A TEXTBOOK OF POSTPARTUM HEMORRHAGE - PART 8 pptx

Medium- and high-risk regimens include the use of etopside, methotrexate, actinomycin, vincristine, cyclophosphomide and 6-mercapto - purine 36,37 . Women with choriocarcinoma are most appropriately treated through specialist trophoblastic disease referral centers 14 . Coagulopathies Women with inherited coagulation disorders such as von Willebrand’s disease and carriers of hemophilia A and B are likely to bleed post - partum if maternal clotting factors are low (< 50 IU/dl). Prophylactic administration of desmopressin (DDAVP) and clotting factor concentrates may prevent postpartum hemor - rhage 15 . The aim is to raise factor levels above 50 IU/dl during labor and delivery and maintain these for up to 5 days after delivery. In the event of postpartum hemorrhage 15 , replacement of deficient clotting factors should be made and identification and treatment of the cause be instigated. Management should be in close liaison with hematologists and specialist hemo- philia centers as available. In cases of prolonged or intermittent secondary postpartum hemor- rhage 15 , the use of tranexamic acid (a fibrino- lytic inhibitor) 38 or combined oral contraceptive pill has been reported 15 . Hemorrhage from postpartum acquired hemophilia is treated acutely with factor VIII (either human, porcine) or recombinant factor VIIa 15 . Immunosuppressive drugs such as corticosteroids, cyclophosphamide and aza - thioprine may be used to accelerate the dis - appearance of factor VIII inhibitors, although complete remission is likely to occur spontane - ously with time. Reversal of bleeding due to anticoagulants should follow normal protocols. Vitamin K should be considered in women with uncon - trolled bleeding secondary to warfarin use and protamine sulfate may be considered if hemor - rhage results from the use of heparin, although this has a much shorter half-life. Secondary postpartum hemorrhage is an important cause of maternal morbidity and mortality. Basic resuscitation followed by inves - tigation and treatment of the specific cause of hemorrhage are essential. The diverse nature of its etiology and often acute presentation make research in the form of a randomized controlled trial difficult. However, particularly for the treatment of hemorrhage due to uterine infec - tion and/or retained placental tissue, this should be achievable and would provide valuable information to further our understanding of the management of secondary postpartum hemorrhage. References 1. Thompson W, Harper MA. Postpartum haemorrhage and abnormalities of the third stage of labour. In Chamberlain G, Steer P, eds. Turnbull’s Obstetrics, 3rd edn. Edinburgh: Churchill Livingstone, 2001;619–33 2. Hoveyda F, MacKenzie IZ. Secondary post - partum haemorrhage: incidence, morbidity and current management. Br J Obstet Gynaecol 2001; 108:927–30 3. King PA, Duthie SJ, Dong ZG, et al. Secondary postpartum haemorrhage. Aust NZ J Obstet Gynaecol 1989;29:394–8 4. Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage. The Cochrane Database of Systematic Review 2002 Issue 1, Art. No: CD002867. DOI: 10.1002/ 14651858.CD002867 5. Lédée N, Ville Y, Musset D, et al. Management in intractable obstetric haemorrhage: an audit study on 61 cases. Eur J Obstet Gynecol 2001; 94:189–96 6. Matthews NM, McCowan LME, Patten P. Pla - centa praevia accreta with delayed hysterectomy. Aust NZ J Obstet Gynaecol 1996;36:476–9 7. Jaffe R, DuBeshter B, Sherer DM, et al. Failure of methotrexate treatment for term placenta percreta. Am J Obstet Gynecol 1994;171:558–9 8. Ggosh H. Arteriovenous malformation of the uterus and pelvis. Obstet Gynecol 1986; 68(Suppl):40–3 9. Gaylis H, Levine E, van Dongen L, et al. Arterio - venous fistula after gynaecologic operations. Surg Gynecol Obstet 1973;137:655–8 10. Pelage J-P, Soyer P, Repiquet D, et al. Secondary postpartum haemorrhage: treatment with selec - tive arterial embolization. Radiology 1999;212: 385–9 11. Kelly SM, Belli AM, Campbell S. Arteriovenous malformation of the uterus associated with secondary postpartum haemorrhage. Ultrasound Obstet Gynecol 2003;21:602–5 12. Nanda S, Singhal S, Sharma D, et al. Nonunion of uterine incision: a rare cause of secondary 323 Management of secondary postpartum hemorrhage 345 