Conservative surgical management for immediate postpartum hemorrhage

This study was approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (certificate of approval no.920/2017).

The medical records of patients who had immediate PPH between January 2011 and December 2016 were reviewed. PPH is defined as blood loss of more than 500 ml following vaginal delivery and 1,000 ml following cesarean delivery. Conservative surgical management included B-Lynch uterine compression suture, Bakri balloon tamponade, and uterine artery ligation. Demographic data such as age, parity, gestation of pregnancy at delivery, and cause of PPH were recorded. The operative outcomes, intraoperative and perioperative complications, and need for subsequent hysterectomy were recorded.

The standard protocols of uterotonic agents for controlling PPH at the King Chulalongkorn Memorial Hospital were oxytocin infusion 20–40 IU in 1,000 ml 0.9% NaCl; methylergometrine 0.2 mg intravenous, repeated every 15 min to a maximum dose of 1 mg; and sulprostone 500 μmg intravenous drip for 1 h. If the bleeding continued, conservative surgical management or hysterectomy was chosen according to the patient’s preference and surgeon’s judgment. The Bakri balloon tamponade was filled with 300–500 ml saline and placed in the uterine cavity for 24–48 h. Uterine compression suture was performed as described by Allam and B-Lynch [9].

The conservative surgical treatment was considered successful if the patient did not require subsequent hysterectomy. For the patients with successful conservative surgical treatments, postoperative complications at 6 weeks postpartum were collected from the medical records and subsequent pregnancy outcomes were acquired via direct contact by telephone.

Of 30,271 deliveries, 669 patients experienced immediate PPH, or 2.2% of total deliveries. Most patients had successful treatment with uterotonic agents, and only 61 patients (9.1%) did not respond to the medical treatment. Hysterectomy was selected initially for 30 patients (49.2%). Conservative surgical management was performed in 31 patients (50.8%). The demographic data are shown in Table 1. Mean age of the patients was 33 years, ranged between 20 and 41 years. Twenty-one patients (67.7%) delivered at term gestation. Emergency cesarean delivery was the most common route of delivery.

Indications for cesarean delivery included cepholopelvic disproportion (CPD), placenta previa, and previous cesarean delivery. The most common cause of PPH was uterine atony, accounting for 74.2% of patients, followed by bleeding from the placental bed without evidence of placenta previa (19.4%) and placenta previa (6.5%).

B-Lynch uterine compression suture was performed in 13 PPH patients due to uterine atony. The Bakri balloon tamponade was performed in 15 patients. Three patients had continued bleeding after Bakri balloon tamponade, and B-Lynch uterine compression suture was applied. Uterine artery ligation was done in 3 patients. The surgical outcomes are shown in Table 2. There were no maternal deaths in this series; however, disseminated intravascular coagulopathy (DIC) was detected in 8 patients (25.8%): 5 patients in the Bakri balloon tamponade group and 3 patients in the uterine compression suture group. Massive blood transfusion was defined as receiving packed red blood cells (PRC) of 10 units or more [10]. Only 1 patient in the Bakri balloon group (3.2%) required a massive blood transfusion and developed pulmonary edema. Intra-abdominal injuries such as bladder and bowel injury were reported during cesarean delivery in 4 patients in the Bakri balloon tamponade and uterine compression suture groups.

Hysterectomy could not be avoided in 8 PPH patients (25.8%) – 4 in the Bakri balloon tamponade group, 3 in the B-Lynch uterine compression suture group, and 1 in the uterine artery ligation group. Two patients were primigravida. Three patients performed elective cesarean sections, and the other 5 patients performed emergency cesarean sections. Success rates were 73.3%, 76.9%, and 66.7% for Bakri balloon tamponade, B-Lynch uterine compression suture, and uterine artery ligation, respectively. Per protocol analysis, there were 3 patients who failed Bakri balloon tamponade and preceded to perform uterine compression suture, and the success rate of uterine compression suture was 75% (12/16 patients) but 66.7% (8/12 patients) for Bakri balloon tamponade.

