Key-points
-
Postpartum hemorrhage is the world’s leading cause of peripartum hysterectomy, even
among women with a desire for future fertility.
-
Vascular ligation and uterine compression sutures must precede hysterectomy in the
surgical treatment of postpartum hemorrhage.
-
The main technique of vascular ligation is bilateral uterine artery occlusion, although
progressive devascularization techniques may optimize the surgical control of postpartum
hemorrhage.
-
Uterine compression sutures are heterogeneous and the choice of technique to be applied
must correlate with the hemorrhage etiology and the topography of the hemorrhagic
focus.
-
The combination of uterine compression suture and vascular ligation increases the
effectiveness of surgical treatment of postpartum hemorrhage.
-
Surgical techniques for controlling postpartum hemorrhage should be used immediately
after failure of drug therapy, preferably within the “golden hour”.
-
All pregnant women with placenta previa and previous cesarean section must have assisted
birth in a tertiary service.
-
Damage control surgery is indicated when the patient with postpartum hemorrhage is
already in the lethal triad and definitive interruption of bleeding was not possible
or requires excessive time.
Recommendations
-
In the surgical treatment of postpartum hemorrhage, when choosing vascular ligation
and/or uterine compression sutures, the technique option must correlate with the topography
of the hemorrhagic focus and the surgeon's skill and experience.
-
If uterine atony occurs during cesarean section and drug therapy fails, uterine compression
sutures of B-Lynch and Hayman and/or bilateral ligation of the ascending branches
of the uterine arteries are excellent surgical options.
-
In hemorrhage from placenta accreta that affects the uterine body, the Cho compression
suture is an excellent surgical option. In placenta accreta of the uterine segment,
both the Cho compression suture and low selective vascular ligations show excellent
results in hemorrhagic control.
-
If surgical techniques for uterine preservation fail, hysterectomy is indicated and
should be performed as early as possible, before coagulopathy is installed. Unless
there is concomitant infection or the hemorrhagic etiology is an invasive central
placenta previa, subtotal hysterectomy should be preferred.
-
The spectrum of placenta accreta in its previous increta and percreta varieties can
be treated by means of hysterectomy or uteroplacental segmental excision followed
by restoration of the uterine anatomy. Hysterotomy and fetal extraction should be
performed outside the invaded uterine area, usually in the uterine fundus. Vascular
neoformation must be carefully and selectively ligated and hysterectomy must be performed
with the placenta in situ. In the face of bladder invasion by the placenta, partial
cystectomy and/or reimplantation of the ureters may be necessary.
-
In damage control surgery, the incisions must be large to facilitate technical execution.
Open pelvic packing techniques with drainage reduce intestinal fistulas and increase
the rate of primary closure. In patients undergoing total hysterectomy, damage control
can be achieved through closed packing by adapting an intrauterine balloon in the
pelvis.
-
Skill training programs and simulations should be implemented in order to optimize
the safety of care teams when applying surgical techniques to control postpartum hemorrhage.
Background
Postpartum hemorrhage (PPH) is the world's leading cause of peripartum hysterectomy,
even among women with a desire for future fertility.[1] The main etiologies are uterine atony, birth canal trauma, ovarian tissue retention
and coagulation disorders. Uterine atony is the etiology with the highest incidence
and placenta accreta is the one with the highest lethality. The placenta accreta spectrum
shows its higher incidence that correlates with the contemporary increase in cesarean
section rates. Undoubtedly, the placenta percreta is the etiology of PPH that imposes
greater surgical difficulty, especially when neighboring organs are affected.[2]
In recent decades, several techniques have been developed to preserve the uterus in
PPH. Vascular ligation (VL), uterine compression suture (UCS), intrauterine balloons
(IUBs), arterial embolization (AE) and intravascular balloons stand out. When well
applied, surgical techniques (VL and UCS) can provide faster hemorrhagic control and
potentially preserve fertility.[3]
When and how to apply surgical techniques for uterine preservation?
When and how to apply surgical techniques for uterine preservation?
