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Management of hemorrhage in gynecologic surgery

Management of hemorrhage in gynecologic surgery
Literature review current through: Jan 2024.
This topic last updated: Jun 02, 2022.

INTRODUCTION — Intraoperative hemorrhage is generally defined as blood loss exceeding 1000 mL or requiring a blood transfusion [1]. Massive hemorrhage refers to acute blood loss of more than 25 percent of a patient's blood volume or bleeding that requires emergency intervention to save the patient's life [2].

Severe postoperative anemia impacts perioperative morbidity and mortality [3]. This was illustrated in a study of hospitalized patients who refused blood transfusion for religious reasons: mortality increased as hemoglobin levels fell below 7 g/dL.

This topic review will discuss management of hemorrhage in gynecologic surgery. Surgical technique for specific procedures, incisional bleeding, and management of other complications of gynecologic surgery are reviewed separately (see "Complications of abdominal surgical incisions" and "Complications of gynecologic surgery"). (Also see individual gynecologic surgery topic reviews.)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

PREOPERATIVE EVALUATION — Preoperative evaluation with a focus on preventing and preparing for perioperative hemorrhage is discussed below. Preoperative assessment for gynecologic surgery is discussed in full elsewhere. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)

Medical history — Important elements of the history are a personal or family history of prolonged bleeding, transfusion, or persistent anemia. Nongynecologic etiologies of bleeding symptoms may be present. For example, menorrhagia, a common indication for gynecologic surgery, can be a presenting symptom of von Willebrand disease (VWD). (See "Approach to the adult with a suspected bleeding disorder".)

Further evaluation by a hematologist is warranted if a bleeding disorder is suspected. Timely diagnosis allows for preoperative correction of coagulation defects.

Medication history — Prescription, over-the-counter, or alternative medications can act as anticoagulants. Deciding whether to discontinue a medication perioperatively depends upon the risk of bleeding versus the risk of morbidity from a hiatus of medical treatment. Consultation with a patient's primary care provider and an anesthesiologist is appropriate. Perioperative use of medication is discussed separately. (See "Perioperative medication management".)

Laboratory evaluation

A baseline hematocrit (Hct) is useful (table 1) [4]. If a patient has abnormal uterine bleeding or another cause for anemia, testing should be performed early in the surgical planning process to allow time for correction of anemia. (See "Preoperative medical evaluation of the healthy adult patient".)

A blood sample for ABO and Rh typing and antibody screen is typically sent to the blood bank for patients undergoing surgery in which the expected blood loss is greater than minimal; if significant bleeding is anticipated, it is prudent to prepare two to four units of donor blood by crossmatching with the patient's serum with the donor red cells to check for incompatibility. (See "Pretransfusion testing for red blood cell transfusion".)

Questions have been raised regarding whether routine preoperative type and screen testing is cost effective (versus testing intraoperatively if transfusion is indicated). Observational studies in women undergoing gynecologic surgery have reported that transfusions were infrequent and did not require initiation of transfusion in less than 30 minutes [5,6]. Thus, any proposal for intraoperative testing alone would require reliable delivery of blood to the patient within 30 minutes of onset of hemorrhage. Also, provisions would need to be made for patients who require initiation of transfusion in less than 30 minutes (eg, massive hemorrhage or comorbidities) or in whom compatibility testing is time-consuming (eg, antibodies). Further study is required before such a proposal is implemented.

Routine tests of hemostasis (prothrombin time [PT], activated partial thromboplastin time [aPTT], platelet count) are NOT necessary unless the patient has a known bleeding diathesis, an illness associated with bleeding tendency, or takes a medication that may cause anticoagulation (table 1) [4]. (See "Preoperative assessment of bleeding risk".)

PREPARATION FOR SURGERY — Discussion of possible blood transfusion is part of the informed consent process. A patient's concerns about transmission of blood-borne pathogens should be discussed in the context of current incidence reported by blood banks (table 2). (See "Overview of preoperative evaluation and preparation for gynecologic surgery" and "Blood donor screening: Laboratory testing".)

Women with blood transfusion incompatibilities or religious beliefs that preclude allogeneic blood transfusion should be identified prior to surgery. (See "Approach to the patient who declines blood transfusion" and "Red blood cell (RBC) transfusion in individuals with serologic complexity".)

In addition to careful surgical technique, strategies to avoid allogeneic blood product transfusion include correction of anemia, autologous blood donation, cell salvage, and hemodilution.

