The most significant cause of maternal death worldwide is severe bleeding. More than half of these deaths occur within 24 hours of delivery, and every year an estimated 140,000 women worldwide die from postpartum hemorrhage. Though several risk factors have been identified for postpartum hemorrhage, it often happens without warning, so obstetric units and physicians must have the equipment, facilities, and personnel in place ready to manage this medical emergency.
Severe postpartum hemorrhage is life-threatening and requires a multidisciplinary approach that takes into account laboratory, clinical, and medical imaging diagnostics. The goal is to not only save the mother’s life, but also to avoid hysterectomy and preserve fertility if possible.
Laboratory blood analysis of indicators like hemoglobin and hematocrit can help in estimating blood losses, but in cases of acute hemorrhage, hours could pass before these levels reflect blood loss and platelet count. Other laboratory studies in cases of postpartum hemorrhage may include coagulation studies, electrolytes, BUN / creatinine, fibrinogen, and liver function tests.
Medical imaging studies used in cases of vaginal bleeding and decreasing red blood counts in postpartum patients typically include ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI).
Ultrasonography for Postpartum Hemorrhaging
Ultrasonography is the first-line medical imaging technique for cases of postpartum hemorrhage. Dedicated pelvic ultrasonography can be performed bedside, and can help in identifying retained placental fragments, intrauterine abnormalities, and hematomas. Doppler ultrasound can be used to identify vascular structures and differentiate between clots and retained placenta fragments. Abdominal ultrasound views can identify fluid in the abdominal cavity that may be the result of a hemorrhage. But while it can detect the presence of fluid in the abdominal cavity, it is not ideal for identifying bleeding into this area. However, although ultrasonography can’t reliably differentiate between blood and fluid, the presence of any fluid in the abdomen warrants further investigation.
Computed Tomography for Postpartum Hemorrhaging
Computed tomography (CT) is a helpful follow-up when ultrasonography is insufficient. CT may also be the first-line imaging study in cases when pelvic hematoma or abscess is suspected, because these may be missed with ultrasonography. Though traditional pelvic CT has not been ideal for study of pelvic structures because of artifacts from the pelvic bones, modern multidetector CT studies do not have this problem. Multidetector CT studies enhanced with intravenous or intra-intestinal contrast can show detail of pelvic hematomas, retained placenta fragments, and cesarean delivery wound rupture.
In cases of postsurgical or intra-abdominal complications, multidetector CT is the initial medical imaging method of choice. It can provide information about the location of bleeding sites and hematomas, and can provide vascular mapping and rule out other causes of postpartum hemorrhage. Three of the most common causes of postpartum hemorrhage are intra-abdominal bleeding, failed embolization of uterine arteries, and incomplete uterine rupture, and multidetector CT can help doctors differentiate between these causes.
Magnetic Resonance Imaging for Postpartum Hemorrhaging
Magnetic resonance imaging (MRI) is time consuming, and so is rarely performed in emergency departments in cases of postpartum hemorrhage. However, it can be used to determine if collected fluid is located inside or outside the uterus in cases where ultrasonography or CT imaging cannot clarify.
In most postpartum hemorrhage cases, the presentation of significant bleeding prompts rapid intervention based on clinical signs rather than documented images, so MRI is not considered a first-line medical imaging technique in these cases. However, MRI can delineate tissue planes and clarify location of bleeding when ultrasonography and CT are unable to do so.
Though these three medical imaging techniques are considered standard in cases of postpartum hemorrhage, sometimes use of other medical imaging technology is dictated by circumstance, as in the following case.
A Case of Life-Threatening Intraoperative Hemorrhage
A woman presented with uncontrollable obstetrical hemorrhage during surgery at Coral Springs Medical Center. Bleeding continued despite multiple surgical maneuvers, as well as blood transfusions, and ultimately a hysterectomy. The radiologist assigned to the case was David H. Ring, Jr., MD, of North Broward Radiology in Fort Lauderdale. Dr. Ring specializes in vascular and interventional radiology.
To determine the location of the bleeding, an intraoperative pelvic angiogram was performed, despite the technical challenge of an operating room that was not set up for angiography. A C-arm fluoroscopy unit was used in the performance of successful embolization at the location of the sources of bleeding, using catheters and guide wires brought in from Interventional Radiography.
Because of the fluoroscopic medical imaging and guidance of the embolization process, the patient’s bleeding was finally controlled. She was then treated and her condition managed in the intensive care unit for several days, and ultimately recovered from what could have been a lethal hemorrhage. This was a clear case of a life being saved due to quick action based on medical imaging technology.
The Challenge of Defining and Managing Postpartum Hemorrhage
Defining postpartum hemorrhage can be complex, because waiting for a patient to meet postpartum hemorrhage criteria can delay intervention, particularly in cases of sudden hemorrhages. The American College of Gynecology (ACOG) says that bleeding with the potential to cause hemodynamic instability if left untreated should be considered postpartum hemorrhage and managed as such. ACOG also recommends that rapid response teams should be designated and trained, and should practice drills and simulations, since successful intervention in these cases requires a carefully choreographed response.
Generally, ultrasonography, computed tomography, and sometimes magnetic resonance imaging are used in locating the source of postpartum bleeding, though the case study described above relied upon fluoroscopic imaging in an intraoperative setting. Regardless, the importance of medical imaging in cases of obstetrical hemorrhage is clearly demonstrated. Severe postpartum hemorrhage is still the leading cause of maternal death throughout the world, and medical imaging has a critical role to play in diagnosing and managing the condition.
SteleRAD’s Role in Medical Imaging
SteleRAD is a Florida radiology practice owned and operated by board-certified radiologists who have been providing medical imaging services for over four decades. SteleRAD has an unparalleled commitment to outstanding services, delivering timely and accurate medical imaging interpretations to hospitals, physician groups, and imaging centers. SteleRAD is also experienced in advanced teleradiology techniques, providing services to facilities across the country. For more information on how SteleRAD can help your practice or facility,contact us online or call (954) 358-5250.
Image credit: arztsamui / freedigitalphotos.net