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Damage-Control Surgery for Obstetric Hemorrhage

Article  in  Obstetrics and Gynecology · July 2018

DOI: 10.1097/AOG.0000000000002743

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Maternal Morbidity and Mortality: Current Commentary

Damage-Control Surgery for

Obstetric Hemorrhage
Luis D. Pacheco, MD, M. James Lozada, DO, George R. Saade, MD, and Gary D. V. Hankins, MD

packed red blood cells, fresh-frozen plasma, and pla-

Damage-control surgery (abdominopelvic packing fol-
telets is initiated in a 1:1:1 ratio. After completion of
lowed by a period of medical stabilization in the
the procedure, there is evidence of diffuse oozing from
intensive care unit) is a life-saving intervention usually
the surgical site with a serum fibrinogen level of 74
reserved for critically injured patients who may not
survive an attempt to achieve hemostasis and complete
mg/dL, platelet count of 31,000/mm3, temperature of
repair of the damage in the operating room. Most 34°C, and arterial pH of 7.13. A decision is made to
obstetricians have little or no experience in this area, pack the abdomen and pelvis and transfer the patient
although the use of damage-control surgery in selected to the surgical intensive care unit for further resusci-
cases may be life-saving. This approach should be tation and medical treatment of the coagulopathy.
considered when arterial bleeding has been controlled
and persistent bleeding is deemed to be secondary to INTRODUCTION
coagulopathy that is refractory to blood product replace- Damage-control surgery is a well-established life-saving
ment, particularly in the presence of hypothermia, management approach in trauma and other surgical
acidosis, and vasopressor requirement. A prototypical specialties.1 Damage-control surgery is usually
(albeit hypothetical) case is described here in which reserved for the critically injured patient who may
damage-control surgery is indicated. not survive an attempt to achieve hemostasis and com-
(Obstet Gynecol 2018;0:1–5) plete repair of the damage in the operating room. In
DOI: 10.1097/AOG.0000000000002743 these patients, the bleeding cannot be controlled surgi-
cally, mostly because of a combination of hypothermia,

I n a prototypical case, a 33-year-old patient with acidosis, coagulopathy, and hypocalcemia.

a diagnosis of placenta percreta undergoes a sched- In these situations, temporizing measures aimed at
uled cesarean hysterectomy at 35 weeks of gestation. slowing the bleeding are better than continuing futile
Intraoperatively, there is evidence of placental inva- attempts in the operating room that further exacerbate
sion of the bladder and the left broad ligament. As the reasons for the refractory bleeding. The same
a result of massive blood loss, a massive transfusion of approaches used in a damage-control surgery in trauma
and other specialties can be applied in obstetrics.
However, most obstetricians have little or no experi-
From the Departments of Obstetrics & Gynecology and Anesthesiology, the Uni- ence in this area. In this article, we provide an approach
versity of Texas Medical Branch, Galveston, Texas; and the Division of to the intraoperative management of obstetric patients
Obstetrical Anesthesiology, Department of Anesthesiology, Vanderbilt University
Medical Center, Nashville, Tennessee. with uncontrolled intraabdominal hemorrhages that is
Each author has indicated that he has met the journal’s requirements for author-
modeled after the approaches used in damage-control
ship. surgery and provide guidance on their subsequent
Received March 27, 2018. Received in revised form May 16, 2018. Accepted May medical management in the intensive care unit (ICU).
17, 2018.
Corresponding author: Luis D. Pacheco, MD, The University of Texas Medical SURGICAL DAMAGE CONTROL
Branch at Galveston, 301 University Boulevard, Galveston, TX 77555-0587; Damage-control surgery consists of performing a lim-
email: ldpachec@utmb.edu.
ited surgical intervention to immediately abate life-
Financial Disclosure
The authors did not report any potential conflicts of interest. threatening conditions (eg, bleeding, contamination
© 2018 by the American College of Obstetricians and Gynecologists. Published
from bowel injury) with definitive surgical control
by Wolters Kluwer Health, Inc. All rights reserved. deferred until a period of medical stabilization has
ISSN: 0029-7844/18 been completed in the ICU.2 It is key that all bleeding

