Comparative analysis of appropriate second line therapies for management of severe postpartum hemorrhage – a prospective study

Objective: To explore appropriate second line therapies for management of severe postpartum hemorrhage at caesarean and vaginal delivery. Methods : A prospective study was done of 100 women at Lalla Ded Hospital of GMC, Srinagar, of primary postpartum hemorrhage unresponsive to standard medical therapy. In all of these PPH cases, women were treated with appropriate oxytocic agents and prostaglandin analogues. Intravenous infusions of oxytocin, intravenous methergine and / or intramuscular carboprost tromethamine were all used in accordance with our hospital protocol. 50 patients of failed medical therapy were managed with utero vaginal packing, and in another group of 50 patients Sengstaken Blakemore Oesophageal Catheter [SBOC] was inserted. Women with traumatic PPH and secondary infection were excluded from our study. Coagulation studies were carried out in all patients to exclude coagulopathy as the cause of, or a catalyst for the hemorrhage. Result : In the SBOC group, balloon tamponade succeeded in arresting hemorrhage in 47 patients out of 50 (94% success rate), whereas 3 patients who developed PPH after caesarean section failed the tamponade test and underwent urgent caesarean hysterectomy, (6% failure), due to the ongoing hemorrhage. In the uterine packing group, success was achieved in arresting hemorrhage in 39 patients (78% success rate) and failed in 11 patients (22% failure rate). 6 underwent caesarean hysterectomy and 5 patients who developed PPH after normal vaginal delivery underwent postpartum hysterectomy. Statistically, there was a significant difference with respect to outcome of tamponade procedure between the two groups (p-value = 0.021). There was no statistical significance with respect to the cause of PPH, mode of delivery, duration of labour or gestation at delivery. Conclusion : The results from our observations strongly support the use of balloon tamponade for unresponsive postpartum hemorrhage. Balloon tamponade showed a higher success rate of 94%, as compared to 78%, in the uterine packing group, with least morbidity and lower intervention rates.