Appropriate second-line therapies for management of severe postpartum hemorrhage

Objective

To explore appropriate second-line therapies for management of severe postpartum hemorrhage at cesarean delivery.

Methods

A retrospective study was done of 87 women who underwent cesarean delivery and received uterotonics after placental separation at the Beijing Haidian Maternal and Child Health Hospital, China, between 2009 and 2013. Group 1 (n = 52) included patients with 500–700 mL of blood loss before application of intrauterine gauze tamponade or B-Lynch suture as second-line therapy, while group 2 (n = 35) included patients with blood loss of more than 700 mL before application of either gauze tamponade or B-Lynch suture.

Results

Management was successful in all patients in group 1. In group 2, additional management was needed in three of four patients who underwent a B-lynch suture. Factors significantly associated with total blood loss were blood loss before application of second-line therapy (P < 0.001), fibrinogen levels (P < 0.001), and time from placental separation to second-line therapy (P = 0.015).

Conclusion

When blood loss is 500–700 mL, compression sutures or intrauterine gauze tamponade can be used as second-line treatment of postpartum hemorrhage. When blood loss is more than 700 mL, intrauterine gauze tamponade should be used.     

产后出血的保守性手术治疗

产后出血是分娩期常见而且严重的并发症,在药物和子宫按摩不能控制出血时,需采取手术干预。保守性手术是指保留子宫的手术方法,包括血管结扎、宫腔填塞压迫止血、子宫压迫缝合等。B-Lynch缝合技术在产后出血的保守性手术治疗中具有里程碑式的意义,并且由此改良出多种子宫压迫缝合方法。这些技术各有利弊和不同的适应证,根据产后出血的不同原因选择合适的保守性手术方式,才能达到良好止血和减少并发症的目的。     

Successful of the B-Lynch compression suture in the management of massive postpartum hemorrhage: case reports and review

The authors describe three patients who developed massive primary postpartum hemorrhage and review the case reports. In two patients, primary postpartum hemorrhage was due to uterine atony, and in one patient it was due to atony and thrombophilia. In all three patients, excellent effect was achieved with hemorrhage reduction by a compression B-Lynch suture alone, with bimanual compression following medicamentous uterotonic therapy. B-Lynch suture is an efficient, safe, and simple method for the treatment of primary postpartum hemorrhage during cesarean section, which successfully reduces the number of urgent postpartum hysterectomies, also preserving subsequent fertility. In our opinion, the method should be included in the algorithm of primary postpartum hemorrhage management at all obstetric departments.     

子宫压迫缝合术治疗产后出血

子宫压迫缝合术是一种简便高效的产后出血保守性手术方法,本文分析目前国内外的多种子宫压迫缝合术在临床应用中存在的局限性与弊端,并讨论在产后出血中的临床应用及注意事项。     

难治性产后出血干预性治疗方法的对比研究

目的探讨难治性产后出血的各种干预性措施在抢救过程中的合理应用及应用价值。方法分析1998年1月至2003年8月间，采用宫腔填塞纱布(塞纱)、盆腔动脉结扎、经导管动脉栓塞术等干预性措施的88例难治性产后出血病人的临床资料。结果全部抢救成功，其中18例宫腔塞纱者成功12例(66．7％)，12例盆腔动脉结扎中成功4例(33．3％)，30例经导管动脉栓塞术(TAE)治疗全部成功(100％)，42例一次开腹行全子宫切除术或加盆腔塞纱者成功36例(85．7％)。结论宫腔塞纱可压迫止血。TAE可替代子宫切除术。当子宫成为凝血功能障碍的病因时，主张行子宫切除．     