VOL. 0, NO. 0, MONTH 2018 OBSTETRICS & GYNECOLOGY 1

Copyright Ó by American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
sources amenable to surgical intervention (eg, arterial addition of hemostatic agents such as thrombin spray
bleeding) should be controlled before considering or fibrin glue may be a useful approach to limit ongo-
a damage-control procedure. In many cases, massive ing bleeding together with packing.
transfusion protocols have already been activated Despite no consensus regarding the use of pro-
without improvements in the severity of bleeding. phylactic antibiotics while packing is in place, some
Common indications for damage-control surgery re- recommend their use.8 In our institution, we use
sulting from bleeding include difficult access to the broad-spectrum antibiotics, usually a second-
bleeding site, venous bleeding not amenable to surgi- generation cephalosporin (eg, 2 g cefoxitin intrave-
cal control, persistent intraoperative blood product nously every 6 hours) until the packing is removed.
and fluid requirements in the setting of nonarterial In patients allergic to b-lactam agents, the combina-
bleeding, hemodynamic instability, and development tion of levofloxacin (500 mg intravenously daily) with
of ventricular arrhythmias, and coagulopathy result- metronidazole (500 mg intravenously every 8 hours)
ing from a combination of hypothermia, acidosis, and may be used. We discourage the use of aminoglyco-
loss of clotting factors.3,4 Typically, these patients sides in this setting as a result of the risk of acute
develop persistent diffuse oozing in the absence of kidney injury.
formed clots in the operative field despite maximal Once packed, it is imperative to monitor for signs
surgical efforts. The usual indications for damage- of intraabdominal hypertension, including difficulty
control surgery secondary to bleeding are summa- ventilating the patient (usually clinically evident as
rized in Box 1. elevated peak airway pressures secondary to cephalad
As in damage-control surgery in other surgical displacement of the diaphragm), unexplained hemo-
fields, packing is the cornerstone of damage control in dynamic instability (secondary to increased inferior
obstetric patients. Most surgeons pack the abdomen vena cava compression with decreased preload and
and pelvis with conventional sterile laparotomy pads.5 cardiac output), and oliguria.
The pads should be placed directly over the bleeding Because the abdominal closure is temporary, the
surfaces with sufficient pressure to stop the bleeding. ideal method should be easy to apply and remove,
Excessive pressure, however, may result in increased protect the abdominal contents from evisceration,
intraabdominal pressure, resulting in abdominal com- prevent development of enteroatmospheric fistulas,
partment syndrome (discussed later).6 In cases with an and prevent lateral retraction of the fascia, because the
open vaginal cuff, a pelvic umbrella pressure pack latter may result in inability to complete definitive
exiting the vagina has been described as an effective abdominal wall closure when the patient returns to the
measure to control bleeding.7 The evidence regarding operating room. Although some surgeons may decide
the addition of hemostatic agents, either directly on to close the fascia after packing, we caution that this
the tissue or already included in the pads, is limited. In intervention may raise intraabdominal pressure sig-
a retrospective review of trauma patients, Choron nificantly resulting in the development of abdominal
et al5 compared the use of usual laparotomy pads or compartment syndrome. The simplest method of
pads or gauze impregnated with kaolin (combat gauze abdominal closure is approximating the skin with
and trauma pad) and found no additional benefit over sutures or towel clips. This technique, however, may
packing alone. We have found that in some cases, the result in skin damage, and the risk of evisceration is
high.9
Another popular and inexpensive method in-
volves the use of a plastic silo constructed from a 3-
Box 1. Common Intraoperative Indications for L sterile urology irrigation plastic bag, also known as
Damage-Control Surgery Secondary to Bleeding the “Bogota bag.” The latter is simply sutured to the
 Venous bleeding not amenable to surgical control edges of the fascia allowing temporary closure.2 The
 Persistent bleeding despite transfusion of large Bogota bag may cause injury to the fascia, and the risk
amounts of blood products (greater than 10 units of evisceration remains significant.9 More recently,
packed red cells) the use of negative pressure wound therapy devices
 Persistent and escalating fluid requirements in the
setting of active nonarterial bleeding has allowed for continuous fluid collection from the
 Hemodynamic instability or development of ventric- cavity (decreasing edema and ascites) while maintain-
ular arrhythmias ing tension on the fascia, allowing higher rates of pri-
 Coagulopathy resulting from a combination of hypo- mary fascial closure.10,11 These devices may be safely
thermia (temperature less than 35˚C), acidosis (pH placed in patients with an open abdomen by using
less than 7.3), and loss of clotting factors
a visceral protective layer (commercially available

2 Pacheco et al Damage-Control Surgery for Obstetric Hemorrhage OBSTETRICS & GYNECOLOGY

Copyright Ó by American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
with the vacuum device) that is placed between the further bleeding, transfer to a higher level of care
exposed viscera and the foam layer of the device. The facility may be considered.
use of vacuum-assisted closure has been associated In the ICU, the main objective should be to
with improved survival and higher delayed fascial clo- manage all the conditions that are likely to contribute
sure success compared with other temporary closure to the ongoing coagulopathy. Excessive crystalloid (or
techniques.12 We favor the use of negative pressure colloid) administration should be avoided because it
vacuum devices for temporary abdominal wall clo- will contribute to hypothermia and dilutional coagul-
sure where available. opathy and worsen third spacing (mainly crystalloids),
There is limited evidence regarding the timing for which will increase intraabdominal pressure.15 Plate-
reoperation, either to remove or replace the intra- let transfusion is recommended for levels below
abdominal packing. Most experts agree that early 50,000/mm3 in the presence of active bleeding. Sim-
removal (within 24 hours) may result in serious ilarly, in the setting of ongoing bleeding, the serum
rebleeding and should be avoided.1 On the other fibrinogen should be maintained above 150 mg/dL
hand, leaving packs for longer than 72 hours is con- and ideally above 200 mg/dL.16 The latter may be
sistently associated with more complications from accomplished with the use of cryoprecipitate or fibrin-
infection (eg, abdominal abscess formation).13 Pro- ogen concentrates (where available). Conventional
vided the patient is stable and physiologic derange- bleeding times (eg, prothrombin time and activated
ments have been corrected (temperature, pH, partial thromboplastin time) should be kept in the
electrolyte anomalies, and coagulopathy), the optimal normal range with the use of fresh-frozen plasma
time to remove the pack appears to be between days 2 and cryoprecipitates.
and 3 postoperatively.1 Obviously, it is best to time The use of viscoelastic tests (eg, thromboelastog-
the reoperation when the coagulopathy has been raphy or thromboelastogram) to guide blood product
reversed. In most cases, the operation may be per- transfusions and adjuvant pharmacologic agents such
formed by an experienced obstetrician. as tranexamic acid may be considered when there is
ongoing bleeding. Importantly, in a hemodynamically
ROLE OF SURGICAL DAMAGE CONTROL stable patient without active bleeding, a blood product
IN OBSTETRICS transfusion for the purpose of correcting laboratory
values alone should be avoided.
Several obstetric conditions may benefit from
Hypocalcemia (secondary to chelation from cit-
damage-control surgery such as persistent bleeding
rate contained in blood products) can impair coagu-
from placenta accreta, ruptured liver hematomas
lation and should be corrected. Massive transfusion
associated with preeclampsia, and attempts at placen-
may result in hyperkalemia, which, if present, needs
tal removal in cases of abdominal ectopic pregnancies.
aggressive treatment. Warming the patient—most
As expected, the available literature involving
commonly with the use of surface warming devices
abdominal–pelvic packing in obstetrics is limited to
such as the Bair Hugger—is imperative to allow opti-
a few case series (PubMed review from 1990 until
mal clotting function.17
present using the terms control surgery, pregnancy,
Metabolic acidosis is usually the result of lactate
hemorrhage). In a recent mail survey study from
accumulation and will improve with correction of
South Africa including more than 1 million deliveries,
tissue perfusion and coagulopathy. In most cases, the
1 of every 14 peripartum hysterectomies was treated
use of sodium bicarbonate is not needed.
with abdominal packing.14 Despite the limited avail-
Conventional critical care management, includ-
able data, obstetric patients requiring damage-control
ing lung-protective mechanical ventilation, targeted
surgery resulting from postpartum hemorrhage
sedation with daily spontaneous breathing trials, early
should be managed following the same principles as
enteral feeding (which is not contraindicated in the
in nonpregnant individuals.
setting of an open abdomen), and thromboembolism
prophylaxis (mechanical until bleeding risk is
POSTOPERATIVE CARE decreased), should be applied routinely. The use of
Most patients who have intraabdominal packing enteral feeding in the setting of an open abdomen
should remain mechanically ventilated and are best results in improved rates of successful facial closure
cared for in an ICU involving a multidisciplinary and fewer complications from infection, likely as
team. If packing occurs in a setting of limited a result of decreased intestinal bacterial translocation.9
resources (eg, limited blood bank capacity), in hemo- In the setting of an open abdomen, analgesia and
dynamically stable patients, with no evidence of sedation are required because most patients will be

