Treatment Of Severe Postpartum Hemorrhage Research Articles

Resuscitative efficacy of hemoglobin vesicles for severe postpartum hemorrhage in pregnant rabbits

We aimed to investigate the resuscitative efficacy of hemoglobin vesicles (HbVs) as a red blood cell (RBC) substitute for the initial treatment of severe postpartum hemorrhage (PPH). Twenty-five pregnant rabbits underwent cesarean section; uncontrolled hemorrhage was induced by transecting the right uterine artery to establish a severe PPH model. During the first 30 min, all rabbits were administered 6% hydroxyethyl starch (HES) of an equivalent volume to the hemorrhage every 5 min. Thereafter, they received any of the following three isovolemic fluids for resuscitation every 5 min: RBCs with platelet-poor plasma (RBC/PPP) (n = 8), 6% HES (n = 7), or HbVs with 25% human serum albumin (n = 10). After surgical hemostasis at 60 min, survival was monitored until 12 h. No rabbits receiving only HES infusion survived beyond 6 h, whereas all rabbits receiving RBC/PPP transfusion survived. The rabbits receiving HbV infusion showed significantly higher mean arterial pressure and hemoglobin levels than the HES-receiving rabbits, and 8 of 10 rabbits survived for 6 h. The HbV group showed significantly higher survival than the HES group but worse survival than the RBC/PPP group. In conclusion, HbV infusion for severe PPH effectively prevents lethal hemorrhagic shock in a pregnant rabbit model.

Shock parameters and shock index during severe post-partum haemorrhage and implications for management: a clinical study

The aim of this study was to report the association between shock severity, laboratory parameters and treatment in patients with severe post-partum haemorrhage (PPH) requiring the transfusion of ≥4 blood unit. Patients were divided into two groups: (1) conservative therapy and (2) emergency post-partum hysterectomy. The aggressive decision was always shared by two consultants. Out of 26,094 deliveries, severe PPH occurred in 34 (0.13%) women, emergency post-partum hysterectomy was required in 13 (0.05%), while 21 (0.08%) were treated conservatively. Grade of shock, shock index (SI) and the number of blood units transfused were significantly higher in the hysterectomy group. No statistically significant difference among the two groups was observed for haemoglobin and coagulation results. The severity of shock was associated with the therapeutic choice in the treatment of severe PPH. Therefore, grade of shock and SI should be taken into consideration by the leading obstetrician in the decision making process toward the emergency hysterectomy.Impact StatementWhat is already known on this subject? Primary post-partum haemorrhage (PPH) is the leading cause of maternal death in developing and industrialised countries. Emergency post-partum hysterectomy is considered a life-saving procedure performed when the women is experiencing a life-threatening haemorrhage.What the results of this study add? Therapeutic dichotomy between conservative and aggressive approach in severe PPH has not been defined, in particular emergency post-partum hysterectomy timing. Shock index (SI) has been proposed as an indicator of adverse maternal outcome. However, the association between shock parameters and advanced treatment modalities has not yet been reported. In our study, grade of shock, SI and the number of blood units transfused were significantly higher in the patients which needed hysterectomy suggesting that it may have a role in the decision making among conservative and aggressive treatment. No statistically significant difference was observed for haemoglobin and coagulation results.What the implications are of these findings for clinical practice and/or further research? Grade of shock and SI should be taken into consideration in the decision making process toward the emergency hysterectomy in severe PPH. The choice between conservative and aggressive treatment should be based on hemodynamic parameters that may represent, in more accurate way, the severity of blood loss. Nevertheless, these data need further confirmation in a larger study.

