Advances in the Treatment of Postpartum Hemorrhage

Alison M El Ayadi; Nuriya Robinson; Stacie Geller; Suellen Miller


Expert Rev of Obstet Gynecol. 2013;8(6):525-537. 

In This Article

Temporizing Measures & Other Procedures for PPH

Temporizing measures recommended for intractable atonic and non-atonic PPH include external aortic compression, bimanual uterine compression and the non-pneumatic anti-shock garment (NASG).[6] External aortic compression significantly reduces blood flow to the pelvic organs while preserving blood supply to surrounding organs.[61] It has traditionally been accomplished manually, with a provider applying pressure with a closed fist on the abdominal aorta slightly to the patient's left and immediately above the umbilicus.[62] Recently, the external aortic compression device (EACD), a hand-made spring device held in place by a leather belt, was used as a first aid temporizing intervention. EACD use was associated with significantly reduced time to cessation of uterine bleeding in one study; however, additional research is necessary to determine the effectiveness of this device.[61]

The NASG (Figure 4) is a low-technology first-aid device for stabilizing women suffering hypovolemic shock secondary to obstetric hemorrhage (OH). It is a lightweight, re-usable lower-body compression garment made of neoprene and VelcroTM. The NASG plays a unique role in hemorrhage and shock management by reversing shock and decreasing blood loss; thereby stabilizing the woman until definitive care is accessed. The NASG increases blood pressure by decreasing the vascular volume and increasing vascular resistance within the compressed region of the body, but does not exert pressure sufficient for tissue ischemia like its predecessors. It can be used for OH of any etiology, applied by individuals with minimal training, and does not compete with the use of other PPH management interventions. Quasi-experimental studies at the tertiary care facility level have shown significantly reduced measured blood loss, more rapid recovery from shock and decreased mortality.[63–65] The NASG is recommended as a temporizing measure for PPH by the WHO and FIGO,[6,27] and RCOG indicates that NASG may be useful in UK settings during transfer from midwife-led to consultant-led units.[22] It also may have a role during transport of hemorrhaging women from rural areas to urban treatment centers, or while awaiting procedures or surgery.

Figure 4.

Non-pneumatic anti shock garment.

Arterial balloon occlusion and UAE are procedures that can prevent major blood loss, obviating the need for blood transfusion and hysterectomy, and are recommended for trial prior to surgical intervention.[66] These procedures are performed by an experienced interventional radiology team. Occlusion is often prophylactic for known placenta accreta by placement of occlusive balloons in the internal iliac or uterine arteries, which are inflated in the event of PPH.[67] If bleeding continues despite inflation, embolization can be performed via the balloon catheters, or via dedicated catheters by placement of microparticles, polyvinyl alcohol, gel foam or coils, which occlude blood flow to the uterine arteries.[68] UAE is recommended as a conservative management alternative for multiple hemorrhage etiologies where resources are available.[6] It is not widely used despite case studies demonstrating high clinical success rates (95%), low complication rates (4.5%) and preliminary evidence of fertility preservation.[69] Other research reports a comparative advantage of shorter operating time for UAE, lower operating blood loss and higher success rate in placenta accreta when compared with other hemostatic surgeries.[70] Complications such as uterine necrosis, thromboembolic events or fistula have been reported; thus, these techniques require sufficient expertise.[71]