A TEXTBOOK OF POSTPARTUM HEMORRHAGE - PART 10 pdf

The following guidelines are in use for cell salvage in obstetric use in the Swansea NHS Trust Hospitals, UK: 1 It may be used for any situation in which allogeneic blood is used, but in

remain have no significant clinical effect

Plate-lets are activated during salvage, but the

major-ity are removed during the process Leukocytes,

complement and kinins are also activated

during salvage, but systemic inflammatory

responses have not been reported as clinically

relevant

POSSIBLE CONTRAINDICATIONS

Following a seminal report7 supporting this

technology, it now is accepted that three areas

exist where the process of red cell salvage needs

to be used with caution and following necessary

risk–benefit analysis, depending on the clinical

urgency of the situation These involve the use

of red cell salvage when spilt operative blood

may contain malignant cells, or be heavily

con-taminated with bowel bacteria Another area of

caution is the use of red cell salvage when

con-taminated by amniotic fluid It is accepted that,

in the presence of any of these preconditions,

cell salvage is not used unless considered

necessary

The non-availability of a safe allogeneic

blood supply is clearly a situation when the use

of cell salvage is justified in an attempt to

pre-serve the patient’s own blood and help oxygen

carriage In the UK, current blood conservation

recommendations promote the use of cell

sal-vage8 The current drive for blood conservation

is multifactorial, but the most topical reason is

the potential decrease in the availability of

donor blood resulting from the introduction of a

test for the presence of abnormal prion protein

However, reduced numbers of donors is a

prob-lem that had its inception prior to the present

testing concerns, as the presence of HIV and

other viral pathogens have also restricted the

number of potential donors

It is against this backdrop that consideration

of cell salvage in postpartum hemorrhage was

made, and the remainder of this chapter

exam-ines the use of intraoperative cell salvage during

postpartum hemorrhage Fortunately, the

wide-spread use of such devices has confirmed the

safety of this process, providing there is no

technical failure and the correct procedure for

machine operation is practiced The use of such

devices is endorsed by national guidelines and

by several workers, and has not been found to

be a problem in practice12–16 The difficulty isthat the precise elements of amniotic fluid,which cause the rare, and unpredictable

‘anaphylactoid syndrome of pregnancy’ (asAFE is more correctly called), remain unknown

To conduct a prospective, randomized, trolled trial with an 80% power to demonstratethat cell salvage does not increase the incidence

con-of AFE by five-fold would require up to 275 000patients, a number so enormous that the effort

is unlikely ever to be undertaken To strate the absolute safety of a technique withoutrandomized, controlled trials requires carefulclinical audit of a large number of cases,

demon-supported by robust in vitro evidence.

IN VITRO STUDIES OF AMNIOTIC

FLUID CLEARANCE:

In vitro studies have examined the clearance

ofα-fetoprotein14, tissue factor15, trophoblastictissue12, fetal squames and lamellar bodies13from maternal blood by the cell salvage process.Small molecules are removed in the plasma frac-tion by the centrifuge and wash process alone,and particulate material is removed by the use

Intraoperative autologous blood transfusion

of specialized leukodepletion filters Using the

combination of cell salvage and these

special-ized filters, every element of amniotic fluid that

has been studied so far has been effectively

removed from salvaged blood prior to

re-transfusion12–16

CLINICAL CASES

Prior to 1999, approximately 300 cases in which

cell-salvaged blood was administered to patients

had been reported world-wide16 No obstetric

clinical or physiological problems were

encoun-tered, despite the fact that filters were not used

at this time This means that each of these

patients had some exposure to amniotic fluid,

and with no ill effects Waters and colleagues

shed some light on this topic13by describing not

only the complete clearance of squamous cells

and phospholipid lamellar bodies from filtered,

cell-salvaged blood, but also by clearly

demon-strating the presence of both these amniotic

fluid markers circulating in the maternal central

venous blood at the time of placental

separa-tion In 100% of patients in this trial, amniotic

fluid was demonstrated in the circulation of

healthy parturients undergoing elective Cesarean

section It is therefore probable that amniotic

fluid routinely enters the maternal circulation

and does no harm in the vast majority of cases

This exposure may trigger the syndrome of AFE

due to an anaphylactoid reaction to an as-yet

unidentified endogenous mediator in a very

small number of women, the incidence of

which varies between 1 in 8000 and 1 in 80 000

patients17 [Editor’s note: since it has never

been studied, there is no evidence to state that

entry does not occur in an unknown number

of cases of vaginal parturition.] Clearly,

re-infusion of cell-salvaged blood, even if

contami-nated with traces of amniotic fluid, presents no

extra risk to the woman from whom that blood

has come, as she has already been exposed to it

In 1999, a single report appeared describing

a seriously ill Jehovah’s Witness woman with

severe pre-eclampsia complicated by HELLP

syndrome (hemolysis, elevated liver enzymes,

low platelets) who died in Holland, after having

received cell-salvaged blood18 It has been

quoted as a ‘death due to obstetric cell

sal-vage’19 It should be noted, however, that a

patient who is seriously ill with HELLP drome and who refuses platelet and coagulationfactor transfusion is unlikely to survive, andthat, under such circumstances, her deathshould logically not be related to the use of cellsalvage, but rather to her refusal to accept bloodcomponent therapy

syn-Cell salvage in obstetrics was introduced inthe UK in 1999, and its use is growing rapidly,with most major obstetric units now advocatingthe technique in selected circumstances TheConfidential Enquiry into Maternal and ChildHealth 2000–2002 (CEMACH)20 stated that

‘ (cell salvage) may be used in any case of ric haemorrhage, not just women who refuse blood transfusion’ and described the technique as ‘a new development which will prove helpful in the future’ It further stated that ‘the risk of causing

obstet-coagulopathy by returning amniotic fluid to thecirculation is thought to be small’ Subsequent

to this, the 2005 revised Guidelines for ric Anaesthetic Services were published jointly

Obstet-by the UK Obstetric Anaesthetists Association(OAA) and the Association of Anaesthetists ofGreat Britain and Ireland (AAGBI)21, stating

that ‘an increasing shortage of blood and blood

products and growing anxiety about the use of donor blood are leading to an increasing interest in the use of cell salvage in obstetrics Staff will have to

be suitably trained, and equipment obtained and maintained .’

In November 2005, the UK National Institutefor Clinical Excellence (NICE) reported on CellSalvage in Obstetrics22, describing cell salvage as

‘an efficacious technique for blood replacement,well established in other areas of medicine’ and

pointing out the theoretical concerns when used

in obstetrics NICE goes on to recommend thatclinicians using it in the UK should report anyside-effects to the UK Department of HealthRegulatory Authority (MHRA), that patientsshould be fully informed prior to its use, and thatcell salvage in obstetrics should be performed bymultidisciplinary teams that have developedregular experience in its use

PRACTICAL USE OF CELL SALVAGE

IN OBSTETRICS

There presently exists a substantial experiencewith the use of cell salvage in obstetrics in thePOSTPARTUM HEMORRHAGE

UK; cases include major hemorrhage due to

placenta previa, placenta accreta, ruptured

uterus, extrauterine placentation, massive

fibroids and placental abruption, as well as

routine use in Jehovah’s Witnesses to avoid

postoperative anemia14

The following guidelines are in use for cell

salvage in obstetric use in the Swansea NHS

Trust Hospitals, UK:

(1) It may be used for any situation in which

allogeneic blood is used, but in practicethis has so far been confined to Cesareansections and uterine re-exploration orlaparotomy following postpartum hemor-rhage There is no reason why vaginalblood loss could not be collected andcell-salvaged, as fears about infection haveproved unfounded in abdominal gunshotwounds as long as the patients are onantibiotics – but the technical problemwith physically collecting vaginal bloodloss has yet to be solved! [Editor’s note:

the routine and planned use of theBRASSS technique described in Chapter

4 would be useful to overcome this lem as well as underestimation of loss.]

prob-(2) The machine is set up and operated

according to standard operating dure, with an ‘in-continuity’ set-up forJehovah’s Witnesses (this means that thewhole circuit is run through with salineand the re-transfusion bag connected tothe intravenous cannula before startingthe salvage suction, thereby establishing acontinuous circuit between the blood lostand the recipient vein)

proce-(3) In cases where there is doubt about the

extent of expected blood loss, it is nomical to set up the aspiration and reser-voir kit only – the decision to process andre-transfuse can be made when the degree

eco-of hemorrhage has become clear (e.g

‘expected’ bleeding from placenta previa)

