CONSERVATIVE MANAGEMENT IN THE TREATMENT OF SECONDARY PPH WITH EXCESSIVE BLOOD LOSS OF UNKNOWN ETIOLOGY, COULD IT AVOID SURGERY? A CASE REPORT
Main Article Content
Keywords
postpartum hemorrhage, conservative management, KIWI delivery, tranexamic acid
Abstract
Introduction: Tranexamic acid is an antifibrinolytic agent typically used in managing hemorrhage. This is the first reported case to use tranexamic acid as the main treatment protocol in secondary PPH in a case with severe vaginal bleeding which would have rather been only managed by surgical intervention.
Case Presentation: A 38-year-old patient, who had an uncomplicated one pull ventouse KIWI delivery followed by primary PPH of unknown etiology from the common causes. Then ten days post-delivery had secondary PPH with excessive blood loss. Common causes of primary and secondary PPH have been excluded while the only identifiable cause was a bacterial vaginosis; Gardenalia infection detected by high vaginal swap however not sufficient as a main reason to cause such extensive hemorrhage. The case was managed conservatively and medically while avoiding surgical intervention which is usually the inevitable destination of such a case.
Conclusion: In line with the WHO guidelines, we recommend that Tranexamic acid to be considered as a first line treatment of secondary PPH regardless of the etiology. Although treating the cause is a must, but commencing Tranexamic acid with continuous administration until the hemorrhage completely settles is a strong recommendation to control the bleeding and avoid the progression to severe blood loss where hysterectomy or other surgical or radiological interventions will be the remaining treatment options.
References
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18. Doumouchtsis SK, Nikolopoulos K, Talaulikar VS, Krishna A, Arulkumaran S. Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Mar;121(4):382-8. https://doi.org/10.1111/1471-0528.12546.
19. Spreu A, Abgottspon F, Baumann MU, Kettenbach J, Surbek D. Efficacy of pelvic artery embolisation for severe postpartum hemorrhage. Archives of gynecology and obstetrics. 2017 Dec;296:1117-24. https://doi.org/10.1007/s00404-017-4554-y.
20. Koethe Y, Rizzuto GA, Kohi MP. Retained placenta accreta presenting as secondary postpartum hemorrhage. Obstet Gynecol Cases Rev. 2015;2:035. Retained Placenta Accreta Presenting as Secondary Postpartum Hemorrhage (semanticscholar.org).
21. Du R, Davies R, Supramaniam PR. Fertility preserving management for postpartum haemorrhage secondary to subinvolution of the placental implantation site. BMJ Case Reports CP. 2021 Sep 1;14(9):e245009. http://dx.doi.org/10.1136/bcr-2021-245009.
22. Sathe NA, Likis FE, Young JL, Morgans A, Carlson-Bremer D, Andrews J. Procedures and uterine-sparing surgeries for managing postpartum hemorrhage: a systematic review. Obstetrical & gynecological survey. 2016 Feb 1;71(2):99-113. DOI: 10.1097/OGX.0000000000000273.
23. Sentilhes L, Merlot B, Madar H, Sztark F, Brun S, Deneux-Tharaux C. Postpartum haemorrhage: prevention and treatment. Expert review of hematology. 2016 Nov 1;9(11):1043-61. https://doi.org/10.1007/978-3-319-93572-0_11.
24. Collis R, Guasch E. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best practice & research Clinical anaesthesiology. 2017 Mar 1;31(1):107-24.
https://doi.org/10.1016/j.bpa.2017.02.001.
25. Dumont A, Bodin C, Hounkpatin B, Popowski T, Traoré M, Perrin R, Rozenberg P. Uterine balloon tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage: a randomised controlled trial in Benin and Mali. BMJ open. 2017 Sep 1;7(9):e016590. http://dx.doi.org/10.1136/bmjopen-2017-016590.
