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Appropriate second-line therapies for management of severe postpartum hemorrhage
IJG-08023; No of Pages 3 International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Appropriate second-line therapies for management of severe postpartum hemorrhage Ying Zhao a, Yunping Zhang a,⁎, Zhao Li b a b
Department of Obstetrics, Beijing Haidian Maternal and Child Health Hospital, Beijing, China Department of Obstetrics and Gynecology, Dalian Central Hospital, Dalian Medical University, Dalian, China
a r t i c l e
i n f o
Article history: Received 5 November 2013 Received in revised form 25 April 2014 Accepted 30 June 2014 Keywords: B-Lynch suture Cesarean delivery Intrauterine gauze tamponade Management Postpartum hemorrhage Second-line therapy
a b s t r a c t Objective: To explore appropriate second-line therapies for management of severe postpartum hemorrhage at cesarean delivery. Methods: A retrospective study was done of 87 women who underwent cesarean delivery and received uterotonics after placental separation at the Beijing Haidian Maternal and Child Health Hospital, China, between 2009 and 2013. Group 1 (n = 52) included patients with 500–700 mL of blood loss before application of intrauterine gauze tamponade or B-Lynch suture as second-line therapy, while group 2 (n = 35) included patients with blood loss of more than 700 mL before application of either gauze tamponade or B-Lynch suture. Results: Management was successful in all patients in group 1. In group 2, additional management was needed in three of four patients who underwent a B-lynch suture. Factors significantly associated with total blood loss were blood loss before application of second-line therapy (P b 0.001), fibrinogen levels (P b 0.001), and time from placental separation to second-line therapy (P = 0.015). Conclusion: When blood loss is 500–700 mL, compression sutures or intrauterine gauze tamponade can be used as second-line treatment of postpartum hemorrhage. When blood loss is more than 700 mL, intrauterine gauze tamponade should be used. © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality [1]. The management of PPH includes less invasive methods, such as uterine massage and administration of uterotonic agents, and aggressive surgical techniques, such as a peripartum hysterectomy. First-line treatments of PPH include the manual removal of retained placental tissue, uterine massage, application of bimanual compression, continuous intravenous application of oxytocin, and volume replacement. If first-line therapies are not successful, second-line treatment of PPH must be undertaken, such as sulprostone infusion, compression sutures [2,3], uterine sandwich (B-lynch suture and balloon tamponade), selective arterial embolization [4,5], or hysterectomy. The appropriate second-line procedure may achieve hemostasis of intractable hemorrhage and prevent the need for more severe surgical procedures. Uterine tamponade is one of the main methods to achieve hemostasis in patients with PPH (cotton gauze is usually used to pack the uterus) [6]. It is particularly successful in cases of hemorrhage caused by uterine atony. A tamponade is applied as soon as uterotonics are deemed ineffective. The uterine cavity can be packed with gauze or a balloon, which may avoid the need for conservative surgical procedures, such ⁎ Corresponding author at: NO.33 Haidian Road (South), Beijing Haidian Maternal and Child Health Hospital, Haidian District, Beijing, 100080 China. Tel.: +86 13911631326; fax: +86 01062581834. E-mail address: [email protected] (Y. Zhang).
