Pharmacological and surgical therapy for primary postpartum hemorrhage

Acute Sheehan’s syndrome manifesting initially with diabetes insipidus postpartum: a case report and systematic literature review

Purpose

Acute Sheehan’s syndrome is a rare, but potentially life-threatening, obstetric event that can be complicated by diabetes insipidus. Little information on the diagnosis and treatment of Sheehan’s syndrome with diabetes insipidus is available. We report on a 28-year-old patient who developed acute Sheehan’s syndrome with diabetes insipidus after giving birth, and on a systematic review of similar cases.

Methods

We performed a systematic review of the literature cataloged in PubMed and Google Scholar using the keywords “Sheehan syndrome” OR “Sheehan's syndrome” AND “diabetes insipidus” to identify relevant case reports published between 1990 and 2021. Eight Reports met the inclusion criteria (English-language abstracts available, onset in the puerperium, information about the day of the onset).

Results

In the present case, postpartum curettage was necessary to remove the residual placenta. The total amount of blood loss was severe (2500 ml). On the second day postpartal, the patient developed polyuria. Laboratory analysis revealed hypernatremia with increased serum osmolality and decreased urinary osmolality. Hormone analysis showed partial hypopituitarism involving the thyroid, corticotropic, and gonadotropic axes. The prolactin level was elevated. Brain magnetic resonance imaging showed pituitary gland infarction. Desmopressin therapy was initiated and resolved the polyuria. Hormone replacement therapy was administered. Four months later, the patient was well, with partial diabetes insipidus. The literature review indicated that this case was typical in terms of symptoms and disease onset. Most reported cases involve hypotension and peripartum hemorrhage, but some patients without hemorrhage also develop Sheehan’s syndrome. Elevated prolactin levels are uncommon and associated with poor prognosis in patients with Sheehan’s syndrome.

Conclusion

Acute Sheehan’s syndrome with diabetes insipidus involves nearly all pituitary hormone axes, indicating severe disease. Prolactin elevation could suggest that a case of Sheehan’s syndrome is severe.

Intravenous Oxytocin versus Intramuscular Oxytocin for the Management of Postpartum Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND

Postpartum Hemorrhage (PPH) is one of the primary causes of maternal mortality and morbidity during the third stage of labor. Oxytocin is the gold standard uterotonic agent for the prevention of PPH.

OBJECTIVE

We aimed to compare the efficacy of oxytocin administered Intramuscularly (IM) or Intravenously (IV) for the preventive management of PPH.

METHODS

We searched six databases for relevant clinical trials evaluating the administration of oxytocin for the prevention against PPH through July 2019. Data on blood loss, PPH (≥500 ml), severe PPH (≥1000 ml), blood transfusion, the change in hemoglobin, the use of additional uterotonics, and the incidence of retained placenta were extracted and pooled in a meta-analysis model using RevMan version 5.3.

RESULTS

Seven studies with a total of 6996 participants were included. IM oxytocin group was associated with higher incidence rates of PPH (≥500 ml) (RR=1.35; p=0.003), severe PPH (≥1000 ml) (RR=1.58; p=0.04), and blood transfusion (RR=2.43; p=0.005). In terms of blood loss, the IV route was superior to the IM route (SMD= 0.15; p=0.00001). However, we observed no statistically significant difference between the two routes regarding the change in Hb (SMD=-0.02; p=0.72) and the use of additional uterotonics (RR=0.96, p= 0.94).

CONCLUSION

IV oxytocin infusion is maybe superior to IM injection for the management of PPH. Further studies with larger sample sizes are still needed to support these findings.

The effectiveness of the double B-lynch suture as a modification in the treatment of intractable postpartum haemorrhage

A broader range of more effective compression techniques are needed in the patients who have an intractable postpartum haemorrhage due to uterine atony despite medical treatment and B-Lynch sutures. The aim of this study was to report the outcome of a series of patients with haemorrhage who were managed by double B-Lynch suture. Fourteen patients who were treated in a tertiary hospital between July 2010 and February 2015 were included in the study. The intractable haemorrhage rate was 0.35% over 5 years (14/4000 births). Bleeding was controlled in all the patients with a double B-Lynch suture. The mean age of the patients was 24 ± 3.4 years. The mean estimated blood loss was 1696 ± 272.075 mL, and the mean transfusion rate was 4.2 ± 2.5 units. Pregnancy was observed in five patients at follow up. The double B-Lynch suture seems to be an effective and reliable solution to an intractable postpartum haemorrhage resulting from uterine atony and has no unfavourable impacts on fertility. It should be considered before the use of any aggressive surgical techniques such as a hypogastric artery ligation or a hysterectomy. This the first study to investigate the effectiveness of the double B-Lynch suture, and we showed that the hysterectomy and/or hypogastric artery ligation rate can be decreased by adding a second B-Lynch suture in cases where the medical treatment or a single B-Lynch has failed. Impact statement What is already known on the subject? Uterine atony is the most common cause of a primary postpartum haemorrhage. When a simple massage of the uterus and medication failed to manage this condition, various surgical solutions have been sought, including uterine compression sutures, uterine artery ligation, devascularisation of the uterus, internal iliac artery ligation and, ultimately, a hysterectomy. The B-Lynch suturing technique is particularly useful because of its simplicity of application, life-saving potential, relative safety and capacity for preserving the uterus and subsequent fertility. To-date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications. However in the cases of when it falls, usually a hysterectomy or a hipogastric artery ligation is preferred. What does this study add? A 'double B-Lynch suture seems to be an effective and reliable method in an intractable postpartum haemorrhage due to a uterine atony and has no unfavourable impact on fertility'. What are the implications of these findings for clinical practice? The double B-Lynch suture seems to be an effective, reliable and technically easy method. With this aspect, it might be considered before any aggressive surgical techniques, such as a hypogastric artery ligation and hysterectomy in selected cases.

Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis

Uncontrolled massive bleeding with subsequent derangement of the coagulation system is a major challenge in the management of both surgical and seriously injured patients. Under physiological conditions activators and inhibitors of coagulation regulate the sensitive balance between clot formation and fibrinolysis. In some cases, excessive and diffuse bleeding is caused by systemic activation of fibrinolysis, i. e. hyperfibrinolysis (HF). Uncontrolled HF is associated with a high mortality. Polytrauma patients and those undergoing surgical procedures involving organs rich in plasminogen proactivators (e. g. liver, kidney, pancreas, uterus and prostate gland) are at a high risk for HF. Antifibrinolytics, such as tranexamic acid (TXA) are used for prophylaxis and treatment of bleeding caused by a local or generalized HF as well as other hemorrhagic conditions. TXA is a synthetic lysine analogue that has been available in Austria since 1966. TXA is of utmost importance in the prevention and treatment of traumatic and perioperative bleeding due to the resulting reduction in perioperative blood loss and blood transfusion requirements. The following article presents the different fields of application of TXA with particular respect to indications and dosages, based on a literature search and on current guidelines.

Evaluation of measured postpartum blood loss after vaginal delivery using a collector bag in relation to postpartum hemorrhage management strategies: a prospective observational study

AIM

To evaluate the incidence of postpartum hemorrhage (PPH) and severe PPH via routine use of a pelvic drape to objectively measure blood loss after vaginal delivery in connection with PPH management.

METHODS

This prospective observational study was undertaken at the obstetrical department of the Charité University Hospital from December 2011 to May 2013 and evaluated an unselected cohort of planned vaginal deliveries (n=1019 live singletons at term). A calibrated collecting drape was used to meassure blood loss in the third stage of labor. PPH and severe PPH were defined as blood loss ≥500 mL and ≥1000 mL, respectively. Maternal hemoglobin content was evaluated at admission to delivery and at the first day after childbirth.

RESULTS

During the study period, 809 vaginal deliveries were analysed. Direct measurement revealed a median blood loss of 250 mL. The incidences of PPH and severe PPH were 15% and 3%, respectively. Mean maternal hemoglobin content at admission was 11.9±1.1 g/dL, with a mean decrease of 1.0±1.1 g/dL. Blood loss measured after vaginal delivery correlated significantly with maternal hemoglobin decrease.

CONCLUSIONS

This study suggests that PPH incidence may be higher than indicated by population-based data. Underbuttocks drapes are simple, objective bedside tools to diagnose PPH. Blood loss should be quantified systematically if PPH is suspected.

Intramuscular versus intravenous prophylactic oxytocin for postpartum hemorrhage after vaginal delivery: a randomized controlled study

PURPOSE

Prevention of postpartum haemorrhage (PPH) is essential in the pursuit of improved health care for women. Oxytocin, the most commonly used uterotonic agent to prevent PPH, has no established the route of administration. In this study we aimed to compare whether the mode of oxytocin administration, i.e., intravenous and intramuscular administration, has an effect on the potential benefits and side effects.

MATERIALS AND METHODS

A total of 256 women were randomised into two groups: intramuscular group (128) or intravenous group (128).

RESULTS

Estimated blood loss during the third stage of labour was similar between the two groups (p = 0.572). Further there were no statistically significant difference was noted between the two groups in terms of the mean duration of labor, duration of the third stage of labor, manual removal of the placenta, need for instrumental delivery, need for blood transfusion, PPH ≥500 mL, PPH ≥1000 mL, or length of hospital stay.

CONCLUSION

Using oxytocin by intravenous and intramuscular route has a similar efficacy and adverse effects.