26. Rasheed SM, Amin MM, Abd Ellah AH, Elhassan AM, El Zahry MA, Wahab HA. Reproductive performance after conservative surgical treatment of postpartum hemorrhage. International Journal of Gynecology & Obstetrics. 2014 Mar 1;124(3):248-52.
https://doi.org/10.1016/j.ijgo.2013.08.018.
27. Muñoz M, Stensballe J, Ducloy-Bouthors AS, Bonnet MP, De Robertis E, Fornet I, Goffinet F, Hofer S, Holzgreve W, Manrique S, Nizard J. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfusion. 2019 Mar;17(2):112. https://doi.org/10.2450%2F2019.0245-18.
28. Wellner UF, Kulemann B, Lapshyn H, Hoeppner J, Sick O, Makowiec F, Bausch D, Hopt UT, Keck T. Postpancreatectomy hemorrhage—incidence, treatment, and risk factors in over 1,000 pancreatic resections. Journal of Gastrointestinal Surgery. 2014 Mar;18:464-75. https://doi.org/10.1007/s11605-013-2437-5.
29. Kong CW, To WW. Prognostic factors for the use of intrauterine balloon tamponade in the management of severe postpartum hemorrhage. International Journal of Gynecology & Obstetrics. 2018 Jul;142(1):48-53. https://doi.org/10.1002/ijgo.12498.
30. Kaler M, Gailer R, Iskaros J, David AL. Case Report Postpartum Pyomyoma, a Rare Complication of Sepsis Associated with Chorioamnionitis and Massive Postpartum Haemorrhage Treated with an Intrauterine Balloon. https://doi.org/10.1155/2015/609205/].
31. Boka O, Jagodkina S, Vitina S. Postpartum hemorrhage and polycythemia vera: a case report. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2016 Nov 1;206:e17-8. https://doi.org/10.1016/j.ejogrb.2016.07.073.
32. Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane database of systematic reviews. 2014(2).
https://doi.org/10.1002/14651858.CD003249.pub3
2. Abdul‐Kadir R, McLintock C, Ducloy AS, El‐Refaey H, England A, Federici AB, Grotegut CA, Halimeh S, Herman JH, Hofer S, James AH. Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion. 2014 Jul;54(7):1756-68. https://doi.org/10.1111/trf.12550.
3. Wicaksana A, Setiawan A. Unilateral Uterine Artery Embolization Therapy For Secondary Postpartum Hemorrhage In Pseudoaneurysma Of The Sinistra Uterinary Artery Post-Cesarean Section. Asian Journal of Health Research. 2022 Jul 27;1(2):57-63.
https://doi.org/10.55561/ajhr.v1i2.31.
4. Sentilhes L, Kayem G, Silver RM. Conservative management of placenta accreta spectrum. Clinical obstetrics and gynecology. 2018 Dec 1;61(4):783-94. Frequency and Clinical Outcome in Patients with Placenta Accreta Spectrum | Journal of The Society of Obstetricians and Gynaecologists of Pakistan (jsogp.net)
5. Benkirane S, Saadi H, Serji B, Mimouni A. Uterine necrosis following a combination of uterine compression sutures and vascular ligation during a postpartum hemorrhage: A case report. International journal of surgery case reports. 2017 Jan 1;38:5-7.
https://doi.org/10.1016/j.ijscr.2017.07.005.
6. Sentilhes L, Kayem G, Mattuizzi A. Conservative approach: Intentional retention of the placenta. Best Practice & Research Clinical Obstetrics & Gynaecology. 2021 Apr 1;72:52-66. https://doi.org/10.1016/j.bpobgyn.2020.07.010.
7. Brown M, Hong Jr M, Lindquist J. Uterine artery embolization for primary postpartum hemorrhage. Techniques in Vascular and Interventional Radiology. 2021 Mar 1;24(1):100727. https://doi.org/10.1016/j.tvir.2021.100727.
