Arterial ligation for massive hemorrhage during cesarean section may often fail to achieve hemostasis because of abundant collateral circulation. In recent years, various methods of hemostasis have been used, of which the most common are compression sutures, uterine balloon tamponade. In cases of massive hemorrhage, patients must be kept in good systemic condition, and local hemostasis must be achieved while paying attention to the possible occurrence of coagulopathy under monitoring of fibrinogen levels. When concomitant coagulopathy is present, local hemostasis is difficult to achieve because of hemorrhagic tendency. In such a case, obstetrical damage control procedures should be performed. First, the hemorrhagic area should be compressed with a towel or balloon, and at the same time, the artery should be blocked or compressed to reduce the blood flow into the uterus. The following resuscitation must also be implemented for warming intervention; blood transfusion to maintain the circulating blood volume; and the treatment of coagulopathy by “triple C supplement,” such as combined administration of fresh-frozen plasma and concentrated coagulation factors promptly to obtain a blood fibrinogen level of at least 150–200 mg/dL. If coagulopathy is eliminated, the conventional hemostatic procedures become effective. Hysterectomy is the last measure for hemostasis.
Part of the book: Recent Advances in Cesarean Delivery
Cesarean scar pregnancy (CSP) and cervical pregnancy are categorized as non-tubal ectopic pregnancy, because these are associated with a high burden of maternal and fetal morbidity including early uterine rupture, prevalence of placenta previa accrete spectrum, massive hemorrhage, and hysterectomy. Although management methods vary according to the week of gestation, recent reviews and reports support an interventional or a combination of surgical and medical approaches for treatment of unruptured CSP and cervical pregnancy rather than medical approach alone. In cases of massive hemorrhage, pressure hemostasis using balloon tamponade should first be performed. If such hemostasis proves to be ineffective, surgical excision or transcatheter arterial embolization (TAE) should be selected next. TAE reportedly achieves a high hemostasis rate. However, complications such as subsequent endometrial hypoplasia, menstruation disorder, infertility, placenta accreta, and uterine rupture have been reported, even in cases that have undergone successful hemostasis with TAE using an absorbable embolus. Recently, a minimally invasive hemostatic strategy in obstetrics, which aims to preserve uterine function and enhance the safety of subsequent pregnancies, has been developed. Therefore, we should reconsider uterus-preserving hemostatic strategies for critical hemorrhage and management of non-tubal ectopic pregnancy under these circumstances by using safe and minimally invasive treatment modalities.
Part of the book: Non-tubal Ectopic Pregnancy