Emergency Peripartum Hysterectomy

Uterine atony is a major cause of postpartum hemorrhage (PPH), an emergency event that remains one of the leading causes of maternal morbidity and mortality worldwide. This study reviews a case of severe atonic PPH after a primary cesarean, which resulted in an emergency peripartum hysterectomy. In the United States, prevalence studies have revealed a peripartum hysterectomy rate of almost 1 per 1,000 births. Multidisciplinary collaboration using effective communication is needed when responding to the severity of Stage 3 PPH. A 28-year-old woman, gravida 3 para 0, at 40.0-weeks gestation arrived at the labor and delivery unit in active labor. During labor, she received oxytocin augmentation and an epidural. Cervical dilation progressed slowly, with the patient remaining at 9.5 cm for 5 hr. On complete dilation, the patient pushed for 1.5 hr before the decision was made to proceed with a cesarean due to failure of the fetus to descend and maternal exhaustion. After the successful birth of a 4,042-g newborn by cesarean, persistent uterine atony developed. Interventions were then enacted, guided by the California Maternal Quality Care Collaborative Obstetric Emergency Management Plan. Additional staff arrived in operating room to provide support. Multidisciplinary teamwork was achieved through use of effective communication techniques, including situation–background–assessment–recommendation and closed-loop communication. Pharmacologic interventions included the use of oxytocin, misoprostol, methylergometrine maleate (×2), and carboprost tromethamine (×2). Procedural interventions by the physician included bimanual uterine massage, uterine packing, B-Lynch suture, and intrauterine balloon tamponade. Maternal hypotension and tachycardia developed, leading to the initiation of the massive transfusion guidelines. Despite interventions, severe uterine atony and brisk vaginal bleeding continued, resulting in a total quantitative blood loss of 4 L. The decision was made to proceed with an emergency peripartum hysterectomy. Postpartum emotional support was provided by a multidisciplinary team that included nursing, physician, chaplain, and social services. The mother and her newborn were discharged home on Postoperative Day 4. This case study demonstrates the success of quickly initiated PPH protocol interventions that are necessary to prevent maternal mortality and knowing the current literature on risk identification, management, and treatment of severe PPH.

A novel tamponade agent for management of post partum hemorrhage: adaptation of the Xstat mini-sponge applicator for obstetric use

BackgroundAlthough uterine tamponade is an effective treatment for postpartum hemorrhage (PPH), current methods have key limitations in their use, particularly in low resource settings. The XStat™ Mini Sponge Dressing (MSD) is approved for the management of non-compressible wounds in the battlefield/trauma setting. The MSD applies highly compressed medical sponges capable of stopping high-flow arterial bleeding within seconds. The objective of our study was to adopt the MSD for use in managing PPH.MethodsWe performed desktop testing using a uterine model with pressure sensors to compare key design elements of the obstetrical prototype MSD (fundal pressure achieved, reduction in fluid loss, time to deploy, and time to remove) with alternativetechniques (uterine packing, balloon tamponade). To evaluate safety, we delivered the fetus of pregnant ewes by cesarean section and used the prototype to deliver the MSD into one uterine horn, and closed the hysterotomy. We followed the clinical recovery of animals (n = 3) over 24 h, and then removed the reproductive tract for histologic evaluation. To evaluate late effects, we surgically removed the MSDs after 24 h, and followed the clinical recovery of animals (n = 6) for an additional seven days before tissue removal.ResultsThe obstetrical prototype has a long tapered delivery system designed to be deployed during vaginal examination, and administers three times the volume of the approved MSD trauma bandage. The MSD are deployed within a mesh bag to facilitate removal by vaginaltraction. On desktop testing, the MSD resulted in the highest average fundal pressure (113 mmHg), followed by the MSD bag device (85.8 mmHg), gauze packing (15.5 mmHg), and the uterine balloon (8.2 mmHg). The MSD bag test group achieved the largest fluid flow reduction of −74%, followed by gauze packing (−55%), MSD (−35%), and uterine balloon (−19%). Animal testing demonstrated good uterine fill with no evidence of adverse clinical recovery, uterine trauma or infection at 24 h, or up to 7 days following device removal.ConclusionWe adapted a highly effective trauma dressing and applicator for use in the treatment of severe PPH. Preliminary desktop and animal testing provide a basis for initial clinical trials in women.

