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Holding the uterine cervix may induce uterine contractions in atonic bleeding

2011; Informa; Volume: 90; Issue: 12 Linguagem: Inglês

10.1111/j.1600-0412.2011.01233.x

1600-0412

Shigeki Matsubara, Tomoyuki Kuwata,

Pregnancy-related medical research

Sir, A textbook (1) describes a balloon catheter for atonic bleeding in the category of uterine packing. Previous reports regarding this issue indicated that hemostasis can be induced by the compression of the bleeding surface by balloon catheter. Is hemostasis brought about only by this mechanism? We read with interest the article by Yorifuji et al. (2). A balloon catheter, even though it was placed in the cervix and thus did not directly compress the uterine body lumen (bleeding surface), stopped the atonic bleeding. Acoustic radiation force impulse elastography showed an increased uterine consistency after balloon insertion, suggesting that the balloon stopped bleeding via induction of uterine contractions. This notion is new and agrees with our experience. As previously described (3), we have a departmental treatment protocol for atonic bleeding. Both the anterior and posterior cervices are held using conventional cervix-holding forceps, the kind usually employed for the repair of cervical laceration (3,4). Thus, with the cervix closed and the bleeding unable to exit, the hemorrhage remains within the uterus. During the past 10 years, we have performed this cervix-holding technique in approximately 200 cases of postpartum hemorrhage (mainly atonic bleeding) and, with the exception of three cases, all had hemostasis without further procedures (3). Some women had emergency postpartum hysterectomy without receiving cervix-holding and we did not use a balloon catheter during this period. Thus, it is unclear whether all atonic bleeding cases are candidates for this technique or whether this technique provides better hemostasis than balloon catheter insertion. However, it is noteworthy that almost all those who we believed would achieve hemostasis with this technique, actually achieved it. At first, we believed that intrauterine blood compressed the bleeding surface, leading to hemostasis. Later we found that the uterine body becomes contracted immediately after holding the cervix. Combining the findings of Yorifuji et al. (2) with our observation, we believe that although compressing the bleeding surface may play some roles in hemostasis, ‘holding the cervix’ itself may induce uterine contractions and lead to hemostasis. Mechanical stretching or manipulation of the cervix increases labor uterine contractions: neuronal reflex may partly account for this (5). We agree that uterine contractions may be regulated by different mechanisms before vs. after delivery. However, it might be reasonable to assume that manipulation of the cervix may also induce uterine contractions in postpartum uterus in atonic bleeding. The cervix-holding technique, a non-intrauterine maneuver, is manageable by non-experienced physicians. The cervix-holding is free from a troublesome phenomenon observed in balloon catheter insertion, namely the prolapse of the balloon out of the cervix. Considering that atonic bleeding can occur in postpartum women who previously had an uneventful course, non-obstetric specialists must be prepared to deal with this disorder. We believe that the cervix-holding technique may be an ‘everybody, and even non-specialist, manageable’ technique of hemostasis for atonic bleeding. This technique may also be a treatment option while waiting for transfer. Further study is needed to confirm our observation.