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Re: Placenta percreta (Long)From: RModugno@aol.comWed Jun 16 07:16:56 2004
Just for you,el: Case Report November 2002 Volume 100, Number 5, Part 2 Pages 1061 - 1063 Pelvic Umbrella Pack for Refractory Obstetric Hemorrhage Secondary to Posterior Uterine Rupture Rebecca J. Howard,a J. Michael Straughn, Jr, MD,a Warner K. Huh, MD,a and Dwight J. Rouse, MDa Background: Pelvic hemorrhage continues to be a serious complication of pregnancy and can lead to significant maternal morbidity. The pelvic umbrella pack is a useful alternative to control pelvic bleeding when standard measures fail. Case: A patient with a previous low transverse cesarean delivery presented in active labor at term. After an uneventful vaginal delivery, defects in the posterior vaginal wall and lower uterine segment were identified. A hysterectomy with repair of the vaginal laceration was performed, but diffuse bleeding persisted. After routine surgical techniques failed to achieve adequate hemostasis, a pelvic umbrella pack was successfully used to tamponade pelvic bleeding. Conclusion: In the event of continued hemorrhage after hysterectomy, bleeding that is uncontrolled by surgical intervention may be controlled with a pelvic umbrella pack. aDepartment of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA (Obstet Gynecol 2002:100:1061-1063. © 2002 by The American College of Obstetricians and Gynecologists.) Pelvic hemorrhage continues to be a serious complication of pregnancy and can lead to significant maternal morbidity. Placenta previa, placenta accreta, uterine atony, and uterine rupture can lead to excessive pelvic hemorrhage. Women with a history of cesarean delivery have a 1-2% risk of uterine rupture when subsequent vaginal delivery after cesarean is attempted.1 In the event of uterine rupture, hysterectomy may be necessary to control hemorrhage. However, in some cases, conventional surgical methods and blood product replacement are not successful in controlling persistent hemorrhage after puerperal hysterectomy. The transvaginal pelvic umbrella pack is a straightforward technique to obtain hemostasis when more conventional methods fail to control pelvic hemorrhage. Case A multiparous woman presented to labor and delivery at term complaining of uterine contractions. She was contracting regularly, and her cervix was 4 cm dilated on presentation. Her obstetric history was significant for a previous low transverse cesarean delivery for active phase arrest and a subsequent vaginal delivery of a 3572-g infant without complications. She had also undergone an uncomplicated dilation and curettage for a first-trimester miscarriage. On admission, the patient's body mass index was greater than 40, hematocrit was 35%, and platelet count was 172,000/mm3. Several hours after admission to labor and delivery, active phase arrest of labor was diagnosed, and intravenous oxytocin was initiated. Cardiotocography revealed suspicious decelerations that resolved with the discontinuation of oxytocin. Without further augmentation, spontaneous vaginal delivery of a vigorous 3695-g infant with Apgar scores of 8 and 9 ensued. Blood loss at delivery was estimated to be 400 mL. After spontaneous delivery of the placenta, fluid was noted to be draining from the posterior vagina. Careful examination revealed a defect in the posterior vaginal wall that extended into the lower uterine segment. The patient was taken to the operating room for exploratory laparotomy to delineate the nature and extent of the uterine rupture and vaginal laceration. At the time of laparotomy, active bleeding was noted in the posterior cul-de-sac, and inspection of the posterior uterus and cervix revealed a 7-cm lower uterine defect that extended laterally into the upper vagina. The anterior cervix and uterine wall were intact. It was the opinion of the attending surgeons that this defect could not be safely repaired without a hysterectomy. After removal of the uterus, hemostasis of the vaginal cuff was challenging, and several attempts to suture the vaginal mucosa were unsuccessful. The tissue was edematous, friable, and bled easily. Although the surgical pedicles appeared secure, diffuse pelvic bleeding continued. Coagulation studies (prothrombin time and partial thromboplastin time) were normal, and platelet count was 132,000/mm3. Conventional attempts to control bleeding, including additional sutures, electrocautery, pressure, and bovine thrombin spray were unsuccessful. To prevent further hemorrhage, a pelvic umbrella pack was placed to tamponade the bleeding. The pack was created by filling a sterile plastic bag (used to cover x-ray film) with three rolls of gauze that had been knotted together. The bag's drawstrings were tightened around the protruding tail of the gauze. The resultant pack was inserted abdominally and placed at the vaginal cuff, whereas the lower portion of the pack, drawstrings, and gauze tail were pulled through the vagina. Traction was placed on the pack by securing a 1-L intravenous fluid bag to the pack with surgical tubing and hanging the bag from the end of the patient's bed (Figure 1). Before placement, care was