Surgical Management of Postpartum Hemorrhage Case File

Surgical Management of Postpartum Hemorrhage Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 21

A 19-year-old G1P0 Hispanic woman presents at 41 weeks’ gestation for induction of labor. Her pregnancy was complicated by A1 gestational diabetes. Her estimated fetal weight was 9 lb (4 kg) by Leopold maneuver. The patient has a favorable cervix and adequate pelvis, and thus induction was begun with oxytocin (Pitocin). The patient progressed with a protracted labor course. An epidural anesthesia was placed after the patient reached 4 cm dilation. The nurse commented that the oxytocin was at 40 mU/min for greater than 8 hours even before the patient completed the first stage of labor. Oxytocin was continued at the same rate throughout the second stage of labor which lasted 2.5 hours.

An infant weighing 10 lb 3 oz (4.54 kg) was delivered via spontaneous vaginal vertex delivery over a third-degree midline laceration. The laceration was repaired while awaiting placental detachment. The placenta was delivered spontaneously and was intact. Immediately after the placental delivery, significant vaginal bleeding was noted. Attempts at uterine massage and intravenous dilute Pitocin administration were employed without success. The patient received methylergonine (Methergine) and prostagladin F2α (Hemabate) that were also utilized to no avail. Estimated blood loss was nearly 2000 mL at this point. She is complaining dizziness/light-headedness and is found to have a pulse of 128 beats/min and BP of 86/42 mm Hg.

➤ What is the most likely diagnosis?

➤ What is your next step?

➤ What techniques may be utilized?

ANSWERS TO CASE 21:

Surgical Management of Postpartum Hemorrhage

Summary: This is 19-year-old woman G1P0 at 41 weeks’ gestation status post a spontaneous vaginal vertex delivery complicated by postpartum hemorrhage. Medical management for this condition has failed.

➤ Most likely diagnosis: Postpartum hemorrhage most likely secondary to

uterine atony.

➤ Next step: Operative management.

➤ Techniques utilized: Arterial embolization, hypogastric artery ligation, B-lynch stitch, G stitch, packing of uterus, Logothetopulos pack (umbrella pack), SOS Bakri balloon tamponade (Cook Medical Inc., Bloomington, IN).

ANALYSIS

Objectives

1. Describe the symptoms and signs of postpartum hemorrhage.
2. List the management of the medical and surgical options for management of postpartum hemorrhage.
3. Be familiar with the techniques available for surgical management.

Considerations

This is a 19-year-old G1P0 Hispanic woman presenting at 41 weeks’ gestation with a pregnancy complicated by gestational diabetes. Suspicion of a macrosomic infant was encountered at intake of the patient. The patient progress along a protracted first stage approached the upper limits of normal. Throughout her labor course oxytocin augmentation was continued at the upper level of normal as well. The delivered infant was indeed macrosomic. Bleeding persisted after the delivery of the placenta and after initial routine postdelivery protocols (oxytocin and uterine massage). Uterine atony was immediately suspected as it is the number one cause of postpartum hemorrhage. Of low suspicion were retained placental parts. This could be initially ruled out by inspection of delivered placenta and (if necessary) manual exploration of the uterus.

Given the patient’s vital signs (mean arterial pressure of 50 mmHg) and symptoms, the patient is in advanced trauma life support (ATLS)-classified class 3 hypovolemic shock. The administration of fluids and IV access are imperative. Blood should be typed/crossed if possible and ready for transfusion. The patient needs to be monitored closely for the development of disseminated intravascular coagulation (DIC). Once the etiology of the hemorrhage is confirmed to be atony, multiple different medications can be given, including prostaglandins (prostaglandin E1 [PGE1] analogue [misoprostol per rectum] and F2α [Hemabate] and semisynthetic ergot alkaloids [methylergonine]). Because of the patient’s clinical condition and the fact that medical management has failed, surgical intervention is necessary. Given the young age and future fertility desires of the patient, a more conservative surgical course must be considered. Options available include B-lynch stitch, G-stitch, various methods of compression via endometrial tamponade, and ligature of the uterine vasculature. These efforts must be considered in this patient as long as she is stable, before hysterectomy is deemed necessary.

APPROACH TO

Postpartum Hemorrhage

DEFINITIONS

POSTPARTUM HEMORRHAGE: Hemorrhage following delivery from excessive bleeding from the placental implantation site, trauma to the genital tract and adjacent structures, or both. Loss of 500 mL of blood or more after completion of third stage of labor of a vaginal delivery or loss of 1000 mL of blood or more during a cesarean delivery. Significant bleeding that may result in hemodynamic instability if unabated.

