Surgical Management Of Postpartum Hemorrhage Research Articles

The uterine tourniquet, a simple maneuver that may facilitate surgical management of postpartum hemorrhage.

SynopsisThe uterine tourniquet is a temporary intervention that facilitates the application of other procedures for definitive control of postpartum hemorrhage.

Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage

Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports. Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories. This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals. Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68). Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.

Surgical Management of Postpartum Hemorrhage at Cocody University Hospital in the De Facto Capital City of Ivory Coast

Surgical Management of Postpartum Hemorrhage at Cocody University Hospital in the De Facto Capital City of Ivory Coast

A RETROSPECTIVE STUDY OF OUR NINE YEARS OF EXPERIENCE WITH ABNORMAL PLACENTATION — RISK FACTORS AND PREGNANCY OUTCOMES

Purpose: Placenta previa and morbidly adherent placenta are life-threatening conditions that necessitate close monitoring during pregnancy and can result in increased ante- and intrapartum complications. This study aims to evaluate the frequency of placental disorders in our population, reveal the impact of the known risk factors on maternal morbidity, and study new predisposing conditions and their effects on pregnancy outcomes. Materials and Methods: We performed a single-centered retrospective study in which we analyzed 330 women diagnosed with abnormal placentation—placenta previa and placenta accreta spectrum (PAS). We included all the women that gave birth at Nadezhda Hospital, from March 2013 to August 2021. We processed the data using the chi-square test, Cramer's V test, and cross-section analysis. Results: The frequency of placenta previa in our population is higher than the worldwide reported data. We were unable to demonstrate the connection between previous uterine manipulations (c-section, D&amp;C, operative hysteroscopy, etc.) and the occurrence of higher-grade placenta previa in our population. However, the more surgeries performed, the more complications during pregnancy and delivery occur (antepartum bleeding, increased blood loss, surgical management of postpartum hemorrhage, peripartum hysterectomy). Pregnancies following assisted reproductive techniques (ART) are at a three-times higher risk of placenta previa. Endometriosis determines a greater risk of developing an abnormally adherent placenta. Conclusion: More prospective studies need to be performed to define the exact risk factors for abnormal placentation that affect the Bulgarian population. A better understanding of the condition will lead to better management of higher-risk pregnancies, thus reducing maternal and fetal morbidity.

Analysis of surgical management of postpartum hemorrhage: At tertiary centre

Postpartum hemorrhage (PPH) is one of the leading cause of maternal morbidity and mortality. Major blood loss of over 1000ml of blood occurs in 1-5% of deliveries. WHO statistics suggest that 25% of maternal deaths are due to PPH, accounting for more than 1,00,000 maternal deaths annually.2 Internal Iliac Artery Ligation (IIAL) is effective method to control intractable PPH and prevent maternal mortality. In our R.L. Jalappa hospital, a tertiary referral centre, we did a retrospective study of patients who are managed for PPH between Jan 2006- Jan 2016. In our study, out of 110 PPH patients eighty of them underwent IIAL during the study period. Out of 80 IIAL cases, PPH due to uterine atony (55%), uterine rupture (23%), placenta previa (8%), placental abruption (6%), placenta increta (4%) and broad ligament hematoma (4%). Medical management was successful in 30 cases. Hysterectomy was done in 6 cases. IIAL was proved to be successful method of controlling hemorrhage in our study. We found that this is one of the best surgical method of management of PPH, so as to retain uterus thereby future fertility. Keywords: Postpartum hemorrhage (PPH), Internal iliac artery ligation (IIAL).

Surgical management of postpartum hemorrhage.

Surgical management of postpartum hemorrhage.

Emergency surgical obstetrics simulation training: an ex vivo low-cost model using bovine uterus and porcine bladder for haemostatic uterine brace suture techniques

Postpartum haemorrhage remains a leading cause of maternal mortality and morbidity. While conventional obstetrics training curricula describe at length the management of postpartum haemorrhage, obstetrics trainees rarely have exposure to...

A Low-Cost Trainer for the Surgical Management of Postpartum Hemorrhage.

