Postpartum hemorrhage: Management approaches requiring laparotomy

INTRODUCTION — Postpartum hemorrhage (PPH) is an obstetric emergency that is managed with many potentially effective medical and surgical interventions (table 1). In patients with PPH who have had a vaginal birth or whose cesarean birth has been completed (closed abdomen), medical and minimally invasive approaches are the preferred treatment approaches; laparotomy is generally performed after less invasive interventions have been tried and failed. During cesarean birth, uterotonic medications and manual uterine massage/compression are the initial treatments for bleeding due to atony, as in vaginal births, but operative interventions for control of hemorrhage are performed sooner since the abdomen is already open.

This topic will discuss treatment approaches for PPH that require laparotomy. Related content is available separately:

●Medical and minimally invasive management of patients with PPH (see "Postpartum hemorrhage: Medical and minimally invasive management").

●Incidence, pathogenesis, risk factors, clinical presentation and diagnosis, general principles of planning and management, morbidity and mortality, and recurrence of PPH (See "Overview of postpartum hemorrhage".)

EVALUATION OF THE ABDOMEN AT LAPAROTOMY — Following a vaginal birth, midline laparotomy provides the best exposure of both the pelvis and abdomen for assessment and treatment of suspected pelvic bleeding, in the author's opinion. For patients undergoing or who are post-cesarean birth, the existing incision can be extended, if needed, to provide adequate exposure. A self-retaining retractor (eg, Balfour, Bookwalter, or Omni) helps to provide adequate lateral and superior exposure (superior exposure will be required if access to the aorta is needed).

The abdominal cavity is irrigated to remove blood and clots and inspected for the source of bleeding, which is usually from the uterus. The source of bleeding is often readily apparent (atony, retained placental fragments, uterine laceration, uterine incision) but may not be immediately recognized when it is inside the uterine cavity after vaginal birth or after closure of the hysterotomy at cesarean, retroperitoneal (including vaginal and vulvar hematomas from trauma to branches of the pudendal or uterine arteries and veins), or due to a posterior uterine wall rupture. These sites should be systematically evaluated in patients with compensated shock (normal blood pressure with increasing heart rate).

Intra-abdominal blood without an obvious uterine rupture or bleeding vessel may be due to hepatic or splenic rupture, or rupture of a visceral artery aneurysm or pseudoaneurysm. (See "Overview of visceral artery aneurysm and pseudoaneurysm" and "Treatment of visceral artery aneurysm and pseudoaneurysm" and "Splenomegaly and other splenic disorders in adults", section on 'Trauma/rupture'.)

TEMPORARY MEASURES FOR STABILIZING HEMODYNAMICALLY UNSTABLE PATIENTS — Severe bleeding often continues while the surgeon is preparing to perform and while performing surgical procedures for controlling hemorrhage. Temporizing maneuvers should be attempted prior to performing any surgical procedures that will take significant time before the source of bleeding is identified and/or controlled. Even a hysterectomy that the surgeon thinks will be easy and uncomplicated can be very difficult to perform if the pelvis or retroperitoneum fills with blood, especially when structures that were not bleeding start to bleed because of coagulopathy.

The following measures, in addition to fluid administration and transfusion of blood products, help to support the patient hemodynamically in preparation for and during surgical evaluation and treatment, and can be lifesaving. The option chosen depends on the urgency to control bleeding, the source of bleeding (intrauterine versus extrauterine), and the surgeon's expertise and preference.

Patients at imminent risk of exsanguination

Manual aortic compression — If there is an imminent threat of exsanguination (ie, within a few minutes), the surgeon should apply direct pressure to the aorta to compress it against the vertebrae a few centimeters superior to the sacral promontory (figure 1); the bifurcation into the common iliac arteries is just distal to this point. Compression can be applied using a closed fist or the heel of the hand.

Alternatively, the aorta can be compressed just below the renal arteries, which will minimize collateral flow to the uterus from the ovarian and inferior mesenteric arteries. Compression at either site will slow the volume of bleeding and will afford a better opportunity for finding and controlling the source of hemorrhage. Compression just above the bifurcation may be easier to accomplish but is less effective than below the renal arteries because of the extensive collateral blood supply to the uterus.

Balloon occlusion of the aorta (REBOA) — Resuscitative endovascular balloon occlusion of the aorta (REBOA) involves placement of an aortic balloon catheter below the renal arteries to control or reduce catastrophic or potentially catastrophic obstetric hemorrhage [1,2]. In an appropriately equipped operating room, the balloon can be placed percutaneously by appropriately trained obstetricians using ultrasound guidance or fluoroscopy, ideally when the patient is still stable. REBOA has been effective when used prophylactically in patients with placenta accreta spectrum undergoing cesarean birth [3]. Although it is more difficult to place the catheter in desperate situations (massive bleeding with imminent or actual hemodynamic collapse), REBOA may offer a minimally invasive approach to aid in resuscitation, particularly in low-resource environments where surgical resources and blood banking are unavailable. (See "Placenta accreta spectrum: Management" and "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Consider resuscitative endovascular balloon occlusion of the aorta' and "Endovascular methods for aortic control in trauma".)