(4) Where practicable, amniotic fluid should

be removed by separate suction prior tostarting cell salvage

(5) Suction should be via the wide-bore

suction nozzle in the kit, and the surgeon

should try to suction blood from ‘pools’rather than ‘dabbing’ tissue surfaces withthe suction tip, as this minimizes erythro-cyte damage

(6) Blood from swabs can be gently washedwith saline and salvaged from a sterilebowl into the main reservoir

(7) Suction pressure should be kept as low

as practicable (< 300 mmHg) to avoidred cell damage, although higher vacuumcan be safely used if necessary withonly a minimum increase in red celldamage

(8) It is advisable to use a leukocyte depletionfilter (Leukoguard RS Pall) in the re-transfusion circuit if there is any risk

of amniotic fluid contamination This iscurrently the only filter that has beenshown to remove all particulate elements

of amniotic fluid (fetal squames, lamellarbodies) This filtration process will neces-sarily slow down the rate at which bloodcan be infused, but it is permissible topressurize the bag of salvaged red cells

up to 200 mmHg after having ensuredthere is no air in the bag (otherwise itmay burst!), or to use a large-volumesyringe and three-way tap In situationswhen hemorrhage is rapid, it is possible

to connect more than one suctionnozzle to the reservoir, and two filtersand a dual giving-set to the re-infusionbag

(9) As with any transfusion, the patientshould be carefully monitored, preferably

in an obstetric ‘critical care’ facilityfor 24 h Coagulation tests should beobtained post-transfusion, and repeated ifabnormal or if clinically indicated

(10) If the patient is Rh-negative, a Kleihauer–Braun–Betke test should be performedand Anti-D administered as appropriatewithin 72 h

Units that use obstetric cell salvage shouldkeep careful records for Audit reporting indue course – with any problems also beingreported to the MHRA as per NICEGuidelines

Intraoperative autologous blood transfusion

The use of intraoperative cell salvage is a safe

method of conserving operative blood loss and

minimizing the need for allogeneic transfusion

In an environment where allogeneic blood is in

limited supply or the demands for blood

trans-fusion are so great, as in the case of massive

postpartum hemorrhage, the use of

intra-operative cell salvage may be life-saving and its

use in this area is gaining clinical acceptance

References

1 Blundell J Experiments on the transfusion of

blood by the syringe Med Chirg Trans 1818;9:

57–92

2 Allen JG Discussion Ann Surg 1963;158:137

3 Landsteiner K Ueber

Agglutinationser-scheinungen normalen menschlichen Blutes

Wien Klin Wochenschr 1901;14:1132–4

4 Gharehbaghian A, Haque KM, Truman C, et al.

Effect of autologous blood on postoperative

natural killer cell precursor frequency Lancet

2004;363: 1025–30

5 Tawes RL, Duvall TB The basic concepts of an

autotransfusor: the cell saver In Tawes RL, ed

Autotransfusion Michigan: Gregory Appleton,

1997

6 Hughes LG, Thomas DW, Wareham K, et al.

Intra-operative blood salvage in abdominal

trauma: a review of 5 years’ experience

Anaesthe-sia 2001;56:217–20

7 Council on Scientific Affairs Autologous blood

transfusions JAMA 1986;256:2378–80

8 A National Blood Conservation Strategy for

NBTC and NBS Compiled by Virge James on

behalf of the NBS Sub-Group ‘Appropriate Use

of Blood’, January 2004

9 NHS Executive Better Blood Transfusion:

Appro-priate Use of Blood London: Department of

Health, 2002 (Health Service Circular 2002/009)

10 Peri-operative Blood Transfusion for Elective

Surgery http://www.sign.ac.uk

11 Fong J, Gurewitsch ED, Kump L, Klein R.Clearance of fetal products andsubsequentimmunoreactivity of blood salvaged at Cesarean

delivery Obstet Gynecol 1999;93:968–72

12 Catling SJ, Williams S, Fielding AM Cell vage in obstetrics: an evaluation of the ability ofcell salvage combined with leucocyte depletionfiltration to remove amniotic fluid from operative

sal-blood loss at caesarean section Int J Obstet Anesth 1999;8:79–84

13 Waters JH, Biscotti C, Potter PS, Phillipson E.Amniotic fluid removal during cell salvage in the

Cesarean section patient Anaesthesiology 2000;

92:1531–6

14 Thornhill MI, O’Leary AJ, Lussos SA,Rutherford C, Johnson MD An in vitroassessment of amniotic fluid removal fromhuman blood through cell saver processing

Anaesthesiology 1991;75:A830

15 Bernstein HH, Rosenblatt MA, Gettes M,Lockwood C The ability of the Haemonetics

4 cell saver to remove tissue factor from

blood contaminated with amniotic fluid Anesth Analgesia 1997;85:831–3

16 Catling SJ, Freites O, Krishnan S, Gibbs R.Clinical experience with cell salvage in obstetrics:

4 cases from one UK centre Int J Obstet Anesthes

2002;11:128–34

17 Morgan M Amniotic fluid embolism sia 1979;34:20–32

Anaesthe-18 Oei SG, Wingen CBM, Kerkkamp HEM

(letter) Int J Obstet Anesth 2000;9:143

19 Controversies in Obstetric Anaesthesia Meeting,London UK, March 2004

20 Confidential Enquiry into Maternal and ChildHealth (CEMACH) 2000–2002 The 6th report

of the Confidential Enquiries into MaternalDeaths in the UK

21 AAGBI Guidelines for Obstetric AnaestheticServices, Revised Edition 2005

22 Intra-operative blood cell salvage in obstetrics.National Institute for Health and Clinical Excel-lence, November 2005

POSTPARTUM HEMORRHAGE

TREATING HEMORRHAGE FROM SECONDARY ABDOMINAL

PREGNANCY: THEN AND NOW

N A Dastur, A E Dastur and P D Tank

INTRODUCTION

Abdominal pregnancy is an unusual but real

cause of postpartum hemorrhage The high

maternal morbidity and mortality associated

with abdominal pregnancy are a function of

abnormal placentation which leads to

intra-abdominal hemorrhage or the aftermath of

retention of large amounts of dead tissue

Presently, no evidence-based guidelines have

been published on this subject This chapter

begins with a series of four cases treated at

the Nowrosjee Wadia Maternity Hospital in

Mumbai, India, which are illustrative of the

available treatment options Wadia Hospital is a

tertiary-care center with a wide referral base,

both inside the city and throughout the

sur-rounding areas This is followed by a discussion

on the technical aspects of the surgical

interven-tion and a review of the literature on modern

treatment options

CASE 1

In 1970, a primigravida aged 24 years was

referred to the hospital with an abnormal

pre-sentation The senior author (NAD) was

prac-ticing as a junior trainee At that time, it was

routine to confirm the diagnosis of abnormal

presentation with abdominal radiography

Because the radiograph was suspicious of an

abdominal pregnancy, the senior consultant

planned an exploratory laparotomy to deliver

the woman A male child weighing 2700 g

was delivered in good condition However, the

placenta was attached to the mesentery, and

an attempt to separate it set off massive

hemorrhage Local measures such as ligation of

vessels and compression failed to reduce the

hemorrhage, so the peritoneal cavity was packedunder pressure with a large bed sheet as a lastresort She was stable for the first 6 h postopera-tively, but then developed hypovolemic shockfrom intraperitoneal hemorrhage and died onthe first postoperative day

CASE 2

The second case occurred 4 years later at thesame institute A Cesarean delivery was under-taken to deliver a 30-year-old multiparouswoman with no progress in labor On openingthe peritoneum, the amniotic sac was encoun-tered directly A 2400-g female child was deliv-ered The placenta covered the lateral pelvicwall and posterior surface of the uterus Thesenior consultant was called and an attempt atplacental separation was made This effort wassoon abandoned in view of the difficulty in sepa-ration and ensuing hemorrhage The cord was

then cut short and tied, the placenta left in situ

and the abdomen closed The abdomen waspacked under pressure with large abdominalpacks for control of the hemorrhage However,the patient developed a disseminated intra-vascular coagulopathy and died within 48 h ofthe surgery

