凶险性前置胎盘致产后大出血的防范

凶险性前置胎盘引起的产后出血可导致急诊切除子宫甚至危及患者生命,该文就防范产后大出血的措施包括产前诊断和监测、术前准备、术中止血方法的使用及术后管理进行阐述,以供同道借鉴。     

Bilateral uterine artery ligation plus B-Lynch procedure for atonic postpartum hemorrhage with placenta accreta

Objective

To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta.

Method

This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta.

Results

Two women died from disseminated intravascular coagulopathy. In the remaining 24 women, placental remnants completely disappeared within 8 months and ovulation resumed after a mean ± SD of 51.6 ± 3.2 days. Moreover, 18 women (75%) became pregnant within 12 months.

Conclusion

Atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta can be safely controlled by bilateral uterine artery ligation followed by B-Lynch compression suturing in women who desire to remain fertile.     

A local hemostatic agent for the management of postpartum hemorrhage due to placenta previa and placenta accreta: a cross-sectional study

Purpose

To describe the use of a local hemostatic agent (LHA) for the management of postpartum hemorrhage (PPH) due to bleeding of the placental bed in patients taken to caesarean section at Fundación Santa Fe de Bogotá University Hospital.

Sample

A total of 41 pregnant women who had a caesarean section and developed PPH.

Methods

A cross-sectional study. Analysis of all cases of PPH during caesarean section presented from 2006 up to and including 2012 at Fundación Santa Fe de Bogotá University Hospital.

Main outcome measure

Emergency hysterectomy due to PPH.

Results

The proportion of hysterectomies was 5 vs. 66 % for the group that received and did not receive management with a LHA respectively (PR 0.07, CI 95 % 0.01–0.51 p < 0.01). For the group managed without a LHA, 80 % of patients needed hemoderivatives transfusion vs. 20 % of patients in the group managed with a LHA (PR 0.24, CI 95 % 0.1–0.6 p < 0.01). A reduction in the mean days of hospitalization in addition to a descent in the proportion of patients admitted to the intensive care unit (ICU) was noticed when comparing the group that received a LHA versus the one that did not.

Conclusion

An inverse association between the use of a LHA in patients with PPH due to bleeding of the placental bed and the need to perform an emergency obstetric hysterectomy was observed. Additionally there was a significant reduction in the mean duration of hospital stay, use of hemoderivatives and admission to the ICU.     

B-Lynch suture, intrauterine balloon, and endouterine hemostatic suture for the management of postpartum hemorrhage due to placenta previa accreta

Objective

To report our experience with a new conservative management approach to treat postpartum hemorrhage (PPH) due to placenta previa accreta.

Methods

A retrospective study of 9 patients with placenta previa accreta who underwent a conservative management protocol. The protocol consists of preventive radiological catheterization of the descending aorta, cesarean delivery, use of Affronti endouterine square hemostatic sutures, and placement of an intrauterine Bakri balloon in conjunction with B-Lynch suture. In the event of failure of the protocol, subsequent management employs ligation and/or reversible embolization of the uterine arteries followed by hysterectomy if unsuccessful.

Results

Conservative management of PPH was successful in all 9 patients evaluated and avoided the need for ligation and/or reversible embolization of the uterine arteries.

Conclusion

Management of PPH is dictated by several considerations including hemodynamic status and desire to preserve fertility. The initial results of this conservative protocol for treatment of PPH in high-risk patients with placenta previa accreta are encouraging.     

Parallel vertical compression sutures to control bleeding in cases of placenta previa and accreta

Objective: To evaluate the effectiveness of full-thickness vertical compression suture and intrauterine catheter in cases with placenta previa/accreta.

Study design: This study was conducted on Obstetrics and Gynecology emergency unit of Sohag University Hospital. Two longitudinal parallel full-thickness suture was taken using delayed absorbable suture (No. 2 Vicryl…) the entry of needle through anterior wall of lower uterine segment just above the internal os 2–3?cm medial to lateral aspect of lower uterine segment then completely piercing the posterior wall and then return from posterior wall to anterior wall 1–2?cm below incision line of the uterus. Another suture was taken in other side in the same manner. The Foley’s catheter was inserted through the incision line into the cervix and balloon was inflated by 20–30?cc saline.

Results: Two hundred and seventy-eight cases were included in the research. There were 107 cases without significant bleeding from lower uterine segment and no maneuver was needed. The remaining 171 cases were managed by vertical compression suture and intrauterine Foley’s catheter which was successful in 168 cases (98.2%) to stop the bleeding. Only three cases cesarean total hysterectomy was needed.

Conclusions: Vertical lateral compression sutures with inserting inflated balloon of Foley’s catheter is an effective method for controlling bleeding in cases of placenta previa/accreta.     

Uterine compression sutures: surgical management of postpartum hemorrhage

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 prostaglandins, 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 postpartum 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.     

Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas

Puerperal hematomas, although rare, can be potentially morbid or life-threatening events. Early surgical management, including clot evacuation, layered closure, drainage, antibiotics, and fluid replacement (including blood), usually result in satisfactory outcome. Prevention is clearly preferable and often achievable with careful initial repair of episiotomies and lacerations.