The balloon catheter can also be placed directly into the aorta at the bifurcation using a Seldinger technique (initial needle followed by a guidewire over which the balloon catheter is inserted). The catheter is advanced up the aorta to position the balloon below the renal arteries, above the inferior mesenteric arteries and at or above the ovarian arteries (figure 1). The surgeon can measure this distance before insertion using the external markings on the catheter, and then advance the catheter to the selected marking. The balloon is then inflated. The position of the tip of the catheter can be confirmed by palpated after inflation of the balloon. A balloon in this position should substantially reduce uterine blood flow. Placing the intra-aortic balloon at a lower level, such as just above the aortic bifurcation, may not substantially reduce uterine blood flow because of the extensive collateral blood supply to the uterus. The ovarian arteries supply the uterus via the utero-ovarian branches (figure 2); therefore, if the ovarian arteries are not occluded, then uterine blood flow may not be substantially reduced despite uterine artery, and even internal iliac artery, ligation. Similarly, the inferior mesenteric artery is continuous with the uterine arterial collateral system via the superior rectal artery and its posterior collaterals (lumbar and median sacral arteries); therefore, uterine blood flow may not be substantially reduced if the inferior mesenteric artery is not occluded. Even with balloon position above the inferior mesenteric artery, uterine blood flow can occur through collaterals from the superior mesenteric artery, whose origin is above the renal arteries, and via retrograde flow from the iliac arteries.

When the patient has been resuscitated, the balloon is deflated intermittently to prevent ischemic limb or colon complications from aortic occlusion, and distal pulses are monitored frequently. Consultation with a vascular surgeon is recommended, especially prior to removal of the catheter, as the insertion site needs to be repaired if the catheter is larger than 7F.

Patients not at imminent risk of exsanguination

Uterine tourniquet — Tourniquets have been used to control bleeding at myomectomy and for other types of uterine hemorrhage, and they may be useful as a temporizing measure in PPH [4-6]. This procedure markedly reduces blood loss and provides time for the anesthesia team to catch up with transfusion requirements.

A Penrose drain or urinary catheter is placed as low as possible around the lower uterine segment without incorporating the urinary bladder, and then the two ends are pulled in opposite directions and as tightly as possible around the corpus to mechanically occlude the vascular supply. A second or third tourniquet can also be applied, as needed. The tourniquet(s) can be held in place with a clamp (figure 3).

When the patient is hemodynamically stable, the tourniquet(s) is removed and the surgical procedure is completed. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Tourniquets'.)

Intrauterine postpartum hemorrhage-control devices — Commercially available and improvised balloon-type devices have been used successfully to tamponade bleeding from the uterine cavity after vaginal or cesarean birth. Continued excessive bleeding when the device is in place indicates that tamponade is not effective. A device that applies low-level intrauterine negative pressure to facilitate uterine compressive forces is another approach to controlling uterine bleeding. These techniques are described separately. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device".)

Ligation of uterine and utero-ovarian arteries — Uterine and utero-ovarian artery ligation (figure 2) can decrease uterine bleeding by reducing perfusion pressure in the myometrium. It will not completely control bleeding from uterine atony or placenta accreta spectrum but may decrease blood loss while other interventions are being attempted. It does not harm the uterus and does not appear to impact reproductive function [7]. (See 'Laceration of the uterine artery or utero-ovarian artery branches' below.)

Clamp across utero-ovarian ligaments — Placing a large clamp across the utero-ovarian ligaments bilaterally is a rapid and simple means of occluding uterine blood flow through ovarian artery collaterals. However, it also effectively ligates the fallopian tubes (figure 4), precluding future conception without in vitro fertilization. It will not completely control bleeding from uterine atony or placenta accreta spectrum but may decrease blood loss while other interventions are being attempted.

Pelvic packing — Pelvic packing to create tamponade pressure exceeding arterial pressure can control bleeding from small pelvic arteries. It can be useful as a temporizing measure in the management of broad ligament or retroperitoneal hematomas, lacerations that are difficult to repair because of their location or friable tissue, bleeding related to coagulopathy while clotting factors are being replaced, and posthysterectomy bleeding. The technique is described below. (See 'Damage control approach for persistent bleeding after hysterectomy' below.)

