Algorithm for HPP

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t is estimated that every year, about 600,000 to 800,000 women die during childbirth around

the world. In the developing world, postpartum haemorrhage (PPH) accounts for up to half of

all maternal deaths. Even in developed countries, life-threatening PPH occurs in about 1 in

1,000 deliveries. The latest Confidential Enquiries into Maternal Deaths in the UK has listed PPH

as the third most common direct cause of maternal mortality.1 And we should not forget that many

women survive with severe morbidity. Apart from anaemia, fatigue, depression and the risks of

blood transfusion in the short term, many women require a hysterectomy to save their lives. This

results in the loss of fertility in the prime of their lives, leading to social and psychological conse-

quences. It is also well known that severe PPH can cause necrosis of the anterior pituitary gland,leading to Sheehan’s syndrome.

Three delays have been identified as the causes of maternal death: delay in seeking medical

care, delay in reaching healthcare facilities and delay in receiving appropriate care in a healthcare

institution. The former two are seen mainly in developing countries. The latter, however, is common

to both developing and developed countries. The Confidential Enquiries has in fact emphasized that

deaths caused by PPH are due to “too little done too late”.1

In this article we present an algorithm to manage atonic PPH, a condition that contributes

to significant maternal morbidity and mortality in both the developing and developed world. The

algorithm incorporates measures aimed at timely and appropriate management of atonic PPH to

save lives and to avoid serious morbidity.

DEFINITION

PPH refers to the loss of more than 500 mL of blood from the genital tract after delivery.

A volume of 500 mL is an arbitrary cutoff volume. In an anaemic patient, even less blood loss may

cause morbidity and mortality. During caesarean sections, many obstetricians would consider blood

loss of 1,000 mL as a cutoff point. This provides an allowance for more bleeding that occurs during

a caesarean section as compared with vaginal delivery. Blood loss is often underestimated by

healthcare professionals. It has been estimated that PPH occurs in 2% to 11% of deliveries; if an

Management Algorithm for AtonicPostpartum Haemorrhage

Edwin Chandraharan, MBBS, MS(Obs&Gyn), DFFP(UK), MRCOG;

Sabaratnam Arulkumaran, MBBS, MD, PhD, FRCOG

JPOG MAY/JUN 2005 • 106

OBSTETRICS

I



objective assessment of blood loss is made, the incidence

may rise up to 20%. A practical definition of PPH would be“any bleeding from the genital tract that results in haemo-

dynamic instability, which may endanger the life of the

mother”. PPH that occurs within the first 24 hours of deliv-

ery is called primary PPH. Common causes are atonic

uterus, trauma to the genital tract, presence of retained

placenta and membranes, and coagulopathy. An atonic

uterus is the commonest cause of primary PPH, account-

ing for 80% of all cases.2 Bleeding that occurs after 24

hours is called secondary PPH, and is commonly due to

retained tissue and/or infection. In this article, we focus

our discussion on the management of primary PPH caused

by uterine atony.

MANAGEMENT OF ATONIC PPH

PPH is an obstetric emergency. Overtreatment causes less

harm than inaction. Accurate estimation of blood loss,

appropriate replacement of volume and coagulation fac-

tors and a multidisciplinary approach are essential.Management should follow a clear and logical sequence

of steps. We have attempted to formulate a management

algorithm for this serious and potentially fatal condition.

(Figure 1) The mnemonic “HAEMOSTASIS” spells out the

suggested actions that may facilitate the management of

atonic PPH in a logical and stepwise manner.

Ask for HELP

It is prudent to ask for help. The presence and advice

of a senior obstetrician, midwife, anaesthetist and

haematologist are vital. Services of ancillary staff should

be sought to help in the management. A multidisciplinary

approach would optimize the monitoring and manage-

ment of fluids, electrolytes and coagulation parameters as

well as provide input if further measures are necessary.

Assess and Resuscitate

It is important to make an initial assessment regarding the

degree of blood loss and the severity of the haemody-

namic instability. It is always

better to overestimate theblood loss and be proactive.

Level of consciousness, pulse,

blood pressure and, if facilities

are available, oxygen saturation

should be monitored. At the

time of the insertion of two

large-bore (14G) IV cannulae,

blood should be taken for inves-

tigations. These include full

blood count (FBC), clotting pro-

file, urea and electrolytes, and

grouping and crossmatching.

Rapid fluid infusion with crys-

talloids and colloids should be

carried out until crossmatched

blood is available. Crystalloids

(0.9% normal saline or

Hartmann’s solution) are pre-

ferred over colloids, as the latter are associated with a4% increase in the absolute risk of maternal mortality

compared with crystalloids.3 The maximum recommended

dosage of colloids is 1,500 mL in 24 hours.

