Compressive uterine sutures to treat postpartum bleeding secondary to uterine atony.

OBJECTIVE: To demonstrate the usefulness of a new method of applying compressive sutures to treat postpartum bleeding secondary to uterine atony. METHODS: Multiple sutures were applied longitudinally and transversally around the uterus of 7 women with postpartum uterine atony and postpartum bleeding. RESULTS: The procedure was successful in all cases. CONCLUSION: Compressive sutures of the uterus were effective in treating uterine atony with postpartum bleeding. LEVEL OF EVIDENCE: III.

Histerectomía puerperal: estudio de 14 años / Puerperal hysterectomy: a 14-year study

Se realizó un estudio retrospectivo, longitudinal y descriptivo en el hospital docente "Julio Trigo López", con el objetivo de caracterizar las histerectomías puerperales en el período comprendido entre Mayo de 1989 a diciembre del 2002 . El universo estuvo comprendido por 99 pacientes para una tasa de incidencia de 21,8 por 100 000 nacimientos. Se encontró que la cesárea se destaca como proceder de riesgo en el 55,7 por ciento de los casos. Las causas fundamentales que llevaron a estas pacientes a la histerectomía fue la atonía en un 28,2 por ciento de los casos, seguida por la infección en un 25,2. Sólo el 25,2 por ciento de las pacientes histerectomizadas presentaron alguna complicación en el posoperatorio. La tasa de mortalidad materna por histerectomía puerperal fue muy baja en este período de estudio, para el 1,1 por cada 10 000 nacimientos(AU)

B-Lynch Brace Suturing in primary post-partum hemorrhage during cesarean section.

Primary atonic post-partum hemorrhage during lower segment cesarean section, which was not controlled by ecbolics--oxytocin, methylergometrine, 15-methyl-prostaglandinF2alpha--was managed by applying a B-Lynch Brace Suture. The test of potential efficacy was the control of hemorrhage by bimanual uterine compression. Six primigravida patients at their term gestation, who underwent emergency cesarean section, all except one under spinal anesthesia, received this type of suture. Interestingly, in every case hemorrhage was controlled successfully with the compression suture. None of them received blood or blood products transfusions or developed disseminated intravascular coagulopathy. Postoperative recovery was good and all patients are in follow-up to assess their future reproductive activity. B-Lynch Brace Suturing is an invaluable procedure for the control of atonic primary post-partum hemorrhage following cesarean delivery.

Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII.

BACKGROUND: Postpartum hemorrhage is one of the most common causes of maternal mortality and morbidity worldwide. The aims of treatment are to maintain the circulation and to stop the bleeding. The latter is achieved by either medical or surgical management. In intractable bleeding, emergency hysterectomy is usually required. CASE: A 30-year-old nullipara presented with major postpartum hemorrhage due to uterine atony and vaginal lacerations. The patient developed hemorrhagic shock, resulting in prolonged prothrombin time, prolonged activated partial thromboplastin time, and low levels of factor VIII and fibrinogen. Treatments with uterotonic drugs, suturing, ligation of internal iliac arteries, subtotal hysterectomy, packing of the pelvis, and blood transfusion failed to control diffuse pelvic and vaginal bleeding. Recombinant activated factor VIIa (60-microg/kg intravenous bolus injection) was given as a final attempt to control the bleeding. The bleeding was successfully controlled within 10 minutes after administration. No side effects were noted. CONCLUSION: Recombinant factor VIIa may be an alternative hemostatic agent in a patient with life-threatening postpartum hemorrhage unresponsive to conventional therapy.

Resultados sobre la etiopatogenia de la atonía puerperal. Vasculopatías aceleradas intramurales como factor desencadenante. Rol del ácido hialurónico / Preliminary results on the etiopathology of uterine atony. Accelerated intramural vasculopathy as a triggering factor. The role of hyaluronic acid

La atonía uterina puerperal es un evento con significativa morbimortalidad materna caracterizado por la incapacidad del útero de contraerse, siendo su consecuencia la hemorragia genital y trastornos de la coagulación. En este trabajo se estudiaron los úteros de 8 casos de histerectomías realizados por atonía uterina y se compararon con 5 casos control de cesáreas electivas de embarazos normales. El estudio histopatológico de los casos de atonía demostró edema y necrosis de las fibras miometrales, observándose además vasculopatías que consistieron en alteraciones de la pared muscular de los vasos con aumento del ácido hialurónico (AH) y marcada proliferación neointimal. Estas vasculopatías fueron observadas en 7 de los 8 casos de atonías. En uno solo de los 5 casos control fue hallado un vaso con mínima proliferación neointimal (p<0.009). Asimismo, los 8 casos de atonías uterinas presentaron aumento del AH intersticial mientras que en los 5 casos control solo mostraron vestigios del mismo (p<0.001). En conclusión, las vasculopatías serían las responsables de la isquemia miometral, con la posterior liberación de AH del miometrio al torrente circulatorio y, las subsecuentes alteraciones en la coagulación, serían probablemente inducidas por el mismo AH a través de su capacidad de ligarse a receptores específicos de las plaquetas

Selective arterial embolization of the uterine arteries in the management of intractable post-partum hemorrhage.