VOL. 0, NO. 0, MONTH 2018 Pacheco et al Damage-Control Surgery for Obstetric Hemorrhage 3

Copyright Ó by American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
receiving mechanical ventilation; however, pharma-
Box 2. Intravesical Pressure Measurement
cologic paralysis is not mandatory.9 The ICU man-
Technique
agement of the patient with an open abdomen is
depicted in Figure 1.  Patient must be in the supine position
 Attach commercially available measurement device
to Foley catheter
ABDOMINAL COMPARTMENT SYNDROME  Distend bladder with up to 25 mL of saline
Pregnancy is a state of chronically elevated intra-  Wait 60 sec
abdominal pressure. The median intraabdominal  Zero pressure transducer at level of the midaxillary
line at the iliac crest
pressure during late pregnancy is reported to range  Document pressure at end of expiration
between 15 and 29 mm Hg. It decreases to a median
pressure of 16 mm Hg at 24 hours postpartum.18,19
Critically ill pregnant patients have a median intra- responsive to fluid therapy together with a distended
abdominal pressure ranging from 7.8 to 14.1 mm abdomen and high peak pressures on the ventilator.
Hg on the day of ICU admission.20 Consequently, The diagnosis must be confirmed with a surrogate
pregnant or postpartum patients will have a higher measurement of abdominal pressure. The latter is
baseline intraabdominal pressure and should not be usually accomplished using intravesical pressure.21
treated based on an isolated measurement in the The technique recommended to measure intravesical
absence of clinical findings consistent with abdominal pressure is described in Box 2.
compartment syndrome. Once the diagnosis is confirmed, definite treat-
As mentioned previously, abdominal compart- ment involves opening the fascia to allow for decom-
ment syndrome may occur in the setting of an open pression. In the setting of damage-control surgery, the
abdomen when packing is excessive and tight or fascia is already open. In cases in which the fascia
secondary to either a massive bowel edema after opening is too small, extension of the incision may
overzealous crystalloid resuscitation or hematoma decrease the pressure within the abdomen. If the
formation. Abdominal compartment syndrome usu- packing is too tight, the clinician may consider
ally manifests with hypotension and oliguria not repacking the patient; however, the risk of bleeding

Fig. 1. Intensive care unit management after damage control for obstetric bleeding. *Tidal volume of 6 mL/kg ideal body
weight with plateau pressure below 30 cm H2O. †Start with a narcotic infusion such as fentanyl (50–200 micrograms/h) or
hydromorphone (0.2–2.0 mg/h). If required, a sedative may be added such as propofol (5–50 micrograms/kg/min), dex-
medetomidine (0.2–1.5 micrograms/kg/h), or midazolam (1–10 mg/h). If paralysis is required, use cisatracurium at 2–4
micrograms/kg/min. ‡Initially use sequential compression devices. Once bleeding risk decreases may transition to phar-
macologic prophylaxis. PTT, partial thromboplastin time; aPTT, activated partial thromboplastin time; DVT, deep vein
thrombosis; ACS, abdominal compartment syndrome.
Pacheco. Damage-Control Surgery for Obstetric Hemorrhage. Obstet Gynecol 2018.