8. Pavord S, Maybury H. How I treat postpartum hemorrhage. Blood, The Journal of the American Society of Hematology. 2015 Apr 30;125(18):2759-70. https://doi.org/10.1182/blood-2014-10-512608.
9. Tan CC, Mathur M, Lo RH. Uterine Arteriovenous Malformation: A Rare Cause of Secondary Postpartum Hemorrhage. Journal of Medical Cases. 2017 May 3;8(5):152-4.
http://hdl.handle.net/10138/313095.
10. Goh WA, Zalud I. Placenta accreta: diagnosis, management and the molecular biology of the morbidly adherent placenta. The Journal of Maternal-Fetal & Neonatal Medicine. 2016 Jun 2;29(11):1795-800. https://doi.org/10.3109/14767058.2015.1064103.
11. Chochkova AM, Nakova M, Chochkov B, Miceva M, Milosheska R. Secondary Postpartum Hemorrhage due to Placental Site Vascular Subinvolution as a Diagnostic Challenge in Women with Preserved Uterus. 1-Chochova_Final.pdf (umed.edu.al).
12. Chen C, Lee SM, Kim JW, Shin JH. Recent update of embolization of postpartum hemorrhage. Korean journal of radiology. 2018;19(4):585-96. https://doi.org/10.3348/kjr.2018.19.4.585.
13. Matsuzaki S, Yoshino K, Endo M, Tomimatsu T, Takiuchi T, Mimura K, Kumasawa K, Ueda Y, Kimura T. Successful anticoagulant therapy for disseminated intravascular coagulation during conservative management of placenta percreta: a case report and literature review. BMC Pregnancy and Childbirth. 2017 Dec;17(1):1-7. https://doi.org/10.1186/s12884-017-1634-8.
14. Revert M, Cottenet J, Raynal P, Cibot E, Quantin C, Rozenberg P. Intrauterine balloon tamponade for management of severe postpartum haemorrhage in a perinatal network: a prospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2017 Jul;124(8):1255-62. https://doi.org/10.1111/1471-0528.14382.
15. Iraha Y, Okada M, Toguchi M, Azama K, Mekaru K, Kinjo T, Kudaka W, Aoki Y, Aoyama H, Matsuzaki A, Murayama S. Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions. Japanese journal of radiology. 2018 Jan;36:12-22. https://doi.org/10.1007/s11604-017-0687-y.
16. Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, Suarez-Rebling D, Eckardt M, Theron G, Burke TF. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis. American journal of obstetrics and gynecology. 2020 Apr 1;222(4):293-e1. https://doi.org/10.1016/j.ajog.2019.11.1287.
17. Lindquist JD, Vogelzang RL. Pelvic artery embolization for treatment of postpartum hemorrhage. InSeminars in Interventional Radiology 2018 Mar (Vol. 35, No. 01, pp. 041-047). Thieme Medical Publishers. https://doi.org/10.53350/pjmhs22162988.
18. Doumouchtsis SK, Nikolopoulos K, Talaulikar VS, Krishna A, Arulkumaran S. Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Mar;121(4):382-8. https://doi.org/10.1111/1471-0528.12546.
19. Spreu A, Abgottspon F, Baumann MU, Kettenbach J, Surbek D. Efficacy of pelvic artery embolisation for severe postpartum hemorrhage. Archives of gynecology and obstetrics. 2017 Dec;296:1117-24. https://doi.org/10.1007/s00404-017-4554-y.
20. Koethe Y, Rizzuto GA, Kohi MP. Retained placenta accreta presenting as secondary postpartum hemorrhage. Obstet Gynecol Cases Rev. 2015;2:035. Retained Placenta Accreta Presenting as Secondary Postpartum Hemorrhage (semanticscholar.org).
21. Du R, Davies R, Supramaniam PR. Fertility preserving management for postpartum haemorrhage secondary to subinvolution of the placental implantation site. BMJ Case Reports CP. 2021 Sep 1;14(9):e245009. http://dx.doi.org/10.1136/bcr-2021-245009.
