Retained tissue

Ensure that resuscitation is well underway by this time, and, if not already started, institute
the massive hemorrhage protocol. If possible, keep the vaginal hand in situ throughout
because it minimizes patient discomfort, the risk of iatrogenic trauma, and, possibly, the risk
of subsequent infection. If the placenta was not delivered before the onset of PPH, an attempt
is now made to deliver it with cord traction and uterine countertraction. Care must be taken
because the risk of uterine inversion is greater if the uterus remains poorly contracted.
Perform manual removal if the placenta is not easily delivered or the cord is avulsed.
Perform manual removal with a level of analgesia that matches the clinical urgency of the
situation. The hand is passed through the cervix and into the lower segment. Care is taken to
minimize the profile of the hand as it enters, keeping the thumb and fingers together in the
shape of a cone in order to avoid damage. Control of the uterine fundus with the other hand is
essential. If the placenta is encountered in the lower segment, it is removed. If the placenta is
not encountered, the placental edge is sought. Once found, the fingers gently develop the
space between the placenta and uterus and shear off the placenta. The placenta is pushed to
the palmar aspect of the hand and wrist, and, once it is entirely separated, the hand is
withdrawn. Do not stop uterotonics while the manual removal is being performed. Restart
bimanual massage, and have an assistant examine the placenta for completeness.
If the placenta has been previously delivered, then exploration of the uterus is still indicated
at this time. The hand is introduced in the same manner, with control of the uterine fundus
with the other hand. Any clots are removed. The cavity is gently explored with attention to
any defects suggestive of uterine rupture. Rupture in the absence of a previous scar is
uncommon. Rupture or dehiscence of a previous lower segment scar does not usually bleed
heavily. The presence of a uterine rupture dictates that a laparotomy be performed.
A partial uterine inversion can be detected as the hand is introduced, just as a complete
uterine inversion would have been detected as the hand was placed in the vagina. If the
condition is encountered, return the uterus to its normal position by pressure on the inverted
fundus from within the uterus. If retained placental tissue is encountered, it is sheared off the
uterine wall and delivered. Adherent placental fragments may be left in situ or removed by
gentle curettage. The risks of curettage include uterine perforation and increased bleeding
caused by laceration of uterine vessels. This may be somewhat minimized by the use of a
large, dull curette. Fragments left in situ may be removed by curettage sometime after the
crisis has passed, although an increased risk of infection probably ensues.
The administration of short-term, broad-spectrum antibiotics following manual removal,
manual exploration, or instrumentation of the uterus in this context is commonly advocated.
Evidence is very limited, but a single small, randomized trial supports the practice. [51]
Immediately resume bimanual massage and compression following exploration and
evacuation of the uterus. Continue infusion of oxytocin, and administer repeat doses of other
uterotonics if the uterus fails to contract and maximal doses have not already been given. The
uterus may contract well, and bleeding abates with massage, followed by uterine relaxation
and increased bleeding when compression and massage are stopped. Prolonged massage at
this point may allow the uterus to contract and retract if it can be kept empty of clots and if
perfusion can be improved with adequate resuscitation. Any period of decreased bleeding
allows fluid and blood component replacement to exceed blood loss and help improve the
patients status.
Surgical management is necessary if the uterus does not remain contracted and bleeding
persists despite all efforts. Packing of the uterus may be an option until the operating room is
ready or if surgery is not an immediately available option. Uterine packing fell into disfavor
during the 1960s as being nonphysiological, concealing ongoing blood loss, and increasing
the risk of infection; however, reports since then have been favorable in very select
circumstances when all previously mentioned maneuvers have failed. [52] The uterus and
vagina must be tightly packed with continuous, layered, 2- or 4-inch gauze under direct
visualization using a speculum and/or retractors or a purpose-built uterine packer.[53] At
times, packing may serve as a definitive treatment. In these cases, the packing is usually
removed in 24-48 hours in a setting where recurrent bleeding can be managed if it occurs.
Intrauterine catheters for tamponade of bleeding have also been used. In the past, large bulb
Foley catheters or Sengstaken-Blakemore tubes have been used. [54]More recently, experience
has been gained using catheters specifically designed for postpartum hemorrhage. One such
device is the SOS Bakri tamponade balloon (Bakri, 2001). In low resource settings, condoms
and surgical gloves have been used successfully to control bleeding. [55] Anti-shock garments
are also being evaluated in low resource settings for both the definitive treatment of uterine
atony as well as a method to allow time to bring other treatments to bear [56]
Manual examination helps to exclude a cervical or vaginal laceration, but direct visualization
confirms that bleeding is coming from the uterus and excludes the possibility of missing
trauma to the lower genital tract. If packing is meant to be definitive treatment, then ongoing
assessment of uterine size, blood loss, and patient status must be maintained. Continue
uterotonics and commence broad-spectrum antibiotics. Remove the pack in 24-36 hours in a
setting that allows for appropriate management if bleeding recurs. Packing may also be used
as a temporizing measure before arterial embolization (see Selective arterial embolization).
Isolated reports of successful uterine tamponade with balloon devices have also been
published. [57]