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:23:51 Color profile: Generic CMYK printer profile Composite Default screen postpartum haemorrhage: a report of 2 cases. Aust NZ J Obstet Gynaecol 1997;37:475–6 13. Paraskevaides E, Stuart B, Gardeil F. Secondary postpartum haemorrhage from non-dehisced lower caesarean section scar: a case for hystero - scopy. Aust NZ J Obstet Gynaecol 1993;33:427 14. Tidy JA, Rustin GJS, Newlands ES, et al. Presen - tation and management of choriocarcinoma after non-molar pregnancy. Br J Obstet Gynaecol 1995; 102:715–19 15. Economides DL, Kadir RA. Inherited bleeding disorders in obstetrics and gynaecology. Br J Obstet Gynaecol 1999;106:5–13 16. Kadir RA, Economides DL, Braithwaite J, et al. The obstetric experience of carriers of haemo - philia. Br J Obstet Gynaecol 1997;104:803–10 17. Greer IA, Lowe GDO, Walker JJ, et al. Haemor - rhagic problems in obstetrics and gynaecology in patients with congenital coagulopathies. Br J Obstet Gynaecol 1991;98:909–18 18. Ramsahoye BH, Davies SH, Dasani H, et al. Obstetric management in von Willebrand’s dis - ease: a report of 24 pregnancies and a review of the literature. Haemophilia 1995;1:140–4 19. Kadir RA, Lee CA, Sabin CA, et al. Pregnancy in von Willebrand’s disease or factor XI deficiency. Br J Obstet Gynaecol 1998;105:314–21 20. Neill A, Thornton S. Secondary postpartum haemorrhage. J Obstet Gynaecol 2002;22:119–22 21. Johanson R, Cox C, Grady K, et al. Massive obstetric haemorrhage. In Managing Obstetric Emergencies and Trauma – The MOET Course Manual. London: RCOG Press, 2003;16: 151–63 22. Achiron R, Goldenberg M, Lipitz S, et al. Transvaginal duplex Doppler ultrasonography in bleeding patients suspected of having residual trophoblastic tissue. Obstet Gynecol 1993;81: 507–11 23. Zuckerman J, Levine D, McNicholas MM, et al. Imaging of pelvic postpartum complications. Am J Roentgenol 1997;168:663–8 24. Neill AC, Nixon RM, Thornton S. A compari - son of clinical assessment with ultrasound in the management of secondary postpartum haemor - rhage. Eur J Obstet Gynecol 2002;104:113–15 25. Thorp JM, Wells SR, Wiest HH, et al. First- trimester diagnosis of placenta praevia percreta by magnetic resonance imaging. Am J Obstet Gynecol 1998;178:616–18 26. Levine D, Barnes PD, Edelman RR. Obstetric MR imaging. Radiology 1999;211:609–17 27. Fernandez H, Claquin C, Guibert M, et al . Sus - pected postpartum endometritis: a controlled clinical trial of single-agent antibiotic therapy with Amox-CA (Augmentin ® ) vs ampicillin- metronidazole ± amnioglycoside. Eur J Obstet Gynecol 1990;36:69–74 28. Schenker JG, Margalioth SJ. Intrauterine adhe - sions: an update appraisal. Fertil Steril 1982;37: 593–610 29. Bakri YN. Amri A, Abdul-Jabar F. Tamponade- balloon for obstetrical bleeding. Int J Gynaecol Obstet 2001;74:139–42 30. Johanson R, Kumar M, Obhrai M, et al. Man - agement of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy. Br J Obstet Gynaecol 2001;108: 420–2 31. B-Lynch C, Coker A, Adegboyega HL, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372–5 32. Alok K, Hagen P, Webb JB. Tranexamic acid in the management of postpartum haemorrhage. Br J Obstet Gynaecol 1996;103:1250–1 33. Boehlen F, Morales MA, Fontana P, et al. Prolonged treatment of massive postpartum haemorrhage with recombinant factor VIIa: case report and review of the literature. Br J Obstet Gynaecol 2004;111:284–7 34. Lurie S, Appelman Z, Katz Z. Subendometrial vasopressin to control intractable placental bleeding. Lancet 1997;349:698 35. Bagshawe KD, Dent J, Newlands SL, et al. The role of low dose methotrexate and folinic acid in gestational trophoblastic tumours. Br J Obstet Gynaecol 1989;96:795–802 36. Newlands ES, Bagshawe KD, Begent RH, et al. Results with EMA/CO (etopside, methotrexate, actinomycin D, cyclophosphamide, vincristine) regimen in high risk gestational trophoblastic tumours, 1979–1989. Br J Obstet Gynaecol 1991; 98:550–7 37. Rustin GJS, Newlands ES, Bergent HJ, et al. Weekly alternating chemotherapy (EMA/CO) for treatment of central nervous system metastases of choriocarcinoma. J Clin Oncol 1989;7:900–3 38. Bonnar J, Guillebrand J, Kasonde JM, et al. Clinical applications of fibrinolytic inhibition in gynaecology. J Clin Pathol 1980;33(Suppl) 14:55–9 324 POSTPARTUM HEMORRHAGE 346 