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An old method still useful in modern times FYI: MM
 Abstract: Management options for postpartum hemorrhage (PPH) include
oxytocics, prostaglandins, genital tract exploration, ligation or angiographic
embolization of uterine/internal iliac arteries, and hysterectomy. After
excluding uterine rupture, genital tract lacerations, and retained placental
tissue, efforts are directed toward contracting the uterus by bimanual
compression and oxytocics. If these are not successful, one must resort to
surgical techniques. At this stage, an alternative option to remember is
uterovaginal packing. Easy and quick to perform, it may be used to control
bleeding by tamponade effect and stabilize the patient until a surgical
procedure is arranged. Uterovaginal packing may sometimes obviate the need for
surgery altogether. Two cases, a primary and a secondary PPH, managed recently
with uterovaginal packing are reported. Despite concerns about concealed
hemorrhage or the development of infection with this intervention, none of these
problems were encountered, and uterine packing was successful even in the case
of secondary PPH with documented infection.Case 1: A 25-year-old primipara attended this hospital with PPH after
vaginal delivery of a 2-kg boy at another hospital 2 hours prior to
presentation. The placenta had been delivered by controlled cord traction. She
was pale (hemoglobin 5.2 g/dL) and had tachycardia and hypotension (blood
pressure 80/60; pulse 140/min). The uterus was 16 weeks size, not well
retracted, and the patient was bleeding continuously. Examination under
anesthesia revealed partial uterine inversion. After manual reposition, the
uterus remained atonic, and bleeding continued despite administration of
bimanual compression, oxytocin, ergometrine, and prostaglandins. Tight
uterovaginal packing was done with packing forceps using 6 units of
povidone-iodine-soaked rolled gauze (knotted end to end). The rolled gauze was
fashioned from a rolled bandage 10 cm wide and 4 meters long, which was folded
lengthwise 4 times. Bleeding stopped and the patient became hemodynamically
stable. She received 5 units of blood transfusion and broad-spectrum
antibiotics. Oxytocin infusion was continued for 12 hours. The pack was removed
uneventfully 36 hours later. Cultures sent from the uterine cavity at the time
of packing grew Escherichia coli with sensitivity to cefotaxime and
amikacin, which she had been receiving. She remained afebrile and was discharged
7 days later.
Case 2: A 27-year-old, para 2, attended this hospital 40 days after
elective cesarean with secondary PPH. During cesarean (at another hospital), the
placenta was found adherent and was removed only partially. She had been
readmitted to that same hospital with PPH and fever 10 days before presentation
to us. There she had received blood transfusion (4 units), oxytocics, and
antibiotics. Because her condition did not improve, she was referred to our
institution. On admission, she was pale (hemoglobin 7.3 g/dL) and febrile
(39°C), but hemodynamically stable (blood pressure 110/80; pulse 110/min). Her
abdomen was soft, and the incision had healed. The uterus was subinvoluted (16
weeks size), the cervix was 2 cm dilated, and placental tissue was extruding
from it. Significant vaginal bleeding was present. Broad-spectrum antibiotics
were started. The uterus was evacuated under anesthesia, and about 100 g of
placental tissue was removed. Despite administration of oxytocics and
prostaglandins, bleeding continued. Tight uterovaginal packing using 3 units of
povidone-iodine-soaked rolled gauze successfully controlled the bleeding. Four
units of blood were transfused during and after the procedure. The pack was
removed uneventfully 44 hours later. Placental culture grew anaerobic bacteria.
She became afebrile after 5 days and was discharged after 10 days.
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