Genital tract trauma

Genital tract trauma is the most likely cause if bleeding persists or is present despite a well-
contracted uterus. Use appropriate analgesia along with good lighting and positioning, which
facilitates excellent exposure. If not already initiated, moving the patient to an operating
room is reasonable at this time. Experienced assistants and an excellent circulating nurse are
essential.
Directly visualize and inspect the cervix with the aid of ring forceps. The anterior lip is
grasped, and the cervix is inspected by using a second ring forceps placed at the 2-oclock
position, followed by progressively "leap-frogging" the forceps ahead of one another until the
entire circumference has been inspected. Small, nonbleeding lacerations of the cervix do not
need to be sutured. Suture any laceration that is bleeding significantly or appears to have the
potential to bleed significantly. Each side of the laceration can be grasped with a ring forceps
back from the torn edge, and gentle traction can be used to aid exposure.
Use an absorbable, continuous interlocking stitch, and use tapered (rather than cutting)
needles for all repairs except for the perineal skin. Ensure that the stitch begins above the
apex of the tear, as with vaginal lacerations and episiotomies. If the apex cannot be
visualized, place the stitch as high as possible and then use it to apply gentle traction to bring
the apex into view. Polyglycolic sutures have largely replaced catgut; however, the latter may
be somewhat less likely to tear the friable tissues of the cervix and vaginal vault and may thus
be useful in repairing lacerations in these areas. The laceration must be observed for bleeding
after the torn edges of the cervix are approximated. The ring forceps can be replaced and left
on for some time if oozing persists.
Lacerations of the vaginal vault must be well visualized and their full extent realized prior to
repair. Lacerations high in the vaginal vault and those extending up from the cervix may
involve the uterus or lead to broad ligament or retroperitoneal hematomas. The proximity of
the ureters to the lateral vaginal fornices, and the base of the bladder to the anterior fornix,
must be kept in mind when repair is undertaken in these areas. Poorly placed stitches can lead
to genitourinary fistulas. An absorbable, continuous interlocking stitch is used. The stitch
must start and finish beyond the apices of the laceration. Great care must be taken because
the tissue is usually very friable. Take a good amount of tissue, and ensure that the needle
reaches the full depth of the tear. Ongoing bleeding and hematoma formation are possible if
small bites are taken.
Again, the laceration must be observed for bleeding after the repair is complete. Pressure or
packing over the repair may achieve hemostasis or allow for better placement of further
hemostatic stitches. Cervical and vaginal vault lacerations that continue to ooze or those that
are associated with hematomas may be amenable to selective arterial embolization (see
Selective arterial embolization).
Traumatic hematomas are rare and may be related to lacerations or may occur in isolation.
They include vulvar and paravaginal hematomas in the lower genital tract and broad ligament
and retroperitoneal hematomas adjacent to the uterus. Patients with lower genital tract
hematomas usually present with intense pain and localized, tender swelling. Broad ligament
hematomas may be palpated as masses adjacent to the uterus. All may result in significant
blood loss that mandates resuscitation.
Lower genital tract hematomas are usually managed by incision and drainage, although
expectant management is acceptable if the lesion is not enlarging. [58] Any bleeding vessels
are tied off, and oozing areas may be oversewn. Place a Foley catheter because urinary
retention can occur because of pain and tissue distortion. Vaginal packing may be useful
following drainage and repair of a paravaginal hematoma. Remove the pack in 24-36 hours.
Embolization may be used in both vaginal and vulvar hematomas that are unresponsive to
surgical management.
Broad ligament and retroperitoneal hematomas are initially managed expectantly if the
patient is stable and the lesions are not expanding. [59] Ultrasound, CT scanning, and MRI all
may be used to assess the size and progress of these hematomas. Selective arterial
embolization may be the treatment of choice if intervention is required in these patients. Use
surgical procedures to evacuate the hematoma, and attempt to tie off any bleeding vessels.
Consider involving a surgeon with extensive experience operating in the retroperitoneal
space.

Coagulopathy

If manual exploration has excluded uterine rupture or retained placental fragments, bleeding
from a well-contracted uterus is most commonly due to a defect in hemostasis. A review of
the history and risk factors along with coagulation test results clarifies this diagnosis. Proceed
with blood product replacement as previously described in order to correct abnormalities of
hemostasis. If the coagulation status is normal and bleeding is ongoing despite a well-
contracted uterus, then the possibilities of uterine rupture or an inadequately repaired uterine
incision (if the patient had a cesarean delivery) must be considered. Revisit any repair to the
cervix or vagina before proceeding to surgical management.
Surgical Therapy
Ongoing bleeding secondary to an unresponsive and atonic uterus, a ruptured uterus, or a
large cervical laceration extending into the uterus requires surgical intervention. Laparotomy
for PPH following a vaginal delivery is rare. In a review of emergency peripartum
hysterectomies over a 5-year period in Los Angeles, Calif, the rate was 1 in 1000 deliveries,
but most of these cases began as cesarean deliveries, usually for placenta previa. [60] A study
from Boston, Mass, found a rate of 1.5 in 1000 deliveries with similar risk
factors. [61] Canadian and Irish studies put the rate at 0.4 and 0.3 per 1000 deliveries,
respectively.
Adequately resuscitate the patient before surgery. This includes optimizing hemoglobin and
coagulation status as previously described. Fully inform anesthetic and operating room staff
as to the nature of the case. Schedule for a second surgeon to be in attendance, if possible. As
mentioned previously, sustained bimanual compression and massage and uterine packing
may be used to gain time to mount a surgical response. Military antishock trousers provide
the equivalent of an approximately 500- to 1000-mL autotransfusion and potentially gain
time during a resuscitation. Only the leg portion of the trousers are inflated in the setting of
PPH. Direct compression of the aorta may be performed for a short period while the
operating room is prepared.
A recent systematic review examined various techniques used when medical management is
unsuccessful. These included arterial embolization, balloon tamponade, uterine compression
sutures, and iliac artery ligation or uterine devascularization. At present, no evidence suggests
that any one method is more effective for the management of severe PPH. Randomized
controlled trials of the various treatment options may be difficult to perform. Balloon
tamponade is the least invasive and most rapid approach and may thus be the logical first
step. [62]

