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1 Continuing Education Column Management of Postpartum Hemorrhage Ahm Kim, MD Department of Obstetrics and Gynecology, Ulsan University College of Medicine akim@amc.seoul.kr J Korean Med Assoc 2007; 50(12): Abstract Despite recent improvements in the intensive care for postpartum hemorrhage, it remains one of the leading causes of maternal mortality and morbidity for obstetricians. Because it is difficult to prevent or predict postpartum hemorrhage, it is important to manage any such patients correctly and promptly. Management of postpartum hemorrhage may vary greatly among patients, depending on the etiology of the bleeding, available treatment options, and the patient's desire for future fertility. When managing postpartum hemorrhage, it is necessary to balance the use of conservative management with the need to control the bleeding and achieve hemostasis. Uterine massage and compression, and the administration of uterotonics such as oxytocin, ergometrine, and prostaglandins are primary, conservative, and noninvasive management techniques for patients with postpartum hemorrhage. Relatively noninvasive procedures such as curettage of remnant tissues, vaginal packing, repair of laceration, and percutaneous angiographic embolization can also be performed. In cases where these management techniques fail, surgical alternatives such as uterine or internal iliac artery ligation, uterine compression sutures, or hystrectomy are used. Surgical treatment of postpartum bleeding, performed as an appropriate and timely intervention, is lifesaving. The management of postpartum bleeding requires a multidisciplinary approach with timely and efficient communication between clinical specialists and preserving fertility. Keywords : Postpartum hemorrhage; Medical management; Surgical management 1096

2 Postpartum Hemorrhage Table 1. Etiology of Postpartum hemorrhage Primary: 24hours postdelivery Uterine atony most common Retained placenta especially placenta accreta Lower genital tract lacerations Uterine rupture Defects in coagulation Uterine inversion Secondary: > 24hours to 6 ~12weeks postdelivery Subinvolution of placenta site Retained products of contraception Infection Inherited coagulation defects 1097

3 Kim A Figure 1. Management of major postpartum hemorrhage (blood loss >1,000ml or clinical shock)(12). 1098

4 Postpartum Hemorrhage Table 2. Uterotonic Agents for Postpartum Hemorrhage(14) Medication Oxytocin (Pitocin) Methylergono vine (Methergin) 15methyl PGF 2 (Carboprost) Dinoprostone (Prostin E 2 ) Misoprostol (Cytotec, PGE 1 ) Dose 1040U in 1,000mL of normal saline or lactated Ringer solution 0.2mg 0.25mg 20mg 800~1,000mcg Primary Route (Alternate) IV (IM,IMM) IM (IMM) IM (IMM) Suppository: vaginal or rectal Rectally Frequency of Dose Continuous infusion Every 2~4h Every 1590min, not to exceed 8 doses Every 2h Abbreviations: IV, intravenously; IM, intramuscularly; IMM, intramyometrial *all agents can cause nausea and vomiting Side effects Usually none, but nausea,vomiting and water intoxication have been reported Hypertension, hypotension, n ausea, vomiting Vomiting, diarrhea, nausea, flushing or hot flashes, chills or shivering Vomiting, diarrhea, nausea, fever, headache, chills or shivering Comments and Contraindication No contraindication Contraindication include hypertension/ toxemia Contraindication includes active cardiac, pulmonary, renal, or hepatic disease Avoid if patient is hypotensive. Fever is common. Stored frozen, it must be thawed to room temperature 1099

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Postpartum Hemorrhage A B Figure 2. A 31 yearold female delivered a baby by vaginal birth at local clinic. A) Arterial angiogram shows that a pseudoaneurysm (arrow) of left uterine artery.

6 Postpartum Hemorrhage A B Figure 2. A 31 yearold female delivered a baby by vaginal birth at local clinic. A) Arterial angiogram shows that a pseudoaneurysm (arrow) of left uterine artery. B) Gelfoam and glue (1:1 mixture with lipiodol) embolization with use of microcatheter. Vascularity of left uterine artery has disappered on postembolization left internal iliac angiogram. 1101

7 Kim A 1102

Postpartum Hemorrhage Fallopian tube Round ligament Broad ligament 3cm 3cm 4cm 3cm 2 3 4 5 6 Figure 3. Suture placement in the BLynch compression stitch for atonic uterine hemorrhage(4). 1 11.

8 Postpartum Hemorrhage Fallopian tube Round ligament Broad ligament 3cm 3cm 4cm 3cm Figure 3. Suture placement in the BLynch compression stitch for atonic uterine hemorrhage(4) Adamson P. A failure of imagination. Progress of Nations. UNICEF 1996: WHO Report of technical working group. The prevention and management of postpartum haemorrhage. Geneva: World Health Organization, 1999: WHO/MCH/ AbouZahr C. Global burden of maternal death and disability. Br Med Bul 2003; 67: Gary A, Dildy III. Postpartum hemorrhage: New management options. Clin Obstet and Gynecol 2003; 45: Seo K, Park MI, Kim SY, Park JS, Han YJ. Changes of maternal ratio and the causes of death in Korea during 1995~ Korean J Obstet Gynecol 2004; 47: Bonnar J Massive obstetric haemorrhage BaillieresBestPract Res Clin Obstet Gynaecol 2000; 14:

9 Kim A 17. Etuk SJ, Asuquo EE. Effects of community and health facility interventions on postpartum hemorrhage Int J Gynecol Obstet 2000; 70: Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991; 77: ACOG, Postpartum hemorrhage. Int J Gynaecol Obstet 1998; 61: Dildy GA 3, Paine AR, George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol 2004; 104: Mason BA. Postpartum hemorrhage and arterial embolization Curr opin Obstet 1998; 10: Hatem A. Mousa, Steven Walkinshaw. Major postpartum haemorrhage Curr opinion in Obstet and Gynecol 2001; 13: Petersen LA, Lindner DS, Kleiber CM, Zimmerman MB, Hinton AT, Yankowitz J. Factors that predict low hematocrit levels in the postpartum patient after vaginal delivery. Am J Obstet Gynecol 2002; 186: ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrican Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gyneco 2006; 108: Du Vigneaud V, Ressler C, Swan JM, Roberts CW, Katsoyannis PG, Gordon S. The synthesis of an octapeptide with the hormonal activity of oxytocin. Journal of the American Chemical Society 1953; 75: Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD DOI: / CD Van Dongen PW, Van Roosmalen J, De Boer CN, Van Rooij. Oxytocins for the prevention of postpartum haemorrhage. A review. Pharm Weekbl Sci 1991; 13: Nan S, Catherin M, Carolyn L, Duncan E. Prevention and management of postpartum haemorrhage. SOGC clinical practive guidelines 2000; 88: Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ, Jr. Uncontrolled postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization. Obstet Gynecol 1979; 54: Dildy GA, 3rd. Postpartum hemorrhage: new management options. Clin Obstet Gynecol 2002; 45: Soriano D, Dulitzki M, Schiff E, Barkri G, Mashiach S, Seidman DS. A. prospecive cohort studyof oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum hemorrhage. Br J Obstet Gynaecol 1996; 103: Buttino L, Jr., Garite TJ. The use of 15 methyl F2 alpha prostaglandin (Prostin 15M) for the control of postpartum hemorrhage by 15 methyl prostaglandin F2 alpaha. Obstet Gynecol 1981; 58: Physicians Desk Reference. Montvale, NJ: Medical Economics, Lokugamage AU, Sullivan KR, Niculescu I, Tigere P, Onyangunga F, El Refraey H, Moodley J, Rodeck CH. A randomized study comparing rectally administered misoprostol versus Syntometrine combined with an oxytocin infusion for the cessation of primary postpratum hemorrhage. Acta Obstet Gynecol Scnad 2001; 80: Sharma S, EI Refaey H. Prostaglandins in the prevention and management of postpartum hemorrhage. Best Pract Res Clin Obstet Gynaecol 2003; 17: Mousa H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev 2007: CD Maier RC. Control of postpartum hemorrhage with uterine packing. Am J Obstet Gynecol 1993; 169: ; discussion Shim JY, Han K. Recent trends in the management of postpartum hemorrhage. Korean J Obstet gynecol 2005; 48: Miller S, Lester F, Hensleigh P. Prevention and Treatement of postpartum hemorrhage: new advances for low resource settings. J Midwifery Womens Health 2004; 49: Bakri YN, Amri A, Abdul Jabber F. Tamponade ballon for obstetrical bleeding. Int J Gynecol Obstet 2001; 74: Nam AN, Kim KJ, Jang BW, Hur SE, Lee SK, Kil KH, Ahn MJ, Lee JY. Effectiveness of SengstakenBlackmore tube to control postpartum hemorrhage. Korean J Obstet Gynecol 2006; 49: Cho PJ, Whang KJ, Lee JY, Choi HJ, Chang HS, Kim MR. Clinical use of a SengstakenBlackmore tube in the management of postpartum hemorrhage. Korean J Obstet Gynecol 2007; 50: Stergios K. Doumouchtisis, Aris T. Papageorghiou, MRCOG, Sabaratnam Arulkumran, FRCOG. Systemic review of conservative management of postpartum hemorrhage: What to do when medical treatement fails. CME Review article. 2007; 62: Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ, Jr. Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization. Obstet Gynecol 1979; 54: Vendantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery embolization: an understand method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997; 176: Shim JY, Yoon HK, Won HS, Kim SK, Lee PR, Kim A. Angiographic embolization for obstetrical hemorrhage: effective- 1104

10 Postpartum Hemorrhage ness and follow up outcome of fertility. Acta Obstet Gynecol Scand 2006; 85: Kang CS, Park SY, Lee JY, Ju WD, Kim SK, Hwang JY, Kim MY, Shim JY, Ko GY, Won HS, Suh DS, Lee PR, Kim A. Applicable indications and effectiveness of the selective arterial embolization in the management of obstetrical he-morrhage. Korean J Obstet Gynecol 2004; 47: Waters EG. Surgical management of postpartum hemorrhage with particular reference to ligation of uterine arteries. Am J Obstet Gynecol 1952; 64: Burchell RC. Internal iliac artery ligation: hemodynamics. Obstet Gynecol 1964; 24: Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet 1985; 160: Burchell RC. Physiology of internal iliac artery ligation. J Obstet Gynecol Br Commonw 1968; 75: Schnarwyler B, Passweg D, von Castelberg B. [Successful treatment of drug refractory uterine atony by fundus compression sutures]. Geburtshilfe Frauenheilkd 1996; 56: BLynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B Lynch surgical technique for the control of massive postpartum haemorrhage: An alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997; 104: Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000; 96: AbdRabbo SA. Stepwise uterine devascularization: A novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994; 171: C BL, Coker A, Lawal AH, Abu J, Cowen MJ. The B lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hystrectomy? Five cases reported. Br J Obstet Gynaecol 1997; 104: Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cearean delivery. Obstet Gynecol 2000; 96: Stanco LM, Schrimmer DB, Paul RH, Mishell DR, Jr. Emergency peripartum hystrectomy and associated risk factors. Am J Obstet Gynecol 1993; 168:

11 Kim A Peer Reviewer Commentary 1106

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding