Pelvic packing in the treatment of severe postpartum posthysterectomiam hemorrhage

Overview

Introduction: Pelvic packing (PP) as a simple method of ”damage control surgery” in severe abdominopelvic hemorrhage in gynecological and obstetric surgery after emergency obstetrics or gynecological hysterectomy. Objective: To present the case of successful PP as a simple and effective method in refractory pelvic bleeding after emergent peripartum hysterectomy and severe obstetric shock with consumptive coagulopathy. Case report: Acording to laboratory findings and clinical condition in a 30-year-old (G2 P2) parturient, it was most likely an obstetric embolism with uterine rupture as the cause of severe postparum hemorrhage with disseminated intravascular coagulopathy and obstetrics hemorrhagic shock development in the described case. Pelvic packing after postpartum hysterectomy was the definitive minimally invasive and simple hemostatic procedure. Conclusion: The use of pelvic packing and obstetrics skills should be included in the protocol as a necessary, life-saving, and uncomplicated vital indication procedure.

Keywords:

Postpartum hemorrhage – obstetrics shock – emergency postpartum hysterectomy – pelvic packing

Introduction

The causes of severe maternal morbidity and mortality have not changed in recent centuries: obstetrics hemorrhage (i.e. postpartum hemorrhage – PPH), hypertensive disorders, and sepsis. Today, maternal mortality caused by PPH is growing in line with the enormous increase in cesarean sections and consequent prevail/morbid malplacentation, severe PPH, and obstetric  shock [1,2].

Massive obstetric hemorrhage is defined by the loss of blood > 2,500 L and is complicated by obstetric shock with disseminated intravascular coagulopathy (DIC), multi-organ failure (MOF), and emergent peripartum hysterectomy (EPH), which often aggravates an already difficult, often moribund condition. About 4–4.5% of maternal mortality was associated with EPH [2,3]. The former obligatory EPH in PPH is replaced by uterine-sparing surgical procedures: vascular ligation (uterine devascularization, and/or internal iliac arteries) and uterine compression sutures (i.e. B-Lynch or Cho’s sutures) with success rates ranging from 60 to 100%, and pelvic packing (PP – pelvic tamponade), in severe refractory bleeding after EPH and DIC development [3–5]. Adequate transfusion supplementation and inhibition of hyperfibrinolysis by tranexamic acid (TXA) contribute to a reduction in maternal mortality [4,5].

We present the case of successful PP as a simple and effective method in refractory pelvic bleeding after EPH and severe obstetric shock with consumptive coagulopathy.