Simulation-based training to manage surgical postpartum hemorrhage allows for improved preparation for these rarely needed life-saving procedures. Our objectives were to design a low-tech simulation model for use in training and evaluation of surgical techniques for the management of postpartum hemorrhage and to present evidence of its validity in assessment and training. Fifty-two obstetrics and gynecology residents and 25 attending physicians from an academic hospital were video recorded while performing the O'Leary and B-Lynch techniques on the low-tech model. Performance was evaluated using a Technical Skills Checklist, for B-Lynch and O'Leary techniques, and the Reznick's Global Rating Scale. Interrater reliability was computed to assess the consistency of the ratings between 2 raters. Average scores were determined and compared between incoming residents, junior residents, senior residents, and attending physicians to show construct validity. For the B-Lynch, Technical Skills Checklist scores (maximum 17 points) of attendings (15.04) and senior residents (15.12) were higher than those of junior residents (5.63) and new residents (3.38). Global Rating Scale scores (maximum 25 points) on the B-Lynch reflected the same increase (22.38, 19.35 vs. 8.85, 6.75, respectively). For the O'Leary stitch, the scores of attendings, senior, junior, and incoming residents were as follows: 15.20, 13.65, 11.54, and 2.83, respectively (maximum 19 points). This supports the construct validity of the model. The model was considered realistic and useful for improving surgical skills in 71.4% of participants. This low-cost, easily constructed model is a useful tool for training these surgical skills.

Management of the third stage of labour: (for the Optimal Intrapartum Care series edited by Mercedes Bonet, Femi Oladapo and Metin Gülmezoglu).

The physiology of the third stage of labour is described. Active management reduces the risk of postpartum haemorrhage (PPH), due to the use of a uterotonic agent. Intramuscular Oxytocin 10 IU has the highest efficacy and lowest side effect profile, although ergometrine, carbetocin and misoprostol are also effective. The appropriate uterotonic in different settings such as home birth by unskilled attendants and at caesarean section is discussed. For the latter, there is less consensus on the optimal dose/route of oxytocin, this topic remaining on the research agenda. Delayed cord clamping enables transfusion of blood to the neonate and is recommended rather than early clamping. Controlled cord traction should only be performed by skilled birth attendants and confers minimal advantage in preventing retained placenta. The importance of early recognition of PPH, and preparedness, is emphasised. An approach to medical and surgical management of PPH is presented.

Training for the surgical management of postpartum hemorrhage: a multicenter survey of resident physicians

Background To actively address maternal morbidity and mortality in Mexico, proficiency among obstetrics and gynecology (OBGYN) residents in the surgical management of postpartum hemorrhage (PPH) is a priority. However, the capacity of programs to provide this training is unknown. Objective The self-reported knowledge, education, and proficiency of common surgical techniques for the management of PPH among OBGYN residents in Mexico was evaluated. Educational resources, perceived barriers to acquiring skills, and clinical decision-making were explored. Materials and methods In July of 2018, an anonymous electronic survey was sent to 86 residents at four hospitals throughout Mexico. Surgical techniques queried included uterine tamponade (UT), uterine compression sutures (UCS), uterine devascularization (UD), hypogastric artery ligation (HAL), and gravid hysterectomy (HT). Participants also answered case-based questions about a patient with PPH. Results The survey response rate was 59.3% (51/86). Seventy-nine percent of residents reported understanding the rationale and techniques for the surgical intervention of PPH. However, 43.9% reported limited ability to perform these procedures with autonomy. Eighty-six percent of residents reported exposure to these techniques while performing a rescue procedure during PPH and 49% reported learning these procedures while performing prophylactic techniques in patients without PPH. Only 25.5% had been exposed to simulation training. Lack of a training module for these skills in their curriculum was noted by 74.5%. The majority of the participants chose UCS, UD, HAL, and HT as the first, second, third, and fourth rescue procedures to perform for PPH, respectively. Conclusion Most residents reported theoretical knowledge of surgical interventions for PPH, but their self-rated ability to independently perform such skills and a curriculum focused on PPH management was suboptimal.

Using a structured assessment of technical skills checklist for surgical management of postpartum hemorrhage

BACKGROUND: Maternal hemorrhage during cesarean sections can often beidentified and managed surgically with use of the B-Lynch compression suture, andO’Leary (bilateral uterine artery ligation) stitch. Residents may improve their performanceof these procedures using a technical skills checklist with global rating scale.OBJECTIVE: To assess the reliability and validity of a technical skills checklist forthe B-Lynch Suture and O’Leary Stitch using a surgical model.METHODS: Two blinded evaluators reviewed the recordings of 52 obstetrics/gynecology residents and 25 attending physicians performing the simulated BLynchand O’Leary Stitch using a felt uterus model from March 1 2017 to August 31,2017. The evaluators completed task-specific OSATS and global rating scales (GRS)for the two simulations. Interrater reliability and construct validity were assessed.RESULTS: Interrater reliability was 97% for task-specific OSATS (task specificchecklist, TSC) and exceeded 98% for GRS. For construct validity regarding B-Lynchsimulation, attending physicians and senior residents scored higher than junior andnew residents; TSC (15.04 and 15.12, respectively vs. 5.63 and 3.38); GRS B-Lynch(22.38 and 19.35, respectively vs. 8.85 and 6.75. For the O’ Leary simulation, seniorresidents and attending physicians scored higher than junior and new resident on TSC(15.20 and 13.65, respectively, vs. 11.54 and 2.83). Similar findings noted for O’LearyGRS (23.76 and 21.32 vs. 14.89 and 6.83).CONCLUSION: There was good interrater reliability and construct validity using atask-specific OSATS for B-Lynch and O’Leary Stitch. This instrument shows promiseas a tool for competency-based evaluations.Key words: Assessment of skills for postpartum hemorrhage