Laparotomy

The choice between a subumbilical vertical incision and a Pfannenstiel incision for entry into
the abdomen is left to the individual surgeon. Both entries have support, and no strong
evidence indicates that either is superior in this setting. [63] If concern exists regarding
pathology in the upper abdomen or if exposure is thought to be a concern, the vertical
incision is recommended. Broad-spectrum antibiotic coverage is advised.
Upon entry, remove any free blood and inspect the uterus and surrounding tissues for
evidence of rupture or hematoma. If uterine rupture is found, a rapid decision must be made
concerning the viability of repair versus hysterectomy. Bleeding may be reduced in either
instance by grasping bleeding points on the torn edges with clamps. The number of layers
used for any repair is dictated by the thickness of the tissue and the hemostatic response to
suturing. Principles are similar to those of cesarean delivery incision repair. Ensure that
bleeding is stopped and not merely internalized because this would result in ongoing vaginal
bleeding or hematoma formation. Any repair must be carefully observed for hemostasis
before abdominal closure is performed. Uterine exteriorization may improve exposure and
decrease operating time, but great care must be taken to not worsen uterine trauma and to
keep the uterus warm and well perfused to avoid worsening atony.
Hemostasis must be reassessed after the uterus is returned to the abdominal cavity. Consider
placement of a suction drain.
If the uterus is intact upon entry and the bleeding has been caused by atony, then direct
bimanual massage and compression may be performed while systemic uterotonics are
continued. Direct injection of oxytocin, carboprost, and/or ergonovine may be successful in
overcoming atony.

Uterine artery ligation

Uterine artery ligation is a relatively simple procedure and can be highly effective in
controlling bleeding from uterine sources. These arteries provide approximately 90% of
uterine blood flow. The uterus is grasped and tilted to expose the vessels coursing through the
broad ligament immediately adjacent to the uterus. Ideally, place the stitch 2 cm below the
level of a transverse lower uterine incision site. A large atraumatic (round) needle is used
with a heavy absorbable suture. Include almost the full thickness of the myometrium to
anchor the stitch and to ensure that the uterine artery and veins are completely included. The
needle is then passed through an avascular portion of the broad ligament and tied anteriorly.
Opening the broad ligament is unnecessary. Perform bilateral uterine artery ligation. While
the uterus may remain atonic, blanching is usually noted and blood flow is greatly diminished
or arrested.
Local oozing may be controlled with direct injection or compression with warm saline packs.
In a series of 265 cases, a 95% success rate was reported using this procedure in PPH
unresponsive to uterotonics in patients who had cesarean births.[64] Another series of 103
cases had a 100% success rate if a stepwise approach was taken. [65] After initial uterine artery
ligation, subsequent stitches were placed 2-3 cm below the initial stitches following bladder
mobilization, and, finally, ovary artery ligation was performed if required. Menstrual flow
and fertility were not adversely affected.

Ovarian artery ligation

The ovarian artery arises directly from the aorta and ultimately anastomoses with the uterine
artery in the region of the uterine aspect of the uteroovarian ligament. Ligation is performed
just inferior to this point in a manner similar to that of uterine artery ligation. The amount of
uterine blood flow supplied by these vessels may increase following uterine artery ligation.
The procedure is easy to perform; however, the potential benefit must be weighed against the
time required to perform the ligations.

