In cases of placenta accreta or increta, simple hysterectomy generally will suffice. In rare cases of accreta, however, the uterus may invade other organs, making immediate surgery difficult, if not impossible. Under such circumstances, abnormal vascularity may be evident. These cases often require the expert assistance of a urologist, gynecologic oncologist, or vascular surgeon.
In some instances, the placenta cannot be successfully removed without maternal exsanguination. In these cases, delivery of the fetus through a fundal incision, so that the placenta is left intact, has been described. Some patients benefit from chemotherapeutic agents such as methotrexate to enhance placental shrinkage in the postpartum period. In most cases, however, a return to the OR will eventually be necessary. Even so, significant placental/uterine involution will have occurred by then, making surgery significantly easier.
Angiographic embolization. This is an exciting technique that is rapidly developing into an effective way to control postpartum hemorrhage. Its main limitation is that it is time-consuming and, thus, generally unsuitable for the rapid treatment of massive intra-operative or peripartum hemorrhage. However, a slowly evolving retroperitoneal hematoma or other forms of gradual, persistent hemorrhage often are amenable to angiographic identification followed by embolization. Indeed, a number of studies have suggested good outcomes in carefully selected, hemodynamically stable patients.10,11 In these cases, angiographic embolization may help the physician avoid laparotomy and hysterectomy.
Blood-product infusion. When trying to stop a hemorrhage, do not overlook the need for blood and component therapy. The appropriate use of packed red blood cells, crystalloid solution, fresh frozen plasma, and platelets is beyond the scope of this discussion. While an experienced physician certainly can direct both blood-banking infusion and the surgical approach to hemostasis, it sometimes is helpful to formally delegate blood and component replacement to another specialist, e.g., the anesthesiologist.
Conclusion
Although postpartum hemorrhage carries the potential for serious maternal morbidity—even mortality—it generally can be managed successfully if it is approached in a systematic manner. The first step is determining the cause of bleeding: uterine atony, genital-tract laceration, retained placenta, or coagulopathy. While the cause of bleeding usually is singular, things aren’t always that simple. A laceration may accompany uterine atony, or retained placenta may contribute to persistent uterine atony.
Uterine compression, oxytocin infusion, and/or other medical management often are effective approaches to atony. For lacerations and retained placenta, a surgical approach often is necessary. Although it should be the last resort, hysterectomy sometimes is required. The wise clinician anticipates this possibility and plans accordingly.
Dr. Clark reports no affiliation or financial arrangement with any of the companies that manufacture drugs or devices in any of the product classes mentioned in this article.