Obstetric Haemorrhage

In an Editorial in January 2005 I wrote about the use of ergometrine and the strange reluctance to use it in managing post-partum haemorrhage (PPH) to produce effective uterine contraction and retraction (MacLean, 2005).

In the same issue Baskett & O'Connell (2005) had reviewed severe maternal morbidity over 15 years in Halifax, Nova Scotia. Haemorrhage requiring more than five units of blood had occurred in 115 cases of 159,896 deliveries (0.74 per 1000) and emergency hysterectomy was performed for 88 patients(0.55/ 1000). The need to perform hysterectomy for life-saving treatment is extreme, but sometimes the only option when medical treatment failed.

Our latest Confidential Enquiry into Maternal Deaths in the United Kingdom (Cantwell et al, 2011) records that deaths from obstetric haemorrhage declined in the triennium 2006-2008, but recommends that all clinicians responsible for the care of pregnant women should carry out regular skills training, and that early senior multidisciplinary team involvement is essential in the management of major obstetric haemorrhage.

In this issue I have collected together a series of reports or case histories that describe alternatives to hysterectomy. Although some of these treatment options have been available for some years, the recognition of complications following their deployment is now accruing and needs including in any discussion with a patient before proceeding.

Keriakos & Chaudhuri (2012) have reported their experience in Sheffield of 40 surgical interventions for major obstetric haemorrhage with 30,466 deliveries over 4 years; major PPH complicated 1.6% of these deliveries and surgical intervention was necessary in 7.8% of these PPHs or 0.1% of the total deliveries. These surgical interventions include 31 cases where Rusch balloons were used for tamponade, eight insertions of B-Lynch sutures, and eight cases that ultimately required hysterectomy. The article contains thoughtful analyses of those cases where interventions failed and hysterectomy became necessary. It has appended to it the guidelines developed in Sheffield for the management of post-partum haemorrhage and the insertion of a Rusch balloon, and anyone who needs updating on these skills is advised to read on.

The Case Report by Lodhi et al (2012) describes that not everything used in the management of obstetric haemorrhage produces a successful outcome; their case had a B-Lynch suture inserted at Caesarean section when the atonic uterus did not retract and when haemorrhage continued an intrauterine balloon was inserted. Although this combination achieved haemostasis the patient returned ten weeks later and required hysterectomy for uterine necrosis.

Nakash et al (2012) write a similar message when infection plus necrosis compromised the uterus of three women who had undergone uterine artery embolisation to control obstetric haemorrhage. These patients had been given multiple antibiotics to combat puerperal sepsis but the embolisation of the uterine vessels seemed to restrict the antibiotics reaching the site of the infection. Two of these women required hysterectomy while the third made a slow recovery to eventually have return of menstrual function.

Pandey et al (2012) describe a rare complication of uterine artery embolisation used in gynaecology to shrink uterine fibroids; eight months later their patient returned with vaginal discharge and a laparotomy performed when she continued to deteriorate found loops of small bowel adherent to the serosal surface of the fibroid and fistulous discharge of enteric contents into the uterus.

A Case Report from Srivastava et al (2012) describes a successful use for the Rusch balloon, positioned and inflated within the vagina after a midcavity forceps delivery had produced haemorrhage from extensive vaginal wall tears.

Finally, Nandi et al (2012) describe the use of FloSeal, bovine derived gelatine which is mixed with and activated by human derived thrombin, to control bleeding arising at caesarean section from the anterior surface of the uterus where previous surgery had produced adhesions with the bladder and the rectus sheath. The usual techniques of suturing, diathermy and mechanical pressure had failed to improve things but application of FloSeal had produced rapid and effective haemostasis.

Such cases remind us that haemorrhage is a constant challenge, that ergometrine and medical management has much to commend it, but that surgical intervention may become necessary and might not always allow successful outcomes. The resort to hysterectomy for major obstetric haemorrhage is less but still necessary; for further comment see Chapter 4 in Cantwell et al (2011).