Case report

A 30-year-old (G2 P2) parturient with a proper personal, family, and gynecological history was admitted to the maternity ward due to the spontaneous onset of term delivery in 40 weeks of pregnancy. The course of the pregnancy was orderly. Vital functions at admission were normal, cardiotocography was 140–150/min, reactive curves were present, contractions were 2/10, and she had a 5 cm cervix dilatation. An amniotomy was performed and two hours after spontaneous regular contractions, a live male newborn (3,050/50 cm) was born with an Apgar score of 10-10. The intact placenta was expelled spontaneously with oxytocube (Syntocinone®, Novartis India Ltd) at 2.5 UI I.V. While the perineal rupture of the first degree in the fourth delivery period was being taken care of, the mother experienced pain in the lower abdomen on the left side. She was bleeding profusely on one occasion. Ergometrine (Ergometrin®, Lek Ljubljana, Slovenia) was administered at 0.2 mg i.v., and she was bleeding from the atonic cervix which was shown through the specula. She was given tranexamic acid (Cyklokapron®, Pfizer Ltd, NY) at 1 g i.v. and carboprost tromethamine (Carboprost® Woodward Pharma Services Ltd, UK) at 1 amp intracervically. Owing to the prescribed therapy the bleeding was stopped, but 15 min later the mother felt hot and lost consciousness followed by immeasurable blood pressure and filiform tachycardic pulse of around 100/min without bleeding from the vagina and with a contracted uterus. Considering the development of the obstetric shock, infusions of colloids and crystalloids were started immediately. An anesthesiologist was called to intubate the patient and an obstetrician did a manual exploration of the uterus, but found no retained parts of the placenta. The uterus became atonic and bled profusely. The orienting emergency ultrasound did not find free fluid in the abdomen, the state of shock did not improve, so it was decided to perform an urgent exploratory laparotomy under general anesthesia. A large retroperitoneal hematoma with a 5 cm isthmic rupture of the uterus was found from which there was profuse bleeding with atony of the uterus. A supracervical hysterectomy was performed because of a difficult condition of the secundipara and findings, but an uncontrolled DIC developed despite parallel intensive resuscitation procedures. Heavy vaginal bleeding was found, so a cervicectomy was performed, but the whole pelvis bled profusely and uncontrollably (Fig. 1). PP was done and 10 long swabs were placed next to two drains along the situationally sutured anterior abdominal wall. During the four-hour operation, she received: 2,750 mL of concentrated erythrocytes A (+), 1,520 mL of cryoprecipitate, 8 L of crystalloids and colloids, TXA (Cyklokapron®) at 2.0 g i.v., recombinant factor VII (NovoSeven®, NovoNordisk) ino­tropic support of atropine, ephedrine, noradrenaline, dopamine, and dobutamine. Laboratory findings indicated a severe form of DIC, so the patient in a state of prolonged severe obstetric hemorrhagic shock was placed in the ICU for further intensive treatment and monitoring. After 48 hours from the first surgery and coagulation-hemodynamic stabilization, tampons soaked in warm physiological solution were removed under general endotracheal anesthesia (Fig. 2). There was no sign of active bleeding, so the abdominal drain was placed and closed. On the second postoperative day, about 250 mL of blood was drained, vital functions were normal, so the drain was removed. The postoperative course was complicated by a febrile condition with antibio­tics and secondary anemia due to massive transfusions with orderly primary wound healing. On the tenth postoperative day, the patient was discharged in a good general condition with normal vital functions and oral antianemic preparation.

Discussion

PP began to be applied in gynecological surgery in the early 20^th century [6] with sporadic successful reports in women with severe gynecological and obstetric hemorrhage. In the last decade, it has been suggested as a method of treating refractory and severe pelvic bleeding after EPH [7–9]. In surgical journals, abdominal packing has been shown as a successful primary method in resolving bleeding in various visceral injuries and retroperitoneal bleeding with the aim of compressive hemostasis and prevention of hypothermia, acidosis and coagulopathy [10] and MOF development. The goal of PP after EPH is compressive hemostasis and stabilization of obstetric shock so that definitive, secondary surgery can be done to evacuate the tamponade and primary closure of the abdominal cavity.

There are two approaches to PP in gynecological and obstetric surgery after EPH and gynecological hysterectomy, most often due to malignancy: transvaginal and transabdominal (intraabdominal, pelvic packing, pelvic pressure packing) with closed abdomen or laparostomy modalities. In 1926, Logothetopoulos described a pack for the management of uncontrolled post-hysterectomy pelvic bleeding: transvaginally, he placed a large gauze tamponade 45 × 28 cm into which he pushed a 10-meter-long tamponade, the size of a child’s head, and achieved a complete compression hemostatic effect [6]. Later, authors named this transvaginal technique mushroom, parachute, umbrella, or pelvic pressure, with or without minor modifications [11,12].

