AMY : POS1PARTUMHAEMORRHAGE

treatment of choice will consist in the selective angiographicembolization of the vessel(s) involved.Step 6. Exploration of the genital tract may reveal still otheranomalies.

Placenta accretaIn the event of an abnormal placenta (placenta accreta, increta orpercreta), the plane of cleavage along which the placenta normallyseparates from the uterine wall during the third stage of labour,does not exist. If one does not attempt to forcefully remove theplacenta by tearing it off peacemeal, haemorrhage will not occur.Hysterectomy should be considered, as every form of conserva-tive management is associated with a high risk of mortality.

Uterine inversionAcute uterine inversion is usually associated with a fundal inser-

0.5 mg methyl ergometrine i.rn.Massage and compress the uterusInfuse solution of 20 units oxytocin i.v,~--------------------~Order (fresh whole) blood,

transfuse when available

Examine genital tract; Remove retainedsecundines; Suture lacerations.Perform laparotomy if uterine rupture

Inject transvaginally into the myometrium0.5 mg PGE2 or 1-2 mg PGF2a or0.125-0.25 mg 15-methyl PGF2aRinse the uterine cavity with 2 Lphysiological saline at 50°C..--------

I Assess the coagulation andL correct clotting defects

Moderate bleeding: Do selective - - - - - Iangiographic embolization I

ISevere bleeding or failure of embolization

Give general anaesthesia,monitor vital functions

Ligate ascending branch of uterinearteries transvaginally

Perform laparotomy: Ligate ascendingbranch of uterine arteries at lower(if not done transvaginally) and upper ends

IIIIIIIIIII.J,

or Ligate anterior branch of hypogastricarteries and upper end of ascendingbranch of uterine arteries

Carry out (subtotal) hysterectomy

Fig 1. Management of severe postpartum haemorrhage (Carry outsequentially until the arrest of haemorrhage)

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tion of the placenta. In case of complete inversion the diagnosisis obvious as a large mass protrudes through the introitus, fre-quently with the placenta still attached. Partial inversion may notbe diagnosed at once. Manual exploration should be carried outwithout delay in the event of excessive bleeding and the develop-ment of shock-its importance is much more than that of bloodloss. The uterine fundus cannot be palpated through the abdomi-nal wall.

Correction of the inversion must be done at once, if possibleunder general anaesthesia; if not, without it. The intravenousadministration of a tocolytic agent (e.g. ritodrine 400 mg/minute)will facilitate the procedure. If the placenta is still adherent, theuterine fundus is reduced before any attempt is made to removethe placenta. The administration of an oxytocic drug after reduc-tion of the inversion will cause a tetanic contraction of themyometrium and thereby prevent the recurrence of inversion.

Uterine ruptureLaparotomy should be carried out without delay if a rupture of thelower uterine segment or uterine corpus is found. The cause of therupture, the parity and general condition of the patient, the extentand site of the tear will all have to be taken into account todetermine whether the rupture can be sutured, or a subtotal or totalhysterectomy should be performed.

TREATMENT OF HYPOTONIC HAEMORRHAGEStep 1. In the absence of the above complications, and if thebleeding is thought to be due to uterine hypotony, 1-2 mgprostaglandin (PG) F2a or 0.5 mg PGE2 or 0.125--0.25 mg 15methyl-PGF2a in 10-20 ml physiological saline is injected intothe myometrium via the vaginal route. In more than 90% of casesthe uterus contracts rapidly, and the bleeding diminishes consid-erably. Asthma is the major contraindication for the administra-tion of PGF compounds and sickle cell anaemia for PGE deriva-tives.

Step 2. In case bleeding persists, the uterine cavity is rinsed with2 L of physiological saline at 50 "C. This also causes sustainedtetanic contraction of the myometrium and arrest ofhaemorrhage.

Packing of the uterus is usually ineffective, and consequen-tially a waste of time and dangerous.

Step 3. Assess the coagulation and correct clotting defects, ifany. Acute disseminated intravascular coagulation (DIC) causesa marked lengthening of the thrombin time, and low fibrinogenand factor vm levels. Treatment should consist ofthe administra-tion of 10 units of cryoprecipitate in addition to fresh frozenplasma.'

Step 4. If the bleeding is still not under control, one must choosepromptly between either selective angiographic embolization ofthe bleeding vessel(s), or surgical treatment. The first optionentails that the patient should be transported to the radiologydepartment and therefore inappropriate when dealing with anacute and massive postpartum haemorrhage. But it is the treat-ment of choice for persistent bleeding of moderate intensity,particularly when it has caused a haematoma to develop.

Selective angiographic embolization requires only local anaes-thesia.It may be carried out even on patients with severe coagulo-pathy. If the blood loss originates from the uterus, both uterinearteries should be occluded because of the existence of innumer-able vascular anastomoses between the left and right sides of theuterus. At times, embolization of the ovarian arteries is alsorequired. A variety of particulate matter is available for angio-

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graphic embolization, the selection of which depends on the sizeof the vessel to be occluded and whether short term or permanentobliteration is desired. Metal coils with numerous Dacron fibresattached are available in various sizes and effect permanentocclusion of large vessels. More commonly, small particles ofgelfoam are used to obtain short term (10-30 days) occlusion ofsmall bleeding arteries. Uneventful pregnancies have been re-ported after this procedure. Complications of the percutaneoustechnique are infrequent. They include isolated cases of paresis ofthe lower limb, effort-related ischaemia of the gluteus muscle,muscular necrosis and thrombosis of the femoral artery.

