Hemorrhage is a well-known complication of hysterectomy, especially during radical gynecologic oncology and emergency obstetric procedures. Postpartum hemorrhage complicates 4% of vaginal births1 and 6% of cesarean deliveries2 and leads to emergency hysterectomy in 0.35 per 1,000 births.3 Hemorrhage remains one of the top etiologies of maternal mortality in the United States,4 the United Kingdom,5 and particularly, developing countries.6 Rates of maternal mortality after emergency obstetric hysterectomy have been reported at 1.6–4.0% in industrialized countries and 13.6% in developing nations.3,7,8
Posthysterectomy bleeding may occur, even with secure surgical pedicles, in the setting of acquired coagulopathy from massive bleeding. In 1926, Logothetopoulos described a pack for the management of uncontrolled pelvic bleeding, which has subsequently been called the “mushroom,” “parachute,” “umbrella,” “pelvic pressure,” or “Logothetopoulos” pack.9 This technique is well-known in the authors' institutions and has been used for refractory cases of severe posthysterectomy hemorrhage. The purpose of this paper is to describe 11 previously unreported cases of use of the pelvic pressure pack at our facilities (five hospitals in four states) between the years 1968 and 2006.
MATERIALS AND METHODS
This is an observational descriptive report of 11 surgical cases performed by the authors between 1968 and 2006, with a review of the contemporary published literature. Previously published cases were identified by performing a MEDLINE search (through July 2006) with focus upon terms for hemorrhage (“hysterectomy & hemorrhage,” “postpartum hemorrhage”), synonyms for the pack (“parachute pack,” “mushroom pack,” “umbrella pack,” “Logothetopoulos pack,” “pelvic pressure pack”), and other combinations of search terms (“hemorrhage & pack” and “hysterectomy & pack”). The bibliographies of these references were reviewed to identify other published cases.
The new cases in this series were obtained by individual recollection and retention of copies of old records by the authors. The patient records were abstracted and de-identified for this report. Some desired variables are not described because, in some cases, of incomplete medical records that are no longer available or existent. The Louisiana State University Health Sciences Center Institutional Review Board (IRB) determined that this project was exempt from IRB approval or oversight. Statistical analysis (confidence intervals for binomial proportions) was performed with True Epistat 5.3 (Epistat Services, Richardson, TX).
The pack is constructed (Fig. 1) by filling a sterile bag (eg, X-ray cassette drape) with gauze rolls tied end-to-end (in this case, five 11.4 cm × 2.8 m Kerlix rolls; Tyco Healthcare, Mansfield, MA), starting at the “dome” of the pack (A), with the “tail” of the gauze protruding from the “neck” of the pack (B–D). The index finger indicates the inferior extent of the pack at D. The pack should have a slick surface, so if gauze is used instead of plastic as the external veil, it should be covered with a sterile lubricating substance such as lubricating jelly, to avoid adhesion, which could incite bleeding during removal. We prefer using an X-ray cassette drape (a sterile polyethylene bag for surgical procedures that require a nonsterile X-ray cassette to be used in the sterile field), which is readily available in all hospitals. The pack is introduced transabdominally into the pelvis, and the “neck” is delivered transvaginally through the introitus by passing a surgical clamp through the vagina, thus grasping the “neck” of the pack (D). Care is taken to avoid trapping small bowel behind the pack. Traction to the pack is applied by tying intravenous tubing (F) to the neck of the pack (C) and suspending a one-liter intravenous fluid bag (G) off the foot of the bed. This can also be accomplished by attaching the pack to a cord over an orthopedic pulley from the foot of the bed, with the patient in Trendelenburg position. Compression can also be maintained by placing the “neck” through a Number 80 doughnut pessary (not shown), applied flush against the perineum with a surgical clamp, but care must be taken to avoid pressure necrosis. A large-gauge, closed-system drain (eg, Jackson-Pratt) is placed in the peritoneal cavity to monitor for postoperative bleeding. An indwelling urinary catheter is placed to monitor urine output and avoid outflow obstruction. After stabilization of the patient (correction of coagulopathy, anemia, hypovolemia, acidosis), an attempt to remove the pack transvaginally is made by first removing the gauze rolls (E), under intravenous sedation. The gauze within the veil can be removed slowly and intermittently, usually about 24–72 hours postoperatively, to allow gradual decompression without causing bleeding. In some cases, the pack will have to be removed by relaparotomy or with laparoscopic assistance.