Establish Aetiology, Ensure

Availability of Blood and Ecbolics

Establish Ae tiology

It is vital to try to identify a cause while resuscitation is

being carried out to save valuable time. For the purpose of

this article we confine our discussion to atonic PPH. The

uterus should be examined for contraction and retraction;

it may also be worthwhile to check for “free fluid” in the

abdomen, if the history suggests trauma (previous cae-

sarean section, difficult instrumental delivery) or if the

patient’s condition is poor compared with what is expect-

ed based on the estimated blood loss. It is important to

ask about the completeness of the placenta and mem-

branes. If there is doubt, the patient should be prepared

for examination under anaesthesia. It is important to


OBSTETRICS

Figure 1. Management algorithm for

of atonic PPH – “HAEMOSTASIS”.

H

A

E

M

O

S

T

A

S

I

S

Ask for help

Assess (vital parameters, blood loss) and

resuscitate

Establish aetiology, ensure availability of

blood, ecbolics (syntometrine, ergometrine,

bolus Syntocinon)

Massage uterus

Oxytocin infusion/prostaglandins –

IV/per rectal/IM/intramyometrial

Shift to theatre – exclude retained products

and trauma/bimanual compression

Tamponade balloon/uterine packing

Apply compression sutures –

B-Lynch/modified

Systematic pelvic devascularization –

uterine/ovarian/quadruple/internal iliac

Interventional radiologist – if appropriate,

uterine artery embolization

Subtotal/total abdominal hysterectomy



exclude any trauma to the genital tract. During caesarean

section, the uterine cavity may be explored to removeremnants of placenta and membranes, if present. A mor-

bidly adherent placenta may pose a problem during both

vaginal delivery and caesarean section. Aggressive,

appropriate and timely management is essential to reduce

morbidity and mortality. If difficulty is experienced during

the removal of the placenta or if the placenta is deemed

incomplete, the uterine cavity should be explored to

exclude retained products. Following vaginal delivery, a

uterine tamponade can be attempted prior to laparotomy

to arrest haemorrhage in cases of placenta accreta. If

haemorrhage due to a morbidly adherent placenta occurs

during a caesarean section, haemostatic sutures, sys-

temic pelvic devascularization and uterine artery

embolization may be tried. A placenta increta or percreta

may be encountered during caesarean section, especially

in the presence of a previous uterine scar.

E cbolics

Once atonic uterus has been identified as the cause ofPPH, measures should be taken to ensure uterine

contraction and retraction. Syntometrine (or, if not avail-

able, ergometrine) can be repeated. Syntocinon (10 units)

can be administered as a slow IV bolus.

E nsure Availability of Blood and

Blood Products

Replacement of the circulating blood volume with

crystalloids and colloids should be followed by restoration

of the oxygen-carrying capacity of the blood and correc-

tion of any derangements in coagulation. This involves

transfusion of blood and blood products. In special cir-

cumstances, autotransfusion may be considered,

although during a caesarean section this carries a theo-

retical risk of amniotic fluid embolism and infection.

Autotransfusion involves collection of maternal blood and

the use of a cell-saver device to wash and filter the blood

to remove the leukocytes and reinfuse the red cells.4

However, autotransfusion and other blood products may

not be acceptable to some patients. Hence, anaesthetists

and haematologists should be involved very early toensure optimum fluid management. In the case of mas-

sive PPH, where more than 30% of blood volume is lost,

blood transfusion should be considered very early, espe-

cially in the presence of continued bleeding. Until

crossmatched blood is available, O negative or uncrossed-

matched group-specific blood may be transfused if there

were no abnormal antibodies in the recipient’s blood.

Massage the Uterus

It is important to massage the uterus to stimulate uterine

contraction and retraction and this should be commenced

very early. It may act synergistically with the uterotonic

drugs.

Oxytocin Infusion/Prostaglandins

Syntocinon 40 units can be added to 500 mL of normal

saline and infused at a rate of 125 mL/hour. It is important

to avoid fluid overload, as fatal pulmonary and cerebral

oedema with convulsions due to dilutional hyponatraemiahas been reported. This is caused by the antidiuretic hor-

mone (ADH)-like effect of oxytocin. Hence, careful

monitoring of fluid input and output is essential if oxytocin

is infused in large amounts.

