Pelvic Hemorrhage During Gynecologic Surgery

GYNECOLOGIC SURGERY
Pelvic Hemorrhage
During Gynecologic Surgery
Donald G. Gallup, MD
FOCUSPOINT
Patients at risk
for intraoperative
hemorrhage include
those with a family
history of bleeding
disorders, those
with poor nutrition,
and those who
are obese.
Intraoperative hemorrhage is a serious
complication of gynecologic or obstetric
surgery, and catastrophic hemorrhage
sometimes results in panic. A calm, stepwise
approach, as outlined, will enable
the surgeon, his/her consultants, and the
operating team to successfully manage a
potentially lethal problem.
A29-year-old woman, gravid 2,
para 2, had an emergency hysterectomy
for placenta accreta and
persistent bleeding at a hospital
50 miles from our institution. The
abdomen had been closed, but the cuff was still
“oozing.” She had tachycardia and blood pressure
in the range of 60/40 mm Hg. A helicopter
brought her to our facility. Further
transfusion of packed red
blood cells (RBCs) and fresh
frozen plasma was administered,
and she returned to the
operating room for a left salpingo-oophorectomy
and bilateral
hypogastric artery ligation
through a midline incision.
Bleeding persisted, and a “pack
and go” technique over a hemostatic
agent was used. A vacuum-assisted
closure (VAC)
was used. Neither the skin nor
fascia was closed.
Thirty-six hours later, she
was again reoperated on. No
bleeding was encountered
after removal of the 4″ Kerlex gauze. The abdominal
fascia and skin were closed using
standard sutures and techniques.
Donald G. Gallup, MD, is Professor and Chair, Department of
Obstetrics and Gynecology, Mercer University School of
Medicine (Savannah), Savannah, GA.
RISK FACTORS
Patients at risk for intraoperative hemorrhage
include those with a family history of bleeding
disorders, those with poor nutrition (eg, high
alcohol intake), and those who are obese. The
most common congenital platelet disorder is
von Willebrand disease, and suspect patients,
ie, patients with prior history of bleeding after
surgery on tooth extractions or with family history
of bleeding, should have preoperative
evaluations and management recommendations
from a hematologist. Patients who abuse
alcohol or are malnourished should have preoperative
liver function and coagulation studies.
The primary laboratory test to evaluate potential
bleeding is the platelet count. For any
surgery or invasive procedure, such as insertion
of a central line, a platelet count of 50,000 is
recommended. 1
Patients should stop taking aspirin, NSAIDs,
and medications such as warfarin or clopidogrel
7 days prior to surgery. Certain alternative
medicine products can impair coagulation
(Table 1), so a thorough history should be obtained.
Stop these products 5 to 7 days prior to
surgery. 2
CONTROLLING PELVIC BLEEDING
The first step in controlling bleeding is application
of pressure with a finger or sponge stick.
Then, call for assistance and obtain exposure,
which usually requires extending the incision
and using a fixed table retractor. Pressure on
the aorta with a hand, weighted speculum, or
aortic compressor can be temporarily applied
TABLE 1. Alternative Medicine
Supplements Implicated in Bleeding
• Beta-carotene
• Fish oil
• Garlic
• Ginkgo
• Ginseng
• St. John’s wort
• Vitamin E
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GALLUP
to help locate the source of massive pelvic
bleeding. Individual vessels should be secured
with fine-tipped clamps and clips or smallcaliber
sutures. Never use electrocautery for
large lacerations. Packs (hot or cold) can be
used to temporarily control pelvic bleeding
and should be carefully placed from sidewall to
sidewall and removed sequentially after a period
of at least 5 minutes to allow for adequate
pressure.
Guidelines for component replacement therapy
should be followed after primary volume
expansion. In general, for every 8 units of RBCs
replaced, give 2 units of fresh frozen plasma. If
more than 10 units of RBCs are replaced, give 10
units of platelets. If fibrinogen is low, give 2 units
of cryoprecipate. Using fresh frozen plasma in a
ratio of 1:1 or 1:2 with RBC units earlier has been
shown to improve survival in presence of massive
hemorrhage. 3,4
The Haemonetics Cell Saver should be used
when massive bleeding is anticipated. It is accepted
by many Jehovah’s Witnesses. 5 Relative
contraindications to its use include malignancy,
bacterial contamination from a ruptured abscess,
and inadvertent injury to unprepared
bowel.
