Case of the Month #45 Major Obstetric Haemorrhage - Part 2

This will depend on the cause of MOH. Specific management steps for MOH secondary to PPH (the most common cause of MOH) are detailed below. 

1. Pharmacological (primarily treats uterine atony) 

• After prophylactic administration of uterotonics (10 IU syntocinon IM following vaginal delivery or 5 IU syntocinon IV following operative delivery), Oxytocin 5 IU by slow IV injection - first line, acts via oxytocin receptors on myometrial cell membrane. Caution with haemodynamic instability or known cardiac disease. 

• Ergometrine 0.5 mg (in 20ml 0.9% saline) by slow IV or 0.5mg in 1ml IM injection - second line, Ergot Alkaloid acting via dopamine, a-adrenergic and 5-HT3 receptors. Contraindicated in hypertension, myocardial ischaemia. Consider giving an antiemetic with administration.  

• Oxytocin infusion (40 IU over 4 hours). 

• Carboprost 0.25 mg IM - second line, via prostaglandin receptors. Repeated at intervals of 15 minutes to a maximum of eight doses, although more than four doses rarely effective. Caution with asthma/ obstructive lung disease. 

• Misoprostol 400-600 micrograms (max 800) rectal, vaginal or sublingual - second line, via prostaglandin receptors. Can be repeated after 15 minutes if required. Caution with asthma/ obstructive lung disease. 

Tranexamic acid (TXA) is an anti-fibrinolytic and a dose of 1g IV should be administered as early as possible once blood loss is approaching 1000 ml and is ongoing. A second dose can be administered after 30 minutes if bleeding continues. 

2. Mechanical 

• External uterine massage 

• Bimanual uterine compression 

• Ensured the bladder is emptied/insert a Foley’s catheter 

• Manual reduction of an inverted uterus 

3. Surgical 

• Manual removal of placenta/retained products of conception 

• Repair of genital tract/perineal tears 

• Prompt repair of any extensions of uterine incisions at caesarean section 

• Vaginal/uterine packing 

• Intrauterine balloon tamponade (“Backri” balloon). Appropriate first line surgical intervention where uterine atony is found to be the only or major causes of ongoing bleeding. 

• Brace or “B-Lynch” suture - a conservative surgical intervention used second line, depending on clinical circumstances and available expertise. May be considered first line at the time of Caesarean section or laparotomy. 

• Laparotomy and bilateral ligation of uterine arteries or internal iliac arteries. 

• Hysterectomy - must be at least considered early with uncontrolled bleeding to allow mobilization of a second experienced clinician, where feasible. 

4. Interventional Radiology 

This may be considered where there is provision of this service.  

• Selective endovascular balloon occlusion (internal iliac or uterine arteries). 

• Selective uterine artery embolization. 

Transfer to a radiology suite may not be appropriate in significant maternal haemodynamic instability.