Carbetocin versus oxytocin for prevention of postpartum hemorrhage after vaginal delivery in high risk women

OBJECTIVE

To compare effectiveness and tolerability of carbetocin versus oxytocin in prevention of postpartum hemorrhage (PPH) after vaginal delivery.

METHODS

A prospective double-blinded randomized study conducted on 200 pregnant women randomized into two groups: Group 1 (100 women) received single 100 μg IM dose of carbetocin and Group 2 received of 5 IU oxytocin IM. Both groups received their drug after fetal and before placental delivery.

RESULTS

There was a statistically significant difference between the two study groups regarding amount of bleeding (337.73 ± 118.77 versus 378 ± 143.2), occurrence of PPH (4 versus 16%), need for other uterotonics (23 versus 37%) and hemoglobin difference between before and after delivery (0.55 ± 0.35 versus 0.96 ± 0.62) (all being lower in carbetocin group) and measured hemoglobin 24 h after delivery (being higher in carbetocin group); however, there was no significant difference between the two study groups regarding occurrence of major PPH and the need for blood transfusion. Women in carbetocin group showed a statistically significant lower systolic and diastolic blood pressure immediately after delivery and at 30 and 60 min than women in oxytocin group. There was no significant difference between the two study groups regarding occurrence of nausea, vomiting, flushing, dizziness, headache, shivering, metallic taste, dyspnea, palpitation and itching. Women in carbetocin group experienced tachycardia more than women in oxytocin group.

CONCLUSIONS

Carbitocin is a better alternative to traditional oxytocin in prevention of PPH after vaginal delivery with minimal hemodynamic changes and similar side effects.

The maternal cardiovascular effect of carbetocin compared to oxytocin in women undergoing caesarean section

OBJECTIVE

To compare haemodynamic changes, measured noninvasively using the USCOM monitor, after combined spino-epidural anaesthesia and after administration of two different uterotonic drugs, oxytocin and carbetocin, in a population of pregnant women during elective caesarean delivery.

METHODS

Haemodynamic measurements were obtained with the USCOM system, by positioning a probe at maternal suprasternal notch (SSN) until the aortic valve flow's profile was optimally identified. Evaluations of the haemodynamic profile were obtained in seven different moments: before anaesthesia; during skin incision; 60, 180 and 300s after administration of uterotonic drug, at closure of the uterus, at closure of the skin. Doses of uterotonic drugs were: Oxytocin 5UI in 500cc NaCl eV, Carbetocin 100mcg in bolus eV. Main measured parameters were: heart rate, mean blood pressure, stroke volume, cardiac output and total vascular resistance.

RESULTS

We enrolled 32 pregnant women. Patients were randomized in two groups: oxytocin and carbetocin. A reduction in mean blood pressure, a reduction of total vascular resistance and an increase of cardiac output and of stroke volume were seen, while heart rate values remained stable in both treatment groups. No statistically significant differences were found.

DISCUSSION

Administration of carbetocin is associated with a substantial global haemodynamic stability in patients undergoing elective caesarean section without any difference with oxytocin. This observation allows us to consider carbetocin comparable to oxytocin, with minimum haemodynamic impact on the maternal circulation. This minimal effect on global haemodynamic stability might extend the use of this uterotonic drug in patients at high haemorrhagic risk with preeclampsia.

Recombinant human factor VIIa prevents hysterectomy in severe postpartum hemorrhage: single center study

OBJECTIVE

To evaluate the effectiveness of human recombinant activated factor VII (rhFVIIa, NovoSeven) in avoiding hysterectomy postpartum in the management of severe postpartum hemorrhage (PPH).

METHODS

We performed a prospective cohort study at our university tertiary care center. Patients with severe post partum hemorrhage (blood loss >2000 mL) and failed medical and uterus-preserving surgical management, were treated with intravenous bolus administration of rhVIIa. Main outcome measures were cessation of bleeding, postpartum hysterectomy and thromboembolic events.

RESULTS

In 20/22 patients included, PPH was caused primarily by uterine atony, including 7 (32%) with additional lower genital tract lesion; in two women, it was due to pathologic placentation (placenta increta, 9%). One case of amniotic fluid embolism and one woman with uterine inversion were included. Recombinant hFVIIa was successful in stopping the PPH and in preventing a hysterectomy in 20/22 women (91%). The remaining two patients with persistent bleeding despite rhFVIIa treatment, who underwent postpartum hysterectomy, had placenta increta. No thromboembolic event was noticed.

CONCLUSIONS

This study describes the largest single center series of rhFVIIa treatment for fertility preservation in severe postpartum hemorrhage published to date. Our data suggest that administration of rhFVIIa is effective in avoiding postpartum hysterectomy after conservative medical and surgical measures have failed. Although randomized studies are lacking, rhFVIIa should be considered as a second-line therapeutic option of life-threatening postpartal bleeding, in particular if preservation of fertility is warranted and hysterectomy is to be avoided.