Correction of anemia — Women planning gynecologic surgery to treat bleeding issues have typically declined or failed medical therapy. However, most women will accept a short course of preoperative therapy with the goal of increasing Hct and, thereby, avoiding the need for blood transfusion. Iron deficiency anemia associated with menorrhagia or dietary deficiency is the most common cause of anemia in the gynecologic population [7]. Strategies to correct anemia preoperatively are used in the order listed below:

Iron supplementation – In surgical patients, intravenous iron alone increased hemoglobin levels by 1 to 2 g in as little as one week and a review of 14 studies reported a clinically and statistically significant increase in hemoglobin in patients treated with intravenous iron alone [8,9]. Oral option is a good option in nonurgent cases. (See "Treatment of iron deficiency anemia in adults".)

Medical treatment of abnormal uterine bleeding. (See "Causes of female genital tract bleeding" and "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)

Erythropoiesis-stimulating agents (recombinant human erythropoietin [rHuEPO] and darbepoetin alfa) – Data from randomized trials in gynecologic [10,11], orthopedic [12-15], and cardiac surgery [16] suggest preoperative rHuEPO reduces risk of allogeneic transfusion. For women who do not tolerate, or do not wish to take, GnRH-agonists, we have found epoetin particularly useful. However, preoperative use in gynecologic surgery is not well-established and insurance reimbursement is variable.

While safety concerns have been raised about the use of rHuEPO, these risks were confined to repetitive use in cancer patients receiving chemotherapy. The US Food and Drug Administration (FDA) has issued a warning based on reports that erythropoiesis-stimulating agents are associated with serious cardio- and thrombovascular events and more rapid tumor progression and increased mortality in cancer patients (including cervical cancer) [17].

However, there may be a role for preoperative EPO to correct anemia in patients who would refuse allogeneic transfusion are too anemic to qualify for autologous blood donation. (See "Introduction to recombinant hematopoietic growth factors" and "Surgical blood conservation: Preoperative autologous blood donation", section on 'Erythropoietin (rarely indicated)'.)

Preoperative transfusion may be required for patients who become unstable or who continue to bleed heavily before definitive therapy can be performed. We agree with guidelines which emphasize that the decision to transfuse is based not only on hemoglobin level, but also includes individual patient characteristics and symptoms. (See "Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Overview of our approach'.)

Autologous transfusion methods — In addition to correction of anemia, preoperative preparations can be made to use autologous blood in the event a transfusion is necessary. Methods of autologous transfusion are listed below:

Autologous blood donation – A patient scheduled for surgery who is not anemic may bank one or more units of her own blood. (See "Surgical blood conservation: Preoperative autologous blood donation".)

Intraoperative and postoperative blood salvage – Blood that is shed during or after surgery is retrieved, processed, and returned to the patient. (See "Surgical blood conservation: Intraoperative blood salvage".)

Acute normovolemic (isovolemic) hemodilution – Blood is removed from a patient, either immediately before or shortly after induction of anesthesia, with isovolemia maintained using crystalloid and/or colloid replacement. The blood withdrawn is anticoagulated and is reinfused into the patient as needed during, or after, the surgical procedure. (See "Surgical blood conservation: Acute normovolemic hemodilution".)

A systematic review of high- and low-quality data regarding methods of avoiding allogeneic blood transfusion found that reports are variable and no consensus could be reached regarding which method is more cost effective and acceptable to patients [18].

In our practice, we have used blood salvage (eg, Cell Saver) effectively during myomectomy and hysterectomy [19]. The device suctions blood from the operative field, mixes it with heparinized saline and stores the blood in a canister. If the patient requires blood re-infusion, the stored blood is washed with saline, filtered, centrifuged to a hematocrit of approximately 50 percent, and transfused into the patient.

Use of intraoperative cell salvage avoids the need for preoperative autologous blood donation and homologous (non-autologous, allogeneic) blood transfusion can often be avoided [20]. Use of the cell-saver avoids the risks of transmission of infectious disease and eliminates transfusion reactions. In addition, recent evidence shows that storage of blood products leads to a progressive decrease in the quality of stored blood and an increase in inflammatory mediators [21]. This would affect patients receiving either autologous or homologous blood.

The cost of using a blood salvage compared with donation of autologous blood has not been studied for gynecologic procedures. Most hospitals charge a minimal fee for having the blood salvage equipment available "on-call" and charge additionally if it is used.