CASE 3

In 1980, the senior author was involved in thethird case of abdominal pregnancy A 20-year-old primigravida was referred to the hospital atfull term with abdominal pain thought to be of

a surgical cause There was a strong clinicalsuspicion of acute appendicitis which didnot respond to conservative treatment A

laparotomy was performed A full-term

abdomi-nal pregnancy was found with the sac just below

the peritoneum A female child weighing 2600 g

was delivered in good condition The placenta

was firmly adherent to the right pelvic side-wall

No attempt was made to remove it The cord

was cut short and tied and the abdomen was

closed with a pelvic drain The postoperative

course was complicated by fever for the first

10 days in spite of antibiotics She continued

to have abdominal pain for 6 months after

delivery This patient had sequelae of a retained

placenta but survived the pregnancy

CASE 4

Although this is not a case of an abdominal

pregnancy, it is used to illustrate the

manage-ment of abnormal placentation In 2001, the

senior author performed a Cesarean section for

a 25-year-old primigravida at term She was

diagnosed to have an anterior placenta previa

with accreta Blood vessels were seen invading

into the bladder wall on color Doppler After

delivering a 2500-g male child in good

condi-tion, no attempt at placental separation was

initiated Rather, a decision was made to leave

the placenta in situ followed by methotrexate

therapy The woman was monitored in hospital

for 3 weeks after delivery and administered

a prolonged course of antibiotics She had an

uneventful course Further follow-up was

pro-vided on an outpatient basis with color Doppler

and serum β-hCG levels The placental mass

gradually involuted over a period of 5 months

and the patient resumed menstruation 7 months

after delivery

INCIDENCE

Abdominal pregnancies are rare events In the

United States, it is estimated that it occurs once

in 10 000 live births and once also for every

1000 ectopic pregnancies1 A more recent

Afri-can report provides a much higher estimate of

4.3% of ectopic pregnancies, which is probably

a reflection of referral patterns in that region as

well as a higher baseline rate of inherent tubal

disease in the patient base of the hospital

catch-ment area2 However, it also may be reasonable

to presume that the incidence of abdominal

pregnancies may have risen over the years, sidering that the risk factors such as ectopicpregnancy, infertility from tuberculosis andendometriosis, pelvic infections and infertilitytreatments are more common today Regard-less, an obstetrician practicing alone may nevercome across an abdominal pregnancy in a careerspanning decades In the singular instancewhere he/she does have the need to treat such apatient, it may be in circumstances far fromideal Although unusual, obstetricians should

con-be aware of this potentially fatal condition, acircumstance amply illustrated by the first twocases described above

DIAGNOSIS

A primary abdominal pregnancy presents in thefirst trimester in much the same fashion as anectopic pregnancy An advanced secondaryabdominal pregnancy, on the other hand, ismuch more difficult to diagnose Presentingcomplaints may include abdominal pain (rang-ing from mild discomfort to unbearable pain),painful or absent fetal movements, nausea,vomiting, abdominal fullness, flatulence,diarrhea and general malaise On examination,there may be an abnormal lie (15–20% ofcases), easily palpable fetal parts, a closed unef-faced cervix on vaginal examination, and thefailure to stimulate contractions with oxytocin

or prostaglandins on attempting an induction oflabor3 Obviously, these symptoms and circum-stances are far from specific Taken together,however, they may (and should) raise a questionabout the location of the pregnancy On review-ing the laboratory findings, one may also find

an unexplained transient anemia in early nancy corresponding to the time of tubal rup-ture or abortion The serumα-fetoprotein valuemay be abnormally elevated without explana-tion Early diagnosis has been described inresponse to evaluation of abnormal biochemicalscreening results4

preg-The diagnosis can be established with fargreater certainty by imaging studies Ultrasound

is ubiquitously used in pregnancy, but it doesnot always provide an unequivocal diagnosis.Even under ideal conditions, the diagnosis ismissed on ultrasound in more than half ofPOSTPARTUM HEMORRHAGE

cases3 Akhan and colleagues5report the

follow-ing criteria suggestive of abdominal pregnancy:

(1) Visualization of the fetus separate from the

uterus;

(2) Failure to visualize the uterine wall between

the fetus and the maternal urinary bladder;

(3) Close approximation of fetal parts to the

maternal abdominal wall;

(4) Eccentric position (relation of fetus to

uterus) or abnormal fetal attitude (relation

of fetal parts to one another) and

visualiza-tion of extrauterine placental tissue

In the past, radiography was commonly used to

establish or at least point to this diagnosis

Fea-tures such as absence of uterine shadow around

the fetus, maternal intestinal shadow

intermin-gling with fetal parts on anteroposterior view,

and overlapping of the maternal spine by fetal

small parts in a lateral view were all described

Today, however, radiography is largely

sup-planted by magnetic resonance imaging and

computed tomography Both these techniques,

with their ability to produce images in different

planes, have much greater accuracy and

speci-ficity than ultrasound There is little to choose

between the two imaging modalities in cases of

fetal demise If the fetus is alive, magnetic

reso-nance imaging may be preferable since ionizing

radiations are avoided

TIMING OF INTERVENTION

Maternal mortality is about 7.7 times higher

with an abdominal pregnancy as compared to a

tubal ectopic pregnancy and 90 times higher as

compared to an intrauterine pregnancy1 These

risks are thought to be chiefly related to the

delay in diagnosis and mismanagement of the

placenta To minimize the risk from sudden,

life-threatening intra-abdominal bleeding, it

seems prudent to time intervention as soon

as feasible after the diagnosis is confirmed

There is no controversy if there is maternal

hemodynamic instability, the fetus is dead or

pre-viable (less than 24 weeks pregnancy), has

oligohydramnios or gross abnormalities on

ultrasound The hypothesis that fetal death

will bring about placental involution and hence

reduced bleeding at laparotomy is not ated Surgical intervention is mandated if any ofthe above conditions are present

substanti-Some clinicians argue that, if there is anongoing abdominal pregnancy greater than 24weeks, a conservative approach should be taken

to allow fetal maturity and improve chances ofsurvival6 However, even after 30 weeks, fetalsurvival is only 63%, and 20% of fetuses havedeformations (craniofacial and various jointabnormalities) and malformations (centralnervous system and limb deficiencies)7 Withadvancing gestation, one also has to contendwith the growing placenta and greater risk ofbleeding In our opinion, it would very rarely bejustified to manage an abdominal pregnancyconservatively

PREOPERATIVE PREPARATIONS

The major risk with surgery is torrential rhage When a diagnosis of abdominal preg-nancy is established in advance, the opportunity

hemor-to be prepared should not be lost At least sixunits of blood should be cross-matched andread to transfuse in the operating room, andother blood products should also be available.Two intravenous infusion systems capable ofdelivering large volumes of fluids rapidly should

be established A mechanical bowel preparationshould be affected if time permits A MAST(medical antishock garment) suit has beenutilized successfully in controlling intractablehemorrhage with an abdominal pregnancy8,but these garments are not always available(see Chapter 14 for a full discussion) Kerrand colleagues9 have advocated preoperativetransfemoral catheterization and embolization

of selective vessels before surgical intervention.This intervention was used successfully in threecases and the catheters can be left in place fortheir potential help in treating postoperativebleeding as well The operating team should

be an experienced one, and preferably shouldinclude a general, vascular and genitourinarysurgeon The anesthesia team should be com-prised of senior consultants and their assistants.The operating room and nursing staffs should

be fully aware of the nature of the diagnosis andits implications and schedule extra personnel inthe room and as ‘runners’

Treating hemorrhage from secondary abdominal pregnancy

SURGICAL APPROACH

A mid-line vertical approach is preferential, as it

can easily be extended above the umbilicus if

necessary The amniotic sac may be adherent to

the abdominal wall and viscera It should be

dissected free and opened in an avascular

area away from the placenta The fetus should

be removed in such a manner as to minimize

placental manipulation and avoid bleeding If

the pregnancy has been retained for a long

period after fetal death, the fetus will have

undergone suppuration Bacterial

contamina-tion and abscess formacontamina-tion are highly likely,

especially if the placenta is adherent to the

intestines There may be frank pus upon

enter-ing the peritoneal cavity Rarely, the fetus may

be mummified and calcified into a lithopedion

or become converted into a yellow greasy mass

called adipocere formation

MANAGEMENT OF THE PLACENTA

The torrential hemorrhage that often ensues

with surgery for abdominal pregnancy is related

to the lack of constriction of the hypertrophied

opened blood vessels after placental separation

Usually, the placenta is firmly attached to the

parietal peritoneum, mesentery and bowel and

there is no bleeding if it is left alone The umbilical

cord should be ligated close to the placenta,

excess membranes trimmed away and the

abdo-men closed with drainage Only very rarely is

the placental implantation limited to the

repro-ductive organs by a single pedicle, so that it can

be easily removed10

In some instances, the placenta may separate

spontaneously, simulating an abruption, but

the situation in which hemorrhage becomes

uncontrollable is more likely to arise from failed

attempts at placental removal Some clinicians

advocate routine placental removal3,8, but these

papers were written before the obstetrics

com-munity appreciated the value of methotrexate

in such instances Placental separation requires

complete ligation of the blood vessels supplying

the placenta and manipulating it at its insertion

More importantly, placental separation is not

always straightforward and fails in 40% of

cases3 This is where the blood supply cannot

be completely ligated, resulting in massive

hemorrhage and shock2 The hemorrhage fromthe placenta is now torrential and rapid surgicalaction is essential Various local techniques such

