure that may be used to arrest postpartum hemorrhage resulting from uterine atony.
CASES: This paper describes simple modifications of this technique that make this procedure less complex to perform. Three clinical case scenarios illustrate the context in which the sutures may be used.
CONCLUSION: Compression sutures placed into the post-partum uterus may provide a simple first surgical step to control bleeding when routine oxytocic measures have failed. We suggest that the technique we have described is a simple procedure and should be tried before more complex interventions are used.

Bilateral iliac artery ligation is an effective second-line procedure to control massive obstetric and gynaecological haemorrhage, it is life-saving in certain cases and has the advantage that it preserves fertility, which is particularly important in young women of low parity. Bilateral ligation of internal iliac arteries is a life-saving procedure in cases of massive obstetric haemorrhage. It has the advantage of preserving fertility compared with the commonly performed emergency obstetric hysterectomy. It has also proved effective in cases of secondary pelvic haemorrhage in gynaecological operations. We report here a case series of 11 women who had bilateral internal iliac artery ligation for severe pelvic haemorrhage in a period of 10 years in our department. Ten of them were obstetric cases and one was a case of haemorrhage following vaginal hysterectomy. The outcome was favourable in 10 out of the 11 cases and there was only one case of massive postpartum haemorrhage where the procedure failed and required an emergency hysterectomy

PURPOSE OF REVIEW: Haemorrhage remains a cause of significant maternal morbidity and mortality. This review summarizes the prevention, management and treatment of obstetric haemorrhage and highlights recent advances and developments.
RECENT FINDINGS: Postpartum haemorrhage is the most common cause of major obstetric haemorrhage and is usually due to uterine atony. Pharmacological treatment has not altered much in recent years with oxytocin and ergometrine remaining first-line options. Although controversy surrounds its advantages over other uterotonics, the use of misoprostol has been increasing, especially in resource-poor countries. Placenta accreta is becoming more common, a sequelae to the rising caesarean section rate. Interventional radiology may reduce blood loss in these cases. Uterine compression sutures, intrauterine tamponade balloons and cell salvage have all made their debut in the last decade.
SUMMARY: Accurate diagnosis and appropriate management of obstetric haemorrhage can reduce maternal morbidity and mortality. This review outlines the current evidence.

This is the website for the Wisconsin Association for Perinatal Care and the Perinatal Foundation, and is an information source for perinatal health care professionals and consumers alike. The specific link provides resources related to protocols and management of postpartum hemorrhage, including case studies, case-scenario drills, drill checklists, B-Lynch suture diagrams and more.