Prophylactic tranexamic acid — Prophylactic administration of TXA, an anti-fibrinolytic, has been associated with reduced intraoperative blood loss in both obstetric and gynecologic surgery [22-25]. Discussion of dosing, timing, and supporting data is presented in related content. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Prophylactic tranexamic acid'.)

MANAGEMENT OF INTRAOPERATIVE BLEEDING — As complications cannot be completely avoided, the gynecologic surgical team should be prepared to handle intraoperative hemorrhage. In the obstetric literature, studies of simulation-based teaching of management of postpartum hemorrhage have demonstrated that this approach identifies important deficiencies in clinician knowledge and performance [26,27]. Similarly, simulation in gynecologic surgery has been shown to reduce time to intervention during a crisis and improve surgical skills [28-30]. We employ the following techniques in the order of presentation.

Apply pressure — At the onset of intraoperative hemorrhage, apply pressure to the bleeding area. This helps to control acute bleeding and allows a moment to alert the rest of the operating room team that excessive bleeding is occurring. Immediate and ongoing communication with all members of the surgical team (anesthesiologists, nurses, scrub technicians) is essential to an efficient and effective response to intraoperative hemorrhage.

Laparotomy – Apply immediate pressure with a finger or sponge stick. If localized pressure does not control bleeding, firmly place damp laparotomy pads at the bleeding site. Apply pressure for 10 to 15 minutes, and observe the packs to confirm that bleeding has stopped.

Laparoscopy – Apply an atraumatic laparoscopic grasper to the site of bleeding. For larger bleeding sites, insert 4x8 gauze sponges through a 10 mm port and hold pressure against the bleeding area. Large vessel lacerations (ie, due to trocar insertion) cannot generally be repaired laparoscopically, and thus, make a vertical midline incision to allow surgical access to the great vessels. Tamponade can then be applied directly as described above.

Vaginal surgery – Apply immediate pressure with a finger or sponge stick. If bleeding continues, place a pack of damp pads or sponges in the vagina. Slowly remove the pack to visualize the bleeding vessels. If a vascular pedicle is lost during vaginal surgery, blind clamping or suturing is ill-advised. Laparoscopy can be used to identify and control the bleeding site, with laparotomy reserved for bleeding inaccessible to laparoscopic techniques.

While securing hemostasis is critical, techniques must be used carefully in order to avoid tissue necrosis, organ injury, vascular thrombosis, fistula formation, or nerve dysfunction [31]. Once the bleeding area is identified and tamponade applied, identify the ureter and major vessels to avoid inadvertent injuries to these structures. Also, it is generally better to avoid leaving packs in place at venous bleeding sites due to risk of venous stasis and thrombosis.

In some cases, it is best to apply continued pressure while waiting for a vascular or general surgeon, a gynecologic oncologist, or another gynecologist. Applying pressure to a large vessel (ie, aorta or common iliac) should be reserved for situations in which direct pressure to the bleeding site does not stop or significantly slow the bleeding. Attempts at repair of vessels without experience may worsen the injury, particularly in major retroperitoneal veins.

Identify and control localized bleeding — The most common sites of major blood loss in the pelvis (cephalad to caudad) are inferior vena cava, presacral veins, ovarian vessels, common and external iliac vessels, internal iliac vessels, parametrial and paracervical varicosities, the bladder pillars, and posterior bladder.

To locate bleeding sites from one or more vessels, dissect the pelvic fascia surrounding the source of bleeding, identify vital structures (ie, vessels, viscera), and isolate and ligate the bleeding vessels.

Pelvic dissection — The vascular structures of the reproductive tract are contained within the tissues that surround the pelvic viscera (ie, the paravesical, pararectal, vesicovaginal, and rectovaginal spaces). Development of the appropriate space will often allow control of bleeding sites while avoiding trauma to important pelvic structures [31].

Care should be taken during dissection, as the walls of the major veins are delicate and injury can cause brisk bleeding. Also, blunt dissection along the common iliac vein, inferior vena cava, pelvic sidewall or the presacral area can avulse small tributaries from larger veins with resultant high volume bleeding.

Surgeons who do not perform radical surgery may be less familiar with the paravesical and pararectal spaces (figure 1). The paravesical space is bounded laterally by the external iliac vessels and medially by the obliterated hypogastric artery. Dissection of this space exposes the lateral portions of the bladder, vagina and rectum. (See "Radical hysterectomy", section on 'Operative technique'.)