Role of internal iliac (hypogastric) artery ligation — This technique is challenging even for an experienced pelvic surgeon, especially when in the setting of a large uterus, limited exposure through a transverse lower abdominal incision, ongoing pelvic hemorrhage, or obesity. Successful and safe bilateral internal iliac artery ligation becomes even more difficult when attempted by a surgeon who rarely operates deep in the pelvic retroperitoneal space [8]. For these reasons, uterine compression sutures, uterine artery ligation, and arterial embolization have largely replaced this procedure.

Bilateral ligation of the internal iliac arteries reduces the pulse pressure of blood flowing to the uterus [9]. The utility of the procedure may be compromised when there are extensive collateral vessels (such as in placenta percreta). Reverse filling of the internal iliac arteries has been reported beyond the point of ligation via branches of the external iliac artery (inferior epigastric, obturator, deep circumflex iliac, and superior gluteal arteries) [10,11]. A technical description of the procedure is available separately. (See "Management of hemorrhage in gynecologic surgery", section on 'Internal iliac artery ligation'.)

In trauma surgery, vessel loops or tapes along with vascular clamps or Rummel tourniquets have been used for temporary reduction of internal iliac blood flow and then released subsequent to control of distal hemorrhage.

Role of intraoperative cell salvage — Arranging for cell salvage in patients at high risk for PPH appears to be economically reasonable, while routine use of cell salvage for all cesarean births probably is not [12-14]. Intraoperative cell salvage may be arranged before laparotomy or requested during laparotomy. The American College of Obstetricians and Gynecologists has acknowledged the safety and efficacy of intraoperative cell salvage in patients with PPH [15].

Institutions that offer reinfusion of salvaged blood should have designated personnel, which may include cross-trained operating room employee (eg, an anesthesia technician) or a member of a specialist service (eg, an extracorporeal technologist or perfusionist). These individuals are called to manage the cell salvage equipment and follow written policies and procedures for proper collection, labeling, and storage of the collected blood.

Autotransfusion of blood obtained by intraoperative cell salvage (with a leukocyte filter and washing) can reduce the use of allogeneic blood, but the reduction may be modest [12,16-21]. Although there is a theoretical concern that reinfusing amniotic fluid may cause amniotic fluid embolism, this has been documented only once [22] and may have been prevented by cell washing. Risk of maternal infection from infusion of bacterial contamination is also minimal. Salvaged blood may contain fetal erythrocytes [12], but this is not a major concern, in part because D alloimmunization in a D-negative mother can be prevented by administration of anti-D immune globulin. Although ABO incompatibility reactions cannot be prevented, they are unlikely to be serious because the volume of fetal blood contamination is small and A and B antigens/antibodies are not fully developed at birth. Alloimmunization from other red blood cell antigens is theoretically possible. These risks are probably less than or similar to those from allogeneic transfusion.

Data in obstetric patients show that cell salvage is a potential source of a substantial volume of blood for transfusion and reduces the need for allogenic transfusion. In a study of patients with obstetric hemorrhage in whom intraoperative blood salvage was performed and the blood was reinfused, the mean±standard deviation number of reinfused shed blood units was 1.2±1.1 units, and at least three patients received four, five, or eight reinfused shed blood units [23]. Another group estimated that the use of cell salvage for obstetric hemorrhage saved, on average, 0.68 units of allogeneic packed erythrocytes per patient (95% CI 0.49-0.88), translating to a 32 percent reduction in the use of allogeneic packed erythrocytes [13].

Technical issues of cell salvage are reviewed in detail separately. (See "Surgical blood conservation: Intraoperative blood salvage".)

ETIOLOGY-BASED MANAGEMENT

General principles

●A variety of surgical interventions are effective for controlling postpartum hemorrhage (PPH) [15]. Clinicians should use their clinical judgment in deciding whether to expend time attempting conservative interventions in a patient with severe hemorrhage or whether the patient may be better served by going directly to hysterectomy, which is often the best early approach in those with placenta accreta spectrum or uterine rupture. (See 'Role of hysterectomy' below.)

●Cessation of severe hemorrhage depends on reversal of any coagulopathy, so every effort should be made to reverse contributing factors such as hypothermia, acidosis, and lack of clotting factors. Even if bleeding cannot be completely controlled initially, as long as more blood and blood products are infused than lost, hemodynamic stability can be achieved and maintained. (See "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Transfuse red blood cells, platelets, plasma' and "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Correct clotting factor deficiencies'.)

Myometrial lacerations — Serious hemorrhage from the hysterotomy is generally caused by lateral extension of the incision. Bleeding usually can be controlled by suture ligation. The angles of a transverse incision should be clearly visualized to ensure that they, and any retracted vessels, are completely ligated. This generally requires gentle traction on an exteriorized uterus to provide adequate visualization of the lateral areas of the uterus above and below the edges of the incision.