We report 11 new cases, 10 involving obstetric patients and one involving a gynecologic patient (Table 1). All patients experienced continuing hemorrhage despite having undergone hysterectomy. In half of our cases, other surgical options such as hypogastric artery ligation had failed. Selective arterial embolization was not used in any of our cases, either before or after pelvic packing. In some cases we could establish the minimum number of erythrocyte transfusions, as records were not always complete. Massive red cell transfusion (range 7 or more to 77 or more units) was required in all cases. Coagulopathy was documented in all cases where complete laboratory data were available, with a range of platelet count nadir between 15 and 73×103/μL. The pelvic pressure pack was successful (defined as being the final medical or surgical therapeutic maneuver for control of severe bleeding) in 9 of 11 (82%, 95% confidence interval [CI] 48–98%) of cases. In the two unsuccessful cases where further surgical intervention was required, vaginal lacerations were an accompanying feature. Case 4 responded to repeat laparotomy, ligation of the bleeding point, and placement of a vaginal pack. Case 6 had previously not responded to a vaginal pack, but was ultimately controlled by hypogastric artery ligation. In case 1, two pelvic pressure packs were placed. The first pack was constructed from a pillowcase, and bleeding recurred after the pack was removed, perhaps due to adhesion of the pack to pelvic tissues. The second pack was made from polyester and was removed without problems. Postoperative febrile morbidity occurred in all but one case and there were no maternal deaths.
In 1926, Logothetopoulos described a pack for controlling severe pelvic hemorrhage, which was stated to never fail, although the specifics were not described in the manuscript.9 The pelvic pressure pack controls hemorrhage from large raw surfaces, venous plexuses, and inaccessible areas.10 It has been proposed that the pack effects hemostasis by exerting “well-distributed pressure over potential bleeding areas by compressing them against the bony and fascial resistance of the pelvis.”11 Presumably, in the setting of severe coagulopathy, this pressure prevents further bleeding pending restoration of the coagulation system. During the 1920s to the 1950s, there were several references to the pelvic pack in French and German medical journals. The first reported case series in the English literature appeared in the 1960s for management of gynecologic posthysterectomy bleeding complications.10,11 Several single case reports for obstetric posthysterectomy bleeding have since been published.12–15 Since Logothetopoulos' 1926 paper, only six publications in English containing 26 cases were identified before this series (Table 2). Of these 26 cases, 22 involved gynecology patients and 4 involved obstetric patients who experienced posthysterectomy bleeding. Pelvic pressure pack cases reported in the literature thus far have been uniformly successful in controlling hemorrhage. Including our series, there are now 23 cases of the pack reported for control of gynecologic posthysterectomy hemorrhage and 14 cases for obstetric posthysterectomy hemorrhage, with success rates of 100% and 86%, respectively (Table 2). Although it must be recognized that accurate success rates are difficult to determine based on such rare cases collected retrospectively, successful control of hemorrhage is achieved in the vast majority of cases, based upon the published literature and the authors' collective experience. Publication bias must, however, be considered because it is unlikely that failed cases are as readily reported as successful ones.
Febrile morbidity is the rule in these critically ill, postoperative patients, who have a foreign body intentionally placed in the setting of a contaminated operative field. Sources of infection in our series included urinary tract infection, parametritis, wound infection, intraperitoneal abscess, unknown sources, and generalized sepsis. Some postoperative febrile morbidity may have been related to transfusion, but diagnosis of specific infections was common. Thus, we would recommend prophylactic broad-spectrum antibiotic administration when a pelvic pack is employed. Major bowel complications such as necrosis or evisceration did not occur in our series.