BACKGROUND: To evaluate the efficacy and safety of selective arterial embolization in the management of intractable post-partum hemorrhage. METHODS: Thirty-five consecutive women with severe post-partum hemorrhage (primary, n=25; secondary, n=10) were treated by selective embolization of the uterine arteries. The main cause of immediate post-partum hemorrhage was atonic uterus. Retained placental fragments with endometritis was the main cause of delayed hemorrhage. In all cases, hemostatic embolization was performed because of intractable hemorrhage. Hysterectomy had been performed in two cases before embolization but it had also failed to stop the bleeding. RESULTS: Angiography revealed extravasation in ten cases, spasm of the internal iliac artery in four cases, false aneurysm in two cases and arteriovenous fistula in one case. After embolization, immediate cessation or dramatic diminution of bleeding was observed in all cases. Two patients required repeated embolization the following day. No major complication related to embolization was found. In one patient with placenta accreta, delayed hysterectomy was necessary. Normal menstruation resumed in all women but two who had hysterectomy. One woman became pregnant after embolization. CONCLUSION: Selective emergency arterial embolization is an effective means of controlling severe post-partum hemorrhage. This procedure avoids high risk surgery and maintains reproductive ability.

[Intrapartum hemorrhages in the maternity ward of the Yalgado Ouédraogo University Hospital Center of Ouagadougou, Burkina Faso]. / Les hémorragies de la délivrance à la maternité du Centre Hospitalier National Yalgado Ouédraogo de Ouagadougou (Burkina Faso).

On 12,175 childbirth registered in 4 years, 200 cases of delivery haemorrhage have been observed giving a rate of 1.6% of these accumulated childbirth. 60 patients (30.5%) have been evacuated from region of the country. The main etiology were: placental retention (54.5%), uterine inertia (24.5%) and coagulation disorders (21%). Blood was not available for emergency transfusion of 72 patients (54.1%) 26 deplorable cases of death raised the rate of lethality by 13%. Instant research of risk factors on all parturients, recycling of all personal on elementary first aid and life saving, also an improvement of sanitary references will enable to lower incidences related to haemorrhage by delivery.

Intrauterine irrigation with prostaglandin F2-alpha for management of severe postpartum hemorrhage.

BACKGROUND: Severe postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. The use of prostaglandin F2-alpha to control severe postpartum hemorrhage may avert surgery for the control of bleeding. METHODS: After ruling out the possibility of genital tract injuries, 18 patients with severe postpartum hemorrhage caused by uterine atony were enrolled in the study. None of the patients responded to treatment with oxytocin, methylergonovine, or uterine massage. A Foley catheter was introduced into the uterine cavity and the balloon was inflated with 5 ml sterile saline solution. The catheter was connected to an infusion line of 500 ml saline solution containing 20 mg prostaglandin F2-alpha. The solution was infused at a rate of 3-4 ml/minute for the first 10 min, and then reduced to 1 ml/minute for a period of 12 24 hours. RESULTS: In 17 patients (94.4%) bleeding ceased within several minutes of initiation of intrauterine prostaglandin F2-alpha infusion, the uterus was firmly contracted and uterine bleeding did not recur. In one patient with placenta increta bleeding continued and hysterectomy was performed. None of the patients had any side effects. CONCLUSIONS: Intrauterine irrigation with low concentrations of prostaglandin F2-alpha is a simple, rapid and effective treatment for severe postpartum hemorrhage and facilitates constant and continuous hemostasis. Moreover, the minute dosage used eludes potentially complicating side effects.

Atonía uterina e histerectomía de emergencia en el postparto tardío. Presentación de un caso

Se presenta el caso de una paciente multípara de 34 años de edad, quien ingresó al servicio de urgencias obstétricas con un cuadro clínico de shock hipovolémico grave secundario a una atonía uterina en el décimo primer día del puerperio. Se practicaron maniobras de revisión y masaje uterino, y aplicación parenteral de oxitócicos y methergina, sin lograrse obtenerse respuesta de la contracción uterina. La gravedad de la situación hemodinámica determinó la necesidad de practicar una histerectomía de urgencias. En este caso se destaca lo tardío de la presentación de la atonía postparto, complicación clásicamente considerada dentro de las primeras horas del período puerperal. Es importante además la posibilidad de una relación etiológica entre lo acontecido a esta paciente con la presentación de una circunstancia generadora de un gran estrés emocional-la muerte accidental del esposo- posiblemente con mediación de mecanismos neuroendocrinos que expliquen la relajación uterina súbita

Bimanual uterine compression as a major technique in controlling severe postpartum hemorrhage from uterine atony.