Step 5. If the haemorrhage is life-threatening, surgical treatmentmust be carried out at once. The patient is given general anaesthesia,and her cardiac, pulmonary and renal functions are monitored.Before proceeding with a laparotomy, one should now attempt toarrest the haemorrhage by ligating the uterine arteries transvaginallyas recently described by Philippe et al. 3 The procedure consistssequentially of transverse incision and reflection of the vaginalwall overlying the anterior lip of the cervix, dissection of thebladder cephalad, ligation of the uterine arteries laterally from thelower uterine segment and closure of the initial incision. Ifsuccessful, the bleeding slows down rapidly, and then stops. Theprocedure requires very little time, and allows the obstetrician toavoid a laparotomy on a patient in poor condition because of themassive haemorrhage she has sustained. However, particular careshould be taken to prevent trauma to the ureters when the uterinearteries are isolated and then ligated.

Step 6. In case of persistent bleeding, a laparotomy is performedvia a vertical subumbilical incision. The uterus and other pelvicorgans are thoroughly inspected. If the uterine arteries have notbeen ligated via the vaginal route, the vesico-uterine fold of theperitoneum is incised in a transverse fashion, the uterine arteriesare identified and ligated bilaterally. The terminal part of theascending branch of each uterine artery (which anastomoses in anend-to-end fashion with the terminal part of the ovarian artery) isalso ligated, medially from the ovary.

Step 7. As an alternative to the ligation of the origin of theascending branches of the uterine arteries trans vaginally ortransabdominally, one may elect to ligate the anterior branch ofboth internal iliac (hypogastric) arteries. To this end, and in rapidsuccession, the middle third of each round ligament is suture-ligated twice and divided between the ligatures. The peritoneumof the pelvic wall is undermined and then incised up to the originof the infundibulo-pelvic ligament. The medial edge of the peri-toneum and the underlying ureter are gently retracted. The vesselsof the pelvic side wall, namely the common iliac artery and its two

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 11, No.2, 1998

main branches, the external and internal iliac arteries, are dis-sected free of the loose connective tissue surrounding the vesselsby blunt dissection. The internal iliac artery runs vertically downinto the pelvis, in front of the sacro-iliac joint. After a fewcentimetres, it divides into an anterior or visceral branch, and aposterior or parietal branch. The anterior branch of the internaliliac artery is grabbed and slightly elevated with an atraumaticclamp (e.g. Babcock clamp). A right angle clamp (e.g. Mixterclamp) is then gently inserted under the artery, going from outsideto the inside, care being taken not to damage the underlying vein.A loop of chromic gut No. 1 is grabbed with the end of the Mixterclamp, which is then withdrawn, and the .vesselligated.

Step 8. If the patient is still bleeding, a hysterectomy is per-formed. Subtotal hysterectomy is easier and faster. However,persistent bleeding originating from the area of implantation of aplacenta praevia or from a low lying placenta accreta necessitatesa total hysterectomy.

Ligation of the arteries should not involve their satellite veinsif at all feasible. Interruption of venous return will cause a rise invenous pressure which may adversely affect the blood loss. Theuse of resorbable material (e.g. chromic gut No. I, or a fast resorb-ing polyglycolic suture) allows for recanalization of the vesselsecondarily, as demonstrated by angiographic studies performedseveral months after surgery. Subsequent pregnancies have anormal course.

CONCLUSIONIn the overwhelming majority of cases, hypotonic PPH can bearrested by the timely application of non-surgical means. Ifbleeding of moderate intensity persists, selective angiographicembolization of the involved arteries should be attempted. If, onthe other hand, the bleeding is severe the uterine arteries shouldbe ligated transvaginally before performing a laparotomy.

REFERENCESI de Groot ANJA. Prevention of postpartum haemorrhage. In: Bailliere's Clinical

obstetrics and gynaecology. 1995;9:619-31.2 Rosevear SK, Stirrat GM. Handbook of obstetric management. Oxford:Blackwell

Science, 1996:266-73.3 Philippe HJ, d'Oreye D, Lewin D. Vaginal ligature of uterine arteries during

postpartum haemorrhage. Int 1 Gynecol Obstet 1997;56:267-70.4 Amy JJ. Pelvic haemorrhage: Principles of management. In: Amy JJ (ed.) Jaarboek

1992. Sint Niklaas:Vlaamse Vereniging voor Obstetrie en Gynaecologie, 1993:141-3.

5 Benedetti TJ. Obstetric hemorrhage. In: Gabbe JR, Niebyl JR, Simpson JL (eds).Obstetrics-Normal and problem pregnancies. New York:Churchill Livingstone,1986:485-515.

6 Schwartz PE. The surgical approach to severe postpartum hemorrhage. In: BerkowitzRL (ed). Critical care of the obstetric patient. New York:Churchill Livingstone,1983:285-97.