The pararectal space is bounded laterally by the internal iliac artery and medially by the ureter, and can be entered by incision of the pelvic peritoneum (and preferably the round ligament) lateral to the iliac vessels. Separation of the vessels and the ureter and dissection posteriorly and slightly medially exposes the proximal pelvic ureter, the internal iliac vessels and the rectum.

Retroperitoneal bleeding — If bleeding occurs, and the retroperitoneum is not open or the bleeding is behind the ovarian pedicle, apply direct pressure to the area of bleeding. If bleeding continues, a fast, bloodless approach to exposing this area is to open the peritoneum over the paracolic gutter and mobilize the colon medially. If the peritoneum is already open, then the bleeding source is identified and managed as outlined above.

Ligation — Isolate vessels prior to ligation. Placing sutures, clips, or coagulating multiple layer of tissue may injure surrounding structures.

Small vessels – Bleeding from small vessels may be controlled with coagulation, suture, or surgical clips.

Large vessels – The aorta, vena cava, and common and external iliac vessels perfuse the extremities. Repair of these vessels is best performed by a vascular surgeon. In general, these vessels are repaired by compressing the vessel above and below the injury with vascular clamps and suturing the defect with a running 4-0 to 6-0 monofilament suture on a cardiovascular needle.

The extensive arterial collateral circulation in the peripheral pelvis allows ligation of most other large vessels in a nonirradiated pelvis [31]. Coagulation is not adequate for larger vessels and clips may either fall off or cut into a vessel larger than the clip, thereby enlarging the defect. Placing multiple clips also makes it difficult to isolate and identify the bleeding site.

Large veins – Venous bleeding can be difficult to control due to the relatively high volume of blood flowing through fragile, irregular veins. Gentle pressure with sponge sticks on either side of the venous injury is the most useful method to minimize blood loss.

In addition, the placement of hemoclips will often control venous bleeding. However, application of hemoclips to a "peg hole defect" (avulsion of the small veins that enter the anterior surface of the common iliac vein and the inferior vena cava) can reduce the caliber of the lumen and lead to coagulation and thrombosis.

Manage diffuse bleeding — There are several clinically important causes of diffuse bleeding, each of which must be addressed differently. Assess the volume of bleeding and whether there is flow at all operative surfaces (and intravenous line sites) or it is concentrated in one or more areas.

Alternatively, diffuse low-volume bleeding that is concentrated in several small areas (eg, sites of prior dissection of adhesions) is likely from small venous sources and may be amenable to the use of topical hemostatic agents. When brisk diffuse bleeding arises suddenly in the presacral area, laceration of the presacral vessels should be suspected and immediately addressed.

Topical hemostatic agents — Small areas of low-volume bleeding can be treated with topical hemostatic agents (table 3) [32,33]. Investigation of these agents has focused on vascular, cardiac, and hepatic surgery [34,35]. There are few high-quality data regarding treatment efficacy or use in gynecologic surgery [36]. Thus, choices are made based on surgeon preference, availability, and cost-effectiveness (table 3) [37]. A detailed discussion of all topical hemostatic agents can be found in separate content. (See "Overview of topical hemostatic agents and tissue adhesives".)

Our approach – For gynecologic procedures, the authors typically use gelatin soaked with topical thrombin for localized suture line bleeding (discussed below under topical agents). In settings of diffuse low pressure bleeding, spray thrombin can achieve hemostasis. Use of a combination hemostatic matrix (gelatin granules combined with human thrombin) can also be applied.

Physical agents – These products require an intact coagulation cascade [38]. The physical agent (cellulose, gelatin, starch, or collagen) is placed at the site of bleeding and activates the extrinsic clotting cascade (figure 2).

Gelatin – Gelatin (eg, Gelfoam) is available in sponge or powder form [39,40]. The sponge form can be cut into any shape to facilitate application. Gelatin sponges are rigid when dry, but are pliable when moist and can be passed through laparoscopic ports. Pressure is applied for several minutes after application and the sponge is left in place. Gelatin is completely absorbed after four to six weeks with little tissue reaction or scarring.

Disadvantages of gelatin include: increased incidence of infection, granuloma, and fibrosis formation, as well as potential disruption of the clot if the sponge is removed [39,41].

There are no data regarding use of topical gelatin for hemostasis in gynecologic surgery.

Although it is common practice to apply topical thrombin to gelatin matrix, in attempt to increase hemostasis, there are no data to support this [32].