as selective arterial embolization and arterial ligations. This method can be applied after vaginal or cesarean deliveries [7]. Since the B-lynch suture was first described in 1997 [2], many studies have validated is efficacy. According to the Guidelines of the Royal College of Obstetricians and Gynaecologists [8], each obstetric unit should have the capacity to provide at least one brace suturing technique. Balloon tamponade alone is an accepted second-line treatment method for PPH, not just in combination with a B-Lynch suture: Diemert et al. [9] reported that 60% of patients with severe PPH were successfully treated with the balloon alone. However, balloon tamponade alone may not be sufficient to control severe PPH, unlike intrauterine gauze tamponade, which can create a higher degree of compression. Balloon tamponade is more suitable for vaginal deliveries, whereas intrauterine gauze tamponade is more suitable for cesarean deliveries. Literature on the most appropriate second-line treatment method for the management of PPH is sparse. A few articles discuss the success obtained with the compression suture [10–12], and others explore the application of balloon tamponades [9,13,14]. The aim of the present study was to investigate appropriate second-line therapy for the management of severe PPH at cesarean delivery. 2. Materials and methods A retrospective study was conducted at the Beijing Haidian Maternal and Child Health Hospital, Beijing, China. All women who underwent cesarean delivery and had PPH between January 1, 2009, and
http://dx.doi.org/10.1016/j.ijgo.2014.05.015 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Zhao Y, et al, Appropriate second-line therapies for management of severe postpartum hemorrhage, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.05.015
2
Y. Zhao et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
March 31, 2013, were included. The uterotonics used were oxytocin, carboprost tromethamine, and carbetocin. Informed consent was not needed from included women, because the present study obtained data by a review of medical records. If blood loss had not been controlled after the use of uterotonics, second-line therapies were administered. Patients with 500–700 mL of blood loss before application of second-line therapy consisting of intrauterine gauze tamponade or B-Lynch suture were designated as group 1. Patients with more than 700 mL of blood loss before application of intrauterine gauze tamponade or B-Lynch suture were designated as group 2. Hemorrhages caused by placental factors were treated by suturing of the placental vascular bed. Manual uterine compression would be performed upon uterine atony; if the compression was successful, a B-lynch suture would be used rather than tamponade. If uterine atony persisted, an intrauterine gauze tamponade was inserted. The length of the gauze was 10–15 m and the width was 6–8 cm. The gauze was packed from the fundus to the cervix until it filled the uterine cavity and the particular length used depended on uterine volume, with longer gauzes used for larger volumes. The gauze was folded by a nurse into four layers before insertion and was removed after 15–40 hours. After the procedure, the uterus was observed for blood loss, which was determined by volumetry and weight of the gauze. Vital signs and use of intravenous fluids, blood, and blood products were monitored. All women received intravenous antibiotics. The hemoglobin status and coagulation profiles were monitored, and treatment was provided as appropriate. Fibrinogen levels were measured in all patients when the blood loss had reached 500 mL. If the volume of blood loss increased, fibrinogen levels were measured again. The lowest measured fibrinogen level was used. Statistical analyses were performed using SPSS version 18.0 (SPSS Inc, Chicago, IL, USA). Continuous variables are presented as mean ± SD. An independent t test was used to evaluate the difference between the two groups. A Fisher exact test or χ2 test was performed to compare categorical data. An ANOVA was used to evaluate the factors correlated with total blood loss. P b 0.05 was considered statistically significant. 3. Results A total of 87 women were included in the study. Characteristics and treatment of patients in group 1 (n = 52) and group 2 (n = 35) are shown in Table 1. Blood loss before second-line therapy was initiated, total blood loss, and the time between placental separation and application of second-line therapy were significantly higher in group 2 than in group 1 (P b 0.001) (Table 2). Fibrinogen levels in group 2 were significantly lower than in group 1 (P b 0.001) (Table 2). Factors significantly associated with total blood loss were blood loss before second-line therapy (P b 0.001), fibrinogen levels (P b 0.001), and time between placental separation and application of second-line therapy (P = 0.015). In group 1, the B-lynch suture was used in 27 (52%) women and gauze tamponade in 25 (48%) women. Management was successful in all patients in group 1 (Table 3) and a switch to other second-line procedures was not necessary. In group 2, the B-lynch suture was used in 4 (11%) women and gauze tamponade in 31 (89%) women. Management was successful in all women who received a gauze tamponade (Table 3). Among the 4 patients in group 2 managed with a B-Lynch suture, additional management was needed in three women. One woman received a gauze tamponade within 1 hour of the suture because of uncontrolled blood loss. Subsequently, this patient developed disseminated intravascular coagulation (DIC), and underwent a hysterectomy. One woman was treated with a gauze tamponade 15 minutes after the sutures because bleeding persisted. Her fibrinogen level declined to 1.84 g/L, and a fibrinogen infusion was administered. In this case, a
Table 1 Characteristics and treatment of patients with severe postpartum hemorrhage.a Variables Cause of PPH Uterine atony Placenta previa Placenta accreta Placenta increta Placenta abruption Uterine incision lacerations Biologic characteristics Diffuse intravascular coagulation Previous medical management 20 U oxytocin 500 μg carboprost thromethamine 100 μg carbetocin Transfusion RBC transfusion Number of packed RBC units transfused Fibrinogen transfusion Number of fibrinogen units transfused FFP transfusion Number of FFP units transfused
Group 1 (n = 52)
Group 2 (n = 35)
P value
49 (94) 3 (6) 0 0 0 0
20 (57) 6 (17) 3 (9) 2 (6) 1 (3) 3 (9)
b0.001 0.148 0.062 0.159 0.402 0.062
1 (2)
10 (29)
b0.001
52 (100) 52 (100) 52 (100)
35 (100) 35 (100) 35 (100)
N0.99 N0.99 N0.99
9 (17) 3.44 ± 1.67
35 (100) 5.28 ± 2.85
b0.001 0.072
2 (4) 4 ± 0.00
21 (60) 4 ± 0.00
b0.001 b0.001
9 (17) 213.7 ± 353.3
33 (94) 549.1 ± 408.5
b0.001 0.031
Abbreviations: PPH, postpartum hemorrhage; RBC, red blood cell; FFP, fresh frozen plasma. a Values are given as number (percentage) or mean ± SD, unless otherwise indicated.
