Persistent Postpartum Hemorrhage Research Articles

Menorrhagia and postpartum haemorrhage in women with rare bleeding disorder

In women, von Willebrand disease (VWD) is the most common inherited bleeding disorder. Objectively, it is defined as bleeding that lasts for more than seven days or results in the loss of more than 80 mL of blood per menstrual cycle. The prevalence of menorrhagia in a woman with a bleeding disorder ranges from 32 to 100%. Postpartum hemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide. A treatment algorithm for severe persistent PPH was subsequently developed. These include mechanical or surgical maneuvers, i.e., intrauterine balloon tamponade or hemostatic brace sutures with hysterectomy as the final surgical option for uncontrollable PPH. Pharmacologic options include hemostatic agents (tranexamic acid), with timely transfusion of blood and plasma products playing an important role in persistent and severe PPH.

Evaluation and management of postpartum hemorrhage: consensus from an international expert panel

Postpartum hemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide, although the lack of a precise definition precludes accurate data of the absolute prevalence of PPH. An international expert panel in obstetrics, gynecology, hematology, transfusion, and anesthesiology undertook a comprehensive review of the literature. At a meeting in November 2011, the panel agreed on a definition of severe PPH that would identify those women who were at a high risk of adverse clinical outcomes. The panel agreed on the following definition for severe persistent (ongoing) PPH: "Active bleeding >1000 mL within the 24 hours following birth that continues despite the use of initial measures including first-line uterotonic agents and uterine massage." A treatment algorithm for severe persistent PPH was subsequently developed. Initial evaluations include measurement of blood loss and clinical assessments of PPH severity. Coagulation screens should be performed as soon as persistent (ongoing) PPH is diagnosed, to guide subsequent therapy. If initial measures fail to stop bleeding and uterine atony persists, second- and third-line (if required) interventions should be instated. These include mechanical or surgical maneuvers, i.e., intrauterine balloon tamponade or hemostatic brace sutures with hysterectomy as the final surgical option for uncontrollable PPH. Pharmacologic options include hemostatic agents (tranexamic acid), with timely transfusion of blood and plasma products playing an important role in persistent and severe PPH. Early, aggressive, and coordinated intervention by health care professionals is critical in minimizing blood loss to ensure optimal clinical outcomes in management of women with severe, persistent PPH.

Obstetric Hemorrhage and Coagulation

Globally, postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. In the current treatment of severe PPH, first-line therapy includes transfusion of packed cells and fresh-frozen plasma in addition to uterotonic medical management and surgical interventions. In persistent PPH, tranexamic acid, fibrinogen, and coagulation factors are often administered. Secondary coagulopathy due to PPH or its treatment is often underestimated and therefore remains untreated, potentially causing progression to even more severe PPH. In most cases, medical and transfusion therapy is not based on the actual coagulation state because conventional laboratory test results are usually not available for 45 to 60 minutes. Thromboelastography and rotational thromboelastometry are point-of-care coagulation tests. A good correlation has been shown between thromboelastometric and conventional coagulation tests, and the use of these in massive bleeding in nonobstetric patients is widely practiced and it has been proven to be cost-effective. As with conventional laboratory tests, there is an influence of fluid dilution on coagulation test results, which is more pronounced with colloid fluids. Fibrinogen seems to play a major role in the course of PPH and can be an early predictor of the severity of PPH. The FIBTEM values (in thromboelastometry, reagent specific for the fibrin polymerization process) decline even more rapidly than fibrinogen levels and can be useful for early guidance of interventions. Data on thromboelastography and thromboelastometry in pregnant women are limited, particularly during the peripartum period and in women with PPH, so more research in this field is needed.