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:23:52 Color profile: Generic CMYK printer profile Composite Default screen Section VIII Consequences of postpartum hemorrhage 347 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:23:52 Color profile: Generic CMYK printer profile Composite Default screen 36 PATHOLOGY OF THE UTERUS P. Kelehan and E. E. Mooney BACKGROUND AND AIMS Significant postpartum hemorrhage may occur immediately after delivery, or may be delayed weeks or months. In either case, a Cesarean or later postpartum hysterectomy may be life- saving. The uterus will normally be sent for laboratory examination. To facilitate a useful surgical pathology report, the pathologist must be given details of the antepartum course and delivery. Considering how uncommon these specimens are, direct communication between pathologist and clinician is recommended. The aim of this chapter is to provide a structured approach to the analysis of the specimen, in order to permit a clinically relevant and pathologically sound diagnosis. CLINICAL CORRELATION The parity and gestation should be provided. Any abnormality of the clinical course, in partic - ular pre-eclampsia or polyhydramnios, may be of relevance. Magnetic resonance imaging (MRI) may have been performed for fibroid, placenta creta or congenital abnormality and these images should be reviewed. A history of the use of instruments such as forceps is impor - tant. The clinical appearance of the uterus at operation may provide valuable information on atony. Any therapeutic measures undertaken such as uterine massage or compression suture should be noted, along with transfusion and fluid replacement. A description of the surgery will help the pathologist to interpret the tears and sutures that characterize these specimens. The patient’s postoperative condition will help to guide sampling in the event that amniotic fluid embolism is a consideration. Finally, the placenta must also be available for examination. GROSS EXAMINATION Photography is essential at each step of the dissection, with notes as to what each picture is intended to show. Without a clinical input, however, much effort may be wasted on documenting features of little relevance at the expense of missing more important ones. A detailed macroscopic description of sutures, tears, etc. is important and may be medico - legally relevant. Our approach is to examine the specimen in its fresh state, with photography, and then to open the specimen, avoiding tears and sutures, to permit fixation and further examination. It may be opened laterally, but more information can be gained by complete longitudinal anteroposterior section of the uterus. The approach should be modified to suit the circumstances as predicted from the clinical information. A useful technique that allows good exposure and photographic demon - stration is the placing of two parallel complete longitudinal anteroposterior sections about 2–3 cm apart on either side of the mid-line. How well the uterine cavity has compressed is immediately apparent, contraction band forma - tion can be demonstrated, and blood clot and placental tissue fragments can be assessed in the lumen. In the immediate postpartum period, the uterus is characteristically large. It will weigh 700–900 g and will have substantially reduced in size and volume from its antepartum state. Clamp marks on the broad and round ligaments should be inspected for residual hematoma, remembering that the pathology may be outside the clamp. In the fresh specimen with intact vessels, it may be possible to perfuse the vascu - lature for contrast angiography or vascular casting 1 . 326 348 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 06 September 2006 16:28:08 Color profile: Generic CMYK printer profile Composite Default screen 327 Pathology of the uterus Figure 1 Fixed uterus showing a large anterior and right-sided diverticulum originating in a Cesarean section scar. The specimen was sutured at operation, but placental villous tissue can be seen adjacent to the suture Figure 2 Anteroposterior section of uterus from Figure 1 showing anterior placenta creta 349 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:23:58 Color profile: Generic CMYK printer profile Composite Default screen 328 POSTPARTUM HEMORRHAGE Figure 3 H/E section of lower uterine