Oxidized regenerated cellulose (ORC) – ORC (eg, Surgicel) is supplied as a mesh and can be applied dry directly to bleeding areas. ORC is pliable and can be rolled and passed easily through laparoscopic trocars. It requires a blood-free field to be effective. ORC takes 14 days to be fully absorbed [41]. Fibrillar is loosely woven ORC, having a consistency similar to cotton. It can be applied to irregular surfaces and hard-to-reach areas, and layers can be peeled off to conform to the wound surface. Both products can coagulate even in a bloody surgical field.

ORC also has bactericidal activity against a wide range of gram-positive and negative organisms [42]. However, excessive use of ORC may facilitate infection or formation of adhesions.

Successful use of ORC to control bleeding from small uterine perforations [43] and tubal hemorrhage [44] has been reported in small case series.

Microfibrillar collagen (MC) – MC (eg, Avitene) is an absorbable acid salt obtained from bovine collagen. MC is applied in powder form directly to the bleeding site using a dry, smooth forceps. MC is fully absorbed within three months. Although MC has low antigenicity, it may induce local edema. There is one case report of a systemic allergic reaction during a laparoscopic cholecystectomy associated with MC [45].

Case reports of MC use report successful results in bleeding from uterine perforation [46] and after hysterectomy [47]; adverse effects noted include severe allergic reaction [45] and granuloma formation [48].

Biologic agents This category, which includes topical thrombin and fibrin sealant, bypasses the extrinsic pathway and directly activates the common hemostatic pathway (figure 2) [38].

Topical thrombin (TT) – Bovine or human thrombin is used [49,50]. Bovine thrombin is associated with anaphylaxis and the development of antibodies which can cross react with human factor V or human thrombin, leading to coagulopathy [50,51]. In addition, there is a risk of infection transmission with human pooled plasma-derived thrombin [52]. The development of recombinant thrombin may obviate these concerns, however, data on its use are still preliminary [52,53]. The adverse effect of TT are discussed in full separately. (See "Fibrin sealants", section on 'Complications'.)

TT (eg, Thrombogen) can be applied via direct spray with a needle and syringe or in conjunction with a gelatin sponge in the surgical field [54].

The use of thrombin has not been widely studied in gynecologic surgery [55].

Fibrin sealant – Fibrin sealants (eg, Tisseel) have two components that must be mixed prior the application, one with thrombin and calcium chloride and other with concentrated fibrinogen, factor XIII, fibronectin, and fibrinolysis inhibitor [41]. The mixture can then be directly sprayed onto bleeding sites.

Fibrin sealants are used for hemostasis or as a tissue adhesive. This topic is discussed in more detail separately. (See "Fibrin sealants", section on 'Fibrinogen'.)

There is one case report of transmission of parvovirus after use of a fibrin sealant for hemostasis during a hysterectomy [56].

Combination reparations – Available combination products include thrombin/gelatin granules and thrombin/collagen (table 3). Both preparations are supplied in liquid form and applied to the bleeding site; pressure is then held with a damp sponge.

Successful reduction in blood loss with use of thrombin/gelatin has been reported in myomectomy and in a patient with a groin wound breakdown following lymphadenectomy [57,58].

Comparing topical agents – Representative comparative studies in which topical agents were used for small intraoperative bleeding sites are listed below [34]:

A combined preparation of liquid thrombin and gelatin yielded a significantly higher rate of hemostasis (at 10 minutes after application) compared with a gelatin sponge soaked in bovine TT (88 to 99 versus 57 to 93 percent), according to randomized trials in patient undergoing vascular, spinal, or cardiac surgery [40,59,60].

An autologous fibrin sealant (available in Europe, but not in the United States) resulted in a significantly higher rate of hemostasis (at 5 minutes after application) compared with ORC (94 versus 65 percent) in a randomized trial of 69 patients undergoing obstetric, gynecologic, general, vascular, and cardiothoracic surgery [61].

Presacral bleeding — Laceration of the presacral plexus of veins and/or the middle sacral artery can lead to life-threatening hemorrhage. Pressing a sterile steel thumbtack directly into the bone at the bleeding site has been reported to be effective in observational studies [62]. The tack is not removed, and will show up on subsequent radiographs. Topical hemostatic agents, coagulation, clips, and sutures may also control the bleeding [63]. Another measure that has been reported is to excise a piece of the rectus muscle, place it over the site of bleeding, and then weld it to the bleeding site with electrocautery at a high setting (100 Hz) [64]. As a last resort, an umbrella or parachute pack can be placed until the patient is stabilized [65].