TOPICAL AGENTS
If troublesome bleeding persists after packing
and securing arterial bleeders, a topical hemostatic
agent can be used. A less-expensive product
to try initially is Surgicel or Gelfoam. Some
still use Avitene, but this powder substance
works poorly in the presence of thrombocytopenia
and should be used with caution when
applied near the ureter. Ureteral stricture may
occur with excessive amounts. All these agents
require pressure for 3 to 5 minutes, as pressure
may enhance clot formation and inhibits capillary/small
vessel oozing.
Fibrin glue, consisting of equal amounts of
cryoprecipitate and thrombin, has been successfully
used as a local hemostatic agent in
cardiovascular, thoracic, and reconstructive
surgeries and prostatectomy. 6 The fibrin sealants
used in gynecologic surgery are Tisseel VH
and FloSeal. Both are relatively more expensive
than the above agents. The high-viscosity gel
FloSeal may be preferred, as it can be mixed at
the operating room.
HYPOGASTRIC ARTERY LIGATION
If pelvic oozing persists after topical agent application,
consider hypogastric artery ligation
(HAL), which is successful in
about 50% of patients. 7 HAL
works by decreasing pulse
pressure. A safe method to expose
the vessels is to open the
sidewall along the avascular
line of Toldt. The ureter is retracted
out of harm’s way (Figure
1). After clearly identifying
the common iliac vessels, a
right-angle clamp is passed
from lateral to medial, distal to
the posterior division of the artery
or proximal to the uterine
artery. Two large base sutures
are placed in the tip of the
clamp and later tied (Figure 2).
FOCUSPOINT
A calm, stepwise
approach will enable
the surgical team to
successfully manage
a potentially lethal
problem.
A gynecologic oncologist or vascular surgeon
experienced in pelvic surgery may be called to
assist.
PRESACRAL VEIN INJURY
A relatively rare cause of catastrophic pelvic
hemorrhage is inadvertent injury of the presacral
veins. For the gynecologist, this can occur
during presacral neurectomy or sacrocolpopexy.
This bleeding, seldom controlled with
topical agents, has been successfully managed
with insertion of stainless steel thumbtacks di-
Line of Toldt
External
iliac artery
and vein
Common iliac artery
Hypogastric
artery
Hypogastric
vein
Ureter retracted
medially
FIGURE 1. The sidewall is opened along the avascular
line of Toldt. The ureter is identified at the bifurcation of
the common iliac artery and retracted medically.
Illustrated by R. Kelly Gallup.
Follow The Female Patient on and The Female Patient | VOL 35 JUNE 2010 23

Pelvic Hemorrhage During Gynecologic Surgery
Right angle
clamp
External
iliac artery
and vein
FIGURE 3. The VAC is placed in the operating room in a
patient who was operated for catastrophic hemorrhage.
Courtesy of Donald G. Gallup, MD.
Hypogastric vein
rectly into the sacrum. 8 Harvesting a 2×1 cm of
rectus abdominus muscle fragment, pressing it
against the presacral veins, and indirectly coagulating
them with pure cutting current (welding)
for 2 minutes has also been successful. 9
“PACK AND GO”
If intraoperative bleeding persists despite HAL
and other measures, a pelvic pack should be
placed. Some prefer a Logothetopolous (parachute)
pack. 10 The disadvantages of this pack,
which is brought out through the vagina, are
possible unrecognized further bleeding or injury
to bowel on later removal. We prefer a fast,
simple method used by many trauma surgeons.
11 Tightly packed 2″ to 4″ Kerlex gauze is
TABLE 2. “Pack and Go” Steps
Hypogastric artery
FIGURE 2. A right-angle clamp is passed gently
posterior to the artery with aid of a Babcock clamp.
The artery should be “hugged” in order to prevent
injury to underlying hypogastric vein.
Illustrated by R. Kelly Gallup.
1. Pack Kerlex gauze from sidewall to sidewall.
2. Close skin only with towel clips or running suture.
3. Transfer patient to ICU and correct hypothermia,
acidosis, and coagulopathy.
4. Reoperate and remove pack in 36 to 48 hours.
placed over previously applied FloSeal (Table 2).
The pack should be removed with saline drip assistance.
An alternative to closing the skin is use
of a modified VAC (Figure 3). This closure kit is
available in most operating rooms associated
with trauma services. With this damage control
surgery, upon reoperation, the pelvis is free of active
bleeding, and repacking is seldom needed.
The author reports no actual or potential conflict
of interest in relation to this article.
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24 The Female Patient | VOL 35 JUNE 2010 All articles are available online at www.femalepatient.com.