Internal iliac (hypogastric) artery ligation

Internal iliac artery ligation can be effective to reduce bleeding from all sources within the
genital tract by reducing the pulse pressure in the pelvic arterial circulation. One study
indicated that pulse pressure was reduced by 77% with unilateral ligation and by 85% with
bilateral ligation. [66] Hypogastric artery ligation is much more difficult to perform, more
commonly associated with damage to nearby structures, and less likely to succeed than
uterine artery ligation. One study reported a success rate of 42%. In patients who undergo
hypogastric artery ligation, uterine artery ligation has usually already failed.
Prerequisites for the procedure include a stable patient, an operator experienced in the
procedure, and a desire to maintain reproductive potential. The retroperitoneal space is
entered by incising the peritoneum between the fallopian tube and the round ligament. The
ureter must be identified and reflected medially with the attached peritoneum. The external
iliac artery is identified on the pelvic sidewall and followed proximally to the bifurcation of
the common iliac artery. The ureter passes over the bifurcation. The internal iliac artery is
identified and followed distally approximately 3-4 cm from its point of origin. The loose
areolar tissue is carefully cleared from the artery. A right-angle clamp is passed beneath the
artery at this point, with great care to avoid damage to the underlying internal iliac vein.
A recommendation is to pass the clamp from lateral to medial in order to minimize the
chance of damage to the adjacent external iliac vessels. Gentle elevation of the artery with a
Babcock clamp facilitates this maneuver.
Ligate the artery with heavy absorbable suture, but do not divide it. Palpate the femoral and
distal pulses before and after the ligation to ensure that the external or common iliac artery
was not inadvertently ligated. If possible, place the ligation distal to the posterior division of
the artery because this decreases the risk of subsequent ischemic buttock pain. Identification
of the posterior division may be difficult, and ligation 3 cm from the internal iliac artery
origin usually ensures that it is not included.
Hysterectomy is required if internal iliac artery ligation is unsuccessful. Patients in whom
internal iliac artery ligation has failed have greater morbidity than those in whom the
procedure has not been attempted. The likelihood of benefit from the procedure must be
balanced against the potential risks. The advent of more effective uterotonic agents, the fact
that most cases of intractable hemorrhage are now related to abnormalities of placentation
that are diagnosed or suggested before delivery, and the option of embolization have lessened
the use of hypogastric artery ligation. The number of surgeons comfortable using this
procedure and the opportunities to teach it are rapidly declining.

Hysterectomy

Hysterectomy is curative for bleeding arising from the uterine, cervical, and vaginal fornices.
The procedure of peripartum hysterectomy is well described in several texts and articles
(eg, Hysterectomy), and the technique differs little from that in nonpregnant
patients. [67, 63] While the organ is more vascular, the tissue planes are often more easily
developed. Total hysterectomy is preferred to subtotal hysterectomy, although the latter may
be performed faster and be effective for bleeding due to uterine atony. Subtotal hysterectomy
may not be effective for controlling bleeding from the lower segment, cervix, or vaginal
fornices. Take every opportunity to become involved when peripartum hysterectomies are
performed.

Selective arterial embolization

Angiographic embolization in the management of PPH was first described more than 30
years ago. [68] As with all of the surgical and most of the medical treatments of PPH, no RCTs
regarding its effectiveness have been conducted. This is likely to remain the case for some
time given the relative rarity of intractable PPH. Several case series suggest that selective
arterial embolization may be useful in situations in which preservation of fertility is desired,
when surgical options have been exhausted, and in managing hematomas. [69] Follow-up of
women undergoing successful embolization for severe intractable PPH reports that women
almost invariably have a return to normal menses and fertility. [70]
The major drawbacks of the procedure are the requirement for 24-hour availability of
radiological expertise and the time required to complete the procedure. Patients must be
stable to be candidates for this procedure. Complications include local hematoma formation
at the insertion site; infection; ischemic phenomena, including uterine necrosis in rare
instances; and contrast-related adverse effects. Currently, most PPH cases requiring
hysterectomy are related to placenta previa. These patients are commonly diagnosed before
delivery and are usually delivered by elective cesarean birth. This planning may allow
increased use of invasive radiological services in the management of such cases.
A retrospective study by Park et al indicated that transcatheter arterial embolization (TAE) is
safe and effective for secondary PPH. In the study, the procedure was clinically successful in
47 of 52 patients (90.4%) being treated for secondary PPH (caused in 23 cases by retained
placenta). Gelatin sponge particles were used in 48 patients, either alone or in combination
with permanent embolic materials (eg, microcoils, N-butyl cyanoacrylate); embolization was
performed with permanent materials alone in the remaining four patients. Regular
menstruation returned in the 44 patients who were followed up (for a mean 12.6-month
period), and five patients were known to become pregnant. [71]
Mechanism of action of recombinant activated factor VII (rFVIIa).
Originally, rFVIIa was proposed to work mainly through a TF-
dependent mechanism. However, FXa produced at the TF-bearing cell
is unable to move to the activated platelet surface because at normal
plasma levels, both AT and TFPI rapidly and effectively inhibit FXa
in the fluid phase. It was later discovered that at very high, i.e.
pharmacologic plasma concentrations, rFVIIa binds to the activated
platelet and compensates for the deficiency of FVIIIa and FIXa.
However, it is very important to note that in addition to rFVIIa,
several other coagulation factors are needed to result in fibrin clot
formation (89). [II(a) to XIII(a), (activated) coagulation factors II to
XIII, respectively; vWF, von Willebrand factor; TF, tissue factor;
TFPI, tissue factor pathway inhibitor; AT, antithrombin].

