Pelvic and vaginal packing for intractable venous obstetric haemorrhage: practical tips for the obstetrician

Transcription

1 DOI: /tog The Obstetrician & Gynaecologist ;16: Tips and Techniques Pelvic and vaginal packing for intractable venous obstetric haemorrhage: practical tips for the obstetrician Articles in the Tips and Techniques section are personal views from experts in their field on how to carry out procedures in obstetrics and gynaecology. Wai Yoong MD FRCOG, a, * Viswa Sivashanmugarajan MRCOG, b Morgan McMonagle MD FRCSI, c John Hamilton MBBS, d Mahantesh Karoshi MRCOG, e Wasim Lodhi MRCOG f a Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, Sterling Way, b ST7 trainee in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, Sterling Way, c Consultant Vascular and Trauma Surgeon, Department of Trauma and Vascular Surgery, St Mary s Hospital, Praed Street, London W2 1NY, UK d ST5 trainee in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, William Harvey Hospital, Ashford, Kent TN24 0LZ, UK e Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, Barnet General Hospital, Wellhouse Lane, Barnet, Hertfordshire EN5 3DJ, UK f Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, Sterling Way, *Correspondence: Wai Yoong. waiyoong@nhs.net Accepted on 12 May 2014 Please cite this paper as: Yoong W, Sivashanmugarajan V, McMonagle M, Hamilton J, Karoshi M, Lodhi W. Pelvic and vaginal packing for intractable venous obstetric haemorrhage: Practical tips for the obstetrician. The Obstetrician & Gynaecologist 2014;16: Introduction Surgical interventions in massive obstetric haemorrhage such as intrauterine balloon tamponade, 1 compression sutures 2,3 and selective devascularisation 4 (including internal iliac ligation) have helped reduce the need for peripartum hysterectomy. Furthermore, development of newer haemostatic fibrin sealants have also added to repertoire that the clinician can use to control postpartum haemorrhage (PPH). 5 However, in cases where disseminated intravascular coagulation (DIC) has set in or where haemorrhage persists from large raw surfaces, venous plexuses and inaccessible areas, the concept of packing (i.e. tamponading bleeding points against bony or fascial tissues) is a useful one for the obstetrician to learn. Traditionally, obstetricians and gynaecologists pack with swabs in order to move viscus from field of vision and facilitate access: this is very different from the skill of abdominal and pelvic packing in peripartum haemorrhage. This should also not be confused with uterine packing or various intrauterine balloon tamponade for postpartum haemorrhage due to atony. 1,6 This article aims to serve as a brief guide on how to perform packing and to provide simple tips on when this technique could be used. Why consider packing? Surgical packing is often seen as a bail-out technique for managing pelvic haemorrhage when the surgeon is unable to control by conventional haemostatic techniques such as suturing. The pursuit of complete primary haemostasis in a patient who is haemodynamically unstable is neither sensible nor realistic and, in these cases, more definitive surgery can make the patient more moribund. Packing creates a physical tamponade within the bony and fascial structures of the pelvis itself. 7 The key to this manoeuvre is to pack the true pelvis (below the pelvic brim) and not the false pelvis (above the pelvic brim): in fact, packing above the pelvic brim has minimal tamponade effect, since the major venous bleeding occurs in the plexus of vessels in the true pelvis. In trauma patients, the landmark paper by Rotondo et al. 8 showed a 73% improvement in mortality for injury-matched groups treated with packing over traditional definitive surgery. Damage control surgery performed in tandem with damage control resuscitation adjunctive techniques such as correction of coagulopathy, hypotensive resuscitation and intravenous tranexamic acid have helped improve outcomes in pelvic haemorrhage following trauma cases. 276 ª 2014 Royal College of Obstetricians and Gynaecologists