UTERINE ATONY: Lack of myometrial contraction, clinically manifested by a boggy uterus.

HYPOGASTRIC ARTERY: Also known as the internal iliac artery. Posterior division branches: iliolumbar artery, lateral sacral arteries, superior gluteal artery. Anterior division: inferior gluteal artery, umbilical artery, superior vesical artery, uterine artery (females) or deferential artery (males), vaginal artery (females, can also arise from uterine artery), inferior vesical artery, middle rectal artery, internal pudendal artery.

B- AND G-LYNCH STITCH: Suturing techniques that result in uterine compression when uterine atony is encountered.

CLINICAL APPROACH

Assessment of the etiology of postpartum hemorrhage is paramount to the correct management of the situation. The classic definitions are exceeding 500-mL after vaginal delivery, or exceeding 1000 mL for a cesarean delivery, but these amounts not easily measured. Studies have found that about 5% of women delivering vaginally lost more than 1000 mL of blood and they also observed that the estimated blood loss (EBL) is commonly only half the actual loss. The substantial amount of blood loss that is deemed “routine EBL” is tolerated due to the initial hypervolemia that the pregnant patient develops during pregnancy. Increase of 1500 to 2000 mL of blood volume or 30% to 60% rise is encountered. The mother can encounter a great deal of blood loss before shock ensues.1

Efforts to minimize the amount of blood loss include medical and surgical management options. Medical management begins with routine oxytocin administration either during or immediately after the third stage of labor. Gentle uterine fundal massage is also employed. Further management entails the use of either prostaglandin F2α (Hemabate) and/or semisynthetic ergot alkaloid (Methergine). Misoprostol, a PGE1 analogue, has also been used rectally to induce uterine contraction. Medical management’s approach is aimed at correcting the underlying basis of uterine atony, by promoting myometrial contraction.

When medical management measures fail, surgery must be considered. Hysterectomy is the most definitive and rapid approach to alleviating the bleeding, but of course, prevents future children. More conservative measures may be considered if the patient is stable and desires future fertility. These measures include methods that mechanically contract the uterus (B-lynch and G-stitch), or involve interruption of the vascular flow to the uterus. The focus of the remaining discussion will be on one such vascular interruption.

Bilateral hypogastric artery ligation has been described as a method to conservatively manage severe pelvic hemorrhage. One of the first documented accounts of this procedure was documented in 1893 at Johns Hopkins Hospital when Howard Kelly performed ligation of bilateral hypogastric arteries to control hemorrhage during hysterectomy for uterine cancer.1

Ligation of the hypogastric artery is associated with a 77% decrease in the pulse pressure just distal to the point of the suture. Bilateral ligation decreases pulse pressure by 85%.2 The decreased pulse pressure allows for clot formation at the site of vascular injury. Blood flow is only decreased by 48% in vessels distal to the point of ligature. By ligating the anterior division of the hypogastric artery, it allows isolation of the collateral arterial circulation from the pelvis and reduced pulse pressure in the bleeding artery.

The technical execution of hypogastric artery ligation may be difficult at the time of severe hemorrhage; great precision must be employed to ensure proper anatomical identification to avoid vascular or ureteral injury. The peritoneum is opened on the lateral side of the common iliac near its bifurcation. The ureter is left attached to the medial peritoneal reflection to avoid disruption of its blood supply. It is important to ligate the anterior division of the hypogastric artery distal to the posterior parietal branch. The posterior division must be identified before the anterior division is ligated. The anterior division is dissected from the underlying hypogastric vein. Nonabsorbable suture is passed around the artery generally using a right-angle clamp and tied. The second free-tie suture is placed distal to the first ligature. Transection is not to be employed; in other words, the artery is ligated with suture but the artery is not divided. Ligation of the uterine artery may be performed at this point if it is able to be identified. In matters of postpartum hemorrhage, this may prove to be a valuable addendum to traditional hypogastric artery ligation techniques. The uterine artery is the first branch of the anterior division of the hypogastric artery and may be ligated at that location.3-8

Postpartum hemorrhage involves more than just the uterine artery as the source of blood flow to the uterus. The ovarian artery is an important collateral communication of the aorta to the uterine vasculature; thus, interruption of this large source of blood is beneficial in cases of postpartum hemorrhage. The lateral peritoneal incision is extended above the pelvic brim and the bifurcation of the common iliac artery. Ligation of both the ovarian artery and vein is acceptable if difficulty is encountered, identifying the artery from the vein. Bilateral ovarian arteries are dissected free from the retroperitoneal position at or above the pelvic brim and free-tied. One ligature is utilized and the artery is not to be transected. As with any procedure in this portion of the pelvis, care must be taken to avoid ureteral injury.

