PPH

Postpartum haemorrhage (PPH) accounts for around 28% of maternal deaths in developing countries1—that is, for over 125,000 deaths each year2. There are about 125 million births annually in the developing world3, so the risk of maternal death from PPH is approximately 1 in 1000 deliveries there.
Here in Britain the risk of death from obstetric haemorrhage is about 1 in 100,000 deliveries4. Eight maternal deaths from primary PPH occurred in the UK in 1991 to 1993. Three followed caesarean section, all in women of Afro-Caribbean origin: one followed instrumental delivery, and one was an advanced extrauterine gestation in which the placenta was removed instead of being left in place. Three deaths followed spontaneous delivery, but in two of these cases blood transfusion had been refused. It has been calculated4 that for women who refuse blood transfusion the risk of death from PPH is about 1 in 1000, similar to that in developing countries.
Primary PPH is said to occur after 5% of deliveries5 but the traditional definition — blood loss >500mL in the first 24 h — is now recognised to be of little clinical relevance6–8. Blood loss after delivery is notoriously difficult to measure and PPH may be best defined by a fall in haematocrit or by the need for transfusion8. Regarding measured loss, we should now concentrate on major PPH — loss >1000mL6. Major PPH occurs after 1.3% of deliveries in Britain9.
Risk factors for PPH include maternal obesity and a large baby9, in addition to well known factors such as antepartum haemorrhage and multiple pregnancy. Increased maternal age and prolonged labour were risk factors in a Zimbabwe study10. Maternal age is relevant in Britain too: older women may be less able than younger women to withstand the effects of haemorrhage4. Contrary to widespread belief, grand multiparity is not a risk factor, either in developed or developing countries9,10.
Risk factors are relevant to discussions about the place of delivery and to the need for increased vigilance but PPH occurs unpredictably in low risk women. Research on prevention has focussed on routine measures to be taken in all labours. Active management of the third stage helps prevent PPH and routine administration of an oxytocic reduces the risk of PPH by 40%11. Syntometrine® (Sandoz Pharmaceuticals, Camberley, Surrey, UK) (oxytocin plus ergometnne) is marginally more effective than oxytocin12,13 but causes more nausea and vomiting14. Oxytocin is more stable in tropical climates15. Oral ergometrine is not as effective as parenteral therapy in preventing PPH16.
Major haemorrhage is easy to recognise but in some cases unspectacular bleeding can be persistent, and its seriousness may not be appreciated until compensatory mechanisms fail and blood pressure falls. Careful observation after delivery is important.
The first step in management of PPH is abdominal palpation, after which an intravenous infusion should be set up. If the uterus is well contracted, the cause of the bleeding is likely to be genital tract trauma (e.g. from a vaginal or cervical tear or an episiotomy). This will require exploration and repair, with (in the words of the old adage) good relaxation, good light and good assistance.
If the uterus is atonic and continues to relax despite attempts to ‘rub up’ contractions, the bladder should be emptied and an intravenous injection of ergometrine or Syntometrine given. Persisting uterine atony may be due to retained products of conception and exploration of the uterus should be performed with care while resuscitation is proceeding. Intravenous oxytocin should be infused, usually 20 units in 500 mL saline at a rate not exceeding 100 milliunits/min. A second intravenous injection of Syntometrine or ergometrine may be given5.
If bleeding persists, the next step is intramuscular injection of 250 μg of carboprost (Hemabate®, Upjohn Ltd, Crawley, West Sussex, UK), an analogue of prostaglandin F2α. The injection can be repeated after 90 min if necessary5. In one study it was effective in 88% of patients17. Direct intramyometrial injection is faster and more effective18 but the drug is not licensed for administration by this route. If carboprost is not available there are reports of successful treatment with the insertion of one19 or two20 pessaries of gemeprost (Cervagem®, Rhone-Poulenc Rorer, Eastbourne, East Sussex, UK) into the uterus, combined with uterine compression. When carrying out bimanual uterine compression the hand in the vagina should elevate the uterus to keep the uterine arteries on ‘stretch’. Compression of the aorta against the sacral promontory may be a useful emergency measure8.
Obstetric haemorrhage can quickly lead to coagulation disorders. A team approach to management is important, with the early involvement of a haematologist and an anaesthetist. Fluid replacement is best monitored by a central venous pressure line. Initial fluid replacement should be with a crystalloid solution (e.g. Hartmanns) or with a colloid. Dextran should be avoided as it interferes with platelet function and cross-matching5.
In most cases these measures will control the bleeding but if not, hysterectomy must be considered. Performing this operation too late may put the woman at unnecessary risk if coagulation disorders are developing. Timely hysterectomy may be particularly important if the woman refuses transfusion4. The decision to undertake hysterectomy should be made by a consultant, and the operation should be carried out by a consultant. Subtotal hysterectomy is an acceptable alternative to total hysterectomy, particularly in the unstable patient8.
