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When Simple Measures Fail: Trouble Shooting Refractory PPH

Trouble Shooting:  Lower Uterine Segment Bleeding​

Today we have access to a range of effective uterotonics in Canada.  Therefore, uterine atony, still the most common cause of PPH, can usually be managed medically.  However, bleeding from the lower uterine segment lacks contractile myometrium and may not respond to uterotonic agents.  Mechanical compression may be needed to control bleeding from the lower segment.  ​

  • Bakri (single) balloon may not be enough so vagina needs tamponade in order to compress the lower segment​
  • Strategies:  ​
    • Use a device with vaginal balloon, ​
    • Pack the vagina tightly with layers of Kerlex gauze and insert a Foley into the urethra​
    • Try inflating a blood pressure cuff in a bag in the vagina ​
  • Uterotonics do not help as lower segment is non-contractile​

Trouble Shooting:  Uterine rupture​

  • Think about uterine rupture.  Palpate lower segment through the dilated cervix.  Is the public bone palpable?​
  • Was the labour long (obstructed)? Was there “intrapartum” hemorrhage? ​
  • Ask about any previous uterine instrumentation or attempted instrumentation.​
    • IUCD insertion?​
    • Endometrial biopsy?​
    • Diagnostic D&C?​
    • Abortion?​
    • Hysteroscopy?​
  • Bedside ultrasound: look for intraperitoneal “concealed” bleeding 

Uterine rupture is a very uncommon cause of postpartum hemorrhage and, for that reason, the diagnosis may be delayed with life-threatening consequences.  We normally think of uterine rupture associated VBAC.  Indeed these ruptures are the most common and typically manifest themselves during labour with pain, vaginal bleeding, hematuria or fetal heart rate abnormalities.  However, occasionally vaginal delivery is completed without the uterine rupture being recognized.  Palpation of the old uterine scar will detect a defect through which the pubic bone is palpable.  There are rare cases of uterine rupture which occur as a result of past instrumentation of the uterus.  These are sometimes are called “spontaneous” ruptures and usually involve the uterine fundus.  The patient’s pain may be greater than normally encountered after vaginal delivery and signs of shock may be present that are out of proportion to the amount of vaginal blood loss.  A history should be carefully reviewed again with specific questions regarding previous IUCD use etc.  Point of Care ultrasound examination may reveal a collection of intraperitoneal blood.  Emergency laparotomy is required with closure of the defect, deep compression sutures to tamponade the bleeding site or subtotal hysterectomy.​

Trouble Shooting: PPH after Cesarean Section​

  • Baseline blood loss CS>vaginal delivery (PPH>1000ml)​
  • GA may cause uterine atony​
  • Epidural/spinal associated with hypotension​
  • Manual and visual exploration of cavity is performed to discover the bleeding site​
  • Resort to B-Lynch suture and other compression sutures earlier rather than later​
  • Consider Bakri and uterine packing​
  • Check for “concealed” blood loss per vaginum
  • Internal iliac artery ligation less commonly used

Management of PPH following cesarean section is both more complicated and simpler than PPH after vaginal delivery.  The situation is complicated by the fact that normal cesarean delivery is typically associated with significantly more blood loss than is normal vaginal delivery.  Anesthetics complicate matters further by creating hypotension and uterine atony.  On the other hand, the uterine cavity can be readily explored and wiped with a sponge to remove retained products of conception.  Trial of manual compression of the uterus is straightforward.  Injection of ergometrine or carboprost directly into the myometrium is easier than through the cervix or abdominal wall. It is possible to inflate a balloon in the uterine cavity and pass the tubing through the vagina. This technique has technical disadvantages (eg. potentially puncturing the balloon with the needle during closure of the uterine incision).  Furthermore, the cost of the Bakri balloon is approximately $300 as opposed to gauze or compression sutures.  Consider uterine packing with layers of Kerlix gauze tucked into the cornua and systematically layered down to the lower uterine segment.  If more than one gauze length is required, a secure square knot is made between the two ends and layering is continued.  The end of the gauze it passed through the cervix into the vagina before the uterine incision is closed.  Be aware of infection risk, potential of ongoing unrecognized bleeding and potential repeated surgery for packing removal​

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Updated on February 16, 2022

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