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

Surgical Management of PPH

Failed medical and mechanical approaches to management of PPH warrant surgical exploration.[72] The surgical approach differs by delivery method, suspected etiology and clinical status.[73] The surgeon must decide if a dilation and curettage, laparotomy (or re-laparotomy after cesarean section), with exploration and/or hysterectomy is indicated.

Placement of uterine compression sutures in a suspender fashion to promote uterine contractility may be a useful initial attempt at bleeding cessation while preserving fertility. Similar to manual compression and balloon tamponade, compression sutures should be used as a first step in surgical management when hemorrhage is a result of atony. This technique, referred to as a B-Lynch procedure or Cho suture if a hysterotomy has been performed (delivery via cesarean section) and Hayman suture in the absence of a hysterotomy (vaginal delivery), is technically less challenging than vessel ligation and results in less morbidity than a hysterectomy.[72] Alternatively, the uterine or the internal iliac arteries can be ligated bilaterally to temporarily decrease blood perfusion to the uterus. While ligation of the internal iliac arteries was once more common, uterine artery ligation is now favored for ease of identification and higher success rates (80–96%).[74]

While the aforementioned surgical procedures are often attempted in succession, combining surgical techniques may maximize hemostasis while maintaining fertility. Shahin et al. combined compression sutures and uterine artery ligation on patients with atonic PPH secondary to adherent placenta accreta.[75] While the study sample was small (n = 26), this approach may be a safe and effective option for surgical management of atonic PPH in the future. In the event that compression sutures, vessel ligation and stepwise de-vascularization fail, definitive management of PPH is hysterectomy.