Vascular ligation and UCSs are surgical techniques for controlling PPH that provide
uterine preservation, and may or may not be applied in combination. The main indication
for these techniques is uterine atony with failure of drug therapy, especially during
caesarean section. Other indications include placenta accreta, uterine inversion after
repositioning the uterus and uterine rupture that can be preserved. These techniques
stand out for their low cost, fast learning curves, high percentage of success in
hemorrhagic control, fertility preservation, and for avoiding the additional loss
of two or more liters of blood linked to hysterectomy. Therefore, they are indicated
prior to hysterectomy.[4]
The chosen technique must correlate with the topography of the hemorrhagic focus,
since the genital vascular region S1 (uterine fundus and body) is irrigated by the
uterine and ovarian arteries, while region S2 (segment and cervix) receives blood
supply from the internal pudendal, inferior vesical and middle, upper and lower vaginal
arteries ([Figure 1]). Another important criterion when choosing the technique is the surgeon's skill,
knowledge and experience with the techniques.[5]
Figure 1. Sagittal scheme of the division of S1 and S2 genital vascular regions. Source: Illustration
by Felipe Lage Starling (authorized).
The main VL technique is the bilateral uterine artery occlusion (O'Leary technique).
Bilateral sutures are done in the ascending branches of the uterine arteries. Alternatively,
“high” ligations can be added by using sutures in the utero-ovarian connections bilaterally
located in the mesosalpinx.[6] This technique is excellent for uterine atony of the genital vascular region S1,
good for S1 accretism, but inefficient for hemorrhages in region S2. Very similar
to the O'Leary technique, the Posadas technique consists of flexing the uterus towards
the pubic bone, visualizing, palpating and ligating the ascending branches of the
uterine arteries in their path in the posterior wall of the uterus. In addition, it
is complemented by the occlusion of utero-ovarian connections in the mesosalpinx.[7] In the triple ligation of Tsirulnikov, in addition to the sutures described above,
sutures in the round ligament are added by obstructing the flow of the round ligament
arteries. In step-by-step ligation techniques, sutures are progressively applied at
10-minute intervals. The hemorrhagic control after the application of a certain step
is what determines the interruption in the application of sutures. In the AbdRabbo
technique, the sutures are progressively applied to the ascending branches of the
uterine arteries, to cervicouterine pedicles and to the ovarian arteries (infundibulopelvic
ligaments). In the Morel technique, sutures are progressively applied to the ascending
branches of the uterine arteries, round ligament arteries, utero-ovarian connections
in the mesosalpinx and cervicouterine pedicles ([Figure 2]).[8]
Figure 2. Vascular ligation techniques. Source: Illustrations by Felipe Lage Starling (authorized).
Upper left: bilateral ligation of the ascending branches of uterine arteries and utero-ovarian
connections in the mesosalpinx (O'Leary technique); upper right: Tsirulnikov's triple
ligation (1 - ascending branch of the uterine artery; 2 - round ligament artery; 3
- utero-ovarian connections in the mesosalpinx); lower left: step-by-step AbdRabbo
ligation (1 - ascending branch of the uterine artery; 2 - cervicouterine pedicle;
3 - ovarian artery); lower right: Morel step-by-step ligation (1 - ascending branch
of the uterine artery; 2 - round ligament artery; 3 - utero-ovarian connections in
the mesosalpinx; 4 - cervicouterine pedicle).
In the presence of invasive placenta previa, low selective ligations applied in region
S2 with the use of suture passer are the ideal techniques for hemorrhagic control
from vascular neoformation associated with accretism.[5] As the ligation of the internal iliac arteries (hypogastric) is performed far from
the uterus and its annexes, it is less efficient than the other techniques when used
alone. Its most accurate indications in PPH are severe lacerations of the birth canal
and as a supporting procedure in the control of damage in patients already hysterectomized
and in coagulopathy.[8]
[9] In association with other uterine preservation techniques (IUB and UCS), this technique
reduces hysterectomy rates.[10]
Uterine compression sutures provide mechanical compression in the uterine vascular
sinus with simultaneous occlusion or not of the uterine arteries and other points
of genital irrigation. The techniques are heterogeneous and what differentiates them
is the figure in which the suture is applied, the number of vertical and/or horizontal
suture sets and the penetration/occlusion or not of the uterine cavity. To predict
the success of the technique, the uterus must be compressed bimanually before the
sutures are applied, while the vaginal blood loss is checked simultaneously. The main
UCSs are those of B-Lynch, Cho and Hayman. The mechanism of action of the B-Lynch
suture is the compression of the uterine fundus on the segment, simulating the effect
of a uterine compression maneuver. The Cho suture promotes obliteration of the uterine
cavity and can be selectively applied to hemorrhagic topographies. The Hayman's technique,
on the other hand, has a mixed action mechanism, with compression of the uterine fundus
on the segment, associated or not with the obliteration of the segmental uterine cavity.
