Emergency Management of Postpartum Hemorrhage

Introduction

Postpartum hemorrhage (PPH) is a potentially life-threatening complication that can occur after childbirth, requiring swift and effective emergency management to ensure the well-being of the mother. Defined as the loss of 500 ml or more of blood within 24 hours of childbirth, PPH is a leading cause of maternal mortality worldwide. Timely intervention and a systematic approach are essential for successful outcomes. This article explores the emergency management of postpartum hemorrhage, emphasizing the importance of preparedness, prompt recognition, and appropriate intervention.

In Which Clinical Scenario During Childbirth Are General Surgeons Required?

In the first 24 hours after childbirth, there are three common situations where a general surgeon or acute care surgeon may be needed due to acute postpartum hemorrhage (PPH).

• Cesarean Delivery With Refractory PPH: This scenario represents the most common occurrence, typically involving a patient experiencing persistent and uncontrolled bleeding after a cesarean delivery. The patient's hemodynamic status may be compromised, and disseminated intravascular coagulation (DIC) may be present.

• Vaginal Delivery With Refractory PPH: While less frequent than the cesarean scenario, vaginal delivery with refractory PPH can still pose a significant threat to maternal life. The patient may have sustained severe tearing or lacerations during delivery or may have retained placental fragments.

• PPH in the Delivery Suite: This scenario is the least common and usually involves a patient still in the delivery suite, yet to be transferred to the operating room. These patients may respond to medical interventions, but if bleeding persists, surgical intervention may become necessary.

What Is the Emergency Treatment of Postpartum Hemorrhage?

• Resuscitation: Upon recognizing significant postpartum hemorrhage, resuscitation occurs concurrently with diagnostic efforts. The initial patient assessment follows Advanced Trauma Life Support (ATLS) guidelines, adapting to the ongoing situation. The "ABCs" (Airway, Breathing, Circulation) are evaluated, and necessary interventions are provided. Monitors, including continuous pulse oximetry, heart rate, and blood pressure measurements, are attached, along with a Foley catheter for urine output monitoring. Initial laboratory studies, including type and cross for six units of packed red blood cells (PRBCs), chemistry panel, complete blood count (CBC), coagulation panel, and fibrinogen, are ordered and repeated as needed.

Two large bore IVs (intravenous) are placed, and if necessary, central intravenous access and arterial lines for monitoring and fluid infusion are inserted. Blood bank personnel are notified early, and a preemptive massive blood transfusion protocol is initiated if needed.

• Examination and Initial Interventions: Identifying the cause of hemorrhage is the first step in resolving the issue. The main reasons, listed in decreasing order of occurrence, include uterine atony, retained products of conception, placental abnormalities, uterine inversion, uterine rupture, genital tract trauma, and coagulopathies. An initial physical examination is essential to detect uterine atony, repair lower genital tract trauma, and remove any retained placental tissue.

Uterine atony occurs when the uterus is unable to contract effectively after placenta expulsion, resulting in hemorrhage. Bimanual uterine massage, involving one hand in the vagina and the other on the abdomen at the uterine fundus, stimulates contraction.

Retained uterine products are a common cause of delayed postpartum hemorrhage. If the placenta is not delivered within 15 to 30 minutes, medical management with oxytocin may be attempted. If unsuccessful, regional or general anesthesia, hemostatic reassessment, antibiotics, and oxytocin drip are employed before transvaginal removal. Genital tract injuries can lead to unexpected severe bleeding. Optimal repair involves proper patient positioning, suturing from the tear apex, and, if necessary, vaginal packing for hemostasis, maintained with a Foley catheter for urine monitoring.

• Failure to Control Hemorrhage: If postpartum hemorrhage persists, it is crucial to promptly transfer the patient to the labor and delivery operating room (OR). Notify the anesthesia provider, blood bank (for possible massive transfusion protocol), and specific staff, including a general or trauma surgeon, senior general surgery residents, the patient's nurse, and any available nurse's assistants. Activating the hospital's massive transfusion protocol involves a predetermined ratio of blood products, aiming to prevent early coagulopathy. In obstetrical cases, if immediate type-specific or crossmatched blood is unavailable, type-O, Rh-negative blood is preferred to avoid Rh sensitization. However, Rh-positive blood should not be withheld if needed, recognizing a potential five percent risk of hemolytic transfusion reactions with emergency non-typed blood.

• Medical Management: If initial efforts to control postpartum hemorrhage are not successful, medical therapy offers a step-by-step approach using uterotonics to aid uterine contraction. The first drug used is oxytocin, typically administered after placenta delivery in the U.S. It is given intravenously (IV) in a crystalloid solution at 10 to 20 units, titrated for optimal contractions. Doubling oxytocin (40 units in 1 L) is common in severe cases, but it is not bolused to avoid hypotension or water intoxication.

If oxytocin does not provide sufficient uterine tone, the next-line options are ergot alkaloids (Methylergonovine) or prostaglandins (PGF2α, PGE1, PGE2). Methylergonovine is given intramuscularly (IM), while 15-methyl prostaglandin F2α may be used IM in multiple doses. Monitoring is essential for potential side effects, including hypotension. Response rates are high, especially with 15-methyl prostaglandin F2α.

Other prostaglandins like PGE1 (Misoprostol) are gaining popularity due to fewer contraindications and minimal side effects when administered rectally. PGE2 is an option but has notable side effects. A less common method involves injecting vasopressin sub-endometrial. Bimanual uterine compressions are continued throughout these treatments. If medical interventions fail, surgical options are considered after excluding other causes of postpartum hemorrhage.

• Usage of Uterine tamponade: Uterine tamponade is a medical intervention used to control severe postpartum hemorrhage by applying pressure to the uterine cavity, promoting hemostasis. This technique involves introducing an inflatable balloon, such as a Bakri or a Foley catheter, into the uterine cavity, which is then inflated to compress bleeding vessels and staunch blood flow. Uterine tamponade is particularly effective in cases of uterine atony, trauma, or retained products of conception. This method is a less invasive alternative to surgery, providing rapid and temporary control of bleeding and allowing time for further evaluation and intervention if necessary.

• Selective Arterial Embolization: Selective arterial embolization is a well-established method to manage postpartum hemorrhage, offering success rates of 85 to 100 percent as an alternative to surgery. This procedure targets specific arteries, commonly the uterine artery, to control bleeding. However, its availability is limited to hospitals with trained interventional radiologists. Before embolization, local anesthesia or an epidural is administered. The femoral artery is cannulated, and a catheter is advanced to the bleeding source under fluoroscopy. An angiogram confirms the location and absorbable gel sponges may be used during the procedure. Bilateral embolization is crucial to prevent the risk of secondary bleeding from collateral branches.

Conclusion

In conclusion, timely and systematic management of postpartum hemorrhage (PPH) is imperative to safeguard maternal well-being. General surgeons play a crucial role in three scenarios of acute PPH, emphasizing the need for swift intervention in cesarean and vaginal deliveries with refractory bleeding or PPH cases within the delivery suite. The emergency treatment protocol involves resuscitation, thorough examination, and initial interventions targeting common causes like uterine atony and genital tract trauma. A coordinated approach involving the operating room, blood bank, and specific staff is essential if hemorrhage persists. Medical therapies, including uterotonics and uterine tamponade, offer stepwise interventions, with selective arterial embolization serving as an effective alternative, albeit with limited accessibility.