hysterectomy was not necessary. In the third patient, blood loss continued after the B-lynch suture, and the hemoglobin level decreased from 81 g/L to 51 g/L. A packed gauze tamponade was inserted vaginally. 4. Discussion The best second-line treatment method for PPH at cesarean delivery is unclear. The appropriate method must be effective and should reduce the need for hysterectomy or blood transfusion. In the present study, patients in group 1 (500–700 mL of blood loss during cesarean delivery) were managed with the B-lynch suture or gauze tamponade, and all cases were managed successfully. WHO guidelines [15] recommend that compression sutures should be the first-line treatment. If this intervention fails, uterine, uteroovarian, or hypogastric vessel ligation may be attempted. At Beijing Haidian Maternal and Child Health Hospital, manual uterine massage and compressions are recommended as the first measure when PPH is unresponsive to conventional uterotonics. If uterine massage and compressions are ineffective, bilateral ligation of the uterine arteries should be performed. If these methods do not control blood loss, the uterine cavity should be packed with gauze. If the hemorrhage is affected by other factors such as a bleeding placental vessel, the first measure should be to suture the bleeding site. Suturing of an exposed placental vascular bed does not necessarily
Table 2 Time to application of second-line therapy, blood loss before second-line therapy, total blood loss, and fibrinogen levels in the two groups.a Variables Time between placental separation and application of second-line therapy, min Blood loss before second-line therapy, mL Total blood loss, mL Fibrinogen level, g/L a
Group 1 (n = 52)
Group 2 (n = 35)
t
P value
9.3 ± 4.9
20.2 ± 12.7
4.8
b0.001
580 ± 78
1057 ± 244
11.0
b0.001
758.8 ± 311 3.5 ± 0.8
1801 ± 589 2.4 ± 1.0
9.4 5.7
b0.001 b0.001
Values are given as mean ± SD unless otherwise indicated.
Please cite this article as: Zhao Y, et al, Appropriate second-line therapies for management of severe postpartum hemorrhage, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.05.015
Y. Zhao et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Conflict of interest
Table 3 The application of two methods in the two groups.a Group Group 1 (n = 52) B-lynch suture Gauze tamponade Group 2 (n = 35) B-lynch suture Gauze tamponade a b
3
Number of patients
Successb
Failure
27 (52) 25 (48)
27 (100) 25 (100)
0 0
4 (11) 31 (89)
1 (25) 31 (100)
3 (75) 0
Values are given as number (percentage). No need to use another treatment.