segment showing placenta creta and large vessels in thin myometrium Figure 4 Immunohistochemical stain for desmin accentuates the thin myometrial fibers in scar 350 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:24:04 Color profile: Generic CMYK printer profile Composite Default screen 329 Pathology of the uterus Figure 5 Right lateral endocervical tear at hysterectomy for postpartum hemorrhage Figure 6 Elastin Van Geisson stain showing torn artery at apex of tear (×10). Arrow, torn elastic artery; arrowhead, thin fibrin blood clot 351 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:24:10 Color profile: Generic CMYK printer profile Composite Default screen CERVIX Important pathologies in the cervix include tears. Small shallow endocervical tears are almost invariably found in the postpartum uterus, and may be present even in those cases where there has been a Cesarean section. Signif - icant and deep tears tend to be lateral in loca - tion. These tears may penetrate through to the serosa, with or without hematoma formation, and may extend up into the lower segment or down the cervix into the vagina. Involvement of large uterine arteries should be sought. It is common to find meconium staining of the mucus of the endocervix with fetal distress, and meconium may contaminate the tear. A tear may have severe consequences: an endocervical tear may cause severe blood loss despite a fully contracted uterus. Tears are associated with amniotic fluid embolus or with amniotic infusion and local defibrination. Bleeding can extend into the broad ligament with formation of a large hematoma. Suturing of the tear may not prevent a deep hematoma from forming and secondary rupture can result in shock, despite cessation of external vaginal hemorrhage. In the dilated postpartum cervix, edema, hemorrhage and fiber disarray may make it diffi - cult to identify tears on histologic examination. Torn and contracted muscle fibers and torn arteries with fibrin plugs and tense hematomas provide corroboratory evidence of a tear. Histo - logic sampling should include blocks from above the apex and from below the tear for deep extension and for identification of large torn vessels. Examination of the uterus histologically following amniotic fluid embolism will show no evidence of intravascular disease in most cases. Very occasionally, there may be fibrin clots adherent to vascular endothelium and, rarely, squames admixed with fibrin have been found in vessels in the body of the uterus. In some cases of postpartum hemorrhage, when there have been no clinical features of amniotic infu - sion but bleeding and unexpected severe onset of consumptive coagulopathy, histological 330 POSTPARTUM HEMORRHAGE Figure 7 Amniotic debris in venules (arrows) of cervical stroma following a small endocervical tear in labor. Postpartum hemorrhage and disseminated intravascular coagulopathy necessitated hysterectomy (×20) 352 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:24:13 Color profile: Generic CMYK printer profile Composite Default screen 331 Pathology of the uterus Figure 8 H/E comparison of (a) normal myometrial fibers and (b) myonecrosis in lower uterine segment in hysterectomy specimen for postpartum hemorrhage following Cesarean section (×40). Long arrows, normal viable cell nuclei; short arrows, non-viable necrotic cells (a) (b) 353 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:24:19 Color profile: Generic CMYK printer profile Composite Default screen 332 POSTPARTUM HEMORRHAGE Figure 9 Desmin comparison of same myometrial fibers accentuates the necrosis. (a) Normal; (b) myonecrosis (×40). Long arrow, normal myometrial cells with intercellular edema; short arrow, dense, compacted necrotic myometrial cells at same magnification (a) (b) 354 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 06 September 2006 16:26:12 Color profile: Generic CMYK printer profile Composite Default screen [...]