After exteriorization of the uterus, two loops are applied to the uterine segment
in the anteroposterior direction, each at a 3-4 cm distance from the lateral border
of the uterus, ending with the knots in the uterine fundus.[11] Thus, the B-Lynch suture is excellent for uterine atony in the S1 region, good for
accretion in S1 and ineffective for the S2 region. The Cho's technique is good for
uterine atony in S1 and excellent for accretism both in S1 and S2. The Hayman suture
is an excellent option for uterine atony in S1 and good for accretism both in S1 and
S2 ([Figure 3]).
Figure 3. B-Lynch, Cho and Hayman uterine compression sutures. Source: Illustrations by Felipe
Lage Starling (authorized).
The effectiveness of UCSs increases when they are associated with VL.[12] A simple and efficient option is to associate bilateral ligation of the ascending
branches of the uterine arteries with Hayman's upper vertical compressive loops.[13] This strategy provides an association of techniques performed with only four needle
passages in the uterus and is highly effective for the hemorrhagic control of uterine
atony and accretism in the S1 region ([Figure 4]).
Figure 4. Technique of uterine devascularization and uterine compression suture. Source: Illustration
by Felipe Lage Starling (authorized). Ligation of the ascending branches of the uterine
artery and vertical loops of the uterine compression suture
Another association that optimizes hemorrhagic control is the “uterine sandwich” technique,
in which the UCS is associated with uterine balloon tamponade. In this situation,
the balloon is inserted through the hysterotomy and the suture is applied under direct
vision, preventing the needle from passing through the balloon. The balloon infusion
should be limited to only 100 mL of saline and performed at the end of the surgery,
after closing the UCS and laparorrhaphy.[14]
In order to prevent associated complications, the current trend is towards the development
of removable UCSs.[15]
[16] The main techniques already described are the Aboulfalah and Zhang USCs (removable
B-Lynch and Hayman) ([Figure 5]).
Figure 5. Removable uterine compression sutures. Source: Illustrations by Felipe Lage Starling
(authorized). 1 - Aboulfalah; 2 - Removable B-Lynch by Zhang; 3 - Removable Hayman
by Zhang.
The main complications related to VL and UCSs are infections (pyometrium, endometritis
and endomyometritis), ischemic partial necrosis, erosions, sulcus and defects in the
uterine wall, synechiae, hematometrium, Asherman's syndrome and uterine rupture in
subsequent pregnancy.[4] Both VLs and UCSs must be made only with absorbable thread sutures. Polyglecaprone
is the suture material of choice, with polyglactin and polydioxanone as second options.
For the application of some techniques, straight needles may be necessary.[17]
When and how to perform hysterectomy in uterine atony?
When and how to perform hysterectomy in uterine atony?
Currently, hysterectomy should be the last stage of the surgical approach to PPH due
to uterine atony and performed without delay before the installation of the lethal
triad (coagulopathy, acidosis and hypothermia). Since the removal of the puerperal
uterus imposes an additional loss of two to three liters of blood, its late performance
can worsen the hemorrhagic shock. In the absence of a central placenta previa or infection,
subtotal hysterectomy should be preferred.[2]
How to treat placenta accreta surgically?
How to treat placenta accreta surgically?