There are, however, techniques which, if used judiciously, may avoid the need for hysterectomy. One is uterine packing, which has recently re-emerged as an option after falling into disuse. An American report21 describes nine cases of uterine packing between 1985 and 1991 in a hospital with long experience of the Torpin packer, an instrument which places five yards of 4-inch gauze inside the uterus. In six of the nine women it was used after vaginal delivery and in three after repeat caesarean section. Two of the patients required hysterectomy because the packing failed. In the seven others the pack was left in place for between 5 h and 96 h, and bleeding did not recur at removal.
Removal of a pack is a worrying moment because of concern that the raw uterine surface will bleed again. One case report22 has described a sterile plastic drape fashioned into a bag and inserted into the lower uterine segment and vagina before being packed with two lengths of 4.5 × 48 inch gauze packs soaked in povidone-iodine. The purpose of the plastic was to allow easy removal and in fact the packing was spontaneously expelled 16 h later with the onset of breastfeeding.
Following similar principles, in another report23 of a case of atonic PPH a Sengstaken-Blakemore tube was inserted in the uterus, and the gastric balloon inflated with 300 mL saline. External compression of the uterus was maintained for 10 minutes and controlled the haemorrhage while fluid replacement and correction of the clotting disorder continued. The balloon was left inflated for 24 h and then slowly deflated at a rate of 20 mL per hour. Recovery was complete. The use of a Foley catheter with a large bulb has also been suggested7.
A recent report24 describes the successful treatment of uterine atony by the enucleation of a submucous fibroid which was preventing the uterus from contracting. Another case report25 describes the cessation of haemorrhage after intravenous injection of 1 g of tranexamic acid, a fibrinolytic inhibitor. The authors suggest that this drug may be particularly helpful in severe bleeding from the lower uterine segment when the fundus is already well contracted.
There are also surgical techniques for controlling haemorrhage without the need for hysterectomy. Ligation of the internal iliac artery is well known but infrequently performed. There may be extensive collateral circulation in the pelvis and the technique prevents hysterectomy in only about 50% of cases7. It requires a high degree of surgical skill and complications include laceration of iliac veins, accidental ligation of the external iliac artery, ureteric injury and death. Hysterectomy is usually safer and quicker7.
Direct ligation of the uterine vessels has been described for controlling bleeding at caesarean section. Bilateral mass ligation of the uterine arteries and veins involves placing a suture to include 2 to 3 cm of myometrium, at a level about 2 to 3 cm below the uterine incision. This procedure was used in 265 cases of bleeding at caesarean section in one hospital over a 30-year period26. It failed in only 10 patients and eight of those were cases of placenta praevia or placenta accreta. Uterine viability is maintained by collateral circulation, and the technique can be followed by normal menses and pregnancy.
Stepwise uterine devascularisation has been described in a report from Egypt27. The steps are: 1. unilateral and 2. bilateral uterine artery ligation (at the upper part of the lower uterine segment), 3. low uterine vessel ligation after mobilisation of the bladder, 4. unilateral and 5. bilateral ovarian vessel ligation. Myometrium is included in the ligatures in steps 1 to 3. Steps 1 and 2 were effective in over 80% of cases. This technique can also be followed by normal menstruation and pregnancy. What is unclear in these reports is how strong the indications were for the ligation or devascularisation procedures.
A recent case report from Zurich28 describes a different type of suturing as treatment for uterine atony unresponsive to medical therapy after caesarean section. Bleeding was controlled by three large compression sutures placed across the uterine body to invert the uterine fundus. According to the authors “imminent hysterectomy could thus be avoided”. Another kind of uterine compression suture is described in this Journal (pages 372–375). The B-Lynch brace suture compresses the uterus without inverting the fundus and has the advantage of simplicity.
A technique for which an experienced angiographic radiologist is required30 and which may be available in specialist centres is radiographic embolisation. This can be used for bleeding persisting after hysterectomy29. It may also be used when hysterectomy is contraindicated30 or when the bleeding is from vaginal or cervical lacerations31. Recent case reports describe one woman who required three separate embolisations to control recurrent bleeding30 and another woman successfully treated after two laparotomies (for hysterectomy and internal iliac ligation) and transfusion of 63 units of blood29. Sciatic nerve damage is a rare complication, collateral circulation maintains tissue viability, and pregnancy can follow bilateral internal iliac embolisation.
Severe PPH occurs often enough to be important but infrequently enough for the first-line staff involved to have relatively little experience in its management. Guidelines should be readily available on delivery suites, and practice drills should be carried out regularly32. The surgical techniques mentioned here can be described to trainees during routine caesarean sections. Maternal collapse can be rapid and when PPH occurs senior doctors should be involved promptly. The most serious cases require experienced clinical judgement as to the type of intervention and its timing, and ‘fire drills’ should involve consultants. Careful preparation is necessary to eliminate substandard care from postpartum haemorrhage.

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