B-Lynch and Cho sutures

Recent case series and case reports advocate the use of transmural uterine compression
sutures to rapidly control bleeding. The initial reports described the B-Lynch technique,
which involves opening the lower segment and passing a suture through the posterior uterine
wall and then over the fundus to be tied anteriorly. [72,73] A similar technique has been
described without opening the uterus. A long, straight needle is passed anterior to posterior
through the lower uterine segment; the suture is passed over the fundus and then tied
anteriorly. [74] Both techniques use bilateral stitches. The most recent variant uses multiple
stitches passed transmurally and tied anteriorly at various points over the uterine body. This
technique may be focused in the area of the placental bed in cases of abnormal
placentation. [75] All of these procedures effectively produce tamponade by compressing
together the anterior and posterior walls.
Follow-up reports suggest a normal return to menses and fertility, but the number of cases is
small. The techniques have the advantage of being very simple to perform and may be a
rapidly effective alternative to hysterectomy. [72]

Bleeding at cesarean delivery

In the past, most cases of intractable PPH followed vaginal delivery and were due to uterine
atony; however, more recent case series and national databases show that more cases are now
associated with cesarean delivery. Cesarean delivery for placenta previa carries a relative risk
of 100 for peripartum hysterectomy, with many patients having a diagnosis of placenta
accreta. [76] High-resolution ultrasound with color Doppler may allow antenatal diagnosis of
placenta accreta.
Whenever possible, delivery of the placenta at cesarean delivery should be performed in an
assisted fashion following the administration of a uterotonic agent, preferably oxytocin. This
practice leads to less blood loss and less infectious morbidity. [77]
Uterine rupture has also become a more common cause of severe PPH necessitating
hysterectomy. The vast majority of these cases occur in patients with a previous cesarean
birth. Counsel all women with placenta previa, and especially those with a previous low
segment uterine scar, in the antenatal period regarding the risk of severe PPH and the possible
need for transfusion and even hysterectomy. Ensure that these patients are cared for in
facilities with the resources to manage them successfully if complications arise. [78]
The management of bleeding at cesarean delivery or following uterine rupture is not greatly
different from that following vaginal delivery. Aggressive resuscitation is performed with
attention to restoration of circulating volume and oxygen-carrying capacity and correction of
hemostatic defects. Direct bimanual compression may be used in the case of atony. Retained
tissue may be removed under direct visualization. Abnormally adherent tissue is a concern;
leave it in situ if it cannot be easily removed.
Direct intramyometrial injection of uterotonics may be undertaken. Vasopressin (0.2 U in 1
mL of NS) may also be injected into the myometrium, with great care taken to avoid
intravascular injection. Individual vessels in the placental bed may be ligated. Simple or box
stitches may be placed where continuous oozing is present. [75] In cases of placenta previa, the
lower uterine segment may be temporarily packed; leaving a pack in the uterus is also an
option. The end of the pack is fed through the cervix and into the vagina and is removed 24-
36 hours later. Uterine rupture or extension of a uterine incision requires excellent
visualization and careful repair with attention to adjacent structures.
The stepwise surgical approach described above may be used if these measures are
unsuccessful and preservation of fertility is desired. Strongly consider immediate
hysterectomy if further reproduction is not an issue or if bleeding or damage to the uterus
appears severe. Embolization may be considered in this setting. Its successful use has been
described both intraoperatively to preserve the uterus and after hysterectomy for continued
bleeding. Embolization may also be used for continued postoperative vaginal bleeding. [79]
Persistent bleeding following hysterectomy may also be managed by packing with gauze
brought out through the vagina or by a pelvic pressure pack composed of gauze in a sterile
plastic bag brought out through the vagina and placed under tension. This pack is also known