An enlarging hematoma (or swelling beneath the surface of the broad ligament) beyond the end of the incision or laceration suggests a retracted blood vessel with ongoing bleeding. Given the proximity of the ureter to the vaginal angle and bladder reflection, the surgeon should be extremely cautious when placing hemostatic sutures laterally to control bleeding from an extension of a hysterotomy laceration or retracted vessel. In this circumstance, the ureter should be identified prior to blind placement of additional sutures intended to catch the retracted vessel. In some cases, the ureter(s) may be easily seen and identified. In other cases, ureteric stent(s) need to be placed to confirm the position of the ureters. Once the ureters can be seen or palpated, the broad ligament may need to be opened to isolate the bleeding vessel. Alternatively, sutures can be placed while retracting the ureter safely aside, without opening the retroperitoneum. Once the hemorrhage has been controlled, the integrity of the ureter(s) should be ensured. (See 'Post-laparotomy inspection' below.)

Laceration of the uterine artery or utero-ovarian artery branches — Bilateral ligation of the uterine vessels (O'Leary stitch) is the preferred approach for controlling PPH from laceration of the uterine artery or branches of the utero-ovarian artery [24,25]. It is preferable to internal iliac artery ligation because the uterine arteries are more readily accessible, the procedure is technically easier, and there is less risk to major adjacent vessels and the ureters. (See 'Role of internal iliac (hypogastric) artery ligation' above.)

After identification of the ureter, a large curved needle with a #0 polyglycolic acid suture is passed through the lateral aspect of the lower uterine segment as close to the cervix as possible and then back through the broad ligament just lateral to the uterine vessels. If this does not control bleeding, the vessels of the utero-ovarian arcade are similarly ligated just distal to the cornua by passing a suture ligature through the myometrium just medial to the vessels, then back through the broad ligament just lateral to the vessels, and then tying to compress the vessels (figure 5).

Bilateral ligation of the arteries and veins (uterine and utero-ovarian) is often successful in controlling hemorrhage [25,26] but in some cases may not completely control it, and other methods (see below) may be needed. Bilateral ligation does not appear to affect future reproductive function [7]. Uterine necrosis and placental insufficiency in a subsequent pregnancy have not been described as complications [26,27]. However, there is a single case report of ovarian failure and development of intrauterine synechiae after postpartum ligation of the uterine, utero-ovarian, and ovarian arteries for PPH related to atony [28].

Atony — The nonsurgical interventions for reduction and control of bleeding due to atony are applied in rapid sequence until bleeding is controlled, which may be the result of the cumulative combined effect of multiple interventions. All patients with PPH related to atony receive uterine massage/manual compression and administration of uterotonic medications and tranexamic acid. (See "Postpartum hemorrhage: Medical and minimally invasive management".)

If these measures do not control bleeding, and the patient is hemodynamically stable, we rapidly move on to placement of uterine compression sutures, which are an effective method for reducing uterine blood loss related to atony.

If the patient is hemodynamically unstable, temporizing measures such as placement of a uterine tourniquet, insertion of an intrauterine balloon for tamponade, and/or ligation of the uterine and utero-ovarian arteries can reduce ongoing heavy blood loss before placing compression sutures, and may obviate the need for them. (See 'Patients not at imminent risk of exsanguination' above.)

Uterine compression sutures — The B-Lynch suture is the most common technique for uterine compression; several variations of this technique have been described and no technique has been proven significantly more effective than another [29]. Generally, longitudinal sutures are easier to place and safer than transverse sutures, but this may not always be the case.

Procedure-related complications, such as uterine necrosis, erosion, and pyometra, have been reported rarely [30-35]. Limited follow-up of patients who have had a uterine compression suture suggests that there are no adverse effects on fertility or future pregnancy outcome [7,36]. Although uterine synechiae have been reported on postpartum hysteroscopy or hysterosalpingogram, some of these patients may have also had curettage, which could account for the finding [37].

B-Lynch suture — The B-Lynch suture (named for Christopher Balogun-Lynch) envelops and compresses the uterus, similar to the result achieved with manual uterine compression [38]. In case reports and small series, it has been highly successful in controlling uterine bleeding from atony when other methods have failed [38-42]. The technique is relatively simple to learn, appears safe, preserves future reproductive potential, and does not increase the risk of placenta-related adverse outcomes in a subsequent pregnancy, but may increase chances of developing Asherman syndrome [43,44]. It should only be used in cases of uterine atony; it will not control hemorrhage from placenta accreta spectrum. The effect is temporary; it will not prevent PPH in future pregnancies [43].

A large Mayo needle with #1 or #2 chromic catgut (or any absorbable suture if catgut is unavailable) is used to enter and exit the uterine cavity laterally in the lower uterine segment (figure 6). A large suture is used to prevent breaking, and a rapid absorption is important to prevent a herniation of bowel through a suture loop after the uterus has involuted.