Uterus preserving surgery versus hysterectomy in the treatment of refractory postpartum haemorrhage in two tertiary maternity units in Cameroon: a cohort analysis of perioperative outcomes

BackgroundLittle evidence exists on the efficacy and safety of the different surgical techniques used in the treatment of postpartum haemorrhage (PPH). We aimed to compare uterus preserving surgery (UPS) versus hysterectomy for refractory PPH in terms of perioperative outcomes in a sub-Saharan African country with a known high maternal mortality ratio due to PPH.MethodsThis was a retrospective cohort study comparing the perioperative outcomes of all women managed by UPS (defined as surgical interventions geared at achieving haemostasis while conserving the uterus) versus hysterectomy (defined as surgical resection of the uterus to achieve haemostasis) for PPH refractory to standard medical management in two tertiary hospitals in Cameroon from January 2004 to December 2014. We excluded patients who underwent hysterectomy after failure of UPS. Comparison was done using the Chi-square test or Fisher exact test where appropriate. Bonferroni adjustment of the p-value was performed in order to reduce the chance of obtaining false-positive results.ResultsWe included 24 cases of UPS against 36 cases of hysterectomy. The indications of surgery were dominated by uterine rupture and uterine atony in both groups. Types of UPS performed were seven bilateral hypogastric artery ligations, seven hysterorraphies, six bilateral uterine artery ligations, three B-Lynch sutures and one Tsirulnikov triple ligation with an overall uterine salvage rate of 83.3%. Types of hysterectomies were 26 subtotal hysterectomies and 10 total hysterectomies. UPS was associated with maternal deaths (RR: 2.3; 95% CI: 1.38–3.93.; p: 0.0015) and postoperative infections (RR: 1.96; 95% CI: 1.1–3.49; p: 0.0215). The association of UPS with maternal death was not attenuated after Bonferroni correction. Hysterectomy had no statistically significant adverse outcome.ConclusionHysterectomy is safer than UPS in the management of intractable PPH in our setting. The choice of UPS as first-line surgical management of PPH in resource-limited settings should entail diligent anticipation of these adverse maternal outcomes in order to lessen the perioperative burden of PPH.

Surgical management of postpartum haemorrhage: survey of French obstetricians.

The aim of our study was to assess the theoretical and practical knowledge of French obstetricians about the surgical management of postpartum haemorrhage (PPH). Our study is a national anonymous self-administered survey. A total of 363 obstetricians responded to this questionnaire between December 2013 and April 2014. Questionnaire sent through email to all French obstetricians who are members of either of two federations of hospital-based obstetricians. Answers were collected until the end of June 2014. The main outcome measure was obstetricians’ level of mastery of each surgical technique. The results were analysed descriptively (proportions). Only the 286 questionnaires fully completed were analysed; the complete response rate was 23% (286/1246). In all, 33% (95/286) of the responding obstetricians reported that they had not mastered sufficiently or even at all the technique for bilateral ligation of the uterine arteries, 37% (105/286) for uterine compression suture, 62% (178/286) for ligation of the internal iliac arteries, and 47% (134/286) for emergency peripartum hysterectomy. In all, 18% (52/286) of respondents stated that they had not mastered any of these techniques. Our study shows that a worrisome number of French obstetricians reported insufficient mastery of the surgical techniques for PPH management.

Medical and Surgical Management of Postpartum Hemorrhage in a Woman with Factor XIII Deficiency

Factor XIII deficiency is a rare inherited coagulopathy. Factor XIII is the last clotting factor in the coagulation cascade to insure strength and stability to fibrin clots. Without this enzyme, the fibrous clot is unstable and nonresistant to fibrinolysis. Gravid women with this congenital disease are especially at risk for complications including miscarriages and hemorrhage without appropriate interventions. We present a case of a woman in her 20s with Factor XIII deficiency who was treated with cryoprecipitate and had a successful normal spontaneous vaginal delivery; subsequently, patient suffered from postpartum hemorrhage and consumptive coagulopathy due to consumption of Factor XIII, requiring emergency surgical intervention. Intraoperative management was challenged by an ethical dilemma involving the patient's religious beliefs about not receiving blood. This paper will discuss the mechanism of Factor XIII and the medical and surgical management involved with this patient.