22. Sathe NA, Likis FE, Young JL, Morgans A, Carlson-Bremer D, Andrews J. Procedures and uterine-sparing surgeries for managing postpartum hemorrhage: a systematic review. Obstetrical & gynecological survey. 2016 Feb 1;71(2):99-113. DOI: 10.1097/OGX.0000000000000273.
23. Sentilhes L, Merlot B, Madar H, Sztark F, Brun S, Deneux-Tharaux C. Postpartum haemorrhage: prevention and treatment. Expert review of hematology. 2016 Nov 1;9(11):1043-61. https://doi.org/10.1007/978-3-319-93572-0_11.
24. Collis R, Guasch E. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best practice & research Clinical anaesthesiology. 2017 Mar 1;31(1):107-24.
https://doi.org/10.1016/j.bpa.2017.02.001.
25. Dumont A, Bodin C, Hounkpatin B, Popowski T, Traoré M, Perrin R, Rozenberg P. Uterine balloon tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage: a randomised controlled trial in Benin and Mali. BMJ open. 2017 Sep 1;7(9):e016590. http://dx.doi.org/10.1136/bmjopen-2017-016590.
26. Rasheed SM, Amin MM, Abd Ellah AH, Elhassan AM, El Zahry MA, Wahab HA. Reproductive performance after conservative surgical treatment of postpartum hemorrhage. International Journal of Gynecology & Obstetrics. 2014 Mar 1;124(3):248-52.
https://doi.org/10.1016/j.ijgo.2013.08.018.
27. Muñoz M, Stensballe J, Ducloy-Bouthors AS, Bonnet MP, De Robertis E, Fornet I, Goffinet F, Hofer S, Holzgreve W, Manrique S, Nizard J. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfusion. 2019 Mar;17(2):112. https://doi.org/10.2450%2F2019.0245-18.
28. Wellner UF, Kulemann B, Lapshyn H, Hoeppner J, Sick O, Makowiec F, Bausch D, Hopt UT, Keck T. Postpancreatectomy hemorrhage—incidence, treatment, and risk factors in over 1,000 pancreatic resections. Journal of Gastrointestinal Surgery. 2014 Mar;18:464-75. https://doi.org/10.1007/s11605-013-2437-5.
29. Kong CW, To WW. Prognostic factors for the use of intrauterine balloon tamponade in the management of severe postpartum hemorrhage. International Journal of Gynecology & Obstetrics. 2018 Jul;142(1):48-53. https://doi.org/10.1002/ijgo.12498.
30. Kaler M, Gailer R, Iskaros J, David AL. Case Report Postpartum Pyomyoma, a Rare Complication of Sepsis Associated with Chorioamnionitis and Massive Postpartum Haemorrhage Treated with an Intrauterine Balloon. https://doi.org/10.1155/2015/609205/].
31. Boka O, Jagodkina S, Vitina S. Postpartum hemorrhage and polycythemia vera: a case report. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2016 Nov 1;206:e17-8. https://doi.org/10.1016/j.ejogrb.2016.07.073.
32. Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane database of systematic reviews. 2014(2).
https://doi.org/10.1002/14651858.CD003249.pub3
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Aug 11, 2023
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Albatran, D. (2023). CONSERVATIVE MANAGEMENT IN THE TREATMENT OF SECONDARY PPH WITH EXCESSIVE BLOOD LOSS OF UNKNOWN ETIOLOGY, COULD IT AVOID SURGERY? A CASE REPORT. Journal of Population Therapeutics and Clinical Pharmacology, 30(17), 672–678. https://doi.org/10.53555/jptcp.v30i17.2513
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Author Biography
Dr.Ghada Albatran
MB CHB, FRCOG, DFFP, BSCCP, Specialist, Obstetrician and Gynecologist, Medicine, Mediclinic City Hospital, Mediclinic Middle East, Dubai, UAE.