as compression of the bleeding site, ligating thevascular pedicles, lavage with cold saline, andlocal and/or systemic coagulation promotingagents (tranexamic acid, plasminogen deriva-tives, absorbable gelatin sponge, etc.) have beendescribed Repair of placental lacerations may

be required The removal of the organ to whichthe placenta is adherent (hysterectomy and/orsalpingoophorectomy, resection of the boweland/or bladder) may be justified to controlthe hemorrhage If a hysterectomy has beenperformed and bleeding continues, a Logo-thetopoulos pack brought out through thevaginal cuff can be used to exert pressure

on the pelvic side-walls and bleeding vessels(see Chapter 33 for complete details) As alast resort, the abdomen may be packed tightwith abdominal sponges and closed partially.The packs can be removed 48 h postoperatively

or sooner if directed by hemodynamicinstability

POSTOPERATIVE CARE

Even when the placenta is left in situ,

compli-cations such as infection, abscesses, bowelobstruction secondary to adhesions or wounddehiscence occur in about one-half of thepatients11,12 Although the problems associatedwith an abdominally retained placenta may

be distressing and lead to subsequent repeatlaparotomy, they are potentially less disastrousthan an ill-advised attempt at removing theplacenta Prophylactic antibiotics should beadministered so as to cover a substantial part

of the postoperative course Less commoncomplications of the retained placenta includereversible maternal hydronephrosis13 and pro-longed persistent postpartum pre-eclampsia14

To hasten placental resorption, methotrexate

as a single dose of 50 mg/m2can be used Thistoo is not without its specific problems, how-ever In a series of ten cases, accelerated placen-tal destruction led to accumulation of necrotictissue and abscess formation15 It is difficult toattribute this to methotrexate therapy alone, asthese complications arise even without adminis-tration of methotrexate

POSTPARTUM HEMORRHAGE

The patient with a retained placenta is

moni-tored with clinical evaluation, ultrasound, color

Doppler and serum β-hCG levels Hormonal

parameters drop rapidly in the postoperative

period as most live cells will be destroyed early

The physical mass of the placenta is resorbed

slowly over an average period of 6 months A

resorption period of 5 years has been reported16,

although this is highly unusual

CONCLUSION

Secondary abdominal pregnancy is an

uncom-mon and exceedingly dangerous variant of

ectopic pregnancy It is usually not diagnosed

until laparotomy which leaves the obstetrician

little preparation to face the prospect of

torren-tial postpartum hemorrhage, albeit not from the

usual sources In this situation, minimizing

pla-cental handling and leaving it in the abdominal

cavity can be life-saving

References

1 Atrash HK, Friede A, Hogue CJR Abdominal

pregnancy in the United Status: frequency and

maternal mortality Obstet Gynecol 1987;69:

633–7

2 Ayinde OA, Aimakhu CO, Adeyanju OA,

Omigbodun AO Abdominal pregnancy at the

University College Hospital, Ibadan: a ten-year

review Afr J Reprod Health 2005;9:123–7

3 Costa SD, Presley J, Bastert G Advanced

abdominal pregnancy Obstet Gynecol Surv 1991;

46:515–25

4 Bombard AT, Nakagawa S, Runowicz CD,

Cohen BL, Mikhail MS, Nitowsky HM Early

detection of abdominal pregnancy by maternal

serum AFP+ screening Prenat Diag 1994;14:

1155–7

5 Akhan O, Cekirge S, Senaati S, Besim A

Sonographic diagnosis of an abdominal ectopic

pregnancy Am J Radiol 1990;155:197–8

6 Hage ML, Wall LL, Killam A Expectantmanagement of abdominal pregnancy A report

of two cases J Reprod Med 1988;33:407–10

7 Stevens CA Malformations and deformations in

abdominal pregnancy Am J Med Genet 1993;47:

1189–95

8 Sandberg EC, Pelligra R The medical gravity suit for management of surgically uncon-trollable bleeding associated with abdominal

anti-pregnancy Am J Obstet Gynecol 1983;146:

519–25

9 Kerr A, Trambert J, Mikhail M, Hodges

L, Runowicz C Preoperative transcatheterembolization of abdominal pregnancy: Report of

three cases J Vasc Interv Radiol 1993;4:733–5

10 Noren H, Lindblom B A unique case of inal pregnancy: what are the minimal require-ments for placental contact with the maternal

abdom-vascular bed? Am J Obstet Gynecol 1986;155:

394–6

11 Bergstrom R, Mueller G, Yankowitz J Acase illustrating the continued dilemmas intreating abdominal pregnancy and a potentialexplanation for the high rate of postsurgical

febrile morbidity Gynecol Obstet Invest 1998;46:

268–70

12 Martin JN Jr, McCaul JF 4th Emergent

management of abdominal pregnancy Clin Obstet Gynecol 1990;33:438–47

13 Weiss RE, Stone NN Persistent maternalhydronephrosis after intra-abdominal pregnancy

J Urol 1994;152:1196–8

14 Piering WF, Garancis JG, Becker CG, Beres JA,Lemann J Jr Preeclampsia related to a function-ing extrauterine placenta: Report of a case and

25-year follow-up Am J Kidney Dis 1993;21:

placenta J Ultrasound Med 1986;5:521–3 Treating hemorrhage from secondary abdominal pregnancy

Section X

National experiences

The World Health Organization (WHO)

estimates that, of the 529 000 maternal deaths

occurring every year, 136 000 or 25.7% take

place in India, where two-thirds of maternal

deaths occur after delivery, postpartum

hemor-rhage being the most commonly reported

complication and the leading cause of death

(29.6%)1 The unacceptably high maternal

death ratio (540/100 000 live births)1 in India

during the last few decades remains a major

challenge for health systems

According to the same WHO estimates, for

every maternal death about 20 women suffer

from harm to general and reproductive health

In India, around 70% of the population lives in

villages Out of an estimated 25 million

deliver-ies each year, 18 million take place in peripheral

areas where maternal and perinatal services are

either poor or non-existent India’s stated goal is

to reduce maternal mortality (MMR) from 437

deaths per 100 000 live births that was recorded

in 1991 to 109 by 2015 The MMR for 1998 is

407 Along with this improvement, the

propor-tion of births attended by skilled health

person-nel has increased from 25.5% in 1992–1993 to

39.8% in 2002–2003, thereby reducing the

chances of occurrence of maternal deaths1

The efforts to improve maternal health and

reduce maternal mortality have been

continu-ous in India since 1960 under the public health

program of Primary Health Care – specifically

under the Maternal and Child Health (MCH)

program In various policy documents, the

gov-ernment of India has listed the reduction of

maternal mortality as one of its key objectives

Unfortunately, progress has been less than

hoped for several reasons

One of the critical bottlenecks for providingmore high-quality emergency obstetric care(EOC) was a serious shortage of specialist staffsuch as obstetricians and anesthesiologists atvarious levels in rural areas This deficiency wasaccentuated by the limited capacity for transfu-sion outside of the more sophisticated urbanareas

The present strategies to prevent maternalmortality in India focus on building a better andmore fully functioning primary health-caresystem, from first referral level facilities to thecommunity level It is unfortunate that emer-gency obstetric care is not yet available for allpatients in labor and this should be the mainfocus of the government as well as the medicalprofession

Effective interventions for reducing the incidence of postpartum hemorrhage

Although training programs for traditional birthattendants (TBAs) are designed to improve theroutine care for mothers and newborns at deliv-ery, these interventions have proved ineffective

in reducing maternal deaths2–5 Neither trainedTBAs nor any other category of minimallytrained community health worker can preventthe vast majority of obstetric complicationsfrom occurring Once a complication occurs,there is almost nothing TBAs, by themselves,can do to reduce the chance of morbidity ordeath that can ensue

