If all forms of medical treatment have been undertaken and have failed, then surgical intervention becomes necessary. The patient should be adequately resuscitated as much as possible, and blood and FFP and cryoprecipitate should be given as required to correct DIC.
If the uterus appears contracted, but bleeding is still heavy early recourse to theatre to ensure the cavity is empty and suture any vaginal or cervical lacerations is advocated. This should be undertaken in a theatre setting with adequate light and assistance. If these methods fail, it is worth considering the use of a hydrostatic balloon. The Rusch balloon, which was previously used in Urology for bladder stretching, can be used. Through its drainage port, up to 500 ml of normal saline can be inserted into the catheter balloon, which is inserted into the uterus. A Sengstaken-Blakemore tube can also be used to blow up the stomach balloon, but it is complex to use and expensive.25 The catheter is usually left in situ for 24 hours, while uterine contractions are maintained with Syntocinon. The advantage of the balloon is it prevents the patient from having a laparotomy.26 Another option to create tamponade within the uterus is to pack the uterus.27 Uterine packing can be considered for control of haemorrhage secondary to uterine atony, placenta accrete, and placenta praevia. The instrument used in the referenced paper was a Torpin packer, but the most important issue is to pack the uterine cavity completely and uniformly. The incidence of concealed haemorrhage and infection do not seem to be major problems as long as the patient is covered with systemic antibiotics. The pack is generally removed after 5 to 96 hours.
If uterine atony is unresponsive to the previous measures, then a B-Lynch brace suture can be placed.28 This is undertaken as follows:
(1) The patient is usually under anaesthesia and should have already been catheterised as part of the PPH protocol.
(2) The abdomen is opened by an appropriate Pfannenstiel incision, or if the patient has had a caesarean section the scar should be re-opened.
(3) On entering the abdomen a lower segment incision is made after dissecting off the bladder, and the cavity is evacuated, examined, and swabbed out.
(4) The uterus is exteriorised, and this puts the uterine arteries on stretch. Bimanual compression is commenced to assess the potential success of the suture.
(5) A large needle (B-Lynch used 2 chromic catgut) 1 vicryl suture is used. This punctures the uterus 3 cm from the lower border of the uterine incision and 3 cm from the lateral border. The suture is threaded through the uterine cavity to emerge at the upper incision 3 cm above and, approximately, 4 cm from the lateral border.
(6) The suture, now visible, is passed over to compress the uterine fundus approximately 3 to 4 cm from the ipsilateral corneal border.
(7) The suture is fed posteriorly and vertically to enter the posterior wall of the uterine cavity at the same level as the upper anterior entry point.
(8) The suture is pulled under moderate tension, assisted by manual compression exerted by the first assistant. The length of suture is passed back posteriorly through the same surface marking as on the right side, the suture lying horizontally.
(9) The suture is fed posteriorly and vertically over the fundus to lie anteriorly and vertically, compressing the fundus on that side. The needle is passed in the same fashion on that side through the uterine cavity and out approximately 3 cm anteriorly and below the lower incision margin on the left side.
(10) The two lengths are pulled taut, assisted by bi-manual compression, to minimise trauma and to achieve or aid compression. During this compression, the vagina is checked to see if bleeding is controlled.
(11) The uterus is compressed by an experienced assistant, and the principal surgeon throws a double throw knot followed by 2 to 3 further throws to ensure tension.
(12) The lower transverse incision is closed in the normal way.
(13) For a major placenta praevia they suggest that an independent figure of eight suture be placed at the beginning, anteriorly or posteriorly or both, prior to the application of the B-Lynch suture.
In the original report there were two further pregnancies suggesting this suture does not compromise the uterus. Danso and Reginald reported using a combined B-Lynch suture with intrauterine balloon and suggested that this combination may work well together when one or the other procedure may not work on their own.29
Uterine artery ligation was shown to be successful in 255 patients, with only 10 patients over a 30-year period. The technique involved placing a suture to include 2 to 3 cm of the myometrium at a level of 2 to 3 cm below the uterine incision. Uterine viability is maintained via collateral circulation.30 Stepwise uterine devascularisation has been described in a report from Egypt. The steps involved are:
(1) Unilateral uterine artery occlusion.