prevent PPH from uterine atony, so intrauterine tamponade might still be required, but sutures are necessary if an exposed placental vascular bed has severe active bleeding. The B-lynch suture was initially used in four women in group 2. In one, the management method was switched to insertion of an intrauterine gauze tamponade; however, DIC occurred, blood loss could not be controlled, and a hysterectomy was performed. In another patient, management was switched to a uterine sandwich (B-Lynch suture and balloon tamponade). In the present study, the risk factors associated with total blood loss were blood loss before second-line therapy, fibrinogen levels, and time elapsed before application of second-line therapy. The time elapsed before second-line therapy began was negatively correlated with fibrinogen levels; therefore, prompt treatment should be administered at the onset of PPH. The longer the time interval from onset of PPH to insertion of the tamponade will result in greater blood loss and decreased fibrinogen levels. When the fibrinogen levels cannot be recovered by infusion, DIC may occur. In conclusion, when PPH is unresponsive to drugs, second-line therapy should be administered quickly. If the blood loss is 500–700 mL, compression sutures or intrauterine gauze tamponade should be used. If the blood loss exceeds 700 mL, intrauterine packing with gauze is necessary. Early management leads to better results. The longer the time before application of second-line therapy, the greater the blood loss, the decrease in fibrinogen levels, and the risk of DIC.
The authors have no conflicts of interest. References [1] Högberg U. The World Health Report 2005: “make every mother and child count”— including Africans. Scand J Public Health 2005;33(6):409–11. [2] B-Lynch 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(3):372–5. [3] Huang YY, Zhuang JY, Bao YR, Ying H, Wang DF. Use of early transverse annular compression sutures for complete placenta previa during cesarean delivery. Int J Gynecol Obstet 2012;119(3):221–3. [4] Poujade O, Zappa M, Letendre I, Ceccaldi PF, Vilgrain V, Luton D. Predictive factors for failure of pelvic arterial embolization for postpartum hemorrhage. Int J Gynecol Obstet 2012;117(2):119–23. [5] Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage. Obstet Gynecol 2009;113(5):992–9. [6] Ramsbotham J. The principles and practice of obstetric medicine and surgery: in reference to the process of parturition. Philadelphia, PA: Lea and Blanchard; 1845. [7] Georgiou C. Intraluminal pressure readings during the establishment of a positive 'tamponade test' in the management of postpartum haemorrhage. BJOG 2010;117(3):295–303. [8] Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. London: Royal College of Obstetricians and Gynaecologists; 2009. [9] Diemert A, Ortmeyer G, Hollwitz B, Lotz M, Somville T, Glosemeyer P, et al. The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage. Am J Obstet Gynecol 2012;206(1):65.e1–4. [10] Ghezzi F, Cromi A, Uccella S, Raio L, Bolis P, Surbek D. The Hayman technique: a simple method to treat postpartum haemorrhage. BJOG 2007;114(3):362–5. [11] Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol 2002;99(3):502–6. [12] Allam MS, B-Lynch C. The B-Lynch and other uterine compression suture techniques. Int J Gynecol Obstet 2005;89(3):236–41. [13] Laas E, Bui C, Popowski T, Mbaku OM, Rozenberg P. Trends in the rate of invasive procedures after the addition of the intrauterine tamponade test to a protocol for management of severe postpartum hemorrhage. Am J Obstet Gynecol 2012;207(4):281.e1–7. [14] Tindell K, Garfinkel R, Abu-Haydar E, Ahn R, Burke TF, Conn K, et al. Uterine balloon tamponade for the treatment of postpartum haemorrhage in resource-poor settings: a systematic review. BJOG 2013;120(1):5–14. [15] World Health Organization. Guidelines for the management of postpartum haemorrhage and retained placenta. Geneva: World Health Organization; 2009.