As women at high risk for postpartum orrhage account for only a small percentage ofall maternal deaths, the vast majority of deathsoccur in women with no known risk factors.Stated another way, risk screening programs

hem-have had little impact on overall maternal

mortality levels6–9

Recognizing these flaws in the early

recom-mendations of the Safe Motherhood Initiative,

the present-day clear international consensus

is that scarce resources should not be spent in

trying to predict which women will have

life-threatening complications (Safe Motherhood

Initiative) Rather, maternal mortality reduction

programs should be based on the principle

that every pregnant women is at risk for

life-threatening complications In order to reduce

the maternal mortality ratio dramatically, all

women must have access to high-quality care at

delivery That care has three key elements:

(1) A skilled attendant at delivery;

(2) Access to emergency obstetric care (EOC);

(3) A functional referral system

SKILLED ATTENDANTS AT DELIVERY

Evidence concerning the effect of skilled

attendants at delivery is somewhat confused

by different definitions and by variations across

countries The training of midwives and the

regulations governing the procedures they are

permitted to perform vary considerably In

2004, WHO, the International Confederation

of Midwives, and the International Federation

of Gynecology and Obstetrics issued a joint

statement with a revised definition of skilled

attendant: ‘A skilled attendant is an accredited

health professional – such as a midwife, doctor

or nurse – who has been educated and trained

to proficiency in the skills needed to manage

normal (uncomplicated) pregnancies, childbirth

and the immediate postpartum period, and in

the identification, management and referral of

complications in women and newborns.’

Wide variation exists in the extent to which

skilled attendants are supported and supervised

in the broader health system This is also true

for the number of deliveries that skilled

atten-dants perform annually In a country such as

Malaysia, which dramatically lowered its

mater-nal mortality in the 1960s and 1970s, midwives

became the backbone of the program, each

delivering 100–200 babies per year10 However,

in many other countries, birth attendants

deliver far fewer babies This affects their petence, because specific skills, such as manualremoval of the placenta, require regular practice

com-in order to be macom-intacom-ined In Indonesia, forexample, where tens of thousands of commu-nity midwives have been trained and deployed

to villages around the country, each typicallydelivers fewer than 36 babies a year Assess-ments within 3 years of placement found thatconfidence and competency-based skills wereexceedingly low, with only 6% scoring above

70, the minimum level considered necessary forcompetence11

In addition to being properly trained forconducting routine deliveries, a second andmore promising way in which skilled attendantscan reduce the incidence of postpartum hemor-rhage is by actively managing the third stage oflabor in every delivery12 (see Chapters 11 and13) However, the same techniques of activemanagement that can prevent some postpartumhemorrhages can also cause serious damage

if performed incorrectly This is not just atheoretical risk Incorrect use of oxytocic drugs,for example, can cause the uterus to rupture,which, in the absence of surgical intervention,can lead to death

The EOC Project in India

A project is being established to develop thecapacity of general practitioners and non-specialist medical officers to provide high-quality EOC services in rural areas whereskilled obstetricians are not available to preventmaternal mortality and morbidity13

The Federation of Obstetrics and logical Societies of India (FOGSI) has estab-lished five EOC training centers in rural Indiathat will improve the provision of EOC services

Gyneco-by medical officers, with the ultimate goal ofreducing maternal mortality and morbidity.The project has been funded by the MacArthurFoundation, Baltimore, USA and the AMDD(Averting Maternal deaths and Disability),Columbia University, New York JHPIEGO (aninternational health organization affiliated withJohns Hopkins University) assists FOGSI in itsendeavor to assess and strengthen selectedEOC training sites, train selected trainers andstrengthen FOGSI’s capacity in the area of

Combating postpartum hemorrhage in India

monitoring and evaluation During Phase 2,

FOGSI and JHPIEGO will also work together

to orient key stakeholders to the value of

these innovations in EOC training and service

delivery for feedback in order to gain consensus

among stakeholders for scale-up of the

approaches and technical interventions

FOGSI members who have a keen interest in

training doctors and midwives for rural areas

will run these training centers Each center will

have a coordinator and three to four faculty

members These are all staff of medical colleges

or well-known consultants The District

Train-ing Centers will have one obstetrician

func-tioning as the District Trainer

Design and methods policy

Training centers will be set up in medical

colleges where there are dedicated doctors

inter-ested in rural women’s health All master

train-ers will be trained in EOC at the nodal center

by doctors trained by JHPIEGO Four master

trainers at medical colleges and four at district

level hospitals will provide the training in a

uni-form manner Each training center will offer two

types of courses: a short course of 3 weeks for

upgrading the skills of doctors already working

in rural or under-served areas but not

possess-ing sufficient knowledge of EOC, and a long

course of 16 weeks to provide comprehensive

skills including training in performing a

Cesar-ean section This latter course will be composed

of 6 weeks of training in medical college by four

master trainers and 10 weeks of practical

train-ing in a district-level hospital Courses will be

competency-based and finalized in consultation

with the Department of Health and Family

Wel-fare These courses will be open to any doctor

working in rural and under-served areas, from

the government, NGO or private sectors

The roles of FOGSI/ICOG will be, first, to

coordinate with medical colleges and

govern-ment hospitals to make arrangement for

training, and, second, to regularly monitor the

master trainers, the training program and the

quality of training centers and to formalize

the end assessment and certification At the

end of each course, follow-up and support

activities will ensure that the trainees start to

offer EOC services after going back to their

work places A Certificate will be issued at theend Advocacy with the government and NGOheads is being negotiated to ensure that thetrainee’s facility is functional and to establishone training center in each state of India

Expected outcomes

Five tertiary training centers and 20 districtcenters are well equipped to start the EOCTraining Certification Course Three tertiarycenters and eight district centers have alreadystarted training, whilst two tertiary centers and

12 district centers will start functioning by theend of October 2006 A total of 162 doctors will

be trained during the pilot project of 2 years forthree centers established by FOGSI, MacArthurand JHPIEGO FOGSI plans to develop, in

a phased manner, one center per state in thefuture It is expected that this pilot effort will

be replicated by the government The policyadvocacy efforts will help in this direction toconvince government and other stakeholders

to support and develop the program so as toprovide 24-h EOC services in rural areas

Upscaling the program

The advocacy efforts of FOGSI have resulted

in a significant change in the priorities of thegovernment of India for phase II of the Repro-ductive and Child Health Care program Veryrecently, the Indian government committeditself to the EOC training project of FOGSI.According to the preliminary discussions withthe government, FOGSI has been entrustedwith the task of developing 20 tertiary trainingcenters and 160 district training centers wherein

2000 medical officers will be trained for 16weeks of comprehensive emergency obstetriccare These medical officers will provide askilled high-quality comprehensive EOCthrough the network of first referral units andcommunity health care centers at subdistrictand Taluka places (a Taluka is an administra-tive block consisting of 80–100 contiguousvillages) The whole program has been plannedwithin a time frame of 5 years During the sametime period, the government will upgrade thesecenters with the necessary infrastructure such as

an operating theater, equipment, blood storagePOSTPARTUM HEMORRHAGE

facilities and persons trained in anesthesia This

conceptual change in providing EOC at

under-served places will take EOC to the areas where it

is most needed and will bring about a significant

reduction in the maternal mortality ratio

The AOFOG PPH initiative

The Asia Oceania Federation of Obstetrics and

Gynaecology (AOFOG) has launched a

pro-gram called the AOFOG PPH Initiative14 This

program focuses on the active management of

the third stage of labor in areas with skilled birth

attendants and in areas where misoprostol is

available but without skilled birth attendants

This effort is in support of the FIGO/ICM joint

statement on the management of the third stage

of labor to prevent postpartum hemorrhage

The focus is on training of trainers in the

national societies of those countries whose

maternal mortality ratio exceeds 100/100 000

live births

Objectives

The objectives of the AOFOG PPH initiative

are:

(1) To disseminate a standard protocol for

active management of the third stage of

labor and to ensure uniform and safe

institutional practice;

(2) To train the service providers (doctors,

midwives, nurses, family welfare visitors) in

the institutes to perform active

manage-ment of the third stage of labor for all

women giving birth;

(3) To inform the medical and nursing

profes-sion about the rational use of uterotonic

drugs, such as oxytocin and ergometrine,

and the role of misoprostol for preventing

postpartum hemorrhage;

(4) To discuss, demonstrate and to train

the service providers regarding the

evidence-based management for

post-partum hemorrhage;