Cruikshank and Stoelk9 describe an alternative method to ligation of the ovarian artery in the infundibulopelvic ligament. Instead, the artery is ligated at the point of anastomosis with the uterine artery in the medial mesosalpinx (preserving blood flow to the tube and ovary while decreasing flow to the uterus).

Fehrman goes as far to say that bilateral uterine artery ligation is a more effective treatment for life-threatening uterine hemorrhage than is bilateral hypogastric artery ligation. If this measure is not sufficient, then supplementary ligation of the round ligament and the ovarian ligaments at their junction with the uterine corpus may be employed.

Full-term delivery has been described after hypogastric artery ligation with and without ovarian artery ligation. Collateral blood supply develops over time. These collateral pathways provide enough blood flow to support a developing intrauterine pregnancy.

Morbidity is decreased with hypogastric artery ligation methods compared to hysterectomy as well as a preservation of fertility. Blood loss has been demonstrated to be substantially higher in women undergoing bilateral hypogastric artery ligation and a subsequent hysterectomy secondary to failure than in women who had a hysterectomy without attempts at artery ligation (5125 vs 3209 mL, respectively).1

Vascular complications are generally forgiving due to the rich pelvic anastomoses that are present. Potential complications arise when these collateral pathways are damaged. Several of the complications related to surgical interventions have been described. Complications include sterility, gangrene of  the bladder, urinary tract injury and genitourinary fistula, bowel injury and genitointestinal fistula, vascular injury, pelvic hematoma, and sepsis. Ultrasound of the kidneys following complicated emergency pelvic surgery in order to exclude ureteric obstruction should be considered. Division of the posterior branch of the hypogastric artery has resulted in necrosis of the ipsilateral gluteal muscles. Major intraoperative complications arise from excessive blood loss and the management of shock and fluid replacement. A potential complication may arise if future embolization of bleeding arterial branches is attempted, and may be impossible to perform.10

Hypogastric artery ligation has been described as an option for management of postpartum hemorrhage in the properly selected patient. Fertility is preserved in the great majority of successful outcomes from this effort. Other surgical options in postpartum hemorrhage due to uterine atony include uterine artery ligation (Figure 21–1), B- and G-lynch suturing techniques (Figure 21–2), and ultimately hysterectomy. Uterine artery

Figure 21–1. Internal iliac artery ligation should be distal to posterior trunk, and not incorporate the ureter. (Reproduced, with permission, from DeCherney AH, Nathan L, Goodwin TM,et al.Current Diagnosis & Treatment:Obstetrics & Gynecology, 10th ed.New York: McGraw-Hill, 2007:482.)

Figure 21–2. B-lynch suture is used as an external compression to the uterus. (Reproduced, with permission, from DeCherney AH, Nathan L, Goodwin TM, et al. Current Diagnosis & Treatment: Obstetrics & Gynecology, 10th ed. New York: McGraw-Hill, 2007:483.)

ligation can be performed by most obstetricians in a safe manner. The uterine artery is ligated about 2 to 3 cm below transverse uterine incision with an absorbable suture which is placed 2 to 3 cm medial to uterine vessels through myometrium. Some also advocate ligating the utero-ovarian ligament to decrease collateral flow. Uterine artery ligation appears to work best when bleeding is from the lower uterine segment and success has been reported to be more than 95%.11 Both the B- (Figure 21–2) and G-lynch techniques are considered “compression sutures” and have some limited literature to support their use.1,12-14

Comprehension Questions

21.1 A 21-year-old woman undergoes a vaginal delivery at term. Postpartum hemorrhage is encountered due to uterine atony, which is unresponsive to medical management. Which of the following surgical procedures is most appropriate if the patient desires future fertility?

A. Ligation of the common iliac artery

B. Ligation of the infundibular pelvic ligament

C. Ligation of the ascending branch of the uterine artery

D. Ligation of the posterior trunk of the hypogastric artery

21.2 A 37-year-old G6P5005 woman presents at 40 weeks’ gestation with a diagnosis of hydramnios. After a successful vaginal vertex delivery, the patient experiences postpartum hemorrhage estimated to be in excess of 2500 mL of blood. Medical management attempts are unsuccessful. Which of the following is the next step?