UTERINE COMPRESSION SUTURES: A METHOD OF SURGICAL HAEMOSTASIS DURING CAESAREAN DELIVERY (HYSTEROSCOPIC ASSESSMENT)

Background: to assess the efficiency of uterine compression sutures in treatment of severe postpartum hemorrhage. Materials and methods: 55 patients who had been performed cesarean section from 2013 to 2015 were examined. The basic group included 25 patients with uterine compression sutures that had been performed to stop severe postpartum hemorrhage, the control group – 30 patients without severe postpartum hemorrhage. The main outcome measures were the ability to stop hemorrhage, complications of postpartum period and the assessment of the uterine cavity by hysteroscopy. Results: uterine compression sutures stopped postpartum hemorrhage in 19 of 25 cases (76%). None of the women developed postpartum period complications related to the procedure. Ten women underwent hysteroscopy after uterine compression sutures. Two women (20%) had ligature in the uterine cavity. Conclusion: Our results suggest that uterine compression sutures is an effective and safe treatment for postpartum haemorrhage.

Application of WHO ‘Near-Miss’ Tool Indicates Good Quality of Maternal Care in Rural Healthcare Setting in Uttarakhand, Northern India

Women who experienced and survived a severe health condition during pregnancy, childbirth or postpartum are considered as 'near-miss' or severe acute maternal morbidity (SAMM) cases. Women who survive life-threatening conditions arising from complications related to pregnancy and childbirth have many common aspects with those who die of such complications. To evaluate health-care facility preparedness and perfor-mance in reducing severe maternal out comes at all levels of health care. The present study was carried out over a period of 12 months under the Department of Community Medicine. The cross-sectional study included all the women (937) attending health-care facilities, at all levels of health care i.e. Primary, Secondary & Tertiary level in Doiwala block of Dehradun district. This study was conducted as per the WHO criteria for 'near-miss' by using probability sampling for random selection of health facilities. All eligible study subjects visiting health-care facilities during the study period were included, i.e. who were pregnant, in labour, or who had delivered or aborted up to 42 days ago. It was found that all women delivering at the THC received oxytocin to prevent postpartum haemorrhage. Treatment of severe post-partum haemorrhage by removal of retained products was significantly associated with levels of health care. Majority (94.73%) women who had eclampsia received magnesium sulfate as primary treatment. Application of WHO 'near-miss' tool indicates good quality of maternal care in rural healthcare setting in Uttarakhand, North India. The women would have otherwise died due to obstetrics complications, had proper care not been provided to them in time.

Interventional radiology for critical hemorrhage in obstetrics: Japanese Society of Interventional Radiology (JSIR) procedural guidelines.

There has been an increasing demand for interventional radiology (IR) procedures for the treatment of severe postpartum hemorrhage (PPH) (also called critical hemorrhage in obstetrics). The Japanese Society of Interventional Radiology Guideline Committee developed the practical guidelines for IR procedures for severe PPH using evidence-based methodology. This article aimed to describe the rationale for developing these guidelines and to provide the answers for clinical questions about IR procedures consisting of current available evidence and the consensus among experts.