Prostaglandins are invaluable in the management of

atonic PPH, although they are not recommended as pro-

phylaxis of PPH due to their adverse gastrointestinal side

effects. Hemabate (15-methyl prostaglandin 2 alpha)

250 µg can be administered intramuscularly. The dose can

be repeated every 15 minutes for a maximum of eight

doses (2 mg).5 However, it is advisable to move the patient

to the theatre if profuse bleeding persists after three

doses of Hemabate. Intramyometrial injection of

Hemabate has been tried,6,7 but recent studies have ques-

tioned its effectiveness. One should be aware that serious

complications, including severe hypotension and cardiac

arrest, have been reported with systemic prostaglandin

administration. If the PPH is unresponsive to ergometrine

or oxytocin, rectal misoprostol (800–1,000 µg) may be


OBSTETRICS



tried.8,9 This is a valuable option in developing countries

due to its low cost and relatively easier storage.Apart from IV crystalloids, colloids, blood and oxy-

tocin, infusion of blood products needs to be considered.

In massive obstetric blood loss, rapid infusion of fresh

frozen plasma (FFP) may be required to replace clotting

factors other than platelets. It is recommended that with

every 6 units of blood transfusion, 1 L of FFP should be

administered (15 mL/Kg). Hence, four to five bags of FFP

are required, as each bag contains about 200 to 250 mL of

FFP. It is important to maintain the platelet count above

50,000 by infusing platelet concentrates when indicated.

Cryoprecipitate may also be needed if the patient devel-

ops disseminated intravascular coagulation (DIC) and her

fibrinogen drops to less than 1 g/dL (10 g/L).

Shift to Theatre

If the patient continues to bleed despite initial manage-

ment, it is best to transfer her to the theatre. Examination

should be carried out to exclude any retained placental

tissue or membranes. If retained products are suspected,manual removal and uterine curettage should be

carried out. A bimanual compression can be carried out

at this stage to “squeeze” the uterus between the abdom-

inal and vaginal hands.

Tamponade or Uterine Packing

In the presence of intractable PPH despite initial manage-

ment, it is important to consider the onset of coagulopathy

being superimposed on refractory atony. The use of uter-

ine tamponade may help in arresting haemorrhage. It also

allows adequate time to correct the coagulopathy if pres-

ent. It is advisable to involve senior members of the

obstetric team at this point, if this has not been done ear-

lier. Involvement of a haematologist is mandatory and the

intensive care unit should be alerted. Special protocols

should be in place for the management of massive obstet-

ric haemorrhage. The first step should be to alert all

members of the team (including the haematologist and

the hospital porter) in case of an emergency through the

hospital switchboard (e.g. “Code Blue”). A “tamponade

test”, which has a positive predictive value of 87% for thesuccessful management of PPH, using a Sengstaken tube

was described.10 If the tamponade arrests the bleeding

(i.e. positive), the chances of the patient requiring any fur-

ther surgical intervention is remote. However, if this fails

to control the haemorrhage, the patient needs a surgical

intervention.

Uterine tamponade with a balloon is easy to insert

and takes only a few minutes. It arrests the bleeding and

may prevent coagulopathy due to massive blood loss and

the need for further surgical procedures. It should be con-

sidered in all patients not responding to medical therapy.

Although a Sengstaken-Blakemore oesophageal catheter

(SBOC) is most commonly used, the Rusch urological

hydrostatic balloon11 and the “Bakri SOS” balloon12 may

also be used. Usually a volume of about 300 to 400 mL

may be required to exert the desired counter pressure to

stop bleeding from the uterine sinuses. In developing

countries, if these catheters are not freely available, uter-

ine packing could be tried with sterile gauze. Atamponade in time is likely to reduce the need for blood

transfusion, laparotomy and hysterectomy and thus may

help preserve fertility. Figure 2 shows a tamponade bal-

loon with a pressure-reading device that helps to infuse

the volume needed to achieve a pressure close to the sys-

tolic pressure to stop the bleeding. These special devices

are currently undergoing clinical trials after the success

with SBOC balloons.

Apply Compression Sutures

Failure of the tamponade test to arrest haemorrhage war-

rants laparotomy. The decision to perform a laparotomy

must be made early in these circumstances. Consent for

examination under anaesthesia, tamponade, laparotomy

and hysterectomy should have been obtained as the

patient is being moved to the theatre. This may not

always be feasible due to the patient’s condition or her

level of consciousness. In such cases, it may be advisable

to inform her next-of-kin of the possibility of laparotomy


OBSTETRICS



and its sequelae. Laparotomy allows for direct visualiza-

tion and access to the uterus as well as to the pelvicvasculature. Direct uterine massaging may be tried.