2 Yoong et al. The risk of developing potentially fatal exsanguinating haemorrhage is dependant on factors known as the triad of death in trauma literature: coagulopathy (international normalised ratio [INR]>1.5), acidosis (ph 7.2) and hypothermia (T o <35 C). 9 It is crucial to appreciate that although tamponade pressure exceeding arterial pressure will control smaller arterial and low pressure capillary bleeding, 10 it will not stop larger arterial bleeders; thus, if the latter is suspected, other techniques for managing this must be considered such as arterial-embolisation or ligation of the internal iliac arteries or their branches. Indications for packing are listed in Box 1. (a) Box 1. Specific examples of when packing may be necessary As a last attempt before obstetric hysterectomy Post-hysterectomy bleeding from vault Uncontrolled bleeding from pelvic side walls and inaccessible areas of pelvis Non-expanding broad ligament or retroperitoneal haematoma Disseminated intravascular coagulation (to allow correction of coagulopathy) When there is poor access for suturing (such as tear extending to retropubic space) Vaginal lacerations which are friable (b) How to pack the pelvis through the abdominal route Only larger (at least 30 x 30 cm) sized X-ray detectable swabs should be used for packing. Swabs should be folded tightly in sandwich sized rolls (Figure 1a-c) and then used to pack, thus applying uniform pressure against bleeding sites to produce sufficient tamponade. In cases where the uterus is well contracted and bleeding occurs from pelvic venous plexuses, the uterus is displaced anteriorly and packs are then introduced via the pelvic side walls and packed tightly against sacrum (presacral area) and paravesical region (Video S1), ensuring that the packs are airtight and that there is minimal dead space (Figure 2). This is repeated on the contralateral side. In cases of persistent venous or capillary ooze following peripartum hysterectomy, the true pelvis needs to be packed tightly to occlude any potential dead space. The surgeon should then wait for the blood pressure to normalise in order to check that venous bleeding has been controlled. It is particularly important in DIC not to place repeated unnecessary sutures which can further traumatise tissues and exacerbate bleeding. For obstetric venous bleeding, retroperitoneal access is usually not necessary and packing can be done through the peritoneal route. Drains are usually not necessary and in order to avoid compartmental syndrome, the rectus sheath is not sutured (c) Figure 1. a c: How to construct a pack using a 30 x 30 cm swab and the integrity of the anterior abdominal wall is maintained using skin sutures or staples only. The patient is then transferred to the intensive care unit for stabilisation and correction of any coagulopathy or anaemia and intra-abdominal packs retrieved within hours. 11 The small bowel could temporarily adhere to the packs and this could be prevented by placing it in a synthetic bowel bag (for example, the Aldon Intestinal Bag, Rusch Ltd, Germany) ª 2014 Royal College of Obstetricians and Gynaecologists 277

3 Pelvic and vaginal packing Figure 2. Swabs packed tightly against sacrum, uterus and pubic symphysis Figure 4. Showing how the labia had been sutured to retain the balloon tamponade in the vagina. The Foley catheter and drainage channel of the Bakri balloon can be seen. Figure 3. Aldon Intestinal Bag (PVC) Rusch Ltd, Germany (Figure 3) or use of sterile surgical drapes such as 3M TM Ioban TM 2 Antimicrobial Film on top of the packs, separating this from bowel. Should small bowel adhere to the packs, these pseudo-adhesions can be easily mobilised using hydro-dissection, i.e. irrigating with saline and using this to free and mobilise the bowel. How to perform vaginal packing for uncontrolled venous bleeding? Intravaginal tamponade using packs simultaneously with Bakri, 6 Sangstaken-Blakemore 12 or even a simple blood pressure (BP) manometry cuff 13 have been shown to be effective in PPH secondary to vaginal lacerations or cervical tears. When vaginal tissues are oedematous and friable, placing more sutures is often counter-productive and leads to cheese-wiring and further trauma. A Bakri balloon can then be introduced into the vagina and inflated to a volume of around 300 ml. Because of limited access to the vagina, a balloon is preferable to packing alone in this case as the former is able to generate more evenly distributed tamponade compared to packs. 