4 Pacheco et al Damage-Control Surgery for Obstetric Hemorrhage OBSTETRICS & GYNECOLOGY

Copyright Ó by American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
with removal of the original pack must be considered. 9. Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA,
Biffl WL, et al. The role of open abdomen procedure in man-
Certain medical interventions may lower intraabdo- aging severe sepsis: WSES position paper. World J Emerg Surg
minal pressures, including the use of an oral or 2015;10:35.
nasogastric tube, rectal tube, gastrointestinal proki- 10. Brock WB, Barker DE, Burns RP. Temporary closure of open
netic agents, diuretics, and pharmacologic paralysis abdominal wounds: the vacuum pack. Am Surg 1995;61:30–5.
(allowing a decrease in the abdominal wall muscle 11. Cheatham ML, Demetrides D, Fabian TC, Kaplan MJ, Miles
tone). The latter interventions should not substitute WS, Schreiber MA. Prospective study examining clinical out-
comes associated with negative pressure wound therapy system
for surgical treatment when indicated. and Barker’s vacuum packing technique. World J Surg 2013;37:
2018–30.
DISCUSSION 12. Yanar H, Sivrikoz E. Management of open abdomen: single
center experience. Gastroenterol Res Pract 2013 Nov 17
In obstetric patients who have experienced massive [Epub].
hemorrhage, damage-control surgery should be con- 13. Abikhaled JA, Granchi TS, Wall MJ, Hirshberg A, Mattox KL.
sidered when arterial bleeding has been controlled Prolonged abdominal packing for trauma is associated with
and persistent bleeding is deemed to be secondary to increased morbidity and mortality. Am Surg 1997;63:1109–12.
coagulopathy that is refractory to blood product 14. Deffieux X, Vinchant M, Wigniolle I, Goffinet F, Sentilhes L.
Maternal outcome after abdominal packing for uncontrolled
replacement, particularly in the presence of hypother- postpartum hemorrhage despite peripartum hysterectomy.
mia, acidosis, and vasopressor requirement. PLoS One 2017;12:e0177092.
15. Stewart RM, Park PK, Hunt JP, McIntyre RC Jr, McCarthy J,
REFERENCES Zarzabal LA, et al. Less is more: improved outcomes in surgical
patients with conservative fluid administration and central
1. Ordoñez C, Pino L, Badiel M, Sanchez A, Loaiza J, Ramirez O, venous catheter monitoring. J Am Coll Surg 2009;208:725–35.
et al. The 1-2-3 approach to abdominal packing. World J Surg
2012;36:2761–6. 16. Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins
GD. An update on the use of massive transfusion protocols in
2. Coccolini F, Biffl W, Catena F, Ceresoli M, Chiara O, Cimbanassi obstetrics. Am J Obstet Gynecol 2016;214:340–4.
S, et al. The open abdomen, indications, management and definite
closure. World J Emerg Surg 2015 Jul 25 [Epub ahead of print]. 17. Dutton WD, Diaz JJ Jr, Miller RS. Critical care issues in man-
aging complex open abdominal wound. J Intensive Care Med
3. Benz D, Balogh ZJ. Damage control surgery: current state and 2012;27:161–71.
future directions. Curr Opin Crit Care 2017;23:491–7.
18. Chun R, Kirkpatrick AW. Intra-abdominal pressure, intra-
4. Lamb CM, MacGoey P, Navarro AP, Brooks AJ. Damage con- abdominal hypertension, and pregnancy: a review. Ann Inten-
trol surgery in the era of damage control resuscitation. Br J sive Care 2012 Jul 5;5(suppl 1):S5.
Anaesth 2014;113:242–9.
19. Fuchs F, Bruyere M, Senat MV, Purenne E, Benhamou D,
5. Choron RL, Hazelton JP, Hunter K, Capano-Wehrle L, Gaugh- Fernandez H. Are standard intra-abdominal pressure values
an J, Chovanes J, et al. Intra-abdominal packing with laparot- different during pregnancy? PLoS One 2013;8:e77324.
omy pads and QuickClotTM during damage control
laparotomy: a safety analysis. Injury 2017;48:158–64. 20. Tyagi A, Singh S, Kumar M, Sethi AK. Intra-abdominal pres-
sure and intra-abdominal hypertension in critically ill obstetri-
6. Santhosh MCB, Pai RB, Sachidanand R, Byrappa V, Rao RP. cal patients: a prospective cohort study. Int J Obstet Anesth
Inferior vena cava compression due to excessive abdominal 2017;32:33–40.
packing. Braz J Anesthesiol 2014;64:199–200.
21. Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain
7. Dildy GA, Scott JR, Saffer CS, Belfort MA. An effective pressure ML, De Keulenaer B, et al. Intra-abdominal hypertension and
pack for severe pelvic hemorrhage. Obstet Gynecol 2006;108:1222–6. the abdominal compartment syndrome: updated consensus def-
8. Adam DJ, Fitridge RA, Raptis S. Intra-abdominal packing for initions and clinical practice guidelines from the World Society
uncontrollable hemorrhage during ruptured abdominal aortic of the Abdominal Compartment Syndrome. Intensive Care
aneurysm repair. Eur J Vasc Endovasc 2005;30:516–9. Med 2013;39:1190–206.

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