(5) To develop an action plan to be

imple-mented in respective institutes and to

monitor the outcome

It is expected that the participants of eachindividual institute will be able to state anddemonstrate the standard protocol for activemanagement of the third stage, will practiceactive management of the third stage andhave an updated knowledge and skills for themanagement of postpartum hemorrhage

ACCESS TO EMERGENCY OBSTETRIC CARE

Even under the very best of circumstances, withadequate nutrition, high socioeconomic statusand good health care, approximately 15% ofpregnant women experience potentially fatalcomplications Fortunately, virtually all obstet-ric complications can be successfully treated ifEOC is universally accessible and appropriatelyutilized United Nations guidelines recommend

a minimum of one comprehensive facility andfour basic EOC facilities per 500 000 popula-tion To reduce maternal mortality ratios

by 75%, high-mortality countries mustsubstantially improve access to emergency care

Solution exchange for maternal and child health practitioners in India

India is a vast, powerful storehouse ofknowledge While ‘expert’ knowledge is welldocumented, valuable knowledge gainedthrough practitioner experience is typically lost

or ignored Furthermore, practitioners cannotalways access the knowledge they need, such aswhether a particular idea was tried before orwhere to turn when facing a bottleneck To har-ness this knowledge pool and help practitionersavoid reinventing the wheel, the United Nations

offices in India created the Solution Exchange –

a free, impartial space where professionals arewelcome to share their knowledge and experi-ence15 Members represent a wide range ofperspectives from government, NGOs, donors,the private sector and academia They areorganized into Communities of Practice builtaround the framework of the MillenniumDevelopment Goals Members interact on anongoing basis, building familiarity and trust,gaining in knowledge that helps them contributemore effectively – individually and collectively –

to development challenges

Combating postpartum hemorrhage in India

Communities begin with the Solution

Exchange’s personalized ‘Research Service’

Here individual members post questions on the

Community’s web-based platform about the

development challenges they face; other

mem-bers respond to these questions and the

moder-ation team provides research into them The

tacit knowledge and expert knowledge are

brought together in a summarized

‘Consoli-dated Reply’ which is circulated to the

Commu-nity, normally within 10 working days

The Maternal & Child Health (MCH)

Community, facilitated by WHO, UNICEF

and UNFPA country offices in India, focuses on

implementation issues facing the attainment of

the development goals and targets in the Tenth

Five-Year Plan of India, the National

Popula-tion Policy 2000, Rural Health Mission and

Phase II of the Reproductive and Child Health

Programme, which correspond most closely to

the universally endorsed Millennium

Develop-ment Goals and targets leading to reduction of

maternal and child mortality

The main focuses of the MCH Community

are to improve maternal health and reduce

maternal mortality, and to improve child health

and reduce infant and child mortality The

MCH Community has now been in action for

almost a year, with membership growing from

130 to 725 during this time, representing 28

states and union territories of India and a few

members from outside India as well

Discus-sions have ranged from skilled attendance at

birth, setting up a telemedicine center, exclusive

breast-feeding and complementary feeding,

operationalizing urban Integrated Child

Devel-opment Services, medical termination of

pregnancies, etc

Safe motherhood initiative from FOGSI

‘Optimizing Labor workshops’ were held in 66

societies across the country, and four

Work-shops on postpartum hemorrhage were

spon-sored by AOFOG The Federation was able to

involve doctors from the government service

and nurses practicing in rural areas in the

work-shops along with its members Workwork-shops were

held in the Societies that cater to large rural

populations such as Kalyani in Bengal, Gawhati

in Assam, Rajmundhry and Vijaywada in

Andhra Pradesh, Chidambaram in TamilNadu, Loni, Solapur and Amravathi inMaharashtra, Bijapur and Shimoga inKarnataka, Kota and Ajmer in Rajasthan,Jabalpur and Sagar in Madhya Pradesh, toname just a few16

The take-home messages from these shops were, first, that actively managed andsupervised labor has a better outcome with adecreased incidence of operative deliveries, and,second, that an actively managed third stagedecreases the blood loss and incidence ofpostpartum hemorrhage

work-REFERRAL SYSTEMS

Widely available, good-quality EOC is sary but not sufficient by itself to reduce theincidence of postpartum hemorrhage Appro-priate utilization is also necessary A helpful way

neces-to analyze the barriers neces-to utilization is through

the ‘three delays model’17 Once a complicationoccurs, the key to saving a woman’s life is toprovide her adequate care in time The delaysleading to death can be divided into threecategories:

(1) Delay in deciding to seek care;

(2) Delay in reaching care;

(3) Delay in getting treatment at the facility.One important element of strategies to reducedelays is the strengthening of the referral sys-tem Widespread ‘failures’ in referral systemsare often present, particularly for the poor andmarginalized The recent review by Murray andPearson18found significant gaps in understand-ing how referral systems are currently function-ing in addition to highlighting a fundamentalproblem in the literature, that is, that manystudies rely on a conceptualization of an idealreferral system that has a dangerously tenuousrelationship to realities on the ground

Maternity referral systems were first ceived at a time when risk screening wasthought to be an appropriate maternal mortalityreduction strategy, even for high-mortalitycountries This conception assumed a stepwisehierarchy of increasingly sophisticated facilities,and it assumed that high-risk women would

con-be referred up the ladder as their pregnancyPOSTPARTUM HEMORRHAGE

progressed Today, however, maternal mortality

strategies concentrate on emergencies, because

it is acknowledged that time is critical An

ele-gant model of referral from facility to facility

could be worse than inefficient, it could be

deadly!

Although organized ambulance services

appear to be part of the referral system in every

country that has achieved major maternal

mor-tality reductions, access to transport is only one

part of a far more complex problem Maternal

mortality strategies that address the ‘second

delay’ simply by funding and organizing

transport fail to grapple with perhaps even

more critical systemic issues

First and foremost is the need for referral

facilities that provide 24-h 7-day-a-week care

within a reasonable distance of where people

live Murray and Pearson conclude that

‘Exten-sive pyramidal structures of referral systems

with multiple tiers of facilities would seem to

offer little benefit in the majority of cases for

maternity care and simply delay treatment’18

In most countries, attention should be

concen-trated on referral within the district-level

sys-tem From the perspective of a district health

system as a whole, it is the strength of the

referral facilities and associated supervision and

referral systems that should determine the level

of skill that birth attendants must have in order

to avert maternal deaths, not vice versa Murray

and Pearson provide the example of Yunnan,

China, where accessible referral facilities, a

well-functioning referral system, and a strong

and very active supervision system meant that

semi-skilled village doctors could successfully

conduct normal births, recognize problems,

sta-bilize patients, and refer them onward for more

complex treatment of emergencies With this

system, Yunnan reduced its maternal mortality

ratio from 149 to 101 in the 1990s11

Unfortunately, however, such results have

not been documented for TBAs A stated goal

of many training programs for TBAs is to

improve their referral of women experiencing

obstetric emergencies to facilities that can

man-age them A recent meta-analysis of studies

evaluating training programs designed to

improve referral practices of TBAs found little

effect19 Other recent studies explore why TBAs

often fail to refer even patients with obvious

complications They find that fear of losingprestige and future business often gets in theway

Maternal mortality strategies should focus

on building a functioning primary health-caresystem, from first referral level facilities tothe community level Emergency obstetric caremust be accessible for all women who experi-ence complications in pregnancy and childbirth Skilled birth attendants, whether based infacilities or communities should be the back-bone of the system Skilled attendants for alldeliveries must be integrated with a functioning

district health system that supplies and supports

them adequately

Achievements of the health department

The government of the state of Tamil Nadu iscommitted to providing good-quality medicalcare to the people in the rural areas To achievethis, 105 primary health centers have beenupgraded to 30-bed hospitals20 These hospitalshave been equipped with X-ray machines,ECG, ultrasonography, operation theatersand laboratories Another 180 primary healthcenters provide 24-h delivery care

In addition, 62 Comprehensive EmergencyObstetric and Newborn Care (CEONC) cen-ters have been established for providing 24-hmaternal and child health-care services, includ-ing Cesarean sections These centers have been

so located as to be accessible within an hour’stravel from anywhere in Tamil Nadu In thesecond phase, more hospitals will be upgraded

as CEONC centers so as to reduce the time to

30 min

For the first time in India, a birth companionscheme has been introduced, permitting onefemale attendant to stay with the antenatalmother during labor in the labor room ofall government health institutions to providepsychological support

In this state, maternal deaths have beenreduced by 25% during the last 4 years(2001–2004) An excellent network of bloodbanks and blood storage centers has beenestablished in the government health institu-tions to ensure the supply of blood and its com-ponents (86 blood banks and 26 blood storagecenters)

Combating postpartum hemorrhage in India

In the safe motherhood community today, the

question is often posed as whether to give

high-est priority to training a cadre of workers with

midwifery skills who can attend every birth or to

focus on strengthening emergency obstetric care

services (including the human resources

neces-sary to staff them) in order to treat the

approxi-mately 15% of pregnant women who experience

complications Under the strategy of emergency

obstetric care first, therefore, emergency

ser-vices need to be accessible to all (albeit not used

by all) In theory, the two interventions – skilled

attendants for all births and emergency obstetric

care for complicated ones – do not contradict

each other But, as strategies in

resource-constrained settings, they fit together less easily

Ultimately, both interventions appear to be

nec-essary to reach very low maternal mortality

lev-els: in every country with a maternal mortality

ratio of less than 50 – or even less than 100 – a

high proportion of births are attended by skilled

health personnel and access to emergency

obstetric care is widespread Be that as it may,

the reality in high-mortality countries today is

that policymakers are indeed confronted with a

choice between the two interventions, at least as

a matter of emphasis or priority setting Where

should they put their scarce financial, human,

and managerial resources? How should they

sequence these interventions?