Hemostatic changes in pregnancy

Normal pregnancy is associated with changes in all aspects of haemostasis, including increase in concentrations of most clotting factors, decreasing concentrations of some of the natural anticoagulants and diminishing fibrinolytic activity. These changes help in maintaining placental function during pregnancy but result in a state of hypercoagulability that may predispose to thrombosis and placental vascular complications. During pregnancy, the concentrations of coagulation factors V, VII, VIII, IX, X, XII and von Willebrand factor rise significantly, accompanied by a pronounced increase in fibrinogen levels which increases up to two-fold from non-pregnant levels. Furthermore, there is a decrease in physiological anticoagulants manifested by a significant reduction in protein S activity and by acquired activated protein C resistance. The overall fibrinolytic activity is impaired during pregnancy, but returns rapidly to normal following delivery. This is largely due to placental derived plasminogen activator inhibitor type 2 (PAI-2), which is present in substantial quantities during pregnancy. D-Dimer levels increase in pregnancy but are not thought to indicate intravascular coagulation as fibrinolysis is depressed. These D-Dimers may originate from the uterus. Finally, the platelet count decreases in normal pregnancy possibly due to increased destruction and haemodilution with a maximal decrease in the third trimester. Immediately after delivery there is an increase in platelet count, especially in patients undergoing cesarean section. During treatment of severe post-partum hemorrhage, it is absolutely essential to have the knowledge that the starting values of the platelets are very different as compared to a non-pregnant patient. Moreover, after delivery, also the levels of fibrinogen increase. Since the value of fibrinogen represents a crucial parameter for the management of acute bleeding, it is essential to administer the proper amount of fibrinogen in the case of postpartum hemorrhage. This aspect is emphasized especially in relation to the use of thromboelastography and for a correct interpretation of the results. Thromboelastogram profiles strongly depend on the amount of platelets and fibrinogen in whole blood. Protocols for thromboelastogram guided administration of hemocomponents and coagulation factor concentrates in cases of acute bleeding in pregnancy and post-partum are required.

Temporary treatment of severe postpartum hemorrhage

International Journal of Gynecology & ObstetricsVolume 118, Issue 3 p. 253-254 Brief communications Temporary treatment of severe postpartum hemorrhage Michael Breen, Corresponding Author Michael Breen mpmbreen@gmail.com Monze Mission Hospital, Monze, ZambiaP.O. Box 660029 Monze Hospital, Monze, Zambia. Tel.: + 260 977872854.Search for more papers by this author Michael Breen, Corresponding Author Michael Breen mpmbreen@gmail.com Monze Mission Hospital, Monze, ZambiaP.O. Box 660029 Monze Hospital, Monze, Zambia. Tel.: + 260 977872854.Search for more papers by this author First published: 11 July 2012 https://doi.org/10.1016/j.ijgo.2012.04.008Citations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume118, Issue3September 2012Pages 253-254 RelatedInformation

The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage

The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage

Desmopressin-induced Moschcowitz-like syndrome after treatment of uterine atonic bleeding in a 28-year-old pregnant woman

Here we report of a patient who developed a Moschcowitz-like syndrome following a desmopressin treatment of severe postpartum hemorrhage. The patient got an anaphylactic reaction after cervical ripening with dinoproston, leading to an emergency cesarean. A postpartum uterine atony with a blood loss more than 1500 ml resulted in a disseminated intravascular coagulation that was treated with mass transfusion of blood products, including platelets and factor VII. Desmopressin is used as rescue medication in situations of severe bleeding. It was given in this life-threatening situation and presumably triggered a Moschcowitz-like syndrome. Desmopressin exerts its haemostatic effect by releasing von Willebrand factor, which is elevated in pregnancy per se. This results in an increased risk of developing microthrombi, leading to a Moschcowitz-like syndrome. In conclusion, desmopressin should not be administered in pregnant patients owing to its potential risk of triggering the development of thrombotic-thrombocytopenic purpura.

Balloon tamponade during cesarean section is useful for severe post‐partum hemorrhage due to placenta previa