Predictive factors for failure of pelvic arterial embolization for postpartum hemorrhage

ObjectiveTo assess the efficacy of pelvic embolization in women with postpartum hemorrhage (PPH) and to determine factors associated with embolization failure. MethodsIn a retrospective observational study, data were analyzed from 98 consecutive women who underwent pelvic embolization for intractable PPH between January 2007 and November 2009 at Beaujon Hospital, Clichy, France. Women with persistent PPH despite pelvic embolization were compared with women who had cessation of hemorrhage and attained hemodynamic stability. ResultsAmong the 98 women, 66 (67.3%) had been transferred from another hospital after delivery. Pelvic arterial embolization failed to control PPH in 8 (8.2%) women. On univariate analysis, factors significantly associated with embolization failure were the presence of placenta accreta (P<0.005), hemoglobin level (P<0.05), prothrombin time (P<0.04), fibrinogen level (P<0.03), red blood transfusion (P<0.02), number of packed red blood cell units transfused (P<0.05), and fresh-frozen plasma transfusion (P<0.02). Hospital-to-hospital transfer with a notable time interval between delivery and embolization was not associated with increased risk of failure. ConclusionPredictive factors significantly associated with failed pelvic arterial embolization were the presence of placenta accreta, biologic factors, and transfusional factors. Delay due to inter-hospital transfer did not affect the outcome of embolization.

Peripartum hysterectomy – the edinburgh experience

Peripartum hysterectomy can be required to control persistent postpartum haemorrhage. This audit aimed to review the incidence, management and outcomes of women undergoing peripartum hysterectomy.This was a retrospective audit of...

Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?

Among 23 women who underwent diagnostic hysteroscopy after triple uterine artery ligation with or without hemostatic multiple square suturing for the management of postpartum hemorrhage (PPH), five had abnormal findings. Endometritis was statistically significantly associated with abnormal diagnostic hysteroscopy findings. Twelve patients developed subsequent pregnancies, and four had abnormal obstetric outcomes: one placenta percreta, one placenta accreta, one recurrent postpartum hemorrhage, and one intrauterine growth retardation.

Persistent postpartum haemorrhage after failed arterial ligation: value of pelvic embolisation

To evaluate the role and efficacy of pelvic embolisation in the treatment of persistent postpartum haemorrhage after failed arterial ligation and to identify the complications of this procedure in this specific population. The clinical files and angiographic examinations of 12 consecutive women (mean age 32 years) who were treated with pelvic embolisation because of persistent, severe postpartum haemorrhage after failed arterial ligation were reviewed. Angiography revealed that persistent bleeding was due to incomplete arterial ligation (n = 4) or the presence of newly developed anastomotic routes (n = 8). In 11 women, pelvic embolisation stopped the bleeding. Hysterectomy was needed in one woman with retained placenta. Two complications due to pelvic embolisation, including leg ischaemia and transient sciatic nerve ischaemia, were identified, both after internal iliac artery ligation. In women with persistent postpartum haemorrhage after failed arterial ligation, pelvic embolisation is an effective treatment in most cases. However, embolisation of the anastomotic routes that contribute to persistent bleeding may result in ischaemic complications. These potential complications reaffirm that arterial ligation should not be the favoured option for postpartum haemorrhage and that special care must be given during pelvic embolisation after failed arterial ligation.

Incidence and management of postpartum haemorrhage following the dissemination of guidelines in a network of 16 maternity units in France

Background In France obstetric haemorrhage is the leading cause of maternal death. The aim of this study was to evaluate if the management of postpartum haemorrhage at individual maternity units followed guidelines established by the Aurore Network. Methods A descriptive study was carried out in 16 maternity units of the Aurore network between October 2004 and September 2005. Cases and data were prospectively identified and collected. Results Postpartum haemorrhage occurred in 1144 of 21 350 deliveries, an overall incidence of 5.4 ± 0.3%. Of these, 316 cases were rated as severe. Diagnosis was clinical in 82.5% of severe cases and 77.5% of non-severe cases; the remainder were detected by postpartum laboratory tests. Uterotonic agents were given prophylactically to 46.7% of the 896 patients following vaginal delivery. In cases in which postpartum haemorrhage was due to uterine atony, 83.1% of women underwent examination of the uterine cavity and 96.3% received oxytocin, which proved therapeutic. Sulprostone was administered to 39.5% cases of persistent postpartum haemorrhage. A uterotonic was given prophylactically to 85.4% of the 247 patients at caesarean delivery. Oxytocin was therapeutic in 94.8% of cases of uterine atony. Sulprostone was administered in 84.4% of cases of persistent postpartum haemorrhage. Conclusion The regional guidelines issued by the Aurore network were only partially followed. More effective guideline dissemination and implementation is required to improve the prevention and management of confirmed haemorrhage.

Why stepwise uterine devascularization should be the first‐line conservative surgical treatment to control severe postpartum hemorrhage?