To look for an answer, we should look to

contemporary cases of the few countries or

sub-national units in which maternal mortality ratios

of less than 100 have been achieved In Malaysia

and Sri Lanka, a step-by-step approach, starting

with coverage of basic facilities that can deliver

emergency obstetric care, followed by a focus on

utilization and quality, went hand in hand with

the professionalization of midwifery and a

gov-ernmental commitment to ensuring universal

access to health services, including access by

the poor and people in rural areas10 Over the

course of several decades, both countries

reduced the incidence of postpartum

hemor-rhage and thus halved their maternal mortality

ratios every 6–12 years, going from more than

500 in 1950 to less than 30 by the early 1990s

In a country like India, the vast majority of

births (often more than 80%) take place at

home, very often attended by family members

or neighbors, TBAs or other kinds of minimallytrained community health workers The healthsystem is so weak that there is no hope of pro-viding emergency obstetric care or even a trueskilled birth attendant in rural areas at any time

in the foreseeable future: therefore the strategyshould be to provide some additional training tocommunity health workers or traditional birthattendants, making them, in effect, semi-skilledattendants

The enormous pressure that concernedpolicy-makers feel to do something for the mil-lions of women who give birth in these circum-stances is recognized It is also recognized that asemi-skilled worker may have the potential tosave a substantial number of newborns whootherwise would die But it must be clearlystated that a strategy of training tens of thou-sands of semi-skilled workers who will not bebacked up by a supervision system, a supply sys-tem, or a referral system, is not a strategy thatwill significantly reduce maternal mortality Infact, the proliferation of unsupported, unsuper-vised, semi-skilled workers (‘certified’ aftershort training courses to manage deliveries) whoare deployed in the context of policies effectivelythat marketize and privatize health care has thepotential to increase the dangers for pregnantand delivering women In some cases wheresuch a strategy is being considered, the explicitobjective is to train such workers on theassumption that they will set up their ownprivate practices21 Such private provision will

be quite outside any government supervision,any effective regulatory system, or even anyself-policing professional body

It is not suggested that highly trained ists are not necessary to reduce maternal mor-tality Many categories of health personnel can

special-be taught to provide various health services – aslong as effective systems of support, supervisionand supplies are established

All the interventions necessary to savewomen’s lives can be delivered in a districthealth system – at the primary care and firstreferral levels This does not mean that womenmust give birth in facilities, nor does it meanthat TBAs and other private providers have

no place in a delivery system The case studies

of countries that have substantially reducedPOSTPARTUM HEMORRHAGE

maternal mortality demonstrate that success is

possible with multiple combinations of home

and institutional births, attended by different

categories of health workers, as long as women

have access to emergency obstetric care staffed

by skilled health personnel11

References

1 Lynn P, Freedman RJ, Waldman H de Pinho,

Wirth ME Who’s got the power? Transforming

health systems for women and children UN

Millenium Project Task Force on Child Health

& Maternal Health, 2005:77–95

2 Rosenfield A, Maine D Maternal mortality – a

neglected tragedy: where’s the M in Mch? Lancet

1985;2:83– 5

3 Greenwood AM, Bradley AK, Byass P, et al.

Evaluation of a primary care programme in the

Gambia: the impact of traditional birth

atten-dants on the outcome of pregnancy J Trop Med

Hygiene 1990;93:58–66

4 Goodburn EA, Chowdhury M, Gazi R, et al.

Training traditional birth attendants in clean

delivery does not prevent postpartum infection

Health Policy Planning 2000;15:394–9

5 Smith JB, Coleman NA, Fortney JA, et al The

impact of traditional birth attendant training on

delivery complications in Ghana Health Policy

Planning 2000;15:326–31

6 Danel I, Rivera A Honduras, 1990–1997 In

Koblinsky M, ed Reducing Maternal Mortality:

Learning from Bolivia, China, Egypt, Honduras,

Indonesia, Jamaica and Zimbabwe Washington,

DC: World Bank, 2003

7 McCaw-Binns A Jamaica, 1991–1995 In

Koblinsky M, ed Reducing Maternal Mortality:

Learning from Bolivia, China, Egypt, Honduras,

Indonesia, Jamaica and Zimbabwe Washington,

DC: World Bank, 2003

8 Maine D Safe Motherhood Programs: Options and

Issues New York: Center for Population and

Family Health, Columbia University, 1991

9 Greenwood AM, Greenwood BM, Bradley AK,

et al A prospective study of the outcome of

preg-nancy in a rural area of the Gambia Bull WHO

1987;65:635–43

10 Pathmanathan I, Liljeastrand J, Martins J,

et al Investing in Maternal Health in Malaysia and Sri Lanka Washington, DC: World Bank,

Bank, 2003

12 McCormick M, Sanghvi H, Kinzie B, McIntosh

N Preventing postpartum hemorrhage in

low-resource settings Int J Gynaecol Obstet 2002;77:

267–75

13 Abstract of proceedings submitted by DrPrakash Bhatt, Vice President FOGSI onpersonal communication

14 AOFOG PPH Initiative, FOGSI memories

2005 Publication from Federation of Obstetric

& Gynecological Societies of India

15 Solution Exchange for Maternal & ChildHealth Practitioners in India Personalcommunication by Dr Meghendra Banerjee.mch@solutionexchange-un.net.in

16 FOGSI memories 2005 Publication from

Federation of Obstetric & Gynecological Societies of India

17 Thaddeus S, Maine D Too far to walk: maternal

mortality in context Soc Sci Med 1984;38:

1091–110

18 Murray SF, Pearson S Maternity referralsystems in developing countries: challenges andnext steps A scoping review of current knowl-edge Background paper commissioned by the

UN Millenium Project Task Force on ChildHealth and Maternal Health and the WorldHealth Organization New York, 2004

19 Sibley L, Sipe TAT, Koblinsky M Does tional birth attendant training improve referral ofwomen with obstetric complications: a review of

tradi-the evidence Soc Sci Med 2004;59:1757–68

20 Tamil-Nadu Government Publication on World

Health Day, 2006 Times of India, April 7th,

2005

21 Mavalankar D Auxiliary nurse midwifes’(ANM) changing role in India: Policy issuesfor reproductive and child health Ahmedabad:Indian Institute of Management, 1997

Combating postpartum hemorrhage in India

ELIMINATING MORTALITY: LESSONS FROM LUBLIN

PROVINCE IN POLAND

J Oleszczuk, B Leszczynska-Gorzelak, D Szymula, M Grzechnik, G Pietras,

J Bartosiewicz and J J Oleszczuk

INTRODUCTION

Every year, over half a million women die of

pregnancy, delivery and postpartum

complica-tions – equivalent to the death toll of 15

September 11th tragedies in a single year!

