Laird Harrison

May 08, 2015

SAN FRANCISCO — Icing the uterus might halve the rate of postpartum hemorrhage during cesarean delivery, a new study shows.

"This could be a good preventive measure for postpartum hemorrhage, and potentially for uterine atony," Janice Mitchell, MD, from the Baylor College of Medicine in Dallas, told Medscape Medical News.

Postpartum hemorrhage is the leading cause of worldwide maternal mortality.

Dr Mitchell presented the study results here at the American Congress of Obstetricians and Gynecologists Annual Clinical Meeting 2015, where the research won a Donald F. Richardson prize.

The researchers wanted to know whether cooling the uterus after delivery of the fetus and placenta would promote uterine contraction and involution, resulting in less blood loss. Their hope was that it would prevent the need for uterotonic medications, blood products, and emergency hysterectomies.

The study involved 200 women who underwent a scheduled cesarean delivery or cesarean delivery after a trial of labor. Women who were unable to give consent were excluded from the study, as were women with uteri the researchers did not think they could exteriorize.

Half the women were randomly assigned to uterine cooling and the other half were assigned to a control group.

Surgery was performed in the usual way up to the point of uterine exteriorization for hysterectomy repair. Immediately after placenta delivery, the surgical team switched to a new suction canister. A bolus of pitocin 3 mU was administered, followed by pitocin 10 mU placed in intravenous fluid running at 125 cm³/h.

In the cooling group, the surgical team wrapped the uterine fundi in icy laparotomy sponges prepared using a sterile slush machine. In the control group, they wrapped the uterine fundi in warm laparotomy sponges.

The surgeons administered additional boluses of pitocin or other uterotonic agents at their discretion. They completed surgery in the usual way.

To calculate blood loss, the researchers weighed all sponges, the drape, and any pads used, measured the blood in the second suction canister, and then subtracted the amount of irrigation used. They continued measuring blood loss until the patient was transferred to the postpartum unit.

Before the wrap was removed, the difference in the core temperature of the women was not significant between the two groups. However, when the wrap was removed, the temperature of the uteri in the cooling group was significantly lower.

There was no significant difference between groups in blood loss in the postanesthesia care unit, or in hemoglobin, hematocrit, uterotonics administered, Bakri balloon placement, blood products administered, or additional interventions.

However, blood loss during surgery was 29% lower in the cooling group than in the control group. In addition, postpartum hemorrhage was less common in the cooling group (9% vs 21%; P < .02).

Table. Blood Loss Related to Cesarean Delivery

Timepoint Cooling Group, cm³ Control Group, cm³ P Value
During surgery 418 616 <.001
During postanesthesia care 106 141 .18
Total 536 756 <.001

 

Dr Mitchell reported that, as far as the researchers could tell, this is the first time anyone has tried this method of preventing blood loss.

Although it is a fairly simple and inexpensive approach, she cautioned that further study of the technique is needed before clinicians begin using.

The researchers are planning a trial that focuses on women who undergo cesarean delivery after a trial of labor, Dr Mitchell explained. In addition, the team is looking for ways to increase the use of cooling, such as through vaginal insertion.

After the presentation, a member of the audience suggested that the researchers compare their results with those obtained when the uterus is left in situ for repair.

"That would be a good idea," Dr Mitchell said.

Core body temperature is associated with a risk for postpartum endometritis, "so a lot of anesthesiologists will do all kinds of things to warm mom postpartum, rather than cool her," said Sharon Phelan, MD, from the University of New Mexico in Albuquerque.

She asked whether the researchers had looked at the risk for postpartum endometritis.

"Our study didn't evaluate the number of patients who had endometritis," Dr Mitchell reported. However, the researchers collected data on complications, "and that was not one of them."

"I think this is extremely provocative work," said Caela Miller, MD, from the San Antonio Military Medical Center.

"It would be interesting to see if their results could be duplicated in a multinational trial," she told Medscape Medical News.

Dr Miller, Dr Phelan, and Dr Mitchell have disclosed no relevant financial relationships.

American Congress of Obstetricians and Gynecologists (ACOG) Annual Clinical Meeting 2015: Abstract 31. Presented May 5, 2015.

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