It is very important

to strike the right

balance between the

need to save life and the

desire to preserve the

patient’s fertility. Before

trying any conservative

surgical procedures, it

is essential to reassess

the situation based on

the amount of blood

loss, persistence of

bleeding, haemodynam-

ic status and the

patient’s parity. It is prudent to discuss with the anaes-

thetist regarding her ability to withstand possible further

bleeding if conservative measures fail. This is especially

true in developing countries, where the patient mighthave lost a significant amount of blood by the time

she reaches the referral centre, which might have

limited amount of blood for transfusion. In such situations,

it is wiser to consider radical measures, which include

total or subtotal hysterectomy to save the patient’s

life albeit at the cost of her fertility. On the other hand, if

the patient’s condition is stable, compression sutures can

be tried.

Compression sutures were first described by

Christopher B-Lynch and hence they are often called the

“B-Lynch” sutures.13 Bimanual compression can be

applied to the uterus to determine whether a compression

suture is likely to be of value. The anterior and posterior

walls are apposed by vertical brace sutures using

a delayed absorbable suture material, resulting in contin-

uous compression of the uterus. Various modifications

have been made to this original technique. These include

using two separate vertical compression sutures instead

of one to increase the tension applied and hence the

compression force.14 This technique also alleviates the

need for opening the uterus. Horizontal full thickness com-pression sutures have also been tried, especially to

control bleeding from the placental site in placenta prae-

via at the time of caesarean section.15 These could also be

applied in the lower segment, while taking care not to

obliterate the cervical canal. (Figure 3A) The risk of

damage to the bladder can be prevented by ensuring the

bladder reflection is below the level of suture insertion.

Passage of sutures 2 cm medial to the lateral border of the

uterus is aimed at preventing ureteric injuries.

A combination of multiple vertical compression

sutures may be needed in some cases. (Figure 3B) Cho et

al16 described a “multiple square” suturing technique,

which approximates anterior and posterior uterine walls

at various points, virtually obliterating the uterine cavity.

These vertical compression and multiple square sutures

are easy to perform, less time-consuming and can be

applied by less experienced surgeons as they are well

within the uterine body and do not involve areas traversed

by uterine vessels or ureters.

Systematic Pelvic Devascularization

If the compression sutures fail, ligation of blood vessels

supplying the uterus should be tried. These include liga-

tion of both uterine arteries, followed by tubal branches of

both ovarian arteries proximal to the ovarian ligament

(called the “quadruple ligation”). Uterine artery ligation is

straightforward once the uterovesical fold of peritoneum

is incised and the bladder is reflected down.17 A window

is made in the broad ligament just lateral to the uterine

vessels and the needle is passed through this opening.

Medially, the needle is passed through the lower uterine

myometrium, about 2 cm from the lateral margin, thus

getting a good “bite” and then tie. The same procedure is

repeated on the other side. If bleeding continues, tubal

branches of both ovarian arteries can be tied medial to

the ovarian ligament. The needle should be passed

through a “clear” area of the mesosalpinx on either side

of the blood vessels.


OBSTETRICS

Figure 2. Tamponade balloon with apressure reading device.

Drainage

channel

Tamponade

balloon with 350 mL of

saline

3-way tap to fill the

balloon and to take

pressure readings

Bedside pressure-reading device

(reads 102 mm Hg)



Internal iliac artery ligation is an option if bleeding

persists. This requires an experienced surgeon who isfamiliar with the anatomy of the lateral pelvic wall.

Routine identification of the internal iliac vessels and the

ureters during elective hysterectomies may help obstetri-

cians to build up confidence when faced with an

emergency. The parietal peritoneum may be picked up

divided at the lateral pelvic wall at the level of the pelvic

brim after identifying the ureter as it crosses the common

iliac vessels. It may be then reflected medially along with

the medial leaf of the broad ligament and the ureter be

held away from the internal iliac vessels by a loop. The

internal iliac artery should then be traced from above

downwards until it divides into the anterior and posterior

divisions. The anterior division should be ligated with

black silk or linen (permanent suture material). The pro-

cedure should be repeated on the other side.

Alternatively, the broad ligament may be opened

by clamping, cutting and ligating the round ligaments

and the lateral pelvic wall approached through this

route. Some obstetricians prefer this route as theyare familiar with the same procedure during routine

hysterectomy.

Bilateral internal iliac artery ligation has been found

to reduce the pulse pressure by up to 85% in arteries

distal to the ligation. This translates to an acute reduction

in the blood flow by about 50% in the distal vessels.18

The reported success rate of this procedure has

been between 40% and 75%19 and is invaluable for

avoiding a hysterectomy. Potential complications include

haematoma formation in the lateral pelvic wall, injury to

the ureters, laceration of the iliac vein and accidental

ligation of the external iliac artery. Ligation of the main

trunk of the internal iliac artery may result in intermittent

claudication of the gluteal muscles due to ischaemia.

