What is the role of laparotomy 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

The choice between a subumbilical vertical incision and a Pfannenstiel incision for entry into the abdomen is left to the individual surgeon. Both entries have support, and no strong evidence indicates that either is superior in this setting. [63] If concern exists regarding pathology in the upper abdomen or if exposure is thought to be a concern, the vertical incision is recommended. Broad-spectrum antibiotic coverage is advised.

Upon entry, remove any free blood and inspect the uterus and surrounding tissues for evidence of rupture or hematoma. If uterine rupture is found, a rapid decision must be made concerning the viability of repair versus hysterectomy. Bleeding may be reduced in either instance by grasping bleeding points on the torn edges with clamps. The number of layers used for any repair is dictated by the thickness of the tissue and the hemostatic response to suturing. Principles are similar to those of cesarean delivery incision repair. Ensure that bleeding is stopped and not merely internalized because this would result in ongoing vaginal bleeding or hematoma formation. Any repair must be carefully observed for hemostasis before abdominal closure is performed. Uterine exteriorization may improve exposure and decrease operating time, but great care must be taken to not worsen uterine trauma and to keep the uterus warm and well perfused to avoid worsening atony.

Hemostasis must be reassessed after the uterus is returned to the abdominal cavity. Consider placement of a suction drain.

If the uterus is intact upon entry and the bleeding has been caused by atony, then direct bimanual massage and compression may be performed while systemic uterotonics are continued. Direct injection of oxytocin, carboprost, and/or ergonovine may be successful in overcoming atony.


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