The suture is looped over the fundus and re-enters the lower uterine cavity through the posterior wall. The suture then crosses to the other side of the lower uterine segment, exits through the posterior wall, and is looped back over the fundus to enter the anterior lateral lower uterine segment opposite and parallel to the initial bites. The free ends are pulled tightly and tied down securely to compress the uterus, assisted by bimanual compression.

Proper patient positioning (eg, legs apart, patient flat, or, if stable, in slight reverse Trendelenburg) will enhance the ability to assess the efficacy of these efforts by allowing for better assessment of persistent vaginal bleeding.

The technique has been used alone and in combination with balloon tamponade. This combination has been called the "uterine sandwich." (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device".)

Other uterine compression suture techniques — Other techniques have been reported in small case series and represent modifications of the B-Lynch suture [40,45-52].

●Hayman described placement of two to four vertical compression sutures from the anterior to posterior uterine wall without hysterotomy (figure 7); thus, this is a good choice for surgical treatment of atony after a vaginal birth [45,46,53]. A transverse cervicoisthmic suture can also be placed if needed to control bleeding from the lower uterine segment.

●Pereira described a technique in which a series of transverse and longitudinal sutures of a delayed absorbable multifilament suture are placed around the uterus via a series of bites into the subserosal myometrium, without entering the uterine cavity (figure 8) [47]. Two or three rows of these sutures are placed in each direction to completely envelope and compress the uterus. The longitudinal sutures begin and end tied to the transverse suture nearest the cervix. When the transverse sutures are brought through the broad ligament, care should be taken to avoid damaging blood vessels, ureters, and fallopian tubes. The myometrium should be manually compressed prior to tying down the sutures to facilitate maximal compression.

●Cho described a technique using multiple squares/rectangles (figure 9) [49,54].

Retroperitoneal bleeding — Identification of an isolated bleeding point in the retroperitoneum is often impossible. It is rarely advisable to open the retroperitoneum or attempt dissection of any nonexpanding hematoma or an expanding retroperitoneal hematoma in a coagulopathic, hemodynamically unstable patient. The temporizing procedures described above can be used to stabilize the patient before beginning retroperitoneal surgery. (See 'Temporary measures for stabilizing hemodynamically unstable patients' above.)

●Topical hemostatic agents can be used to control mild diffuse bleeding from peritoneal surfaces (table 2).

●If a discrete retroperitoneal vessel is responsible for hemorrhage, it is clamped and ligated with appropriate suture material. Bleeding adjacent to the uterus without clear bleeding points can be managed by ligation of uterine vessels.

●If ineffective, ligation of the ipsilateral internal iliac artery usually stops the bleeding and avoids the delay associated with searching for the discrete source of bleeding. If bleeding does not respond to ipsilateral internal iliac artery ligation, then bilateral internal iliac artery ligation and/or pelvic packing may be necessary. If time allows, when retroperitoneal bleeding is present and efforts to control retroperitoneal bleeding are necessary, ureteral stents may allow palpation of the ureters and placement of hemostatic sutures with more confidence.

Given the technical difficulties of safely ligating the internal iliac arteries, especially in the setting of disseminated intravascular coagulation and ongoing bleeding, this should only be attempted by surgeons with experience in the procedure and only when adequate blood products and facilities are available.

●For surgeons without the necessary experience, pressure over the bleeding point or area, resuscitation and reversal of any coagulopathy, and calling for help from an experienced surgeon are key temporizing measures. If the hospital has the capability for performing arterial embolization in the operating room, this may be an option. Removal of a hemodynamically unstable patient from an operating room to transport to an interventional radiology suite is not advised.

Management of retroperitoneal bleeding is discussed in more detail separately. (See "Management of hematomas incurred as a result of obstetric delivery", section on 'Retroperitoneal hematomas'.)

Placental abnormalities — Management of the placenta accreta spectrum and placenta previa are reviewed separately. (See "Placenta accreta spectrum: Management" and "Placenta previa: Management".)

POST-LAPAROTOMY INSPECTION — At the completion of the laparotomy and before closing the abdomen, the operative field should be inspected carefully for hemostasis.

Microvascular bleeding usually can be controlled using topical hemostatic agents (table 2) (see "Overview of topical hemostatic agents and tissue adhesives", section on 'Choice of agent'). Clinicians should be familiar with the products available at their facility. We generally start with a cellulose-based surgical mesh (eg, Surgicell or Nuknit), which usually controls slow oozing. If a product that has an expansion property is desired, we will move to a collagen-based product such as Gelfoam. A more reactive product that has fibrin and thrombin can also be employed; we reserve this for more active bleeding because it is impregnated with clotting factors that combine to form an active seal that is more robust than simply providing a cellulose matrix for normal coagulation. For small areas (or those that are difficult to reach), we spray on powdered forms of cellulose such Avatene or Surgicell powder, and in some cases we may use a thrombin spray or a liquid such as Tisseal or Surgi-flow. There are significant cost differentials among these products, which should be considered and discussed with the pharmacy. If exposure to porcine-derived products is a consideration, the product insert will state the origin of the sealant.