Uterine artery embolization for postpartum hemorrhage

An increasing amount of evidence supports the use of interventional radiology, which can be used electively in cases of placenta previa/accreta in which large blood loss is anticipated or in the emergency situation, typically secondary to atonic uterus.Although a lot of single-case studies and short series have been reported, as well as some case-control studies and several systematic reviews, no randomized controlled trials have been identified.There are difficulties with the transfer of unstable patients and not all centers have access to an interventional radiology unit or a senior radiologist.Interventional radiology as an elective and prophylactic measure for hemostatic control of the pelvis is an option if hysterectomy is planned. Ideally, it should be subject to prospective, randomized analysis. If used, intense vascular surveillance is mandatory and catheters and sheaths should be removed at the first opportunity.The primary idea of conservative management is to leave the entire placenta or just the part that is adherent to the myometrium in situ to preserve the uterus. Conservative management should be considered only in highly selective cases when blood loss is minimal and there is desire for fertility preservation. It is not clear whether adjuvant methotrexate or selective arterial embolization is beneficial.Occlusion of the distal uterine artery bed with absorbable gelatine preparations lasts for about 4 weeks, whereupon it recanalizes, thus preserving fertility and reproductive potential if conservative treatment is possible.Resuscitation and stabilization are the initial focus of intervention in patients who are hemorrhaging after a vaginal birth. If temporizing measures are ineffective, arterial embolization can be performed before laparotomy if the woman is hemodynamically stable and facilities for interventional vascular radiology are available or close by.If failure of management occurs during cesarean section, compressive sutures, and stepwise devascularization, which are quick, relatively easy, and effective, should be tried first.For persistent uterine atony, the success rate of emergency arterial embolization varies from 70–100%.

• Elective and prophylactic embolization should ideally be submitted to prospective, randomized analysis.

• Research is needed into how to minimize vascular complications.

• More experience with early embolization for conservative approach in placenta accreta is necessary.

• The timing and place of emergency embolization after vaginal delivery and cesarean section requires investigation.

选择性子宫动脉栓塞术治疗难治性产后出血13例临床分析

目的探讨子宫动脉栓塞术治疗难治性产后出血的时机、疗效及并发症。方法对北京大学人民医院13例难治性产后出血患者,利用数字减影造影（DSA）技术选择子宫动脉及其分支行栓塞治疗。结果 13例产后出血患者分娩时出血量为150～4000ml,平均出血量1200（1200±1215）ml。产后出血总量870～4000ml,平均2555（2555±995）ml。13例患者栓塞前均行按摩子宫,卡孕栓肛塞及欣母沛宫体注射促进子宫收缩,2例剖宫产术中出血患者已行子宫动脉上行支结扎、B-Lynch缝合以及宫腔填纱止血,效果均不佳,经子宫动脉栓塞后12例均成功止血,仅1例未能止血而行全子宫切除术。13例产后出血行子宫动脉栓塞术前存在不同程度的凝血功能异常,在积极纠正凝血功能异常同时行栓塞术。栓塞术后无严重并发症发生,发热为最为常见并发症,但应警惕感染。结论凝血功能障碍并非子宫动脉栓塞术的禁忌证,只要把握好子宫动脉栓塞的时机,子宫动脉栓塞术能有效治疗产后出血,并且并发症少。     

剖宫产手术中并发产后出血保守治疗

剖宫产手术过程中常发生出血增多,若不及时处理可导致严重产后出血。术中根据出血状况及时采取有效治疗措施,避免严重出血带来的一系列并发症极其重要。文章从药物治疗、宫腔填塞、子宫压迫缝合、血管阻断等方面对剖宫产手术中各类止血方案的优缺点和使用时机展开论述,强调止血宜及时,尽早达到止血效果,减少大量出血后并发症的发生。     

产后出血及其临床救治

产后出血是一种常见的并发症,是产妇发病率和死亡率的主要原因。产后出血有许多潜在的原因,但最常见的是子宫收缩乏力。所有产科工作人员和参与孕产妇保健的工作人员,必须有一个产后出血的预防和管理的明确计划。应当记住:一到位,两个重视,三个正确,提高产后出血救治水平。     