Please cite this article as: Zhao Y, et al, Appropriate second-line therapies for management of severe postpartum hemorrhage, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.05.015
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Appropriate second-line therapies for management of severe postpartum hemorrhage Ying Zhao a, Yunping Zhang a,⁎, Zhao Li b a b
Department of Obstetrics, Beijing Haidian Maternal and Child Health Hospital, Beijing, China Department of Obstetrics and Gynecology, Dalian Central Hospital, Dalian Medical University, Dalian, China
a r t i c l e
i n f o
Article history: Received 5 November 2013 Received in revised form 25 April 2014 Accepted 30 June 2014 Keywords: B-Lynch suture Cesarean delivery Intrauterine gauze tamponade Management Postpartum hemorrhage Second-line therapy
a b s t r a c t Objective: To explore appropriate second-line therapies for management of severe postpartum hemorrhage at cesarean delivery. Methods: A retrospective study was done of 87 women who underwent cesarean delivery and received uterotonics after placental separation at the Beijing Haidian Maternal and Child Health Hospital, China, between 2009 and 2013. Group 1 (n = 52) included patients with 500–700 mL of blood loss before application of intrauterine gauze tamponade or B-Lynch suture as second-line therapy, while group 2 (n = 35) included patients with blood loss of more than 700 mL before application of either gauze tamponade or B-Lynch suture. Results: Management was successful in all patients in group 1. In group 2, additional management was needed in three of four patients who underwent a B-lynch suture. Factors significantly associated with total blood loss were blood loss before application of second-line therapy (P b 0.001), fibrinogen levels (P b 0.001), and time from placental separation to second-line therapy (P = 0.015). Conclusion: When blood loss is 500–700 mL, compression sutures or intrauterine gauze tamponade can be used as second-line treatment of postpartum hemorrhage. When blood loss is more than 700 mL, intrauterine gauze tamponade should be used. © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality [1]. The management of PPH includes less invasive methods, such as uterine massage and administration of uterotonic agents, and aggressive surgical techniques, such as a peripartum hysterectomy. First-line treatments of PPH include the manual removal of retained placental tissue, uterine massage, application of bimanual compression, continuous intravenous application of oxytocin, and volume replacement. If first-line therapies are not successful, second-line treatment of PPH must be undertaken, such as sulprostone infusion, compression sutures [2,3], uterine sandwich (B-lynch suture and balloon tamponade), selective arterial embolization [4,5], or hysterectomy. The appropriate second-line procedure may achieve hemostasis of intractable hemorrhage and prevent the need for more severe surgical procedures. Uterine tamponade is one of the main methods to achieve hemostasis in patients with PPH (cotton gauze is usually used to pack the uterus) [6]. It is particularly successful in cases of hemorrhage caused by uterine atony. A tamponade is applied as soon as uterotonics are deemed ineffective. The uterine cavity can be packed with gauze or a balloon, which may avoid the need for conservative surgical procedures, such ⁎ Corresponding author at: NO.33 Haidian Road (South), Beijing Haidian Maternal and Child Health Hospital, Haidian District, Beijing, 100080 China. Tel.: +86 13911631326; fax: +86 01062581834. E-mail address: [email protected] (Y. Zhang).
as selective arterial embolization and arterial ligations. This method can be applied after vaginal or cesarean deliveries [7]. Since the B-lynch suture was first described in 1997 [2], many studies have validated is efficacy. According to the Guidelines of the Royal College of Obstetricians and Gynaecologists [8], each obstetric unit should have the capacity to provide at least one brace suturing technique. Balloon tamponade alone is an accepted second-line treatment method for PPH, not just in combination with a B-Lynch suture: Diemert et al. [9] reported that 60% of patients with severe PPH were successfully treated with the balloon alone. However, balloon tamponade alone may not be sufficient to control severe PPH, unlike intrauterine gauze tamponade, which can create a higher degree of compression. Balloon tamponade is more suitable for vaginal deliveries, whereas intrauterine gauze tamponade is more suitable for cesarean deliveries. Literature on the most appropriate second-line treatment method for the management of PPH is sparse. A few articles discuss the success obtained with the compression suture [10–12], and others explore the application of balloon tamponades [9,13,14]. The aim of the present study was to investigate appropriate second-line therapy for the management of severe PPH at cesarean delivery. 2. Materials and methods A retrospective study was conducted at the Beijing Haidian Maternal and Child Health Hospital, Beijing, China. All women who underwent cesarean delivery and had PPH between January 1, 2009, and
