Novel concepts and improvisation for treating postpartum haemorrhage: a narrative review of emerging techniques

Plain language summaryUnborn babies are nourished by the mother's blood supply to the afterbirth (placenta). After a baby's birth, contractions of the muscles of the womb (uterus) shear the placenta from its attachment and clamp off the mother's blood vessels. This process is assisted by giving an injection which contracts the womb, and pulling gently on the cord to remove the afterbirth. Usually, blood loss is minimal. Occasionally the womb fails to contract effectively or there is bleeding from tears of the birth canal. Bleeding in excess of 500 ml is called postpartum haemorrhage, which can be life-threatening. Excessive bleeding may be treated with medicines to contract the womb or help the blood to clot, rubbing or squeezing the womb, a 'drip' with fluids or blood replacement, placing a balloon or suction device in the womb, and operations to stop the bleeding or remove of the womb (hysterectomy). There is very little hard evidence for the effectiveness of each method. This review highlights recent innovations including approaches to quick diagnosis and rapid treatment, suturing the lower part of the womb via the vagina, improvements in balloon and suction methods, new designs of clamps to apply through the vagina and to clamp the aorta (the main artery of the body), new approaches to giving blood clotting factors, many new types of stitches to compress the uterus, and advanced technology such as ultrasound treatment and artificial oxygenation of the mother's blood. We call for more research to show which methods really work. BackgroundMost treatments for postpartum haemorrhage (PPH) lack evidence of effectiveness. New innovations are ubiquitous but have not been synthesized for ready access.Narrative reviewPubmed 2020 to 2021 was searched on 'postpartum haemorrhage treatment', and novel reports among 755 citations were catalogued. New health care strategies included early diagnosis with a bundled first response and home-based treatment of PPH. A calibrated postpartum blood monitoring tray has been described. Oxytocin is more effective than misoprostol; addition of misoprostol to oxytocin does not improve treatment. Heat stable carbetocin has not been assessed for treatment. A thermostable microneedle oxytocin patch has been developed. Intravenous tranexamic acid reduces mortality but deaths have been reported from inadvertent intrathecal injection. New transvaginal uterine artery clamps have been described. Novel approaches to uterine balloon tamponade include improvised and purpose-designed free-flow (as opposed to fixed volume) devices and vaginal balloon tamponade. Uterine suction tamponade methods include purpose-designed and improvised devices. Restrictive fluid resuscitation, massive transfusion protocols, fibrinogen use, early cryopreciptate transfusion and point-of-care viscoelastic haemostatic assay-guided blood product transfusion have been reported. Pelvic artery embolization and endovascular balloon occlusion of the aorta and pelvic arteries are used where available. External aortic compression and direct compression of the aorta during laparotomy or aortic clamping (such as with the Paily clamp) are alternatives. Transvaginal haemostatic ligation and compression sutures, placental site sutures and a variety of novel compression sutures have been reported. These include Esike's technique, three vertical compression sutures, vertical plus horizontal compression sutures, parallel loop binding compression sutures, uterine isthmus vertical compression sutures, isthmic circumferential suture, circumferential compression sutures with intrauterine balloon, King's combined uterine suture and removable retropubic uterine compression suture. Innovative measures for placenta accreta spectrum include a lower uterine folding suture, a modified cervical inversion technique, bilateral uterine artery ligation with myometrial excision of the adherent placenta and cervico-isthmic sutures or a T-shaped lower segment repair. Technological advances include cell salvage, high frequency focussed ultrasound for placenta increta and extra-corporeal membrane oxygenation.ConclusionsKnowledge of innovative methods can equip clinicians with last-resort options when faced with haemorrhage unresponsive to conventional methods.