taken to avoid entrapment of any bowel or adnexa under the pack. A Jackson-Pratt drain was placed in the pelvis to monitor for continued bleeding. After placement of the pack, careful observation failed to detect any further significant bleeding, either abdominal or vaginal. The patient was started on broad-spectrum antibiotics empirically because of the high risk of febrile morbidity. Figure 1. Pelvic umbrella pack. Illustration by Jo Taylor. Howard. Pelvic Umbrella Pack. Obstet Gynecol 2002. Estimated blood loss during the procedure was 2000 mL, and the patient received four units of packed red blood cells with a final intraoperative hematocrit of 27%. The patient required two additional units of packed red blood cells postoperatively after which the hematocrit remained stable until discharge. On postoperative day 2, with decreasing vaginal bleeding and Jackson-Pratt drain output, the gauze was withdrawn from the pack over a 4-hour period and the bag removed through the vagina. The vaginal cuff was left open, and there was no evidence of further intra-abdominal bleeding or prolapse of small bowel. In the event of rebleeding, embolization of the hypogastric or uterine vessels had been planned with interventional radiology. On postoperative day 4, with the patient remaining afebrile, the Jackson-Pratt drain was discontinued, and the patient was discharged home in good condition. Comment Patients with a previous history of cesarean delivery have a 1-2% risk of uterine rupture when subsequent vaginal delivery is attempted.1 Risk factors for uterine rupture include oxytocin augmentation, prolonged labor, midforceps delivery, cephalic version, precipitous delivery, and previous procedures that traumatize the uterine wall.1 In the event of uterine rupture during labor, surgical repair or hysterectomy may be necessary to control hemorrhage, and, in some cases, these measures may fail to achieve adequate hemostasis. This may be secondary to friable tissue, extensive collateral circulation, or a consumptive coagulopathy.2,3 In the event of diffuse and uncontrollable pelvic hemorrhage, the use of a pelvic umbrella pack to tamponade bleeding can be lifesaving.4 This technique was first introduced by Logothetopulos in 19265 and was later modified by Parente et al6 in 1962. The original pressure pack was made of a sterilized gauze veil, but later modifications replaced the gauze with a polyethylene sheet that allowed for easier removal and less chance for adhesion and subsequent hemorrhage at removal.6 The pack was originally used after major gynecologic procedures such as radical hysterectomy and pelvic exenteration. Recently, it has been described in cases of postpartum hemorrhage after cesarean delivery and placenta accreta.2-4 Potential complications include infection, compression of intestinal or urinary structures, fistulae, and bleeding after removal.6 In this case, the pack was used after uterine rupture to tamponade diffuse hemorrhage that could not be surgically controlled. Uterine rupture during labor usually occurs through the previous scar in the lower uterine segment, but may involve the bladder or broad ligament. The etiology of this patient's uterine rupture is unclear; however, previous uterine curettage and subsequent infection may have played a role. The location of the uterine rupture and the large body habitus of the patient made it extremely difficult to achieve hemostasis. Although the patient received four units of packed red blood cells, she remained hemodynamically stable and did not develop a consumptive coagulopathy as in previously reported cases.2-4 In this case, the decision to use a pelvic umbrella pack was made early and may have avoided severe sequelae and large amounts of blood product transfusion. Obstetricians and gynecologists should consider the use of an umbrella pack as a solution to persistent hemorrhage after hysterectomy, as the pack is easy to assemble, and placement is straightforward. Hemostasis can be quickly achieved with tamponade from a pressure pack and should be considered for treatment of uncontrolled hemorrhage before more serious complications occur. References 1. Lydon-Roche M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345:3-8. 2. Hallak M, Dildy GA, Hurley TJ, Mosie KJ. Transvaginal pressure pack for life-threatening pelvic hemorrhage secondary to placenta accreta. Obstet Gynecol 1991;78:938-40. 3. Cassels JW, Greenberg H, Otterson WN. Pelvic tamponade in puerperal hemorrhage: A case report. J Reprod Med 1985;30:689-92. 4. Robie GF, Morgan MA, Payne GG, Wasemiller-Smith L. Logothetopulos pack for the management of uncontrollable postpartum hemorrhage. Am J Perinat 1990;7:327-8. 5. Logothetopulos K. Eine absolut sichere Blutstillungs methode bei vaginalen und. Zentralbl Gynaekol 1926;50:3202. 6. Parente JT, Dlugi H, Weingold AB. Pelvic hemostasis: A new technic and pack. Obstet Gynecol 1962;19:218-21. Address reprint requests to: J. Michael Straughn, Jr, MD, University of Alabama at Birmingham, Division of Gynecologic Oncology, 619 South 19th Street, OHB Room 538, Birmingham, AL 35249; E-mail: jmstraughn@yahoo.com
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