14,15 Similarly, the use of a small BP cuff, wrapped around a bag of 250 ml normal saline and placed in the vagina has been shown to stop vaginal bleeding: this technique can be of use in a low-resource setting. 13 It is postulated that the inflated balloon exerts a pressure that overcomes systemic arterial or venous pressure, leading to cessation of blood flow and formation of clot locally. 16 The asymmetrical aubergine shape of the Bakri balloon (with the largest transverse diameter nearer to the tip) means that the device often remains within the vagina, although the operator may consider suturing the labia together temporarily to prevent expulsion if it lies low in the vagina (Figure 4). The Bakri has an advantage over the Rusch balloon in this situation, as lochia can drain through the central catheter channel, thus reducing the potential of concealed bleeding. The balloon is usually left in situ for a minimum of 12 hours and there is no advantage in leaving it longer than 24 hours. Once the bleeding has settled, the balloon is deflated sequentially (by 50% inflated volume), followed by observation of vital signs and vaginal bleeding before final deflation and removal. While packing of the vagina with gauze is still sometimes practised, traditional uterine packing with sterile gauze to control haemorrhage is rarely done due to the risk of trauma and infection, the difficulty in achieving uniform tamponade and the risk of concealed bleeding, particularly now that balloon catheters with drainage channels are available. Tips for trainees when performing packing are listed in Box ª 2014 Royal College of Obstetricians and Gynaecologists

4 Yoong et al. Box 2. Top tips when packing Packs work best for low pressure venous bleeding and disseminated intravascular coagulation Packs should be airtight to minimise dead space in pelvis Correct hypothermia, acidosis and coagulopathy prior to return to theatre for removing packs Be aware of possible bowel adhesions when removing pack from the abdomen as there is a risk of bowel injury. Some patients develop severe paralytic ileus following pack removal Do not close rectus sheath as this may lead to compartmental syndrome Do not leave packs for more than 24 hours as sepsis may ensue Never forget the retained pack! Use a stamp or armband to complement clear documentation so that staff are reminded that a pack is in situ Abdominal compartment syndrome (ACS) following pelvic packing Abdominal compartment syndrome (ACS) 17 is a life threatening disorder in critically ill patients caused by rapid pathological elevation of intra-abdominal pressure (>12 mmhg), which may result in multiple organ dysfunctions with a potentially fatal outcome. It is clinically characterised by a massively distended tense abdomen with respiratory, cardiovascular, neurological and renal dysfunction: death may result from left ventricular failure. Primary closure of rectus sheath after pelvic packing 18 can exacerbate ACS; for this reason, the skin can simply be approximated with sutures or staples as the pack should be removed within 48 hours. Conclusion The technique of abdomino-pelvic and vaginal packing had been utilised for many years to control PPH before the obstetrician resorted to hysterectomy. 19 The advent of improved uterotonic agents, together with the introduction of intrauterine balloon tamponade and conservative surgical treatments (such as the B-Lynch suture) has almost led to its demise in contemporary use. Moreover, packing has several disadvantages: An experienced accoucher is required to pack quickly and tightly. As there is no drainage channel, a pelvis or vagina tightly packed with gauze may lead to a delay in diagnosis as bleeding is not revealed. Potential complications such as compartmental syndrome and sepsis. Necessity for a second procedure to retrieve the pack. However, the skill to pack is a useful one to acquire particularly when newly appointed consultants now have less experience with peripartum hysterectomy. Packing is particularly indicated when DIC has complicated the continuous bleeding: in this scenario, inserting more sutures is counterproductive and the concept of pack and go back may prevent maternal death. Timing of decision to perform