Fortunately, these complications are rare. Examining

the femoral pulse prior to tightening the ligature, proper

identification of anatomical structures and ligating

the anterior division of the internal iliac artery may help

to prevent these complications.

Interventional Radiologist

In women who are not acutelycompromised or bleeding severely,

interventional radiology can be

considered. This procedure is usually

performed under fluoroscopic guidance

by an interventional radiologist. The

target vessel (internal iliac, uterine or

ovarian) is reached by passing a

catheter via the femoral artery. Various

materials are used to occlude the ves-

sels. These include gelatin sponge,

polyurethane foam or polyvinyl alcohol

particles, and are usually resorbed

within 10 days.20 The success rates may

be as high as 85% to 95% and the

entire procedure may take about

1 hour.21,22 Uterine artery embolization

helps to avoid radical procedures and

preserve fertility. Menstruation typically

returns within 3 months and subse-quent pregnancies have been

reported.23 This technique is also useful

in the presence of coagulopathy. In

cases where PPH is anticipated (pres-

ence of placenta accreta or increta),

embolization catheters can be placed

prophylactically prior to a planned

caesarean section, as this may help

appropriate management without compromising future

fertility. Complications include vessel perforation,

haematoma, infection and tissue necrosis.24 Uterine

necrosis has also been reported and hence the need

to inform the patient regarding this uncommon

complication. This procedure should be carried out by

radiologists with expertise in interventional radiology.

Subtotal or Total Abdominal

Hysterectomy

Hysterectomy should be total or subtotal depending on


OBSTETRICS

Figure 3. B-Lynch sutures.

(A) Technique of “separate”vertical and

horizontal compression sutures;(B) multiple

vertical compression sutures.

Vertical

compression

sutures

Uterus

Horizontal

sutures after

reflecting

the bladder

down

Multiple vertical compression sutures

A

B



the clinical situation. If the bleeding is predominantly from

the lower segment (as in PPH following a major degreeplacenta praevia), a total abdominal hysterectomy is war-

ranted. A subtotal hysterectomy may be performed if the

bleeding is mainly from the upper segment and the cause

is “unresponsive” uterine atony. Subtotal hysterectomy

has lower morbidity and mortality rates and requires less

time to perform. Hysterectomy is the “last resort” in the

management of atonic PPH. However, one may have to

resort to hysterectomy much earlier if the haemodynamic

condition is unstable and if there is uncontrollable bleed-

ing despite other medical and surgical measures. Due to

the anatomical changes of pregnancy, it is important to

exercise utmost care to prevent visceral trauma, especial-

ly of the bladder and ureters. It is also important to clamp

the ovarian ligament medially to avoid non-intentional or

inadvertent oophorectomy. The 15-year experience of

obstetric hysterectomy from a tertiary centre in Nigeria

revealed a maternal mortality rate of 12.5% and urinary

tract injury rate of 7.5% after this procedure.25 This

emphasizes the need to seek senior help and early inter-vention when necessary.

POSTOPERATIVE INTENSIVE CARE

It is important to remember that the management of

PPH does not stop with the arrest of bleeding. Often,

these patients have received multiple fluid and blood

transfusion and may have undergone surgical procedures.

Hence, it is prudent to manage them, with a multidiscipli-nary input, in a high-dependency unit (HDU) or intensive

care unit (ICU) to ensure continuity of optimum care.

CONCLUSIONS

The algorithm we have proposed (“HAEMOSTASIS”)

aims to help in the management of atonic PPH following

vaginal delivery in a logical and systematic manner, to

avoid maternal morbidity and mortality. PPH is an impor-

tant cause of pregnancy-related deaths in both

developing and developed countries. Atonic PPH during

caesarean section can be managed by direct uterine mas-

sage, intramyometrial injection of prostaglandins as well

as oxytocin infusion. Further measures include uterine

compression sutures, systemic pelvic devascularization

and hysterectomy. Although several case reports exist,

more prospective studies are needed to study the effec-

tiveness of tamponade balloon test and vertical and

horizontal compression sutures. Optimum managementof atonic PPH may help to reduce maternal morbidity and

save many lives.

About the Authors

Dr Chandraharan is Senior Lecturer and Dr Arulkumaran is Professor

and Head at the Division of Obstetrics and Gynaecology, St. George’s

Hospital Medical School, London, United Kingdom.

E-mail: [email protected], [email protected]


OBSTETRICS

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Algorithm for HPP

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