Sir, We thank Dr. Doumouchtsis and colleagues for their interest in our study, and for pursuing the debate regarding what to do when medical treatment fails 1. The main message of our work was that...

B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

Persistent Secondary Postpartum Hemorrhage after Uterine Artery Embolization

with involvement of hepatic and superior mesenteric arteries. Radiology 1999; 212:359–364. 4. Donmez H, Men S, Dilli A, Soylu SO, Hekimoglu B. Giant gastroduodenal artery pseudoaneurysm due to polyarteritis nodosa as a cause of obstructive jaundice: imaging findings and coil embolization results. Cardiovasc Intervent Radiol 2005; 28:850–853. 5. Nakashima M, Suzuki K, Okada M, Takada K, Kobayashi H, Hama Y. Successful coil embolization of a ruptured hepatic aneurysm in a patient with polyarteritis nodosa accompanied by angioimmunoblastic T cell lymphoma. Clin Rheumatol 2007; 26:1362–1364.

Fertility after B-Lynch suture and stepwise uterine devascularization

To report the obstetric outcome in a patient who had previously undergone a stepwise uterine devascularization followed by a B-Lynch suture for severe postpartum hemorrhage (PPH). Case report. University hospital. A 29-year-old woman whose first pregnancy was complicated by severe PPH due to uterine atony. Stepwise uterine devascularization followed by a B-Lynch suture because of persistent PPH. Preservation of reproductive capacity. Two years later, the patient conceived spontaneously and delivered a healthy infant by caesarean section after an uneventful pregnancy. During the operation, the uterus showed no marks of the former B-Lynch suture. This is the first reported case of obstetric outcome after stepwise uterine devascularization and B-Lynch suture. Further case series with mid- and long-term follow-up are required to determine whether the B-Lynch suture has an impact on the patient's subsequent fertility and pregnancies and to establish its place in the PPH surgical management algorithm.

B‐Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

To estimate the effectiveness and safety of the B-Lynch suture for severe persistent postpartum hemorrhage (PPH) following vessel ligation before considering hysterectomy and its impact on menstruation and uterine cavity. Cohort study. University-affiliated tertiary referral center. Population. Fifteen consecutive women who underwent B-Lynch suture for persistent PPH despite vessel ligation. Data were retrieved from medical files and telephone interviews. Hysterectomy, infection, hysteroscopy, future menstruations. In 13 of the 15 cases (86.7%), PPH occurred after cesarean deliveries. B-Lynch sutures controlled the hemorrhage and resulted in an avoidance of immediate hysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for 14 of 15 women (93.3%). In one case hysterectomy was required due to pyometra in an ischemic uterus. In the remaining 11 women where the uterus was preserved, ambulatory hysteroscopy was normal. No women reported any differences in menses or pain compared to that they experienced before pregnancy, or any clinical symptoms of early menopause. One woman reported a subsequent pregnancy with normal conception delay, whereas the ten remaining women had no desired pregnancy due to, in each case, the fear of PPH recurrence. B-Lynch technique appears to be an effective procedure with a relatively low morbidity to control persistent severe PPH following a failure of vessel ligation before considering hysterectomy.

Successful management by recombinant activated factor VII in a case of disseminated intravascular coagulopathy caused by obstetric hemorrhage

Postpartum hemorrhage (PPH) is a life-threatening emergency in obstetrics. Although recombinant activated factor VII (rFVIIa) has become used for the treatment of some cases of massive hemorrhage, its applications in the field of obstetrics are still limited. We describe a case of successful treatment with rFVIIa for PPH due to placenta accreta. The patient was a 33-year-old woman with placental previa. Cesarean section (CS) was performed at gestational week 35. During CS, there was massive hemorrhage due to placenta accreta. After CS, disseminated intravascular coagulopathy and hypovolemic shock were diagnosed. The PPH was not controlled by transfusion therapy. On the fourth day after CS, rFVIIa (90 microg/kg x 2) was given because of the persistent PPH. Bleeding decreased and no further transfusion was required from 2 days after administration. rFVIIa was useful in the treatment of this case of obstetric hemorrhage.