http://dx.doi.org/10.1016/j.ijgo.2014.05.015 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Zhao Y, et al, Appropriate second-line therapies for management of severe postpartum hemorrhage, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.05.015
2
Y. Zhao et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
March 31, 2013, were included. The uterotonics used were oxytocin, carboprost tromethamine, and carbetocin. Informed consent was not needed from included women, because the present study obtained data by a review of medical records. If blood loss had not been controlled after the use of uterotonics, second-line therapies were administered. Patients with 500–700 mL of blood loss before application of second-line therapy consisting of intrauterine gauze tamponade or B-Lynch suture were designated as group 1. Patients with more than 700 mL of blood loss before application of intrauterine gauze tamponade or B-Lynch suture were designated as group 2. Hemorrhages caused by placental factors were treated by suturing of the placental vascular bed. Manual uterine compression would be performed upon uterine atony; if the compression was successful, a B-lynch suture would be used rather than tamponade. If uterine atony persisted, an intrauterine gauze tamponade was inserted. The length of the gauze was 10–15 m and the width was 6–8 cm. The gauze was packed from the fundus to the cervix until it filled the uterine cavity and the particular length used depended on uterine volume, with longer gauzes used for larger volumes. The gauze was folded by a nurse into four layers before insertion and was removed after 15–40 hours. After the procedure, the uterus was observed for blood loss, which was determined by volumetry and weight of the gauze. Vital signs and use of intravenous fluids, blood, and blood products were monitored. All women received intravenous antibiotics. The hemoglobin status and coagulation profiles were monitored, and treatment was provided as appropriate. Fibrinogen levels were measured in all patients when the blood loss had reached 500 mL. If the volume of blood loss increased, fibrinogen levels were measured again. The lowest measured fibrinogen level was used. Statistical analyses were performed using SPSS version 18.0 (SPSS Inc, Chicago, IL, USA). Continuous variables are presented as mean ± SD. An independent t test was used to evaluate the difference between the two groups. A Fisher exact test or χ2 test was performed to compare categorical data. An ANOVA was used to evaluate the factors correlated with total blood loss. P b 0.05 was considered statistically significant. 3. Results A total of 87 women were included in the study. Characteristics and treatment of patients in group 1 (n = 52) and group 2 (n = 35) are shown in Table 1. Blood loss before second-line therapy was initiated, total blood loss, and the time between placental separation and application of second-line therapy were significantly higher in group 2 than in group 1 (P b 0.001) (Table 2). Fibrinogen levels in group 2 were significantly lower than in group 1 (P b 0.001) (Table 2). Factors significantly associated with total blood loss were blood loss before second-line therapy (P b 0.001), fibrinogen levels (P b 0.001), and time between placental separation and application of second-line therapy (P = 0.015). In group 1, the B-lynch suture was used in 27 (52%) women and gauze tamponade in 25 (48%) women. Management was successful in all patients in group 1 (Table 3) and a switch to other second-line procedures was not necessary. In group 2, the B-lynch suture was used in 4 (11%) women and gauze tamponade in 31 (89%) women. Management was successful in all women who received a gauze tamponade (Table 3). Among the 4 patients in group 2 managed with a B-Lynch suture, additional management was needed in three women. One woman received a gauze tamponade within 1 hour of the suture because of uncontrolled blood loss. Subsequently, this patient developed disseminated intravascular coagulation (DIC), and underwent a hysterectomy. One woman was treated with a gauze tamponade 15 minutes after the sutures because bleeding persisted. Her fibrinogen level declined to 1.84 g/L, and a fibrinogen infusion was administered. In this case, a
Table 1 Characteristics and treatment of patients with severe postpartum hemorrhage.a Variables Cause of PPH Uterine atony Placenta previa Placenta accreta Placenta increta Placenta abruption Uterine incision lacerations Biologic characteristics Diffuse intravascular coagulation Previous medical management 20 U oxytocin 500 μg carboprost thromethamine 100 μg carbetocin Transfusion RBC transfusion Number of packed RBC units transfused Fibrinogen transfusion Number of fibrinogen units transfused FFP transfusion Number of FFP units transfused
Group 1 (n = 52)
Group 2 (n = 35)
P value
49 (94) 3 (6) 0 0 0 0
20 (57) 6 (17) 3 (9) 2 (6) 1 (3) 3 (9)
b0.001 0.148 0.062 0.159 0.402 0.062
1 (2)
10 (29)
b0.001
52 (100) 52 (100) 52 (100)
35 (100) 35 (100) 35 (100)
N0.99 N0.99 N0.99
9 (17) 3.44 ± 1.67
35 (100) 5.28 ± 2.85
b0.001 0.072
2 (4) 4 ± 0.00
21 (60) 4 ± 0.00
b0.001 b0.001
9 (17) 213.7 ± 353.3
33 (94) 549.1 ± 408.5
b0.001 0.031
Abbreviations: PPH, postpartum hemorrhage; RBC, red blood cell; FFP, fresh frozen plasma. a Values are given as number (percentage) or mean ± SD, unless otherwise indicated.