Outcomes and complications of severe acute postpartum hemorrhage treated with or without transarterial embolization in a single tertiary referral center: A 20-year experience

ObjectivePPH is usually unpredictable; and such fast, urgent and sudden massive life-threating hemorrhage. This study is to assess the efficacy of transarterial embolization (TAE) in treating severe PPH in a single institution over a period of 20 years.Materials and methodsFrom January 2000 to October 2019, all women with acute PPH more than 1500 cc and/or DIC were enrolled in this retrospective study. These women were divided into two groups according to whether they have received TAE as the second-line treatment. Group 1 (n = 27) included women without receiving TAE from January 1, 2000 to October 31, 2009, and group 2 (n = 30) included those who receiving TAE from November 1, 2009 to October 31, 2019.ResultsThe overall success rate of TAE in control the PPH and preserved the uterus is 80%. The hemoglobin 12 h after PPH in group 2 is significantly lower than in group 1 (7.64 ± 1.6 vs. 8.58 ± 1.9, respectively. P = 0.05). Total unit of packed red blood cell (pRBC) transfusion is significantly higher in the group 2 than group 1 (9.8 ± 5.7 vs. 6.8 ± 3.9; p = 0.03). The rate of hysterectomy is significantly higher in group 1 than group 2 (46.7 vs. 20%; p < 0.001).ConclusionIn conclusion, TAE is safe and effective in control bleeding in PPH with a high success rate to preserve uterus and prevent DIC. TAE should be routinely used as a secondary line of treatment during PPH in all hospitals.     

Pregnancy with asymptomatic uterine complete rupture after uterine artery embolization for postpartum hemorrhage

Objective

Uterine artery embolization has become an effective treatment for postpartum hemorrhage. The safety of pregnancy after uterine artery embolization for postpartum hemorrhage has been established.

Outcome of the management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS”

Objective

To evaluate whether the algorithm “HEMOSTASIS” (help; establish etiology; massage the uterus; oxytocin infusion and prostaglandins; shift to operating theater; tamponade test; apply compression sutures; systematic pelvic devascularization; interventional radiology; subtotal/total abdominal hysterectomy) was of value in the systematic management of postpartum hemorrhage (PPH).

Methods

A retrospective analysis was performed of all women who experienced massive primary PPH (blood loss > 1500 mL) in 2008 at St George's Hospital, London, UK. The success of the HEMOSTASIS mnemonic in PPH management was determined by assessing clinical outcome following adherence to the protocol.

Results

Patient notes were available for 95 (83.3%) of the 114 cases of primary PPH. Hemostasis was achieved in 63 (66.3%) women via use of additional oxytocics (“O”); 19 (20.0%) via suture of tears and 10 (10.5%) via tamponade (“T”); 1 (1.1%) via application of compression suture (“A”); 1 (1.1%) via systematic devascularization (“S”); and 1 (1.1%) via subtotal/total hysterectomy (“S”). There were no maternal deaths.

Conclusion

The decremental pattern of more complex interventions used demonstrates that the algorithm can provide a logical management pathway to reduce blood transfusions, hysterectomies, admissions to intensive care units, and maternal deaths.     

Balloon tamponade in the management of postpartum haemorrhage: a review

Obstetric haemorrhage is a significant contributor to worldwide maternal morbidity and mortality. Guidelines for the management of postpartum haemorrhage (PPH) involve a stepwise escalation of pharmacological and eventual surgical approaches. The method of uterine tamponade using balloons has recently been added to the armamentarium for managing PPH. There are various balloons available including the Bakri, Foley, Sengstaken–Blakemore, Rusch and condom catheter. This paper reviews these uterine tamponade technologies in the management of PPH.     

产后出血的预防和处理

产后出血仍是全球孕产妇死亡的主要原因。根据出血状况及时采取有效治疗措施,避免严重出血带来的一系列并发症极其重要。文章主要讨论产后出血的预防及处理。