... protocols and significant reduction in postpartum hemorrhage3 7 Access, transport, institutional or organizational change Twenty percent of avoidable SAMM in rural South Africa is due to organizational or administrative causes such as the shortage of essential drugs, ambulances and lack of recruitment and 349 371 Z:\Sapiens Publishing \A5 211 - Postpartum Hemorrhage\ Make-up \Postpartum Hemorrhage - Voucher Proofs... hemorrhage in one series7 PLACENTAL PATHOLOGY The placenta should be examined in cases of postpartum hemorrhage Pre-eclampsia may cause retroplacental hemorrhage: recent and old hemorrhages and infarcts may be seen The characteristic changes of acute atherosis are only present in 50% of cases of pre-eclamptic toxemia However, examination of the parenchyma will usually show so-called accelerated villous maturation... prevalence of 11.2% in a population-based study in a female population 50 years and older in the city of San Juan40,41 Of the 48 females out of 3 98 who had fractures, 19 had an early menopause at mean age 39 ± 4.7 years Although the asssociation did not reach statistical significance, an early menopause at age less than 45 years is an important risk factor for fractures and osteoporosis, more so if patients... reports and reports produced by maternal mortality review committees8 This has led to better ascertainment of cause of death, and a more accurate maternal mortality rate of 11 .88 ,9 rather than 7.77 ,8 per 100 000 live births for the period 1991–1999 WHAT IS THE DIFFERENCE BETWEEN A ‘NEAR-MISS’ AND A SAMM? A ‘near-miss’ used to be thought of as a case where a woman had a near brush with death; she would have... use of multiple logistic regression to tease out risk factors Manual removal of placenta had the biggest impact13, in keeping with abnormally adherent placentas being a major cause of postpartum hemorrhage Antenatal anemia, Cesarean section, and the use of antidepressants or antiepileptics at booking also appear to have significant impacts, though their relative importance is difficult 347 369 Z:\Sapiens... referrals in Mulago Hospital, Kampala, Uganda East Afr Med J 2003 ;80 :144–9 Glazener CMA, Abdalla M, Stroud P, et al Postnatal maternal morbidity: extent, causes, prevention and treatment Br J Obstet Gynaecol 1995;102: 282 –7 The mother-baby package: WHO’s guide to saving women’s and infant’s lives Safe Mother 1994;15:4–7 Lazarus JV, Lalonde A Reducing post-partum haemorrhage in Africa Int J Gynaecol... Mustafa MS, Abdel Gader AG Disseminated intravascular coagulation and obstetric haemorrhage Management dilemma Saudi Med J 2002;23;6 58 62 Geller SE, Rosenberg D, Cox SM, et al The continuum of maternal morbidity and mortality: factors associated with severity Am J Obstet Gynecol 2004;191:939–44 Kaye D, Mirembe F, Aziga F, et al Maternal mortality and associated near-misses among emergency intrapartum... failure of total expulsion of the placenta may lead to postpartum hemorrhage A fragment of placenta remains, assumes a polypoid shape (‘placental polyp’), and undergoes compression and devitalization Some viable cells may remain in stem villi Vessels below the retained fragments may show persistent dilatation There may be a plasma cell infiltrate in the adjacent myometrium – this is not diagnostic of. .. Myxedematous facies 88 94 94 44 Secondary sexual characteristics Loss of body hair Loss of pubic hair Loss of axillary hair Other Pallor Polyuria and polydipsia Pigmentation in the face 354 376 Z:\Sapiens Publishing \A5 211 - Postpartum Hemorrhage\ Make-up \Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:24:36 100 98 98 92 4 4 Color profile: Generic CMYK printer profile Composite Default screen... products of conception or trophoblastic proliferation Pathologically, vessels of arterial and venous caliber are present, along with large vessels of indeterminate nature OTHER CAUSES Lacerations of the inner myometrium have been reported to cause postpartum hemorrhage1 1 Women with leiomyomas are at an increased risk of postpartum hemorrhage1 2 Less commonly, endometrial carcinomas and congenital anomalies . It accounted for < 5% of cases of delayed postpartum hemorrhage in one series 7 . PLACENTAL PATHOLOGY The placenta should be examined in cases of postpartum hemorrhage. Pre-eclampsia may cause. South-East Thames region, areas with significant inner-city and migrant 341 Severe acute maternal morbidity 363 Z:Sapiens Publishing A5 211 - Postpartum Hemorrhage Make-up Postpartum Hemorrhage -. understanding of the management of secondary postpartum hemorrhage. References 1. Thompson W, Harper MA. Postpartum haemorrhage and abnormalities of the third stage of labour. In Chamberlain G,