The bladder and ureters should be identified and inspected. The ureter courses horizontally along the peritoneum 1 to 5 cm dorsal to the ovarian vessels and can be identified readily as it passes ventral to the bifurcation of the common iliac artery. Identification of bladder and/or ureteral injury is the same as during gynecologic surgery (ie, visual inspection, possible cystoscopy, dye injection, stent placement to assess for obstruction, ureterography). (See "Urinary tract injury in gynecologic surgery: Identification and management".)

ROLE OF HYSTERECTOMY — Hysterectomy is a definitive treatment of uterine bleeding. Regardless of the etiology of PPH, continued blood loss can lead to severe coagulopathy due to massive loss of coagulation factors. Severe hypovolemia, tissue hypoxia, hypothermia, electrolyte abnormalities, and acidosis can result and further compromise the patient's status. If the patient is not already at laparotomy and has developed these additional complications, then correcting the severe physiological deficits before hysterectomy, if possible, could be lifesaving. (See "Peripartum hysterectomy for management of hemorrhage".)

In patients with placenta accreta spectrum or uterine rupture, early resort to hysterectomy may be the least morbid approach for controlling hemorrhage and may prevent deaths and morbidity caused by delays while ineffective fertility-preserving procedures are attempted. With improving prenatal diagnosis of placental attachment disorders, hysterectomy can often be anticipated and discussed with the patient before planned cesarean birth. (See "Placenta accreta spectrum: Clinical features, diagnosis, and potential consequences" and "Placenta accreta spectrum: Management".)

By contrast, uterine atony can usually be controlled by uterotonic medications alone or in combination with fertility-preserving procedures (eg, uterine compression sutures, uterine artery/utero-ovarian artery ligation, arterial embolization, intrauterine tamponade), as described above. Once the patient is resuscitated and the coagulopathy is reversed, hysterectomy may no longer be required to control hemorrhage. However, if fertility-preserving procedures do not reduce the bleeding to a manageable level, then there is no choice but to proceed with hysterectomy.

Damage control approach for persistent bleeding after hysterectomy — Patients with continued severe bleeding after hysterectomy can enter a lethal downward spiral characterized by hypothermia, coagulopathy, and metabolic acidosis [55,56]. Criteria proposed for this "in extremis" state include pH <7.30, temperature <35° Celsius, combined resuscitation and procedural time >90 minutes, nonmechanical bleeding, and transfusion requirement >10 units red blood cells (RBCs) [57].

●To abort the cycle, the bleeding area is tightly packed, and the skin is closed to prevent heat and moisture loss (either with large sutures or with towel clamps). Placement of a large bore drainage catheter (such as a large Jackson-Pratt drain or a chest tube) in the pelvis at the time of temporary closure will allow early recognition of the need to return to the operating room.

Variations of the abdominal packing procedure have been published ("umbrella pack") [58-66]. One such variation is to fill a sterile plastic bag (eg, drawstring bag used to cover radiographic film) or cloth container with gauze (wet gauze gives it more weight) and place it against the pelvic bleeders. The drawstrings are pulled through the vagina and attached to a weight, which provides traction so that the pack exerts pressure against the pelvic floor.

A balloon tamponade device has also been used as a pelvic pressure pack after hysterectomy for PPH [67,68].

Some surgeons also use hemostatic agents (table 2), which may be applied directly to the bleeding tissue or included in pads for pelvic tamponade [69].

While there is no consensus on use of broad-spectrum prophylactic antibiotics while the pack is in place, the author of this topic gives them because these patients may have had potential breaks in sterility when emergency measures were applied.

●Some authorities favor the use of negative-pressure vacuum devices, where available, in patients undergoing temporary abdominal wall closure [70]. These devices can continuously collect fluid from the wound and abdominal cavity without damaging viscera because a protective layer is placed between the viscera and the device. For example, negative pressure can be applied to the dressing after the surgical team packs, covers, and seals the open abdomen. No study has specifically addressed prophylactic negative pressure wound therapy in patients who have persistent bleeding after hysterectomy for PPH. (See "Negative pressure wound therapy".)

●Under most circumstances, the patient should remain in the operating room with continuous monitoring while replacement of appropriate blood products and correction of physiologic derangements ("damage control") occur [55,57]. This approach halts the downward spiral and lessens the risk of abdominal compartment syndrome, which is more likely if the fascia is closed. Abdominal compartment syndrome is more difficult to define postpartum since postcesarean intra-abdominal pressure appears to be higher than in the general surgical population, especially in patients with elevated body mass index and hypertensive disorders [71-74]. (See "Abdominal compartment syndrome in adults".)