Strategies for persistent bleeding

Internal iliac artery ligation — After initial attempts to regain hemostasis have not succeeded, the next step is to decrease pelvic blood flow. Bilateral internal iliac (hypogastric) artery ligation (IAL) lowers the pulse pressure of the pelvic vasculature by 85 percent and the rate of blood flow by 50 percent; low pressure systems are more amenable to clot formation [66,67] (figure 3).

IAL may help to avoid emergency hysterectomy. In a retrospective case series of patients with severe obstetric hemorrhage, 8 of 19 patients who underwent IAL did not undergo a subsequent hysterectomy [68].

However, IAL precludes subsequent embolization. Therefore, it should be reserved for patients who are unlikely to be candidates for arterial embolization.

The technique for IAL is performed bilaterally as follows:

Open the anterior leaf of the broad ligament (with a Metzenbaum scissors or electrosurgery) and lyse the areolar tissue of the retroperitoneum.

The external iliac artery is readily identified at the medial margin of the psoas muscle, and is followed to the common iliac artery bifurcation. The internal iliac artery is approximately 4 cm in length before it divides into anterior and posterior branches.

Ideally, the dissection should be carried caudally to the anterior and posterior trunks of the internal iliac artery so that the anterior trunk can be selectively ligated. In practice, this is so difficult that the entire internal iliac artery usually is ligated at its origin.

Dissect away the nodal tissue overlying the internal iliac artery by spreading the tissue with a right angle or tonsil clamp or the tips of Metzenbaum scissors. Continue the dissection anterior and lateral to the internal iliac artery. Proceed in the same plane around the circumference of the artery to separate it from the internal iliac vein, which is slightly medial and posterior to the artery. Pass a number 1 silk or nonabsorbable synthetic suture (eg, polypropylene) around the artery from lateral to medial and tie securely. An alternative technique is to use surgical clips to ligate the internal iliac artery, which eliminates the need for circumferential dissection and thus may reduce the risk of iliac vein injury [69].

There are two important technical errors that are easy to commit, both of which may be detrimental:

Ligation of external iliac artery – It is possible to mistakenly ligate the external iliac instead of the internal iliac artery. This usually leads to loss of the ipsilateral lower limb if not promptly corrected. Therefore, the lower limb (dorsalis pedis, or posterior tibial pulse) should be assessed for the presence of a pulse immediately after vessel ligation.

Injury of iliac veins or external iliac artery – The large, dilated, fragile internal iliac vein lies just behind and slightly medial to the artery and is often not visualized during isolation of the artery. Laceration of this vein can lead to rapid exsanguination. The external iliac artery lies lateral to the internal iliac artery and care should also be taken to avoid it.

A review of pregnancy outcome after internal iliac artery ligation for postpartum hemorrhage described 49 pregnancies with no evidence of any increase in adverse events [70].

Uterine artery ligation — Mass ligation of the uterine artery may be performed. The arteries are identified by palpation. To ligate the left uterine artery, the uterus is elevated upwards and to the right. A large blunt needle (eg, size 5 Mayo) with #0 or #1 absorbable suture is passed into and through the myometrium approximately 2 cm medial to and below the uterine vessels. The needle is brought out through the avascular area in the broad ligament, cephalad and lateral to left uterine vessels, and the suture is tied. The procedure is repeated on the contralateral side (figure 3).

Hysterectomy or oophorectomy — If bleeding continues despite conservative measures, removal of the adnexae or uterus may be necessary despite the initial surgical plan. For example, in women undergoing myomectomy or ovarian cystectomy who develop intractable bleeding, the possibility of emergency measures in case of hemorrhage is part of the preoperative consent process. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)

Prolonged pelvic packing — If other measures do not control bleeding, a pressure pack may be left in the pelvis for 48 to 72 hours [71,72]. This is effective for venous bleeding. The patient is monitored closely and appropriate fluid resuscitation and blood transfusion administered in an intensive care setting. Packs may be removed via the vaginal cuff or by re-opening the laparotomy [65,71]. The abdominal incision may be loosely re-approximated so that the incision can be re-opened if needed for persistent bleeding. Our approach to pelvic packing in a patient who had a hysterectomy is as follows [65]:

Fill a large sterile drawstring-closure plastic bag with three rolls of gauze tied end-to-end; leave the tail of the gauze protruding through the bag's opening and tighten the drawstrings. Place the pack is in the pelvis, avoiding bowel or ovary entrapment. Pull the drawstrings and gauze tail through the vaginal cuff. A 1000 mL intravenous fluid bag is attached to the pack with surgical tubing and hung off the end of the bed for traction. Place a Jackson-Pratt drain in the pelvis to monitor for continued bleeding and an indwelling urinary catheter to avoid outflow obstruction and monitor urine output

After 48 to 72 hours, if vaginal and Jackson-Pratt drainage have decreased, remove the gauze through the vagina, slowly over four hours. The bag can then be removed through the vagina and the vaginal cuff left open.

Other measures — The use of medical anti-shock trousers or garments is controversial. While a few case reports and a small case series report successful use in gynecologic and obstetric hemorrhage [73-75], an animal study of intraabdominal hemorrhage found that these devices did not slow bleeding [76]. In abdominal myomectomy, a systematic review found that intravenous tranexamic acid (1 mg/kg) given prior to incision significantly reduced intraoperative bleeding (mean -251 mL, 95% CI -391 to -110) [23]. One randomized trial found no significant decrease in transfusion rates with tranexamic acid administered just prior to surgery [77]. However, in the setting of advanced ovarian cancer surgery, a randomized trial showed significantly reduced blood loss and transfusion rates compared with a control group [78].

MEDICAL STABILIZATION — As noted above, ongoing communication between the surgeon and anesthesiologist are required to safely manage operative hemorrhage. The need for additional monitoring or placement of lines, and blood replacement products should be addressed at regular intervals. The major nonsurgical components of stabilizing a bleeding patient include:

Hemodynamic monitoring – (See "Etiology, clinical manifestations, and diagnosis of volume depletion in adults".)

Fluid and electrolyte management – A general rule of fluid replacement for hemorrhage is a 3:1 ratio of crystalloid fluid to blood loss [79]. A full discussion of crystalloid versus colloid solutions is found separately. (See "Treatment of severe hypovolemia or hypovolemic shock in adults" and "Maintenance and replacement fluid therapy in adults".)

Blood product replacement – Transfusion during perioperative hemorrhage often requires replacement of red blood cell and plasma components (table 4). Disseminated intravascular coagulation (DIC) is of particular concern in a patient with major blood loss (table 5). (See "Massive blood transfusion" and "Evaluation and management of disseminated intravascular coagulation (DIC) in adults" and "Clinical use of plasma components".)

POSTOPERATIVE BLEEDING — Careful inspection of all pedicles before abdominal closure is the best method to prevent postoperative hemorrhage.

Clinical manifestations — Tachycardia, hypotension, oliguria (urine output <20 mL/hour), confusion, and increasing abdominal pain may all signal postoperative intraabdominal bleeding.

Postoperative hemorrhage may be plainly visible, in the case of bleeding from the vagina or wound, otherwise, intraabdominal bleeding should be suspected.

Patients who undergo laparoscopic surgery may also present approximately 72 hours postoperatively with a drop in hemoglobin and a large purplish discoloration or hematoma of a lower quadrant of the abdomen, ipsilateral flank, or in the groin, dissecting down to the ipsilateral labia majora. A computed tomography (CT) scan will reveal a large hematoma within the abdominal wall, which may extend along muscle planes to the flank. The discoloration will resolve over 10 to 14 days as the blood is absorbed. Presumably, a vessel in the anterior abdominal wall was injured, went into spasm, and then relaxed and bled at a later time until it became tamponaded. These patients do not have pain or discomfort.

Evaluation — Evaluation of a patient with suspected postoperative bleeding includes physical examination and assessment of vital signs and urine output. A laboratory evaluation should exclude a decreasing Hct or bleeding diathesis. Of note, postoperative mobilization of fluids from the extravascular space can lead to a falling Hct level without ongoing bleeding.

The patient should be taken promptly to the examining room where the operative site is inspected (including the vaginal cuff if the patient has had a hysterectomy).

Management — If there is suspicion of postoperative hemorrhage, fluid resuscitation should be initiated and preparation made for possible surgical re-exploration. Large-bore intravenous access should be placed, isotonic fluids given (normal saline or Ringers lactate), the Foley catheter reinserted, and the patient maintained nil per os (npo). As noted above, crystalloid fluids should be replaced in a 3:1 ratio of fluid to blood loss.