Uterine Rupture due to Traumatic Assisted Fundal Pressure

Uterine rupture is potentially a life-threatening condition for both mother and infant. In this article, we report a rare occurrence of uterine rupture due to traumatic assisted fundal pressure associated with hydrops fetalis and shoulder dystocia. A 29-year-old woman was admitted for termination of pregnancy at 34 weeks' gestation because of fetal hydrops. Assisted uterine fundal pressure was done during delivery because of coexistent shoulder dystocia. After a series of assisted uterine fundal pressure, a dead hydropic baby weighing 4,000 g was delivered, and persistent postpartum hemorrhage occurred. An emergency laparotomy was performed, which revealed a large left broad ligament hematoma with multiple bleeding points. The bleeders were safely sutured and the tears of the left lateral uterine wall were primarily restored. The patient was discharged 8 days later. Assisted fundal pressure during painful delivery can be traumatic and results in uterine rupture. In this article, we suggest that uterine rupture should be considered whenever a pregnant woman experiences a sudden onset of abdominal pain during the course of assisted uterine fundal pressure.

Arterial embolization for haemorrhage in the obstetric patient

Arterial embolization is a safe and effective treatment for persistent post-partum haemorrhage that is unresponsive to conservative management. Embolization should be the treatment of choice in these patients provided that suitable radiological skills and equipment are available. Embolization is potentially useful in patients with antepartum haemorrhage in the last trimester or in patients at high risk for antepartum haemorrhage.

Role of the interventional radiologist in treating obstetric-gynecologic pathology.

1273 n recent years, the transcatheter and percutaneous techniques of interventional radiology have been applied to the diseases of various organ systems, including the female pelvis. Through development of new procedures and refinement of standard techniques, the interventional radiologist can now offer many services to the obstetrician– gynecologist. These include assistance in the treatment of vascular and nonvascular diseases. From a vascular standpoint, substantial attention has been given recently to the nonsurgical treatment of uterine fibroids by uterine artery embolization and, to a lesser extent, to treating “pelvic congestion syndrome” by ovarian vein embolization. Embolization was also used for many years to treat persistent postpartum hemorrhage and bleeding complications after surgery. On the side of nonvascular interventions, fallopian tube recanalization and transvaginal drainage and biopsy are well-established procedures. More recently, percutaneous treatment of tuboovarian abscesses and uterine fluid collections has received some attention in the literature, in addition to stent placement for malignant cervical strictures [1–3].

Uterine myomas in pregnancy: Two case reports

Myomas are the most common type of benign pelvic tumor in women. It is estimated that they occur in 20–25% of women of reproductive ages. The incidence during pregnancy has been found to range from 0.3–2.6%. Myomas seldom cause problems during pregnancy but they do require appropriate evaluation and anticipatory management. The outcome of pregnancies complicated by myomas is directly related to their size and the location of the myoma in relationship to the placental site. Two case studies are presented of two women who had large myomas. A hysterectomy was required due to persistent postpartum hemorrhage in one, while the other experienced a normal course of labor and delivery.

Control of Persistent Primary Postpartum Hemorrhage due to Uterine Atony with Intravenous Prostaglandin E2. Case Report

Henson, G.; Gough, J. D.; Gillmer, M. D. G.; Hodgkinson, Robert M.D. Author Information

Complications of pregnancy and labor in former oral contraceptive users

Complications of pregnancy and delivery, and obstetric interventions, were studied in a sample of Israeli women questioned post-partum about contraceptive use. The 2,953 women who had used the pill were compared with 13,630 controls. There were no significant differences between users and controls in the frequencies of bleeding in pregnancy, premature rupture of membranes, placenta previa, placental abruption, fetal distress or asphyxia, ABO incompatibility, hydramnios, transverse lie, cephalopelvic disproportion, and persistent occipitoposterior or post-partum hemorrhage. New cases of hypertension, varicose veins, thrombophlebitis, urinary tract infection, and cervicitis were reported in primigravidae and multigravidae without past histories of these conditions; there were no differences between oral contraceptive users and controls other than an excess of cervicitis in primigravidae among former users. There was a slight decrease in normal deliveries in former oral contraceptive users due to an increase in inductions of labor. On the other hand, rates of forceps and vacuum deliveries, caesarian sections, and interventions in the third stage did not differ between former oral contraceptive users and controls. These results indicate that former oral contraceptive users can anticipate the same frequency of complications of pregnancy and labor as women who have used other, or no, methods of contraception.