A 27-year old woman, primigravida, 33 weeks' gestation, presented with complaints of labor pain and absent fetal movement. A dead fetus in utero, abruptio placentae, and labor pain were diagnosed. Severe postpartum hemorrhage from uterine atony and disseminated intravascular cogulopathy was noted after spontaneous delivery of the baby and placenta. Bimanual uterine compression for 40 minutes was performed as a major procedure accompanied by uterotonic drugs, correction of hypovolemic shock and coagulopathy by crytalloid, blood, fresh frozen plasma. The patient had no complications when seen at 6 weeks' postpartum follow-up.

Vaginal ligature of uterine arteries during postpartum hemorrhage.

Immediate postpartum hemorrhage due to uterine inertia is usually treated by injection of oxytocics. In some situations, bleeding continues and distends the uterine cavity, in turn disturbing the hemostasis that accompanies uterine retraction. Uterine bleeding must be rapidly reduced while the coagulation defect is corrected. The authors propose the vaginal ligature of uterine arteries, which can be performed in the delivery room, as an alternative to hysterectomy.

[Treatment of post-partum atonic hemorrhage with prostaglandin F2 alpha analogs]. / Lécba poporodního atonického krvácení analogy prostaglandinu F2alpha.

In the authors' group of patients with haemorrhage during childbirth, in 1990-1994 a total of 28 atonic haemorrhages were recorded, 15 of them were controlled by uterotonic treatment, in the remaining 13 cases haemostasis using PG F2 alpha was applied after ruling out post-partum injury. Some patients were given moreover saline infusions. According to initial results and consistent with the literature analogues of PG F2 alpha are effective uterotonic preparations of a new generation. With regard to their simple and rapid administration they are becoming the drug of first aid in the treatment of acute atonic haemorrhage.

[Practical use of sulprostone in the treatment of hemorrhages during delivery]. / Utilisation pratique du sulprostone dans le traitement des hémorragies de la délivrance.

OBJECTIVE: To assess intravenous use of sulprostone (Nalador), a prostaglandin E2 analogue, is case of post-partum haemorrhage due to uterine atonia. MATERIALS AND METHODS: A retrospective study on 315 cases of post-partum haemorrhage (PPH) from 1st January 1990 to 31st December 1992 in Baudelocque maternity. In 91 cases of PPH due to uterine atonia, usual oxytocin drugs were not sufficient and intravenous sulprostone was used. Characteristics of the patients, mode of sulprostone administration, side effects and treatment failures are reported. RESULTS: One or two dose of 500 micrograms were sufficient in 71% cases. Mean perfusion rate was 8.3 micrograms/mn. Success of treatment was 89% with few side effects (5.5%). No serious complication due to sulprostone was observed. Risk of treatment failure was 8.3 times greater when the delay between diagnosis of uterine atonia and sulprostone administration was more than 30 mn. CONCLUSION: Prostaglandins treatment, and particularly sulprostone, could be used more frequently and earlier in case of PPH due to uterine atonia. Further controlled studies are necessary to know if they should be used as a first line treatment instead of oxytocin in this indication.

[Analysis of risk factors of postpartum hemorrhage in rural women].

Sixty variables during pregnancy, labor and delivery of 951 rural women were analyzed to identify the risk factors of postpartum hemorrhage. The result showed that uterine atony (RR = 13.30, 95% CI = 8.23-21.50) and its related factors were the major risk factors of postpartum hemorrhage. The related factors included prolonged labor (3.49, 1.98-6.15), prolonged second stage of labor (2.72, 1.54-4.78), pregnancy induced hypertension (mild 2.35, 1.11-4.99; > or = moderate 3.04, 1.38-6.70), neonatal weight > or = 3.500 g (2.55, 1.66-3.91). Another category of postpartum hemorrhage risk factors were placental factors (6.32, 2.35-17.01), the third stage of labor > or = 10 minutes (2.65, 1.74-4.01), parity > or = 2 (2.61, 1.69-4.01) and maternal age > or = 30 (2.19, 1.13-4.24). The authors recommends that the stress should be put on the management of labor and delivery, to prevent and management of postpartum hemorrhage, through training the birth attendants to promote their ability to prevent and manage uterine atony and correct management of labor and delivery.

[Epidemiologic study on the risk factors of postpartum hemorrhage].

The 1:2 matched case-control retrospective study of postpartum hemorrhage (PPH) was undertaken in Suizhou, Hubei Province from 1 January 1990 to 31 December 1991. The subjects consisted of 109 women who had a PPH (blood loss equal to or more than 500 ml) and 218 women whose blood loss at delivery was less than 200 ml. The results showed that multiparity, age younger than 20 or older than 36, long second and third stages of labour, abortion, low income, lack of obstetric care, etc, were identified as risk factors statistically.

[Uterine defibrillation in uterine inertia. Report of 2 cases]. / Desfibrilación uterina en útero con inercia. A propósito de dos casos.

The uterine atony are the most common cause of postpartum hemorrhage. Manual compression and pharmacologic methods are usually used with a successful result. When pharmacologic methods fail to control hemorrhage from atony, surgical measures should be undertaken to arrest the bleeding before it becomes life-threatening. We presents the utilization of electrical uterine defibrillation in two cases with acute hemorrhage confirming the effectivity of the proceeding.