Severe post-partum hemorrhage during cesarean section due to placenta previa is still one of the leading causes of maternal mortality. The aim of this study was to evaluate the efficiency of intrauterine tamponade with a Sengstaken-Blakemore tube (SB-tube) for the treatment of severe post-partum hemorrhage in cases of placenta previa. Data were collected from our departmental clinical records on all patients who underwent caesarian section due to placenta previa between 2007 and 2009. During the period analyzed, 37 patients underwent caesarian section due to placenta previa/low-lying placenta. Four (11%) underwent hysterectomy due to placenta accreta and 33 (89%) were treated conservatively. Of the 33 patients with conserved uterus, 10 (28%) patients required a SB-tube during the cesarean section because of continuous post-partum hemorrhage despite appropriate medical treatment. The median bleeding during the operation was 2030±860mL in the patients who used SB-tube. None of them presented severe complications related to these procedures or required any further invasive surgery. Intrauterine balloon-tamponade could successfully control severe hemorrhage from a lower uterine segment of a patient with placenta previa. This technique is simple to use, scarcely invasive, and available at a low cost to all maternity wards, and should be considered as one of the first management options to reduce the risk of undesirable hysterectomy.

The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage

To evaluate intrauterine balloon tamponade with or without B-Lynch sutures in avoiding postpartum hysterectomy in cases with severe postpartum hemorrhage. Retrospective analysis using all women delivering between January 2005 and July 2010 in our center. Prevention of hysterectomy was the main outcome studied. Twenty-four cases of severe postpartum hemorrhage occurred in which medical treatment alone failed. In 20 cases, the Bakri balloon was the first choice to stop hemorrhage. Sixty percent (n = 12) of these were successfully treated with the balloon alone, 30% (n = 6) with the balloon and the B-Lynch suture. Therefore, 90% (n = 18) were successfully treated with the balloon as part of the treatment. The balloon tamponade was not successful in 2 cases. Four cases were treated with emergency hysterectomy a priori. The Bakri balloon with or without B-Lynch sutures in a stepwise approach is an effective option for the treatment of severe PPH.

Recombinant Activated Factor VII in Obstetric Hemorrhage: Experiences from the Australian and New Zealand Haemostasis Registry

Through the Australian and New Zealand Haemostasis Registry, we report on the Australian and New Zealand experience with recombinant activated factor VII (rFVIIa) in obstetric patients. The role of rFVIIa for off-label indications, including trauma, cardiac surgery, and severe postpartum hemorrhage, remains controversial. The Haemostasis Registry established by Monash University in Melbourne, Australia monitors off-label use of rFVIIa across Australia and New Zealand. The purpose of this study was to summarize Registry data for all obstetric hemorrhage patients treated with rFVIIa at participating hospitals between January 2002 and July 2008. The primary outcome measures were reduction or cessation of bleeding (positive therapeutic response), mortality, and hysterectomy rate. During the study period, the Registry received data for 2128 patients. This included 110 cases of administration of rFVIIa in obstetric patients from 38 hospitals, comprising 5% of the total Registry population, 105 of whom were treated for acute hemorrhage. Women received median (interquartile range) individual doses of 92 microg/kg (73-100) of rFVIIa (median total dose 92 microg/kg [58-108]), and 78% of patients received a single dose. The positive response rate to rFVIIa was 76% with 64% responding to the first dose. Ninety-one percent of women were alive at 28 days. Forty-three women (41%) underwent hysterectomy before receiving rFVIIa and, of those remaining, 13 (21%) required hysterectomy after rFVIIa therapy. Two thromboembolic events (1 pulmonary embolism and 1 deep venous thrombosis) and 1 case of hypoxic-ischemic encephalopathy resulting from severe anoxia were reported. The reported effect of rFVIIa in many, but not all, obstetric cases was positive. There was no mortality as a result of thromboembolic complications. Randomized, controlled trials are required to confirm its safety and efficacy and to assess the possibility that use at an earlier stage in treatment of severe postpartum hemorrhage may avoid the need to resort to postpartum hysterectomy for control of bleeding, thus preserving fertility.

