How is trauma-related postpartum hemorrhage (PPH) treated?

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

Genital tract trauma is the most likely cause if bleeding persists or is present despite a well-contracted uterus. Use appropriate analgesia along with good lighting and positioning, which facilitates excellent exposure. If not already initiated, moving the patient to an operating room is reasonable at this time. Experienced assistants and an excellent circulating nurse are essential.

Directly visualize and inspect the cervix with the aid of ring forceps. The anterior lip is grasped, and the cervix is inspected by using a second ring forceps placed at the 2-o’clock position, followed by progressively "leap-frogging" the forceps ahead of one another until the entire circumference has been inspected. Small, nonbleeding lacerations of the cervix do not need to be sutured. Suture any laceration that is bleeding significantly or appears to have the potential to bleed significantly. Each side of the laceration can be grasped with a ring forceps back from the torn edge, and gentle traction can be used to aid exposure.

Use an absorbable, continuous interlocking stitch, and use tapered (rather than cutting) needles for all repairs except for the perineal skin. Ensure that the stitch begins above the apex of the tear, as with vaginal lacerations and episiotomies. If the apex cannot be visualized, place the stitch as high as possible and then use it to apply gentle traction to bring the apex into view. Polyglycolic sutures have largely replaced catgut; however, the latter may be somewhat less likely to tear the friable tissues of the cervix and vaginal vault and may thus be useful in repairing lacerations in these areas. The laceration must be observed for bleeding after the torn edges of the cervix are approximated. The ring forceps can be replaced and left on for some time if oozing persists.

Lacerations of the vaginal vault must be well visualized and their full extent realized prior to repair. Lacerations high in the vaginal vault and those extending up from the cervix may involve the uterus or lead to broad ligament or retroperitoneal hematomas. The proximity of the ureters to the lateral vaginal fornices, and the base of the bladder to the anterior fornix, must be kept in mind when repair is undertaken in these areas. Poorly placed stitches can lead to genitourinary fistulas. An absorbable, continuous interlocking stitch is used. The stitch must start and finish beyond the apices of the laceration. Great care must be taken because the tissue is usually very friable. Take a good amount of tissue, and ensure that the needle reaches the full depth of the tear. Ongoing bleeding and hematoma formation are possible if small bites are taken.

Again, the laceration must be observed for bleeding after the repair is complete. Pressure or packing over the repair may achieve hemostasis or allow for better placement of further hemostatic stitches. Cervical and vaginal vault lacerations that continue to ooze or those that are associated with hematomas may be amenable to selective arterial embolization (see Selective arterial embolization).

Traumatic hematomas are rare and may be related to lacerations or may occur in isolation. They include vulvar and paravaginal hematomas in the lower genital tract and broad ligament and retroperitoneal hematomas adjacent to the uterus. Patients with lower genital tract hematomas usually present with intense pain and localized, tender swelling. Broad ligament hematomas may be palpated as masses adjacent to the uterus. All may result in significant blood loss that mandates resuscitation.

Lower genital tract hematomas are usually managed by incision and drainage, although expectant management is acceptable if the lesion is not enlarging. [58] Any bleeding vessels are tied off, and oozing areas may be oversewn. Place a Foley catheter because urinary retention can occur because of pain and tissue distortion. Vaginal packing may be useful following drainage and repair of a paravaginal hematoma. Remove the pack in 24-36 hours. Embolization may be used in both vaginal and vulvar hematomas that are unresponsive to surgical management.

Broad ligament and retroperitoneal hematomas are initially managed expectantly if the patient is stable and the lesions are not expanding. [59] Ultrasound, CT scanning, and MRI all may be used to assess the size and progress of these hematomas. Selective arterial embolization may be the treatment of choice if intervention is required in these patients. Use surgical procedures to evacuate the hematoma, and attempt to tie off any bleeding vessels. Consider involving a surgeon with extensive experience operating in the retroperitoneal space.


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