Second-line uterotonic use is high in women experiencing severe postpartum hemorrhage, and B-Lynch brace suture placement is the most common surgical intervention. These were among the findings of a retrospective study conducted at Stanford University School of Medicine, in California, that has shed light on women who experience severe postpartum hemorrhage during intrapartum cesarean delivery.
“We conducted this study to learn more about the differences in medical interventions and surgical interventions in women who experience severe postpartum hemorrhage after C-section compared to women who don’t experience postpartum hemorrhage after C-section,” said Katherine Seligman, MD, lead author of the study, which was presented at the 2016 annual meeting of the Society for Obstetric Anesthesia and Perinatology (abstract T-23).
Postpartum hemorrhage is increasingly frequent and is the leading cause of severe maternal morbidity, cardiac arrest and death during hospitalization for childbirth. Women who undergo intrapartum cesarean delivery are at highest risk for postpartum hemorrhage compared with those undergoing prelabor cesarean or vaginal delivery (Anesth Analg 2010;110:1368-1373).
Because management practices and morbidities among women who experience severe postpartum hemorrhage are poorly described, researchers at Stanford conducted a retrospective observational study of women undergoing intrapartum cesarean delivery at their center between 2000 and 2012. They compared the types of interventions between 278 women with severe postpartum hemorrhage and 572 women without severe postpartum hemorrhage undergoing intrapartum cesarean delivery.
The researchers found that second-line uterotonic use was high among women experiencing severe postpartum hemorrhage after intrapartum cesarean delivery (Table). B-Lynch brace suture placement was the most common surgical intervention used in women with severe postpartum hemorrhage (7%), followed by the Bakri balloon (4%), uterine artery ligation (3%) and hysterectomy (4%). One in 10 women required postpartum care in the ICU.
Table. Use of Uterotonics
Uterotonic No Severe Postpartum Hemorrhage Severe Postpartum Hemorrhage
Carboprost (Hemabate, Pfizer)a 3.5% 28.1%
Methylergonovinea 12.4% 43.2%
Misoprostola 4.2% 22.7%
Oxytocinb 30 37
a Percentage of women receiving drug.
b Average units administered.
P<0.001 for all.
“An important finding was that women who experience bleeding during a C-section may [undergo interventions] to preserve fertility,” Dr. Seligman said. “Obstetricians may use techniques to try to arrest blood loss whilst preserving fertility.”
Nearly half of women (44%) required a red blood cell transfusion after their cesarean delivery, and 18% needed a transfusion intraoperatively. “In terms of blood component utilization, it was almost equally likely that someone would get plasma intraoperatively as well as postoperatively,” Dr. Seligman said. “Therefore, it is important to know that women who experience severe postpartum hemorrhage can require blood products intra- and postoperatively.”
Morbidities in patients with severe postpartum hemorrhage included respiratory failure requiring ventilation (6%), pulmonary edema (6%), acute respiratory distress syndrome (1%) and renal failure (1%). “Patients having severe bleeds during the operation are at high risk for hemorrhage-related morbidity,” Dr. Seligman said. She believes that comparative and cost-effectiveness studies are needed to determine the optimal second-line treatment regimens for postpartum hemorrhage during intrapartum cesarean delivery.
Asked to comment on the research, Anne-Sophie Ducloy-Bouthors, MD, president of the French Society of Obstetric Anesthesia, said the study was helpful because knowledge about cesarean delivery–induced hemorrhage is limited. “Despite the retrospective character of the study, this analysis contributes to a better epidemiologic view and gives consecutive data that can be used for further studies,” Dr. Ducloy-Bouthors said. “The take-home messages are that cesarean section–induced severe hemorrhage leads to massive transfusion and major morbidity. Continuous hemodynamic, hemoglobin and coagulation monitoring could improve the resuscitation process and limit the evolution to morbidity.”