as a parachute, mushroom, or umbrella pack. Place a Foley catheter to monitor urine output
and prevent urinary retention. The placement of a suction drain may be useful to monitor
losses in cases of ongoing oozing. Always consider coagulopathy in patients with continued
slow blood loss.
Postoperative Details
Continue resuscitation, and repeat laboratory tests. Monitor vital signs, urine output, and any
ongoing losses. Care in an intensive care setting is advantageous, as is close follow-up by the
obstetric service. The patient must be monitored for complications (see Complications).
Follow-up
Full documentation of the case is imperative, and a careful explanation of events and
interventions must be given to the patient and family. Caregivers must be available and
approachable for questions. Implications and recommendations for future pregnancies may be
discussed during the postoperative stay and reinforced at the postdischarge visit.
Summary
PPH is a common complication of childbirth and a leading cause of maternal morbidity and
mortality. Clinicians should identify risk factors before and during labor so that care may be
optimized for high-risk women. However, significant life-threatening bleeding can occur in
the absence of risk factors and without warning. All caregivers and facilities involved in
maternity care must have a clear plan for the prevention and management of PPH. This
includes sound resuscitation skills and familiarity with all medical and surgical therapies
available.
Complications
Most patients with PPH are quickly identified and successfully treated before major
complications develop. The most common problem is anemia and loss of iron stores, which
results in fatigue in the postpartum period. Clinicians and patients are more tolerant of low
hemoglobin levels, mild postural lightheadedness, and fatigue because of current concerns
over blood transfusion. The risks of transfusion with blood products are well known and have
been previously described.
Not surprisingly, many of the complications of severe PPH are related to massive blood loss
and hypovolemic shock. Damage to all major organs is possible; respiratory (adult respiratory
distress syndrome) and renal (acute tubular necrosis) damage are the most common but are
rare. These conditions are best managed by specialists. Renal failure is usually self-limited,
and renal function recovers fully. Temporary dialysis is seldom required. Pulmonary edema is
uncommon in this previously healthy group; however, it may develop acutely or during the
recovery phase because of fluid overload or myocardial dysfunction. Response to standard
therapy is usually prompt.
Pregnant women are at increased risk of venous thrombosis and embolic events. Many of the
risk factors for PPH are also risk factors for venous thrombosis and embolic events, including
operative vaginal delivery, cesarean delivery, and pelvic surgery. Venous stasis due to shock
and immobility also contribute, and caregivers should maintain a high index of clinical
awareness.
Hypopituitarism following severe PPH (Sheehan syndrome) is due to critical ischemia of the
hypertrophied pituitary. This condition should be considered if a failure to lactate occurs.
Isolated deficiencies of pituitary tropins and hyperprolactinemia have also been reported.
Evidence suggests that prophylaxis against gastrointestinal ulceration is useful in critically ill
patients, especially those requiring ventilation. The recommended agents are sucralfate and
histamine 2 blockers. Both are effective at reducing the risk of ulcers. Sucralfate may be
associated with a lower incidence of pneumonia.[80]
Several of the complications related to surgical interventions have been described.
Complications include sterility, uterine perforation, uterine synechiae (Asherman syndrome),
urinary tract injury and genitourinary fistula, bowel injury and genitointestinal fistula,
vascular injury, pelvic hematoma, and sepsis. Consider ultrasound of the kidneys following
complicated emergency pelvic surgery in order to exclude ureteric obstruction. Patients
undergoing uterine exploration, instrumentation, or laparotomy in this context probably
benefit from antibiotic coverage at the time of the intervention. Good evidence suggests that
all patients having cesarean births should receive prophylactic antibiotics. [81] The duration of
antibiotic coverage following surgery in these circumstance is unknown.