PP as a method of ”damage con­trol surgery” (open abdominal management – laparostomy) was introduced in a severely bleeding patient with multiple lesions of the viscera and vessels, and it has three phases: emergency intervention due to refractory PPH; stabilization of coagulation, thermoregulation, and perfusion; and definitive surgical procedure PP. It is used clinically in severe penetrating injuries of visceral organs (liver, pancreas) and blood vessels, in other heavy bleeding in the abdominal/pelvic cavity, in oncological operations, severe preeclampsia with HELLP syndrome, and liver rupture. After the tamponade with gauze of the abdomen/pelvis, the abdomen is left open and closed with Backhaus forceps, which reduces early postoperative complications (temporary abdominal closure techniques), such as Bogota Stock Exchange techniques [5,10]. Laparostomy [10] is justified in presumed postoperative intra-abdominal hypertension, which in turn prevents abdominal compartment syndrome, reduces visceral edema, fascial tension, and accumulation of intra-abdominal fluid, significantly reducing early and late morbidity and mortality. Today, it is recommended to soak TXA tampons which have a local antifibrinolytic hemostatic effect. Also, a sterile nylon bag can be placed in the abdomen or pelvis in which gauze swabs are placed and soaked in 1 L of saline. PP can be placed transvaginally, which then prevents the need for relaparotomy, but only transvaginally withdraws in 24–48 hours.

With minor venous bleeding, it is possible to obtain a hemostatic effect by applying a hemostatic sponge or chitosan [12,13]. The use of Chitosan (Celox®, Medtrade Products Ltd, UK) for primary hemostasis of open war injuries was introduced into obstetric practice several years ago as intrauterine tamponade. Carles et al. have performed successful PP with Chitosan gauze [14] in severe post-hysterectomy pelvic bleeding. The prophylactic antibio­tic is recommended for preventing infection, presence of a foreign body in the abdomen, applied massive transfusions, and consequent pyrogenic reactions.

In recent years, the success rate of PP of 80–100% has been described in the literature. Dildy et al have shown the success of PP after severe post-hysterectomy bleeding; 100% in 23 gynecological and 85% in 13 obstetric cases [3]. Touhami et al showed 100% success of PP in all cases where it was applied to PPH after EPH; they had intestinal necrosis in nine cases of relaparotomy; there was no difference in the need for a blood transfusion, and there was more fever in the PP group than in patients without PP [8]. Deffieux et al showed 7% EPH in multiple centers with 53 abdominal packs after a failed EPH in PPH control in the years 2003–2013. PP was removed on average after 39.5 hours, the success rate was 62%, and maternal mortality was 24%. They suggested that PP for 24–48 hours is the ultimate procedure for controlling persistent PPH after EPH [9]. Howard et al showed posterior colporexis with uncontrolled pelvic bleeding after EPH and reparation of vaginal lacerations in which a successful pelvic umbrella pack (Logothetopulous) was performed [7]. Robie et al [12] showed successful pelvic hemostasis with tamponade in a patient with cesarean hysterectomy for placenta accreta with PPH. Ghourab et al reported a successful abdominopelvic packing in all four women with severe PPH after cesarean hysterectomy [15]. PP, among other mentioned principles and methods, belongs to the damage control strategy of life-threatening conditions, including traumatized bleeding patients as well as obstetric patients [16].

According to laboratory findings and clinical condition, it was most likely an obstetric embolism with uterine rupture as the cause of severe PPH with DIC in this case.

Conclusion

The use of PP and obstetrics skills should be included in the protocol as a necessary, life-saving, and uncomplicated vital indication procedure in today’s period of obstetrics, increased number of cesarean sections that are a major risk factor for previous and invasive malplacentation, consequent PPH and EPH and increased maternal morbidity and mortality due to severe hemorrhagic obstetric shock. Our case report indicates the need for this.

ORCID authors

D. Habek 0000-0002-7675-7064

G. Pavlović 0000-0003-4410-9895

A. Cerovac 0000-0002-7209-382X

Submitted/Doručeno: 5. 6. 2022

Accepted/Přijato: 22. 9. 2022

Anis Cerovac, MD, PhD

Department of Gynaecology  and Obstetrics

General Hospital Tešanj

Braće Pobrić 17

74260 Tešanj

Bosnia and Herzegovina

cerovac.anis@gmail.com