Every pregnant woman with placenta previa and prior cesarean section must have assisted
birth in a tertiary service, because the treatment, especially of placenta percreta
that invades neighboring organs (bladder, abdominal vessels), requires a multidisciplinary
team.[18]
The surgical approach must be properly planned (reserve of blood components, definition
of the anesthetic technique and laparotomy incision), performed by an experienced
team and guided according to the invaded genital vascular region (S1 or S2). Since
placental blood flow at gestational term is 600 to 700 mL/min, elective interruption
between 35 and 38 weeks is consensus.[5]
[18]
Starting with spinal anesthesia until fetal extraction, then proceeding to general
anesthesia is a good strategy in the face of prolonged surgical time often imposed
by the need for extensive dissection of vascular neoformations. After wide laparotomy
(longitudinal incisions may be necessary) and adequate uterine exposure, hysterotomy
and fetal extraction should be performed outside the invaded uterine area. Thus, fundal
hysterotomies should be preferred. After clamping and removal of the umbilical cord,
hysterorrhaphy is performed with the placenta in situ. The ureters and internal iliac
arteries (hypogastric) should be located and the surgical technique defined. The exeresis
by segmental excision followed by restoration of the uterine anatomy may be preferable
to hysterectomy. Both require experience and dexterity from the surgeon to perform
the low selective ligation (using suture passer) of vascular neoformations, especially
in the uterine segment. In hysterectomy performed by means of high vascularization
and uterovesical adhesion, mobilization and bladder dissection (Pelosi by-pass) performed
in zones of adhesion are useful in preventing urinary tract injuries ([Figures 6], [7], [8] and [9]). In the face of bladder invasion by the placenta, one of the options is to perform
partial cystectomy and "onepiece" hysterectomy (Pelosi technique).[20] As an alternative to partial cystectomy, and especially in the face of invasion
of the bladder trigone (rare), embolization of the uterine and internal pudendal arteries
is a good option for sites with this technical availability. Eventually, ureteral
reimplantation is necessary. An alternative for the control of hemorrhage in the genital
vascular region S2 is the application of segmental UCSs. The most suitable techniques
for this purpose are the Cho UCSs (adapted by Palacios-Jaraquemada),[5]
[19] Dedes and Zioga or the transverse segmental figure-of-8 UCS ([Figure 10]). The strategies described above offer the advantage of onestep surgical resolution.
Figure 6. Steps of the cesarean-hysterectomy technique in the surgical treatment of placenta
accreta
Figure 7. Low selective ligation of vascular neoformations present in the uterine segment in
the surgical treatment of placenta accreta. Exposure of vascular neoformations present
in vesicouterine reflection by means of traction with Allis forceps. Double ligation
performed with a suture passer.
Figure 8. Mobilization and bladder dissection (Pelosi by-pass)
performed in the areas of vesicouterine adhesions in the surgical treatment of placenta
accreta. After performing the low selective ligation of vascular neoformations, mobilization
and blunt dissection of the vesicouterine space are performed.
Figure 9. Exeresis with segmental uteroplacental excision followed by restoration of uterine
anatomy in the surgical treatment of placenta accreta. Left: exeresis of the uterine
segment affected by invasion of placental cotyledons and ovular membranes. Center
and right: final result of restoration of the uterine anatomy with hysterorrhaphy
in the uterine fundus and suture between the uterine body and the lower residual portion
of the segment.
Figure 10. Cho uterine compression sutures (adapted by Palacios-Jaraquemada),[19] Dedes and Zioga and transverse segmental figure-of-8
In exceptional situations, such as in extrauterine placental implantations (in large
vessels or adjacent organs), maintaining the placenta in situ associated or not with
methotrexate or arterial embolization may be the safest resource.[19]
In the face of prenatal diagnostic failure followed by perioperative diagnosis in
non-ideal surgical conditions (lack of experience of the team and/or blood components),
the surgical procedure must be restricted to hysterotomy and fetal extraction outside
the invaded uterine area, followed by hysterorrhaphy with the placenta in situ and
laparorraphy. In these situations, the definitive re-approach (hysterectomy or excision
with uteroplacental segmental exeresis followed by restoration of the uterine anatomy)
is performed after the reorganization of the care conditions (two step).[5]
[19]
When and how to perform damage control surgery?
When and how to perform damage control surgery?
Damage control surgery (pelvic packing and laparostomy, with or without concomitant
ligation of the internal iliac arteries) is indicated when definitive bleeding control
was not possible or when it demands excessive time and the patient is already in the
lethal triad. The goal is to temporarily control the hemorrhagic focus and allow the
restoration of the patient's physiology in intensive care. The surgery is temporary.