The patient can leave the operating room after they have been stabilized, as evidenced by cessation of active bleeding, maintenance of hemodynamic stability, and satisfactory progress in the management/reversal of any coagulopathy. Depending on the degree of blood loss, the amount of resuscitation required, the risk of resumption of bleeding, and the need for ventilation, they can be transferred to a high-care post-anesthesia care unit (PACU) or an intensive care unit (ICU) for one-to-one nursing care and close observation by the physician team as appropriate.

●The need for ≥2 units RBCs per hour for three hours is a sign of significant ongoing bleeding and need to return to the operating room or undergo arterial embolization by an interventional vascular specialist. In one study in which bleeding did not stop in 20 of 53 patients despite abdominal packing, six required a second surgical intervention, six underwent pelvic artery embolization, and eight had further intensive resuscitation and pharmacologic treatments [66].

●Patients who have been stabilized are returned to the operating room to undergo definitive surgical care in approximately 48 hours. Packing should not be removed until coagulopathy has been corrected. If the packing has controlled bleeding, it generally is removed at this time. If it is removed too soon (<24 hours), bleeding will resume, whereas if it is removed too late (>72 hours), pelvic infection or abscess may ensue.

Under general anesthesia, the wound is opened and the gauze is removed with gentle traction. The pelvis is irrigated with saline to clear loose clots and other debris, but aggressive exploration of the pelvis is not performed if no pooling of blood is noted. The wound is then reapproximated in the usual manner.

General principles of damage control surgery in severely injured patients are reviewed separately (see "Overview of damage control surgery and resuscitation in patients sustaining severe injury"). Supportive care for critically ill postpartum patients is also discussed separately. (See "Critical illness during pregnancy and the peripartum period", section on 'Supportive care'.)

ROLE OF EMBOLIZATION — The main settings when embolization may be indicated are:

●At laparotomy, when persistent non-life-threatening deep pelvic bleeding occurs after repair of lacerations or hysterectomy and cannot be controlled by surgical ligation or ablation.

Embolization is an option if the facility has an appropriately equipped operating room (hybrid operating room, or an appropriately sensitive portable C-arm and carbon fiber table).

●After laparotomy, when persistent slow internal bleeding is suspected in a hemodynamically stable patient. The patient can be transferred to the interventional radiology suite for a diagnostic angiogram and embolization (if a bleeding source is seen).

Hemodynamically unstable patients should be evaluated in the operating room, not the interventional radiology suite. If the facility has an appropriately equipped operating room, performing uterine or internal iliac artery embolization in an operating room with the full surgical team in attendance is an option. Laparotomy is performed if the patient deteriorates during evaluation and embolization or if the embolization fails.

●In patients with a placenta accreta spectrum. Embolization can reduce bleeding before and during hysterectomy or when conservative management (leaving the placenta in situ) is attempted. Direct arterial puncture of the internal iliac artery and embolization at cesarean birth has been described in 16 cases of placenta accreta spectrum [75]. The procedure was successful in all of the cases and no complications (eg, fever, buttock pain, acute limb ischemia) occurred. (See "Placenta accreta spectrum: Management", section on 'Endovascular intervention for hemorrhage control'.)

Embolization after a failed uterine artery ligation is more difficult [76,77], although not impossible. In one study, arterial embolization was successful in 10 of 11 cases of failed surgical ligation therapy for postpartum hemorrhage (PPH) [78]. Thus, uterine artery embolization can be considered an option even after failed surgical ligation due to incomplete/ineffective occlusion. (See "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Consider uterine or hypogastric artery embolization'.)

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: Obstetric hemorrhage".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Postpartum hemorrhage (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Abdominal incision – For patients in whom the abdomen is not already open for cesarean birth, we suggest a midline abdominal incision for treatment of postpartum hemorrhage (PPH). For those undergoing or with completed cesarean delivery, extension of the existing incision is more appropriate. (See 'Evaluation of the abdomen at laparotomy' above.)

●Temporizing measures – In hemodynamically unstable patients, temporizing maneuvers to reduce bleeding should be attempted prior to performing surgical procedures that take significant time to control hemorrhage. The option chosen depends on the urgency to control bleeding, the source of bleeding (intrauterine versus extrauterine), and the surgeon's expertise and preference:

•Manual aortic compression (in highly urgent settings) (see 'Manual aortic compression' above)

•Intra-aortic balloon occlusion (see 'Balloon occlusion of the aorta (REBOA)' above)

•Uterine tourniquet (see 'Uterine tourniquet' above)

•Intrauterine postpartum hemorrhage control by balloon tamponade or low level vacuum (see 'Intrauterine postpartum hemorrhage-control devices' above)

•Ligation of the uterine and utero-ovarian arteries (see 'Ligation of uterine and utero-ovarian arteries' above)

•Pelvic pack (see 'Pelvic packing' above)

•Clamp across utero-ovarian ligaments (note: will occlude fallopian tubes) (see 'Clamp across utero-ovarian ligaments' above)

•Internal iliac artery ligation (procedure of last resort) (see 'Role of internal iliac (hypogastric) artery ligation' above)

●Intraoperative blood salvage – Intraoperative blood salvage may be arranged before laparotomy or requested during laparotomy, but its use is investigational in the obstetric setting. (See 'Role of intraoperative cell salvage' above.)

