Endgames Case Report

A case of life threatening postpartum haemorrhage

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a2425 (Published 04 December 2008) Cite this as: BMJ 2008;337:a2425
  1. S Macdonald, consultant1,
  2. K Brown, consultant2,
  3. M Wyatt, consultant3
  1. 1Interventional Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN
  2. 2Women’s Health, Newcastle upon Tyne Hospitals NHS Foundation Trust
  3. 3Vascular Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust
  1. Correspondence to: M Wyatt mike.wyatt{at}nuth.nhs.uk

    A 34 year old pregnant woman (para 4+0, gravida 4) presented because of intrauterine death at 30 weeks after a viral illness. Antepartum haemorrhage occurred during a trial of labour and emergency caesarean section was performed. The patient then had a massive postpartum haemorrhage, which did not respond to intrauterine balloon tamponade. Hysterectomy was performed but bleeding continued. She developed disseminated intravascular coagulation and needed more than 90 units of blood. Haemostasis was achieved after transcatheter embolisation.

    Questions

    • 1 Who is at increased risk of postpartum haemorrhage?

    • 2 What are the management options?

    • 3 What are the benefits and risks of transcatheter embolisation?

    • 4 Under what circumstances can interventional radiological techniques be used electively to prevent major postpartum haemorrhage?

    Answers

    Short answers

    • 1 Patients with a large or overdistended uterus (large baby, twins, or hydramnios), trauma (vaginal or uterine tears), or with abnormalities of placental insertion (placental abruption or placenta praevia).

    • 2 Uterine massage or bimanual uterine compression, oxytocin or per rectal misoprostil (or both), recombinant factor VII, intrauterine balloon tamponade, hysterectomy, surgical ligation of the internal iliac arteries, and transcatheter embolisation of the uterine arteries.

    • 3 It is minimally invasive and achieves (reversible) control of proximal and distal bleeding points without necessitating direct surgical visualisation; minor risks include non-target embolisation and self limiting postembolisation syndrome.

    • 4 In patients with known abnormal placentation, balloons can be positioned across the origins of the internal iliac arteries or into the ostia before delivery to reduce blood loss during caesarean section.

    Long answers

    The World Health Organization’s definition of primary postpartum haemorrhage is the loss …

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