hysterectomy was not necessary. In the third patient, blood loss continued after the B-lynch suture, and the hemoglobin level decreased from 81 g/L to 51 g/L. A packed gauze tamponade was inserted vaginally. 4. Discussion The best second-line treatment method for PPH at cesarean delivery is unclear. The appropriate method must be effective and should reduce the need for hysterectomy or blood transfusion. In the present study, patients in group 1 (500–700 mL of blood loss during cesarean delivery) were managed with the B-lynch suture or gauze tamponade, and all cases were managed successfully. WHO guidelines [15] recommend that compression sutures should be the first-line treatment. If this intervention fails, uterine, uteroovarian, or hypogastric vessel ligation may be attempted. At Beijing Haidian Maternal and Child Health Hospital, manual uterine massage and compressions are recommended as the first measure when PPH is unresponsive to conventional uterotonics. If uterine massage and compressions are ineffective, bilateral ligation of the uterine arteries should be performed. If these methods do not control blood loss, the uterine cavity should be packed with gauze. If the hemorrhage is affected by other factors such as a bleeding placental vessel, the first measure should be to suture the bleeding site. Suturing of an exposed placental vascular bed does not necessarily
Table 2 Time to application of second-line therapy, blood loss before second-line therapy, total blood loss, and fibrinogen levels in the two groups.a Variables Time between placental separation and application of second-line therapy, min Blood loss before second-line therapy, mL Total blood loss, mL Fibrinogen level, g/L a
Group 1 (n = 52)
Group 2 (n = 35)
t
P value
9.3 ± 4.9
20.2 ± 12.7
4.8
b0.001
580 ± 78
1057 ± 244
11.0
b0.001
758.8 ± 311 3.5 ± 0.8
1801 ± 589 2.4 ± 1.0
9.4 5.7
b0.001 b0.001
Values are given as mean ± SD unless otherwise indicated.
Please cite this article as: Zhao Y, et al, Appropriate second-line therapies for management of severe postpartum hemorrhage, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.05.015
Y. Zhao et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Conflict of interest
Table 3 The application of two methods in the two groups.a Group Group 1 (n = 52) B-lynch suture Gauze tamponade Group 2 (n = 35) B-lynch suture Gauze tamponade a b
3
Number of patients
Successb
Failure
27 (52) 25 (48)
27 (100) 25 (100)
0 0
4 (11) 31 (89)
1 (25) 31 (100)
3 (75) 0
Values are given as number (percentage). No need to use another treatment.
prevent PPH from uterine atony, so intrauterine tamponade might still be required, but sutures are necessary if an exposed placental vascular bed has severe active bleeding. The B-lynch suture was initially used in four women in group 2. In one, the management method was switched to insertion of an intrauterine gauze tamponade; however, DIC occurred, blood loss could not be controlled, and a hysterectomy was performed. In another patient, management was switched to a uterine sandwich (B-Lynch suture and balloon tamponade). In the present study, the risk factors associated with total blood loss were blood loss before second-line therapy, fibrinogen levels, and time elapsed before application of second-line therapy. The time elapsed before second-line therapy began was negatively correlated with fibrinogen levels; therefore, prompt treatment should be administered at the onset of PPH. The longer the time interval from onset of PPH to insertion of the tamponade will result in greater blood loss and decreased fibrinogen levels. When the fibrinogen levels cannot be recovered by infusion, DIC may occur. In conclusion, when PPH is unresponsive to drugs, second-line therapy should be administered quickly. If the blood loss is 500–700 mL, compression sutures or intrauterine gauze tamponade should be used. If the blood loss exceeds 700 mL, intrauterine packing with gauze is necessary. Early management leads to better results. The longer the time before application of second-line therapy, the greater the blood loss, the decrease in fibrinogen levels, and the risk of DIC.
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Please cite this article as: Zhao Y, et al, Appropriate second-line therapies for management of severe postpartum hemorrhage, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.05.015