The pelvic pressure pack described herein should not be confused with uterine packing (the intact uterus is packed),16 abdomino-pelvic packing with a bowel bag (which requires relaparotomy in most cases),17 abdomino-pelvic packing with free lap packs (which always requires relaparotomy),18 or the recently described abdomino-pelvic packing with ribbon gauze through a Penrose drain.19
In summary, the pelvic pressure pack is quite simple to construct from commonly available medical materials, and control of hemorrhage is achieved in the majority of cases. When the pelvic pressure pack fails to control bleeding, other medical (eg, recombinant factor VIIa), surgical (eg, hypogastric artery ligation), or interventional radiology approaches (eg, selective arterial embolization) will be necessary to ultimately control hemorrhage. The pelvic pressure pack should be particularly useful in developing countries where more advanced surgical skills for ligating pelvic vessels and technologies such as selective arterial embolization are not available. In industrialized nations, the pelvic pressure pack may be a temporizing measure pending transport to a tertiary care facility. In the majority of cases, the pelvic pressure pack will afford transfer of the critically ill patient to a postsurgical recovery setting, where stabilization of hemodynamic, hematologic, and metabolic parameters can be accomplished. We believe all obstetrician-gynecologists should be familiar with this simple, potentially lifesaving technique.
1. Combs CA, Murphy EL, Laros Jr. RK. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:69–76.
2. Combs CA, Murphy EL, Laros RK Jr. Factors associated with hemorrhage in cesarean deliveries. Obstet Gynecol 1991;77:77–82.
3. Wen SW, Huang L, Liston R, Heaman M, Baskett T, Rusen ID, et al. Severe maternal morbidity in Canada, 1991-2001. CMAJ 2005;173:759–64.
4. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, et al. Pregnancy-related mortality surveillance–United States, 1991–1999. MMWR Surveill Summ 2003;52:1–8.
5. de Swiet M. Maternal mortality: confidential enquiries into maternal deaths in the United Kingdom. Am J Obstet Gynecol 2000;182:760–6.
6. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367:1066–74.
7. Ezechi OC, Kalu BK, Njokanma FO, Nwokoro CA, Okeke GC. Emergency peripartum hysterectomy in a Nigerian hospital: a 20-year review. J Obstet Gynaecol 2004;24:372–3.
8. Kwee A, Bots ML, Visser GH, Bruinse HW. Emergency peripartum hysterectomy: a prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 2006;124:187–92.
9. Logothetopulos K. Eineabsolut sichere blutstillungsmethode bei vaginalen und abdominalen gynakologischen operationen. Zentralbl Gynakol 1926;50:3202–4.
10. Burchell RC. The umbrella pack to control pelvic hemorrhage. Conn Med 1968;32:734–6.
11. Parente JT, Dlugi H, Weingold AB. Pelvic hemostasis: a new technic and pack. Obstet Gynecol 1962;19:218–21.
12. Cassels JW Jr, Greenberg H, Otterson WN. Pelvic tamponade in puerperal hemorrhage: a case report. J Reprod Med 1985;30:689–92.
13. Robie GF, Morgan MA, Payne GG Jr, Wasemiller-Smith, L. Logothetopulos pack for the management of uncontrollable postpartum hemorrhage. Am J Perinatol 1990;7:327–8.
14. Hallak M, Dildy GA 3rd, Hurley TJ, Moise KJ Jr. Transvaginal pressure pack for life-threatening pelvic hemorrhage secondary to placenta accreta. Obstet Gynecol 1991;78:938–40.
15. Howard RJ, Straughn JM Jr, Huh WK, Rouse DJ. Pelvic umbrella pack for refractory obstetric hemorrhage secondary to posterior uterine rupture. Obstet Gynecol 2002;100:1061–3.
16. Maier RC. Control of postpartum hemorrhage with uterine packing. Am J Obstet Gynecol 1993;169:317–21;
17. Finan MA, Fiorica JV, Hoffman MS, Barton DP, Gleeson N, Roberts WS, et al. Massive pelvic hemorrhage during gynecologic cancer surgery: “pack and go back”. Gynecol Oncol 1996;62:390–5.
18. Ghourab S, Al-Nuaim L, Al-Jabari A, Al-Meshari A, Mustafa MS, Abotalib Z, et al. Abdomino-pelvic packing to control severe haemorrhage following caesarean hysterectomy. J Obstet Gynaecol 1999;19:155–8.
19. Awonuga AO, Merhi ZO, Khulpateea N. Abdominal packing for intractable obstetrical and gynecologic hemorrhage. Int J Gynaecol Obstet 2006;93:160–3.