A. Bilateral hypogastric artery ligation

B. Sharp curettage of the uterus

C. Hysterectomy

D. B-lynch stitch

21.3 Which of the following sutures would be preferred when performing a bilateral hypogastric artery ligation?

A. Chromic catgut

B. Plain catgut

C. polyglactin 910 (vicryl)

D. Polydioxanone (PDS

ANSWERS

21.1 C. In a patient with uterine bleeding, decreasing the arterial perfusion is one of the primary therapeutic strategies. Ligation of the ascending branch of the uterine artery bilaterally is effective and allows for fertility. Ligation of the infundibular pelvic ligament means sacrificing both ovaries which will lead to an infertile and castrated patient. Ligation of the common iliac artery should never be performed due to disruption of the arterial supply to the lower extremity. Ligation of the posterior trunk of the hypogastric artery leads to ischemia of the gluteal region.

21.2 C. Careful selection of patients for attempts at conservative management of hemorrhage is crucial to the morbidity of the patient. In this case a multiparous patient with a number of risk factors for postpartum hemorrhage was encountered (high parity, hydramnios). The patient is multiparous and has an excessive blood loss secondary to uterine atony. Given these factors, hysterectomy would be the most appropriate measure. Sharp dilation and curettage of the uterus is an option for patients experiencing postpartum hemorrhage secondary to retained products of conception. The B-lynch stitch is a suture that manually compresses the uterus. The suture has been effective in some cases, although there are limited published data comparing its effectiveness to that of hysterectomy.

21.3 C. Nonabsorbable suture (silk) and delayed absorbable suture (Vicryl) have been utilized in bilateral ligation of the hypogastric artery. PDS has a tendency to cut through the tissue when tying and thus would be contraindicated. The premise of the technique is to ligate the vessel and not to transect. Chromic is absorbable suture.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ The most common cause of postpartum hemorrhage is uterine atony (Level B).

➤ Arterial embolization of uterine vasculature may be impossible to perform after bilateral hypogastric artery ligation (Level B).

➤ Fertility may be preserved with bilateral hypogastric artery ligation (Level B).

➤ Conservative surgical management is a possibility in the properly selected patient (Level C).

➤ Ureteral damage is a complication with bilateral hypogastric artery ligation and must be ruled out if clinically suspected at time of operation or postoperatively (Level C).

REFERENCES

1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC III, Wenstrom KD. Obstetrical hemorrhage. In: Williams Obstetrics. 22nd ed. New York, NY: McGraw-Hill; 2005:809-854. 

2. Burchell RC. Physiology of internal iliac artery ligation. J Obstet Gynaecol Br Commonw. 1969;57:642. 

3. Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet. 1985;160:250. 

4. Fahmy K. Internal iliac artery ligation and its efficacy in controlling pelvic hemorrhage. Int Surg. 1969;51:244. 

5. Reich WJ, Nechtow MJ. Ligation of the internal iliac (hypogastric) arteries: a lifesaving procedure for uncontrollable gynecologic and obstetric hemorrhage. J Int Coll Surg. 1961;36:157. 

6. Rock JA, Jones HW III. Control of pelvic hemorrhage. In: Te Linde’s Operative Gynecology. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:385-387. 

7. Siegel P, Mengert WF. Internal iliac artery ligation in obstetrics and gynecology. JAMA. 1961;178:1059. 

8. Slate WG. Internal iliac ligation. Am J Obstet Gynecol. 1966;95:326. 

9. Cruikshank SH, Stoelk EM. Surgical control of pelvic hemorrhage: bilateral hypogastric artery ligation and method of ovarian artery ligation. South Med J. 1985;78:539. 

10. Given FT, Gates HS, Morgan BE. Pregnancy following bilateral ligation of the internal iliac (hypogastric) arteries. Am J Obstet Gynecol. 1964;89:1078. 

11 O’Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med. 1995;40:189. 

12. B-Lynch CB. Coker A, Laval AH, Abu J, Cowen MJ. The B-lynch surgical technique for control of massive postpartum hemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol. 1997;104:372. 

13. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol. 2002;99:502. 

14. Rock JA, Jones HW III. Obstetric problems. In: Te Linde’s Operative Gynecology. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:827-829.

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