pelvic/vaginal packing is key for the best clinical outcomes as this stabilises the patient to allow transfer to ICU where anaemia and coagulopathy can be corrected. It is imperative to remember to remove all inserted packs and document swab count clearly, especially in an emergency when many simultaneous events are occurring and the patient will be transferred from obstetric theatres to ICU and back. The use of a stamp or wristband can help avoid the occurrence of a never event of an inadvertently retained swab. The authors have supplemented this short article with diagrams and pictures which they hope will be simple to follow. Disclosure of interests All authors declare no conflict of interest. Contribution to authorship WY initiated the proposal, co-wrote the paper, produced Figures 1 and 3 and filmed the video. VS co-wrote the paper and filmed the video. MM co-wrote the paper and filmed the video. JH co-wrote the paper and illustrated Figure 2. WL co-wrote the paper and edited the video. MK co-wrote the paper. Supporting Information The following supplementary information is available for this article online: Video S1. Video illustrating the technique of abdominopelvic packing. References 1 Condous GS, Arulkumaran S, Symonds I, Chapman R, Sinha A, Razvi K. The, tamponade test in the management of massive postpartum haemorrhage. Obstet Gynecol 2003;101: B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. 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: Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol 2002;99: Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH). Scottish Confidential Audit of Severe Maternal Morbidity, 2nd Annual Report, Aberdeen: SPCERH; Mahmoud S, El Hamamy E. Use of fibrin sealants in Obstetric Haemorrhage. In: Arulkumaran S, Karoshi M, Keith LG, Lalonde AB, B-Lynch C, editors. A Comprehensive Textbook of Postpartum Haemorrhage. 2nd edn.. London: Sapiens Publishing; Bakri YN, Amri A, Abdul Jabbar F. Tamponade balloon for obstetrical bleeding. Int J Gynaecol Obstet 2001;74: ª 2014 Royal College of Obstetricians and Gynaecologists 279

5 Pelvic and vaginal packing 7 Moreno C, Moore EE, Rosenberger A, Cleveland HC. Hemorrhage associated with major pelvic fracture: a multispecialty challenge. J Trauma 1986;26: Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, et al. Damage control: approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35: Garrison JR, Richardson JD, Hilakos AS, et al. Predicting the need to pack early for severe intra-abdominal haemorrhage. J Trauma 1996;40: Hsu S, Rodgers B, Lele A, Yeh J. Use of packing in obstetric hemmorhage of uterine origin. J Reprod Med 2003;48: Dildy GA III. The pelvic pressure pack. In: Arulkumaran S, Karoshi M, Keith LG, Lalonde AB, B-Lynch C, editors. A Comprehensive Textbook of Postpartum Haemorrhage. 2nd edn.. London: Sapiens Publishing; Seror J, Allouche C, Elhaik S. Use of Sengstaken-Blakemore tube in massive postpartum haemorrhage: a series of 17 cases. Acta Obstet Gynecol Scand 2005;84: Cameron A, Menticoglou S. Blood pressure cuff tamponade of vaginal lacerations causing significant postpartum hemorrhage. J Obstet Gynaecol Can 2011;33: Yoong W, Ray A, Phillip SA. Balloon tamponade for postpartum vaginal lacerations in a woman refusing blood transfusion. Int J Gynaecol Obstet 2009;106: Tattersall M, Braithwaite W. Balloon tamponade for vaginal lacerations causing severe postpartum haemorrhage. BJOG 2007;114: Ferrazzani S, Guariglia L, Dell Aquila C. The balloon internal uterine tamponade as a diagnostic test. In: Arulkumaran S, Karoshi M, Keith LG, Lalonde AB, B-Lynch, C, Editors. A Comprehensive Textbook of Postpartum Haemorrhage. 2nd Edn. London: Sapiens Publishing; Walker J, Criddle LM. Pathophysiology and management of abdominal compartment syndrome. Am J Crit Care 2003;12: Ertel W, Oberholzer A, Platz A, Stocker R, Trentz O. Incidence and clinical pattern of the abdominal compartment syndrome after damage-control laparotomy in 311 patients with severe abdominal and/or pelvic trauma. Crit Care Med 2000;28: American Congress of Obstetricians and Gynaecologists. Diagnosis and Management of Postpartum Hemorrhage. ACOG Technical Bulletin no 143. Washington DC: ACOG; ª 2014 Royal College of Obstetricians and Gynaecologists