Knowledge of the B-Lynch Brace Suture Technique Among Obstetrics and Gynecology Resident Physicians

Abstract Background: The B-Lynch brace suture is invaluable in the surgical management of postpartum hemorrhage, particularly as a fertility-sparing alternative to hysterectomy. Objective: The aim of this research was to investigate knowledge patterns of the B-Lynch brace suture technique among obstetrics–gynecology resident physicians. Materials and Methods: A short anonymous and voluntary survey was administered to obstetrics–gynecology resident physicians from various university-affiliated and community residency programs located in the northeastern United States. The questions were designed to help assess a resident physician's knowledge about the technique and intraoperative application of the B-Lynch brace suture. Resident physician responses were compared by postgraduate year (PGY) level. Chi-square (χ2) and Fisher's exact tests were used when appropriate. Statistical significance was set at p<0.05. Results: Seventy (58.3%) of 120 resident physicians completed the survey. Of these, 17 (24.3%) revea...

Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review

Uterine-sparing surgical interventions have long been practiced as an alternative to hysterectomy in the management of severe postpartum haemorrhage (PPH); however, the risks of impairment of subsequent fertility from such procedures are unclear. To evaluate the menstrual and fertility outcomes following radiological or conservative surgical interventions for severe PPH. A systematic review of English and non-English articles using the Cochrane Library 2012, PubMed (1950-2012), Embase (1980-2012), and the National Research Register. The keywords used for our search included 'fertility', 'reproductive outcome', 'postpartum haemorrhage', 'embolisation', 'hypogastric artery ligation', 'B-Lynch suture', 'stepwise uterine devascularisation', 'tamponade', and 'uterine compression sutures'. Studies including human female subjects with at least five cases. Independent extraction of articles by two authors using predefined data fields, including study quality indicators. We identified 402 publications and after exclusions, 28 studies were included in the systematic review. Seventeen studies (675 women) reported on the fertility outcomes after uterine artery embolisation, five studies (195 women) reported on the fertility outcomes after uterine devascularisation, and six studies (125 women) reported on the fertility outcomes following uterine compression sutures. Overall, 553 out of 606 (91.25%) women resumed menstruation within 6months of delivery. One hundred and eighty-three out of 235 (77.87%) women who desired another pregnancy achieved conception. Uterine-sparing radiological and surgical techniques for the management of severe PPH do not appear to adversely affect the menstrual and fertility outcomes in most women; however, the number of studies and the quality of the available evidence is of concern.

A tool for teaching the B-Lynch brace suture method: An inexpensive new simulator allows obstetricians to polish an essential technique

The B-Lynch brace suture is invaluable in the surgical management of postpartum hemorrhage, particularly as a fertility-sparing alternative to hysterectomy. In this video, we show how to create a low-cost simulator to teach the B-Lynch brace suture technique, followed by the intraoperative application of the same technique.

A curriculum to teach and evaluate resident skills in the management of postpartum hemorrhage

The aim of this study was the development of a curriculum for the management of postpartum hemorrhage and an objective assessment of technical skills (OSATS) for uterine compression sutures. Twenty-two residents participated in the study. Evaluations included the global rating scale, task-specific checklist, and pass/fail rating for the OSATS and task-specific checklist for the hemorrhage drill. The reliability and validity of the evaluation tools were calculated. The inter-rater reliability was 0.98 for the hemorrhage drill checklist, 0.77 for the global rating scale, and 0.93 for the uterine suture checklist. Construct validity evaluation revealed senior residents performed superiorly to junior residents on the global rating scale (P=0.006) and on the uterine suture checklist (P=0.04). There was an improvement in performance on the post-test in comparison to the pretest (P=0.001). We present an inexpensive, reliable, and valid curriculum to teach and evaluate the medical and surgical management of postpartum hemorrhage.

Uterine-sparing surgical management of postpartum hemorrhage: is it always effective?

To further study the efficacy of uterine-sparing procedures based on triple uterine artery ligation (TUAL) possibly complemented with hemostatic multiple square suturing (HMSS) for the management of post-partum hemorrhage (PPH). Cases of PPH occurring during cesarean section and treated, according to our institution guidelines, by TUAL possibly complemented with HMSS between 2000 and 2009 were retrospectively analyzed. Fifty-six patients were included; 13 (23.2%) had TUAL only, while 43 (76.8%) had additional HMSS performed. Surgical conservative management of PPH was effective in 51 (91.1%) cases. PPH due to placenta accreta, either unanticipated or after failure of conservative management, showed an independent and significant impact on the risk of failure of the procedure (AOR 15.07, 95% CI 1.12-201.9, p = 0.041). Obstetricians should be aware that a higher risk of failure of the procedure is to be expected in cases of PPH due to placenta accreta. In such situation, to avoid any useless delay in management, our findings suggest that peripartum hysterectomy should be immediately considered.

Editorial

Editorial