Ligature des artères iliaques internes face aux hémorragies obstétricales graves en milieu africain

Objectives Assess the efficiency of internal iliac arteries ligation in intractable obstetrical hemorrhage and ascertain success or failure factors. Patients and methods It was a retrospective study which concerned 159 patients who underwent internal iliac arteries ligation for persistent and severe obstetrical hemorrhage from March 1992 to February 2007. Arrest of hemorrhage after ligation with survival of the patient was considered as successful; was considered as failure, persistence of hemorrhage in spite of the ligation or patient death. Results Internal iliac arteries ligation allowed hemorrhage control in 84,3% of cases. Main etiology of hemorrhage were: uterine atony (42,8%), abruptio placentae (31,4%). Coagulation disorders and hypovolemic shock, consequences of long delay of management were identified as bad prognosis factors. Blood transfusion was also singled out as a factor likely to ameliorate prognosis, especially in hemodynamic precarious situations. Surgical complications incidence was 1,89%, represented by two internal iliac vein lesions and one ureteral section successfully repaired. Discussion and conclusion Internal iliac arteries ligation is a prerequisite treatment of severe postpartum hemorrhage. The outcome is better when it is performed precociously ( p = 0,0000003) before the happening of disseminated intra vascular coagulation ( p = 0,006), hemodynamic troubles ( p = 0,0099) and acute severe anemia ( p = 0,02). It is a good alternative to arterial embolization in Africa.

Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization

The purpose of this retrospective study was to evaluate the role of transcatheter arterial embolization in the management of severe postpartum haemorrhage due to a ruptured pseudoaneurysm and to analyse the clinical symptoms that may suggest a pseudoaneurysm as a cause of postpartum haemorrhage. A retrospective search of our database disclosed seven women with severe postpartum haemorrhage in whom angiography revealed the presence of a uterine or vaginal artery pseudoaneurysm and who were treated using transcatheter arterial embolization. Clinical files were reviewed for possible clinical findings that could suggest pseudoaneurysm as a cause of bleeding. Angiography revealed extravasation of contrast material in five out of seven patients. Transcatheter arterial embolization allowed to control the bleeding in all patients and subsequently achieve vaginal suture in four patients with vaginal laceration. No complications related to transcatheter arterial embolization were noted. Only two patients had uterine atony, and inefficiency of sulprostone was observed in all patients. Transcatheter arterial embolization is an effective and secure technique for the treatment of severe postpartum haemorrhage due to uterine or vaginal artery pseudoaneurysm. Ineffectiveness of suprostone and absence of uterine atony should raise the possibility of a ruptured pseudoaneurysm.

Fast and easy provisional treatment of severe postpartum haemorrhage

read with interest the paper by Ghezzi et al. about treating postpartum haemorrhage (PPH) successfully with the Hayman technique. The method is presented as quicker and easier than other methods. Allow me to communicate an even faster and easier method for very basic circumstances e.g. the operator is not a gynaecologist has no access to blood for transfusion or to only 1-2 pints of O negative blood and is also responsible for the child and the anaesthesia (and maybe for keeping the generator going). About 10 years ago I was presented at a referral hospital in Bulawayo Zimbabwe with a woman who had suffered from a severe PPH in a small district hospital. In desperation during the laparotomy the district doctor used a Foleys catheter as a tourniquet around the base of the uterus as is often performed with myomectomies prophylactically. He did not leave the ovarian arteries out as is possible by going through the anterior and posterior leaves of the broad ligament bilaterally beside the cervix. Understandable because there are at the end of pregnancy enormous thin walled easily bleeding veins in evidence in that area. It is also possible that closing only the uterine arteries would not have been enough. She stopped bleeding. The woman was then referred to the provincial hospital for an urgent transfusion and further transport to the tertiary hospital. The second referral was delayed for several reasons and I saw the woman only after 24 hours. On reopening the abdomen a nonvital uterus was in evidence including the adnexa. This was followed by the easiest subtotal abdominal hysterectomy including adnexa that I ever did: two sutures sufficed to substitute the catheter. The woman made an uneventful recovery and was prescribed combined contraceptive tablets to be used continuously till she was 50 years old. Without the delay it might have been possible to save the uterus and/or the ovaries. It is also often feasible to place a tourniquet low enough to stop uncontrollable bleeding after a caesarean section or a uterine rupture to gain time. (excerpt)

