How is postpartum hemorrhage (PPH) caused by tissue retention treated?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Answer

If the uterus continues to contract poorly or to relax when bimanual compression and massage are stopped despite the administration of uterotonics, perform manual exploration. Some authorities advocate earlier exploration; however, this is difficult without general anesthesia unless the patient is in severe shock or an epidural is already in place. Nitrous oxide (Entonox) may be useful in facilitating manual exploration if general anesthesia is not available.

Ensure that resuscitation is well underway by this time, and, if not already started, institute the massive hemorrhage protocol. If possible, keep the vaginal hand in situ throughout because it minimizes patient discomfort, the risk of iatrogenic trauma, and, possibly, the risk of subsequent infection. If the placenta was not delivered before the onset of PPH, an attempt is now made to deliver it with cord traction and uterine countertraction. Care must be taken because the risk of uterine inversion is greater if the uterus remains poorly contracted. Perform manual removal if the placenta is not easily delivered or the cord is avulsed.

Perform manual removal with a level of analgesia that matches the clinical urgency of the situation. The hand is passed through the cervix and into the lower segment. Care is taken to minimize the profile of the hand as it enters, keeping the thumb and fingers together in the shape of a cone in order to avoid damage. Control of the uterine fundus with the other hand is essential. If the placenta is encountered in the lower segment, it is removed. If the placenta is not encountered, the placental edge is sought. Once found, the fingers gently develop the space between the placenta and uterus and shear off the placenta. The placenta is pushed to the palmar aspect of the hand and wrist, and, once it is entirely separated, the hand is withdrawn. Do not stop uterotonics while the manual removal is being performed. Restart bimanual massage, and have an assistant examine the placenta for completeness.

If the placenta has been previously delivered, then exploration of the uterus is still indicated at this time. The hand is introduced in the same manner, with control of the uterine fundus with the other hand. Any clots are removed. The cavity is gently explored with attention to any defects suggestive of uterine rupture. Rupture in the absence of a previous scar is uncommon. Rupture or dehiscence of a previous lower segment scar does not usually bleed heavily. The presence of a uterine rupture dictates that a laparotomy be performed.

A partial uterine inversion can be detected as the hand is introduced, just as a complete uterine inversion would have been detected as the hand was placed in the vagina. If the condition is encountered, return the uterus to its normal position by pressure on the inverted fundus from within the uterus. If retained placental tissue is encountered, it is sheared off the uterine wall and delivered. Adherent placental fragments may be left in situ or removed by gentle curettage. The risks of curettage include uterine perforation and increased bleeding caused by laceration of uterine vessels. This may be somewhat minimized by the use of a large, dull curette. Fragments left in situ may be removed by curettage sometime after the crisis has passed, although an increased risk of infection probably ensues.

The administration of short-term, broad-spectrum antibiotics following manual removal, manual exploration, or instrumentation of the uterus in this context is commonly advocated. Evidence is very limited, but a single small, randomized trial supports the practice. [51]

Immediately resume bimanual massage and compression following exploration and evacuation of the uterus. Continue infusion of oxytocin, and administer repeat doses of other uterotonics if the uterus fails to contract and maximal doses have not already been given. The uterus may contract well, and bleeding abates with massage, followed by uterine relaxation and increased bleeding when compression and massage are stopped. Prolonged massage at this point may allow the uterus to contract and retract if it can be kept empty of clots and if perfusion can be improved with adequate resuscitation. Any period of decreased bleeding allows fluid and blood component replacement to exceed blood loss and help improve the patient’s status.

Surgical management is necessary if the uterus does not remain contracted and bleeding persists despite all efforts. Packing of the uterus may be an option until the operating room is ready or if surgery is not an immediately available option. Uterine packing fell into disfavor during the 1960s as being nonphysiological, concealing ongoing blood loss, and increasing the risk of infection; however, reports since then have been favorable in very select circumstances when all previously mentioned maneuvers have failed. [52] The uterus and vagina must be tightly packed with continuous, layered, 2- or 4-inch gauze under direct visualization using a speculum and/or retractors or a purpose-built uterine packer. [53] At times, packing may serve as a definitive treatment. In these cases, the packing is usually removed in 24-48 hours in a setting where recurrent bleeding can be managed if it occurs.

Intrauterine catheters for tamponade of bleeding have also been used. In the past, large bulb Foley catheters or Sengstaken-Blakemore tubes have been used. [54] More recently, experience has been gained using catheters specifically designed for postpartum hemorrhage. One such device is the SOS Bakri tamponade balloon (Bakri, 2001). In low resource settings, condoms and surgical gloves have been used successfully to control bleeding. [55] Anti-shock garments are also being evaluated in low resource settings for both the definitive treatment of uterine atony as well as a method to allow time to bring other treatments to bear [56]

Manual examination helps to exclude a cervical or vaginal laceration, but direct visualization confirms that bleeding is coming from the uterus and excludes the possibility of missing trauma to the lower genital tract. If packing is meant to be definitive treatment, then ongoing assessment of uterine size, blood loss, and patient status must be maintained. Continue uterotonics and commence broad-spectrum antibiotics. Remove the pack in 24-36 hours in a setting that allows for appropriate management if bleeding recurs. Packing may also be used as a temporizing measure before arterial embolization (see Selective arterial embolization). Isolated reports of successful uterine tamponade with balloon devices have also been published. [57]


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