Bleeding from the vaginal cuff can usually be sutured in the examination room. Likewise, superficial bleeding from wound can be controlled by opening the wound and coagulating or suturing subcutaneous vessels.

Patients who are stable but anemic may be managed conservatively. Transfusion is given, if appropriate, and hemodynamic status, urine output, and Hct are monitored. Further evaluation and more aggressive management are indicated if there is suspicion of ongoing blood loss.

Surgical re-exploration — Patients who are hemodynamically unstable or have an increasing abdominal girth should be surgically re-explored. Identification of bleeding source and control of bleeding proceeds as described above. (See 'Management of intraoperative bleeding' above.)

Abdominal compartment syndrome can be caused by significant intraperitoneal or retroperitoneal bleeding resulting in raised intraabdominal pressure. The increased pressure can be transmitted to the pleural space causing a decrease in lung compliance and hypoxemia and a decrease in venous return. Decreased perfusion of the kidneys can lead to oliguria and renal failure. CT is useful to assess the location and amount of intra- or retroperitoneal blood collection. (See "Abdominal compartment syndrome in adults".)

Embolization — Embolization is typically performed by interventional radiologists and halts pelvic bleeding by occluding pelvic arteries. This is an option for patients in whom volume status can be maintained until the procedure can be completed (approximately two hours). As discussed above, ligation of the internal iliac artery will preclude subsequent embolization.

Preoperative embolization has been used for procedures where the risk of hemorrhage is felt to be high.

Endografts — Patients with postoperative bleeding due to injury to the vena cava or common or external iliac veins may be candidates for placement of stented grafts by an endovascular specialist. (See "Endovascular repair of abdominal aortic aneurysm".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

SUMMARY AND RECOMMENDATIONS

Definition of hemorrhage – Intraoperative hemorrhage is typically defined as ≥1000 mL blood loss; massive hemorrhage refers to acute blood loss of ≥25 percent of a patient's blood volume or bleeding that requires emergency intervention to save the patient's life. (See 'Introduction' above.)

Preoperative evaluation for bleeding diathesis – Prior to surgery, if a bleeding diathesis is suspected based on personal or family history or medication use, evaluation by a hematologist is indicated. Nongynecologic etiologies of bleeding symptoms may be present. As an example, menorrhagia, a common indication for gynecologic surgery, can be a presenting symptom of von Willebrand disease (VWD). (See 'Preoperative evaluation' above.)

Approach to preoperative patient anemia

In women who are unwilling to accept perioperative blood transfusion and who are anemic despite standard therapy (replacement of iron; attempts to control AUB), we suggest preoperative erythropoietic agents (Grade 2C). (See 'Correction of anemia' above.)

Autologous blood donation and intraoperative blood salvage are also options to decrease risk of transmission of blood borne infection and transfusion reactions. (See "Surgical blood conservation: Preoperative autologous blood donation" and "Surgical blood conservation: Intraoperative blood salvage".)

Approach to intraoperative hemorrhage

The initial steps are to apply pressure and communicate with the surgical team to formulate a plan of action. (See 'Management of intraoperative bleeding' above.)

If initial attempts to decrease bleeding are not successful, the next step is to decrease pelvic blood flow. Bilateral internal iliac (hypogastric) artery ligation (IAL) lowers the pulse pressure of the pelvic vasculature, making clot formation more likely. (See 'Internal iliac artery ligation' above.)

Diffuse bleeding from all operative and vascular access sites requires evaluation for disseminated intravascular coagulation. (See 'Medical stabilization' above.)

Techniques to control intraoperative bleeding

In women undergoing gynecologic surgery with areas of low-volume bleeding, we suggest the use of topical hemostatic agents (Grade 2C). (See 'Topical hemostatic agents' above.)

In the absence of high-quality data, in general, surgeons should pick the topical agent with which they are most familiar. If the choice is to use a combination of gelatin and thrombin, we recommend the combined liquid preparation rather than gelatin sponge soaked in thrombin (Grade 1A).

If bleeding persists despite conservative measures, IAL, oophorectomy, or hysterectomy may be indicated. In a patient who continues to bleed despite hysterectomy, pelvic packs may be placed and removed in 48 to 72 hours. (See 'Prolonged pelvic packing' above.)

Postoperative bleeding – Patients with postoperative bleeding who are hemodynamically unstable require surgical re-exploration. (See 'Postoperative bleeding' above.)

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References

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