Intrauterine Balloon Tamponade in the Management of Postpartum Hemorrhage

This article reviews our experience with the use of intrauterine tamponade with balloon catheters in the management of severe postpartum hemorrhage. This is a case series report of 23 patients with postpartum hemorrhage unresponsive to medical therapy managed with intrauterine balloon tamponade. We identified these patients by International Classification of Diseases (ICD-9) codes and by reviewing labor and delivery logs. Balloon tamponade was attempted in 23 patients. When properly placed, catheters controlled postpartum hemorrhage in 18 of 20 cases (90%). In two cases, hysterectomy was required despite successful placement of the catheter. For hemorrhage due to uterine atony, our success rate was 100% (11/11 cases). In three cases, technical difficulties led to placement failure. For bleeding due to retained placenta, our success rate was 80% (4/5; failure with placenta percreta). Vaginal bleeding was stopped with the catheter in two of three cases of amniotic fluid embolus and in one case after dilation and curettage for postpartum septic shock. Thus balloon tamponade is an effective adjunct in the treatment of severe postpartum hemorrhage, especially when due to uterine atony when medical therapy fails.

Successful Use of Recombinant Factor VIIa for Treatment of Severe Postpartum Hemorrhage

1postpartum blood loss still results in severe maternal morbidity, 2 such as hypovolemic shock, renal failure, adult respiratory distress syndrome, hepatic failure, and disseminated intravascular coagulopathy. 3 Early, effective, and preferably noninvasive treatment is therefore essential. Primary postpartum hemorrhage is initially managed by restoration of blood volume, administration of oxytocin and prostaglandins, and the correction of coagulation. 2 If these initial conservative therapeutic measures do not control the bleeding, more drastic and invasive interventions such as bilateral artery ligation, angiography with selective embolization, or, as a last resort, hysterectomy can be performed. Recombinant factor VIIa (rFVIIa; NovoSeven) is a safe and effective drug for the treatment of bleeding episodes in patients with inherited or acquired hemophilia A or B and antibodies to the relevant coagulation factor (VIII or IX, respectively). Recently rFVIIa has been used successfully in patients with congenital or acquired platelet disorders, thrombocytopenia, and severe von Willebrand’s disease (type 3). The use of rFVIIa in patients with severe bleeding without known coagulation factor deficiencies or (preexisting) bleeding disorders has been reported in several case reports. 4-7 We describe a case of severe postpartum hemorrhage due to uterine atony resistant to conservative treatment in which use of a single dose of rFVIIa successfully controlled the bleeding and thereby obviated invasive procedures.

Intrauterine Balloon Tamponade in the Management of Postpartum Hemorrhage

This article reviews our experience with the use of intrauterine tamponade with balloon catheters in the management of severe postpartum hemorrhage. This is a case series report of 23 patients with postpartum hemorrhage unresponsive to medical therapy managed with intrauterine balloon tamponade. We identified these patients by International Classification of Diseases (ICD-9) codes and by reviewing labor and delivery logs. Balloon tamponade was attempted in 23 patients. When properly placed, catheters controlled postpartum hemorrhage in 18 of 20 cases (90%). In two cases, hysterectomy was required despite successful placement of the catheter. For hemorrhage due to uterine atony, our success rate was 100% (11/11 cases). In three cases, technical difficulties led to placement failure. For bleeding due to retained placenta, our success rate was 80% (4/5; failure with placenta percreta). Vaginal bleeding was stopped with the catheter in two of three cases of amniotic fluid embolus and in one case after dilation and curettage for postpartum septic shock. Thus balloon tamponade is an effective adjunct in the treatment of severe postpartum hemorrhage, especially when due to uterine atony when medical therapy fails.