Management Of Severe Postpartum Hemorrhage Research Articles

Selective arterial embolisation in the management of severe postpartum haemorrhage: a review of five cases

The aim of this study was to evaluate the efficacy and safety of emergency selective arterial embolisation to control severe postpartum haemorrhage. Five women with intractable postpartum haemorrhage underwent selective arterial embolisation in our institution between January 2000 and September 2002. In all cases haemostatic embolisation was performed because of intractable haemorrhage that could not be controlled by conservative measures and in one patient after caesarean hysterectomy. The main cause of immediate postpartum haemorrhage was uterine atony in three cases and placenta accreta in two. Angiography revealed arterial extravasation in four women. All patients had embolisation with gelfoam only or gelfoam and coils. External bleeding resolved immediately or was decreased markedly in four cases. One patient had a hysterectomy following failed embolisation. No significant complication related to arterial embolisation was found.

Management of severe postpartum hemorrhage with misoprostol

This descriptive prospective study explored the use of rectal misoprostol in the treatment of severe cases of atonic postpartum hemorrhage not responding to oxytocin or methergine. A total of 18 cases of atonic postpartum hemorrhage at the Department of Obstetrics and Gynecology Assiut University Hospital Assiut Egypt were studied between May and December 1999. It is noted that only 5 women were delivered by cesarean section while 13 were delivered vaginally. Among the 18 cases of severe atonic postpartum hemorrhage not responding to oxytocin methylergometrine and enzaprost 16 cases responded promptly to misoprostol (88.2%). The response to misoprostol appeared within 30 seconds to 3 minutes (mean = 1.4 minutes). This finding indicates that rectal misoprostol is an effective line of treatment in cases of atonic hemorrhage refractory to other drugs. Further study on the pharmacokinetics of rectal misoprostol and a properly designed randomized trial are recommended.

Surgical management of severe postpartum haemorrhage

In the UK maternal deaths as a result of postpartum haemorrhage (PPH) numbered 1 in 60 000 births in the 1970s, falling to 1 in 200 000 births in the 1990s. However, in developing countries this figure may be as high as 1 in 2000–5000 births. The morbidity is 50 times more common than in developed countries. The improved figures from England and Wales are largely due to prophylactic use of oxytocics in the management of the third stage of labour and is similar to the figures of other developed countries. Confidential enquiries in the developed countries point to avoidable factors. Replacement of blood that is ‘too little and too late’ and ‘delay to initiate and perform definitive surgery’ when there is severe PPH that does not respond to medical management have been highlighted. The role of surgery and various surgical methods in the management of severe PPH is discussed.

Intrauterine irrigation with prostaglandin F2‐α for management of severe postpartum hemorrhage

Severe postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. The use of prostaglandin F2-alpha to control severe postpartum hemorrhage may avert surgery for the control of bleeding. After ruling out the possibility of genital tract injuries, 18 patients with severe postpartum hemorrhage caused by uterine atony were enrolled in the study. None of the patients responded to treatment with oxytocin, methylergonovine, or uterine massage. A Foley catheter was introduced into the uterine cavity and the balloon was inflated with 5 ml sterile saline solution. The catheter was connected to an infusion line of 500 ml saline solution containing 20 mg prostaglandin F2-alpha. The solution was infused at a rate of 3-4 ml/minute for the first 10 min, and then reduced to 1 ml/minute for a period of 12 24 hours. In 17 patients (94.4%) bleeding ceased within several minutes of initiation of intrauterine prostaglandin F2-alpha infusion, the uterus was firmly contracted and uterine bleeding did not recur. In one patient with placenta increta bleeding continued and hysterectomy was performed. None of the patients had any side effects. Intrauterine irrigation with low concentrations of prostaglandin F2-alpha is a simple, rapid and effective treatment for severe postpartum hemorrhage and facilitates constant and continuous hemostasis. Moreover, the minute dosage used eludes potentially complicating side effects.

Intrauterine irrigation with prostaglandin F 2 -α for management of severe postpartum hemorrhage

Intrauterine irrigation with prostaglandin F 2 -α for management of severe postpartum hemorrhage

New drugs and new evidence which might affect the usage of existing drugs which act on the pregnant uterus

Few new drugs which act on the pregnant uterus have been introduced in recent years. This review includes a new agent for management of severe postpartum haemorrhage. The use of antiprogestogens in combination with vaginal prostaglandins for medical termination of pregnancy is considered in a previous issue of this journal.’ With improved knowledge of the biochemistry and physiology of normal labour, new preparations of the existing agents or different modes of administration have resulted in new therapeutic options.

Management of severe postpartum hemorrhage by intrauterine irrigation with prostaglandin E 2

Continuous intrauterine irrigation with minute amounts of prostaglandin E 2 was used in 22 patients with severe postpartum hemorrhage unmanageable by conventional therapy. Twenty-one women were treated because of uterine atonic hemorrhage and one because of late postpartum hemorrhage from subinvolution. A quick tetanic contraction of the uterine muscle with dramatic and sustained hemostasis was achieved in all patients. The therapeutic response was continuous and uninterrupted regardless of the predisposing factors for the hemorrhage or the hemodynamic condition of the patients. No side effects were observed.