Maternal haemorrhage

Maternal haemorrhage is the leading cause of preventable maternal death worldwide and encompasses antepartum, intrapartum, and postpartum bleeding. This review highlights factors that predispose to severe bleeding, its management, and the most recent treatment and guidelines. Advances in obstetric care have provided physicians with the diagnostic tools to detect, anticipate, and prevent severe life-threatening maternal haemorrhage in most patients who have had prenatal care. In an optimal setting, patients at high risk for haemorrhage are referred to tertiary care centres where multidisciplinary teams are prepared to care for and deal with known potential complications. However, even with the best prenatal care, unexpected haemorrhage occurs. The first step in management is stabilization of haemodynamic status, which involves securing large bore i.v. access, invasive monitoring, and aggressive fluid management and transfusion therapy. Care for the patient with maternal bleeding should follow an algorithm that goes through a rapid and successive sequence of medical and surgical approaches to stem bleeding and decrease morbidity and mortality. With the addition of potent uterotonic agents and the advent of minimally invasive interventional radiological techniques such as angiographic embolization and arterial ligation, definitive yet conservative management is now possible in an attempt to avoid hysterectomy in patients with severe peripartum bleeding. If these interventions are inadequate to control the bleeding, the decision to proceed to hysterectomy must be made expeditiously. Recombinant factor VIIa is a relatively new treatment that could prove useful for severe coagulopathy and intractable bleeding.

Diagnosis and treatment of peripartum bleeding

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5-5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VIIa.

Emergencies associated with pregnancy and delivery: peripartum hemorrhage

INTRODUCTION

Peripartum hemorrhage is one of the leading causes of maternal death worldwide (25%).

METHODS

Selective literature review, including international guidelines, for assessment of the causes and optimal management of this condition.

RESULTS

The major causes of hemorrhage are uterine atony, placenta previa, and abruptio placentae. The diagnosis of hemorrhage is suspected from its clinical manifestations and confirmed by ultrasonography. In placenta previa, the placenta is implanted in the lower uterine segment and may cover the internal cervical os. Placenta previa is more common in older and multiparous mothers, as well as in mothers who have previously undergone a cesarean section. Placental abruption is defined as separation of the placenta from the uterine wall before delivery of the infant. The risk factors for this condition include preeclampsia, advanced maternal age, and trauma. When it presents with manifestations of acute blood loss, premature abruption placentae must be diagnosed rapidly and treated without delay to save the life of the mother and child. A rare, but highly lethal, cause of bleeding is amniotic fluid embolism, which manifests itself with sudden and unexplained peripartum respiratory distress and cardiovascular collapse. Amniotic fluid embolism is associated with high fetal and maternal mortality (20% and 60% to 80%, respectively) even when it is optimally treated.

DISCUSSION

Peripartum hemorrhage is an important source of maternal and fetal morbidity and mortality. The prognosis for both mother and child can be markedly improved if the risk factors for hemorrhage are recognized and the problem is treated rapidly and appropriately when it arises.

[Air embolism during elective cesarean section, and uterine atony due to fetal macrosomia]

We report the case of a paradoxical air embolism during a scheduled cesarean section for fetal macrosomia (7.010 kg) in a 38-year-old woman with a history of gestational diabetes and preeclampsia. Spinal anesthesia was satisfactory and well tolerated. After approximately 30 minutes (coinciding with uterine exteriorization), the patient presented a sudden episode of dyspnea, confusion, hypotension, and ST segment depression. The episode lasted approximately 10 minutes and resolved spontaneously with no sequelae. Neurological status and the electrocardiogram were normal at the end of surgery and no postoperative lesions were observed. In the immediate postoperative period, the patient presented a massive hemorrhage due to uterine atony. Echocardiography revealed a patent foramen ovale. The clinical signs in this patient are highly suggestive of a paradoxical cerebral and coronary air embolism.

The use of recombinant activated factor VII in obstetric and gynaecological haemorrhage

Recombinant activated factor VII (rFVIIa) was originally developed for the treatment of bleeding in patients with haemophilia A or B and inhibitors. Over the past ten years, it has been successfully used to prevent or control bleeding in several other nonhaemophilic bleeding conditions. Among the newer 'off-label' clinical applications of rFVIIa, there is increasing evidence of its effectiveness in treating obstetric and gynaecological bleeding unresponsive to conventional therapy. The existing literature on the use of rFVIIa in obstetrics and gynaecology is summarised in this review. Although supported by few and uncontrolled studies, on the whole, the published data suggest a potential role of rFVIIa in the management of obstetric and gynaecological intractable bleeding. However, further evidence is needed to improve the assessment of its optimal dose, effectiveness and safety in such conditions.