(2) Bilateral uterine artery ligation (at the upper part of the lower uterine segment).
(3) Lower uterine artery ligation after mobilisation of the bladder.
(4) Unilateral ovarian vessel ligation.
(5) Bilateral ovarian vessel ligation.
Myometrium was included in the ligatures of (1) to (3). Steps (1) and (2) were deemed to be successful in 80% of cases.31 Internal iliac artery ligation appears to control blood loss by reducing arterial pulse pressure, essentially converting the pelvic arterial system into a venous one. In one study, arterial pulse pressure was reduced 14% by contralateral, 77% by homolateral, and 85% by bilateral internal iliac artery ligation.32 The procedure is technically challenging and should only be undertaken with the supervision of an experienced pelvic surgeon or vascular surgeon. It is successful only in about 42% of cases.
Selective Arterial Embolisation, in a literature review in 1997,33 showed a high success rate of selective artrial embolisation for post-partum haemorrhage. Potential complications include haematoma formation (at catheter placement site), infectious complications, and ischaemic phenomena. In addition, this is not available in all centres due to lack of equipment and interventional radiologists.
Hysterectomy was performed as an emergency, in one study, for uterine atony (in 43% of cases), placenta accreta (30%), uterine rupture (13%), low transverse incision extension (10%), and leiomy-omata (4%).34 These can be subtotal or total, the most common for total abdominal hysterectomy was placenta accreta (81%) and subtotal hysterectomy was uterine atony (64%).35
In patients who refuse blood transfusion and where there is access to the technology, autotransfusion can be undertaken.36 One study did not show evidence of infection or amniotic fluid embolism.
Placenta accreta is becoming a more prominent cause of PPH in recent years, probably due to the increase in caesarean section. The incidence of placenta accreta in an unscarred uterus was 0.26%, increasing linearly to 10% in patients with four or more caesareans. Patients with placenta praevia and an unscarred uterus have 5% risk of clinical placenta accreta. This rises to 65% ifthere is a placenta praevia and four or more caesareans.37 Patients with suspected placenta accreta should be delivered electively, preferably before labour starts and prior to serious vaginal bleeding. Some authors have suggested delivery at 35 weeks with prior consideration of amniocentesis, to assess foetal lung maturity. Most units would deliver at about 37 weeks in a well-equipped theatre with adequate numbers of senior staff available and full blood bank and haematology support. General anaesthesia should be considered as these procedures can be prolonged. In cases where serious bleeding is anticipated intra-operative autotransfusion, intra-arterial catheters (for balloon occlusion), selective arterial embolisation, and other modalities should be considered prior to delivery. Adequate operative field access cannot be over-emphasised and, generally, a midline incision is performed. If a decision to perform hysterectomy is taken due to morbid adherence of the placenta, then the placenta is left in situ after delivery of the baby. The uterine incision is closed, and the hysterectomy proceeds. The placenta is always left in situ after delivery of a foetus of an abdominal pregnancy as to attempt to remove a placenta that may be embedded in one of the pelvic vessels, can cause catastrophic haemorrhage leading to death. The placenta is generally left in situ to reabsorb itself over some weeks to months, or administration of methotrexate can be considered.
Bleeding can continue after hysterectomy, often due to an underlying coagulopathy and the use of intra-abdominal38 or pelvic pressure pack.36 The pelvic pressure pack can be made from an X-ray cassette bag. It can be filled with gauze rolls and tied end to end. This will provide enough volume to fill the pelvis. The pack is introduced abdominally with the stalk exiting the vulva. Mild traction is exerted by tying a litre bag of fluid to the stalk and hanging it over the end of the bed.
To summarise, obstetric haemorrhage is frightening. Awareness and rapid assessment of haemorrhage and instituting measures to decrease bleeding can, however, reduce the morbidity and the mortality from haemorrhage.
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