Postpartum hemorrhage is almost always the

number one cause of mortality, and in Poland it

is no different In the 10 years between 1991

and 2000, a total of 135 women died of

postpartum hemorrhage, accounting for about

35% of all maternal mortality In Lublin

Province (2 181 018 inhabitants) in the

south-eastern section of the country, a

well-functioning regionalization system, based on

three levels of perinatal care, introduced in

1993, has led to a marked reduction in perinatal

mortality A total of 25 obstetric units are part

of the system – 18 in level I, five in level II and

two in level III – the latter being the perinatal

centers The organizational structure is

com-prised of the heads of obstetric and neonatal

units all of whom report to the Provincial

Obstetrician-in-Chief who currently is the

Head of the Department of Obstetrics and

Perinatology of the Medical University in

Lublin Since 2002, no maternal death due to

postpartum hemorrhage has been reported in

Lublin Province

This chapter describes the regionalization

system in Lublin Province, along with a specific

pathway that exists for all postpartum

hemor-rhage cases In addition, the system is critically

evaluated, and potential approaches to

replicat-ing this system elsewhere are provided This

effort can be viewed as a population-based,

multicentric, prospective, controlled trial of

an organizational system that aimed, and

succeeded, in eradicating maternal mortalityfrom postpartum hemorrhage in one of thePolish provinces We are of the opinion thatthe findings from our province can be appliedaround the world and have immense impact onreducing unnecessary deaths

as at all times as a ‘last resort’ for the mostsevere postpartum hemorrhage cases If such acase occurs and the local obstetric unit decidesthat an intervention of this senior obstetrician isrequired, the unit pages the Obstetrician-in-Chief asking for immediate support If theObstetrician-in-Chief is unavailable (whichhappened four out of 33 times in the time understudy), the next most senior person in thepostpartum hemorrhage SWAT team is pagedand attends to the patient An ambulance is sent

to pick-up a postpartum hemorrhage ‘rescuekit’ (containing recombinant factor VIIa,NovoSeven®, Novo Nordisk, and a set of fasterabsorption profile sutures for the B-Lynch oper-ation) from the hospital of the Obstetrician-in-Chief and then takes him directly to the localobstetric unit As the farthest unit is approxi-mately 130 km away from the perinatal center

and the transport takes up to 1.5 hours in

extreme cases, the average time from initiating

the call and delivering the Obstetrician-in-Chief

to the unit takes ~90 minutes

The Obstetrician-in-Chief then takes charge

of the local obstetric team, evaluates the status

of the patient and makes a decision about the

most appropriate management approach After

the intervention, the patient usually remains in

the local obstetric unit (or is taken to the local

intensive care unit) to which she was admitted

but rarely is transferred to the perinatal center

During recovery, the Obstetrician-in-Chief

then provides telephone consultations to the

obstetric and intensive care unit teams

RESULTS

A total of 86 237 births were recorded in Lublin

Province between January 1, 2002 and March

31, 2006 During this time, no maternal

mortality due to postpartum hemorrhage was

reported The numbers of maternal deaths from

other direct obstetric causes are summarized

in Table 1 No deaths were caused by indirect

obstetric factors or non-obstetric factors

Between January 1, 2003 and March 31,

2006, 33 cases of postpartum hemorrhage were

managed in the collaborative fashion described

above In all instances, the local obstetric units

did not manage to control the hemorrhage

pharmacologically, and a decision was made

to change the pharmacologic approach or to

switch to surgical management (laparotomy orrepeat laparotomy) In all cases, the Obstetri-cian-in-Chief was paged and took over furthermanagement (See Chapter 22 for a UShospital-based approach to reducing mortality.)Several types of cases can be described,depending on the status of the patient at thelocal obstetric unit as determined by the Obste-trician-in-Chief when he arrived on the scene(see Figure 1):

● Patient undergoing surgery with rhage, difficult to manage but prior to hyster-ectomy;

hemor-Eliminating mortality: lessons from Poland

Year

2006 (1.01–31.03) Total

000100

000000

010000

000000

010200

Table 1 Causes of maternal mortality in Lublin Province between 2002 and 2006

Figure 1 Level of the local obstetric unit in the 33cases of postpartum hemorrhage managed throughthe regionalization system between 2003 and 2006

● Patient undergoing surgery with

hemor-rhage, difficult to manage after hysterectomy;

● Patient after Cesarean section but repeat

laparotomy needed (to perform hysterectomy

or save the uterus);

● Patient after delivery – conservative

manage-ment unsuccessful and a decision was

required to switch to other conservative

approaches or decide to operate

Interventions were performed in six cases of

vaginal delivery and in 27 cases of Cesarean

section (Figure 2) Table 2 shows the various

management approaches used in the 33 cases of

severe postpartum hemorrhage described in this

chapter

DISCUSSION

Using coordinated and well-planned efforts, it is

possible to ‘eradicate’ maternal mortality from

postpartum hemorrhage in a large population

Even if half of these deaths could be prevented

world-wide, 75 000–125 000 lives could besaved every year In all 33 cases, patient statusafter surgery was satisfactory and they quicklyrecovered and were discharged home with noneurologic or other post-hemorrhagic complica-tions It is important to underline that thesepatients experienced the most severe post-partum hemorrhage in which the local obstetricteam, usually very well trained, was helpless andrequired support from the Provincial Obstetri-cian-in-Chief The other cases of postpartumhemorrhage which occurred in the provincewere less severe and responded to a variety

of interventions without the need for outsideassistance

The regionalization system was critical in oursuccess in eradicating maternal mortality due

to postpartum hemorrhage in Lublin Province.The system in principle aimed at ensuring thatthe most complicated cases are transferredantenatally to the perinatal center, whereversuch forecasting was possible (e.g in cases ofplacenta previa in patients after prior Cesareansection) In acute cases, however, when patientPOSTPARTUM HEMORRHAGE

Figure 2 Underlying pathology in the 33 cases of severe postpartum hemorrhage between 2003 and 2006

in the Lublin Province

transport was not possible, it was critical that an

appropriately trained senior obstetrician from

the perinatal center be taken to the patient at

the remote location, along with specialist

supplies that the local hospital did not have

In order to provide appropriate coverage at all

times every day of the year, a team of highly

trained and skilled obstetricians is ready and

available in the perinatal center (a postpartum

hemorrhage SWAT team) Because severe

post-partum hemorrhage is rare, every member of the

postpartum hemorrhage SWAT team should

take every opportunity to observe and/or

per-form most, if not all, of these operations as well

as the simpler interventions to get the

appropri-ate training and familiarity with the surgical

technique

With regard to management approaches,

a number of methods were used, including a

combination of the well-known surgical ligation

methods of the uterine artery, uterine branch of

the ovarian artery and the hypogastric artery

The latter method should, however, only

be performed by the highest skilled surgeonswho are comfortable with retroperitoneal spacesurgery, as these approaches carry a high risk ofvascular or ureteral complications For exam-ple, in one of the cases, the hypogastric vein wasdamaged and subsequently required suture clo-sure In addition, if these conservative surgicalmethods are not successful, hysterectomy is themethod of choice, and it is critical to time thisdecision appropriately In such cases, the uterus

is excised with the cervix (total hysterectomy)but without the adnexa

We see two potential risks with our approachand potential replicas of our approach else-where: reimbursement and legal/malpractice

In Poland, reimbursement is on a quasi-DRG(diagnosis-related groups) basis, but the fullpayment goes to the admitting hospital, withoutspecific breakdown of doctor fees from hospitalfees Thus, our entire system is essentially per-

formed on a pro bono basis by the postpartum

hemorrhage SWAT team Unfortunately, this

is not sustainable for the long term, and thehospital administration of the perinatal center iscurrently negotiating appropriate remunerationfor these services with the Polish national payor.Legal/malpractice is another risk In Poland,physicians are covered by a hospital malpracticeinsurance contract, but theoretically this coversservices provided only within the premises ofthe hospital Thus, our postpartum hemorrhageSWAT team is not covered by malpracticeinsurance while performing the intervention in aremote location Again, this is not sustainable

on a long-term basis, as these cases are the mostdifficult ones and legal proceedings are morelikely than after a physiologic delivery Attemptsare now being made to resolve this issueand introduce a malpractice insurance schemesimilar to that of the ambulance services or theGood Samaritan Act in the United States

CONCLUSIONS

(1) It is possible to ‘eradicate’ maternal ity from postpartum hemorrhage in a largepopulation

mortal-(2) Programs aiming to ‘eradicate’ maternalmortality from postpartum hemorrhage in

Eliminating mortality: lessons from Poland

Bilateral adnexectomy due to septic shock

(with total hysterectomy)

Retroperitoneal hematoma evacuation

Uterine artery ligation

Ligation of the uterine branches of ovarian

arteries

Bilateral hypogastric artery (internal iliac)

ligation

Unilateral hypogastric artery ligation

Repair of cervical laceration

Table 2 Management approaches in the 33 cases

of severe postpartum hemorrhage in Lublin Province

between 2003 and 2006