The control of the remaining hemorrhagic foci and the permanent laparorrhaphy should
be performed two to five days later.[20]
[21]
Open pelvic packing techniques with drainage reduce intestinal fistulas and increase
the rate of primary closure. Longitudinal incisions may be necessary for good technical
execution. A good option for open packing (laparorrhaphy) includes the insertion of
7 to 10 compresses in the pelvis and a fenestrated pouch above the package that will
not be sutured, being loose and below the parietal peritoneum. Above this first bag,
two compresses are allocated. Above these, one or two drains, plus two compresses
for top drain protection are placed. The technique is completed with the insertion
of a second, non-fenestrated pouch sutured directly to the skin. As alternative to
this second pouch, an adherent dressing involving the entire abdominal circumference
can be applied. The drains must be adapted to the suction system at a negative pressure
between -100 and -150 mmHg.[22]
[23]
In patients undergoing total hysterectomy, damage control can be achieved through
closed packing. In this technique, an intrauterine balloon is inserted into the pelvis
and its axis is directed to the vaginal cavity, before the approach to the vaginal
dome. After laparorraphy and the balloon infusion, a weight is connected to its axis
and adapted to the bedside in order to optimize pelvic compression ([Figure 11]). In this technical option, surgical re-approach is not necessary. After physiological
restoration, the balloon is deflated and removed through the vagina.[24]
[25]
Figure 11. Pelvic packing damage control surgery. Left: open pelvic packing; the red arrow indicates
aspiration; the blue arrow indicates the protective pouch of the pelvic pack made
with compresses. Right: closed packing with an intrauterine balloon adapted to the
pelvis.
Still in the context of care to puerperal women in critical situation due to severe
PPH, such as imminent cardiopulmonary arrest and extra-hospital care, the external
manual compression of the infrarenal aorta can be performed as a life-saving maneuver.
Compression should be temporary (maximum 90 minutes) with the application of a force
of approximately 45 kg and performed until the arrival of support and/or the start
of correction of coagulopathy and shock.[26]
Finally, the evolution of the HPP assistance flowcharts with incorporation of several
more recent surgical idealization and evaluation techniques imposed on care teams
the need to acquire new skills and competences. These can be obtained through skills
training programs and simulations aimed at optimizing the safety and technical quality
of the care teams.[27]
Final considerations
Since HPP is the major cause of maternal mortality worldwide, health care teams' ability
to institute surgical treatment, preferably within the "golden hour", becomes essential
in the event of drug treatment failure. The contemporary development of invasive techniques
that preserve the uterus and have high rates of success in hemorrhagic control has
changed the sequencing of surgical treatment for PPH. These techniques, including
IUB, UCS, VL, AE and their associations must precede hysterectomy and their choice
must correlate with the mode of delivery, PPH etiology, topography of the hemorrhagic
focus and valuably, with the skill and experience of professionals. However, in view
of the failure of surgical techniques that preserve the uterus, hysterectomy should
be performed as early as possible, before the installation of coagulopathy. Hysterectomy
is also frequently required as a primary treatment in the face of the spectrum of
placenta accreta, especially in increta and percreta varieties associated with unfavorable
conditions for uteroplacental segmental exeresis and restoration of uterine anatomy.
In these situations, the complexity of the operative tactic and severity of the risks
demand adequate surgical conditions and a qualified and experienced multidisciplinary
team. Since it is a cause of high lethality, high incidence and complex and specialized
surgical treatment, its current impact on the planning and reorganization of care
teams is significant.
President:
Álvaro Luiz Lage Alves
Members:
Gabriel Costa Osanan
Samira El Maerrawi Tebecherane Haddad
Adriana Amorim Francisco
Alexandre Massao Nozaki
Brena Carvalho Pinto de Melo
Breno José Acauan Filho
Carla Betina Andreucci Polido
Eduardo Cordioli
Frederico José Amedée Peret
Gilberto Nagahama
Laíses Braga Vieira
Lucas Barbosa da Silva
Marcelo Guimarães Rodrigues
Rodrigo Dias Nunes
Roxana Knobel
