What is the role of surgery in the treatment of postpartum hemorrhage (PPH)?

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

Ongoing bleeding secondary to an unresponsive and atonic uterus, a ruptured uterus, or a large cervical laceration extending into the uterus requires surgical intervention. Laparotomy for PPH following a vaginal delivery is rare. In a review of emergency peripartum hysterectomies over a 5-year period in Los Angeles, Calif, the rate was 1 in 1000 deliveries, but most of these cases began as cesarean deliveries, usually for placenta previa. [60] A study from Boston, Mass, found a rate of 1.5 in 1000 deliveries with similar risk factors. [61] Canadian and Irish studies put the rate at 0.4 and 0.3 per 1000 deliveries, respectively.

Adequately resuscitate the patient before surgery. This includes optimizing hemoglobin and coagulation status as previously described. Fully inform anesthetic and operating room staff as to the nature of the case. Schedule for a second surgeon to be in attendance, if possible. As mentioned previously, sustained bimanual compression and massage and uterine packing may be used to gain time to mount a surgical response. Military antishock trousers provide the equivalent of an approximately 500- to 1000-mL autotransfusion and potentially gain time during a resuscitation. Only the leg portion of the trousers are inflated in the setting of PPH. Direct compression of the aorta may be performed for a short period while the operating room is prepared.

A recent systematic review examined various techniques used when medical management is unsuccessful. These included arterial embolization, balloon tamponade, uterine compression sutures, and iliac artery ligation or uterine devascularization. At present, no evidence suggests that any one method is more effective for the management of severe PPH. Randomized controlled trials of the various treatment options may be difficult to perform. Balloon tamponade is the least invasive and most rapid approach and may thus be the logical first step. [62]


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