All 23 patients who had successful conservative surgical management reported normal menstruation after the procedures. Eleven of 23 patients desired subsequent pregnancy. Three of them (27.3%), 1 from each conservative surgical treatment group, were able to conceive and carry out viable pregnancy within 1 year.

Incidence of immediate PPH remains high and tends to increase with increasing cesarean section rates. Cesarean delivery, particularly emergency cesarean delivery, is associated with a higher risk of PPH [11]. PPH is problematic and leads to maternal morbidity and mortality worldwide. Uterine atony is the most common cause of PPH, and it is usually managed with uterotonic agents. If medical treatments are unsuccessful, conservative surgical management such as uterine compression suture, balloon tamponade, and uterine artery ligation are considered especially in patients who desire to preserve their fertility function. The incidence of PPH in our study is concordant with the findings from other countries in Asia. In 2012, Calvert et al. reported an incidence of 1.9% in Asia, including Japan, Hong Kong, East Asia, and Thailand [12]. Another study done in Thailand showed a 4.2% incidence rate of PPH [9]. Different definitions of PPH and methods for blood loss assessment might be reasons for different PPH incidence rates [13].

The decisions to perform conservative surgical treatments were made according to the patient’s preference and the surgeon’s professional judgment. Bakri balloon had been reported to achieve hemostasis in PPH related to placental bed bleeding from low-lying placenta [3]. However, it is used not only for the bleeding from the lower segment but also for uterine atony. The uterine compression suture used in our institute was the B-Lynch technique, which has been reported to be effective in the treatment of PPH due to uterine atony. Correct application of the B-Lynch suture distributes tension across the uterine cavity and maintains the uterine tone until involution starts [14]. Some modifications to the compression suture, such as Hayman’s and Cho’s, have been described. The potential setbacks of modified sutures include occlusion of the uterine cavity and retention of blood clots, both of which can interfere with the physiological postpartum involution of the uterus [15, 16]. However, which compression suture techniques is the most effective is unknown because there was no comparative study [17].

A systematic review showed no statistically significant differences in the efficacy of uterine compression suture, balloon tamponade, iliac artery ligation (IAL), and arterial embolization; the success rates were reported as 84% for balloon tamponade, 91.7% for uterine compression suture, and 84.6% for IAL or uterine devascularization [18]. In our study, the Bakri balloon tamponade and uterine compression suture had similar success rates (66.7% and 75%, respectively), which were slightly lower than the study by Kaya et al. (79.1% and 80%) [19]. The success rates were higher when combined with IAL, 95% in the Bakri balloon tamponade group and 91.6% in the B-Lynch group. One previous study in Thailand reported the success rate of uterine compression suture to be 95.8% (23 out of 24 patients). In 6 of them, combination of B-Lynch suture and bilateral uterine artery ligation was performed [8]. Mean estimated blood loss in our study was slightly higher than previous reports. More severity and delayed to perform conservative surgical management might led to lower success rates in our study. In the uterine artery ligation group, hemorrhage could be controlled in 2 out of 3 patients (66.7%). A study from Boynukalin et al. reported a success rate of 20 out of 26 patients (76.9%) [20]. Due to the limited number of patients in our study, more patients are needed to confirm the efficacy of this approach.

The impact of conservative surgical treatment on subsequent pregnancy outcome is interesting. Doumouchtsis et al. reported that it did not involve the menstrual and fertility outcomes in most women. The authors reported that 91.2% women experienced menstruation within 6 months after surgery. Seventy-seven percent of women who desired another pregnancy achieved conception [17]. Resumption of normal menstruation was noted in all patients in our report. However, the subsequent pregnancy rate was lower in our study when compared with previous studies [17, 21, 22]. Longer follow-up is needed to confirm the exact pregnancy rates.

Conservative surgical management is effective for the treatment of intractable immediate PPH, with acceptable success rates and low complication rates. Such procedures tend to have promising fertility outcomes. Medical providers should be encouraged to utilize these treatments without delay. Timely recognition and prompt intervention play a crucial role in preventing maternal morbidity and mortality.