●Treatment approaches based on bleeding site

•Hysterotomy bleeding – Bleeding from a hysterotomy incision can generally be controlled by suture ligation. The angles of a transverse incision should be clearly visualized to ensure that they, and any retracted vessels, are completely ligated. If possible, the ipsilateral ureter should be identified before the bleeding is controlled and, once the hemorrhage has been controlled, the integrity of the ureter should be ensured. (See 'Myometrial lacerations' above.)

•Branch artery bleeding – Bilateral ligation of the uterine vessels (O'Leary stitch) is the preferred approach for controlling PPH from laceration of the uterine artery or branches of the utero-ovarian artery. If this does not control bleeding, the vessels of the utero-ovarian arcade are similarly ligated. (See 'Laceration of the uterine artery or utero-ovarian artery branches' above.)

•Atony – The interventions for reduction and control of bleeding due to atony are applied in rapid sequence until bleeding is controlled, which may be the result of the cumulative combined effect of multiple interventions. If uterine atony persists despite uterine massage and administration of uterotonic medications and tranexamic acid, we suggest rapidly moving on to placement of uterine compression sutures, which are an effective method for reducing uterine blood loss related to atony. Manual compression of the uterus, insertion of an intrauterine balloon for tamponade, placement of a uterine tourniquet, and/or ligation of the uterine and utero-ovarian arteries can reduce brisk ongoing heavy blood loss before placement of compression sutures. In some cases, hemorrhage will cease after one or more of these interventions and the compression sutures will not be needed. (See 'Atony' above.)

•Retroperitoneal bleeding – Identification of an isolated bleeding point in the retroperitoneum is often impossible, so it is rarely advisable to open the retroperitoneum or attempt dissection of any nonexpanding retroperitoneal hematoma or an expanding retroperitoneal hematoma in a coagulopathic, hemodynamically unstable patient. Temporizing procedures can be used to stabilize the patient before beginning retroperitoneal surgery. (See 'Retroperitoneal bleeding' above.)

•Placental site bleeding – Management of PPH from placental abnormalities, including preoperative placement of balloon catheters by an interventional vascular specialist, is reviewed separately. (See "Placenta previa: Management" and "Placenta accreta spectrum: Management".)

●Candidates for hysterectomy and damage control – Early hysterectomy is appropriate in patients with severe bleeding due to diffuse placenta accreta/increta/percreta or a large uterine rupture. Hysterectomy is generally a last resort in patients with atony but should not be delayed in those who have severe coagulopathy and require prompt control of uterine hemorrhage to prevent severe morbidity or death. (See 'Role of hysterectomy' above.)

Patients with persistent severe hemorrhage after hysterectomy can enter a lethal downward spiral characterized by hypothermia, coagulopathy, and metabolic acidosis. To abort the cycle, the bleeding area is tightly packed, and the skin temporarily closed while the patient is actively warmed and resuscitated. The patient should not be moved from the operating room until the bleeding has been controlled and they are hemodynamically stable. The patient should then be transferred to an intensive care unit (ICU) for continuous monitoring, ongoing replacement of appropriate blood products, and correction of physiologic derangements. (See 'Damage control approach for persistent bleeding after hysterectomy' above.)

●Candidates for embolization – The main settings when embolization may be indicated are (see 'Role of embolization' above):

•At laparotomy, when persistent non-life-threatening deep pelvic bleeding occurs after repair of lacerations or hysterectomy and cannot be controlled by surgical ligation or ablation. Embolization is only an option if the facility has an appropriately equipped operating room (hybrid operating room, or an appropriately sensitive portable C-arm and carbon fiber table).

•After laparotomy, when persistent slow internal bleeding is suspected in a hemodynamically stable patient. The stable patient can be transferred to the interventional radiology suite for a diagnostic angiogram and embolization (if a bleeding source is seen).

Hemodynamically unstable patients should be evaluated in the operating room, not the interventional radiology suite. Interventional procedures can only be used in this clinical situation if the facility has an appropriately equipped operating room. Laparotomy is performed if the patient deteriorates during evaluation and embolization or the embolization fails.

•In patients with placenta accreta spectrum. (See "Placenta accreta spectrum: Management".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dr. Allan J Jacobs, who contributed to earlier versions of this topic review.