CASE REPORT

Transvaginal tamponade for intra-operative pelvic haemorrhagein gynaecological oncology patients

Lisa Wong, Sridevi Rao, Desmond P.J. Barton*

Case 1

A 69 year old woman with FIGO Stage IIA squamous cell

carcinoma of the cervix underwent a radical hysterectomy,

bilateral salpingo-oophorectomy and bilateral pelvic lymph

node dissection. Persistent heavy bleeding was encountered

from the right pelvic side wall despite ligation of the right

internal iliac artery. The patient became hypotensive and

developed a coagulopathy. The pelvis was packed with five

large abdominal packs tied end to end and placed in a sterile

bowel bag (‘Vi-Drape’ Isolation Bag, Medical Concepts

Development, St Paul, Minnesota, USA) and the tapered

end of the bag was brought out through the vagina and

through a ring pessary and the purse-string tightened. A

Roberts clamp was placed at the distal end of the pack across

the ring pessary to provide tension on the bowel bag and its

contents and to prevent retraction (Fig. 1). The abdomen was

closed and the patient returned to the High Dependency Unit.

The estimated intra-operative blood loss was 5 L and the

patient received 12 units of packed red blood cells and fresh

frozen plasma intra-operatively. Two days later when the

patient was stable and the coagulopathy had been corrected,

the pelvic packs and then the bowel bag were removed

transvaginally under general anaesthesia (Fig. 2). After a

10 minute period of observation when the vital signs were

stable and there was minimal blood loss, the patient was

returned to the High Dependency Unit. She made an

uneventful recovery and is now alive and well.

Case 2

A 67 year old woman with a large pelvic recurrence of

FIGO Stage IB endometrioid adenocarcinoma of the ovary

underwent an exploratory laparotomy, optimal cytoreduc-

tion of the pelvic mass and an infracolic omentectomy. The

tumour mass was adherent to the rectosigmoid colon, the

bladder, the pouch of Douglas and the pelvic side walls.

There was continuous heavy bleeding from the tumour bed

and a bilateral internal iliac artery ligation was performed.

However, the bleeding persisted and the pelvis was packed

with three large laparotomy packs tied together and placed

in a bowel bag and delivered through the vagina (as

described above). The abdomen was then closed. The

estimated blood loss was 12 L. She received 20 units of

packed red blood cells, fresh frozen plasma, cryoprecipitate

and platelets and was transferred to the High Dependency

Unit and kept intubated. The next day, the pelvic packs and

the bowel bag were removed transvaginally under general

anaesthesia. There was no subsequent bleeding and the

patient was returned to the high dependency unit. She

required a further six days in the high dependency unit

because of respiratory problems. She subsequently made an

uncomplicated recovery and is alive and well.

Case 3

A 42 year old woman underwent a radical hysterectomy

and bilateral salpingo-oophorectomy and a bilateral pelvic

lymph node dissection for FIGO Stage IB adenocarcinoma

of the cervix. After completion of the procedure, there was

a sudden 2 L blood loss from lateral to the right cardinal

ligament. Despite packing the pelvic side wall with large

abdominal packs, the bleeding continued when pressure

was released and a profound coagulopathy ensued. Three

large packs were placed into a bowel bag and the drawn

closed ends of the bag passed out through the vaginal vault

(as described above). The abdomen was then closed. The

estimated blood loss was 4 L. Intra-operatively, the patient

received seven units of packed red blood cells, seven units

of fresh frozen plasma and platelet transfusions, and was

transferred to the high dependency unit. The next day,

when the coagulation profile was stable, the packs and

bowel bag were removed vaginally under general anaes-

thesia. Slight bleeding was noted to be coming from the

edge of the vaginal vault, which was then sutured. The

patient made an uneventful recovery and is alive and well.

BJOG: an International Journal of Obstetrics and GynaecologyJuly 2003, Vol. 110, pp. 707–709

D RCOG 2003 BJOG: an International Journal of Obstetrics and Gynaecology

PII: S 1 47 0 - 0 3 2 8 ( 0 3 ) 0 2 6 63 - 6 www.bjog-elsevier.com

Division of Gynaecological Oncology, Department of

Obstetrics and Gynaecology, St George’s Hospital,

London, UK

* Correspondence: Dr D. P. J. Barton, Department of Obstetrics and

Gynaecology, St George’s Hospital, Blackshaw Road, London SW17 0RE,

UK.

Discussion

The pelvis has an extensive, bilateral and collateral

circulation, and although the arterial tree has few varia-

tions, the venous system is highly variable1. Pelvic haem-

orrhage during gynaecological surgery can be arterial or

venous, and the latter is often the more difficult to control.

Massive blood loss can lead to substantial morbidity such

as disseminated intravascular coagulation, renal failure,

adult respiratory distress syndrome, and can have fatal

consequences. Serious pelvic haemorrhage can be com-

pounded by operator indecision and delay, placement of

blind and deep sutures in the pelvis and difficulty with

surgical access. Arguably, an important factor aggravating

pelvic haemorrhage is delay in pelvic packing and main-

taining tamponade to the bleeding site(s).

Standard surgical principles for securing haemostasis

involve identification of the bleeding vessel and ligation

of, or suturing of, the bleeding pedicle. Adequate lighting

and exposure are prerequisites and additional help may also

be required. Smaller vessel haemorrhage can be controlled

with the use of titanium surgical clips and diathermy. In

most cases, these simple measures are sufficient for arrest-

ing the blood loss. However, when these measures fail, then

ligation of the internal iliac artery(s) may be necessary1. If

this fails, as in two of the cases described, pelvic packing is

a well-established method to control persistent and life-

threatening venous bleeding when the source cannot be

identified accurately, when haemorrhage continues and

coagulopathy develops. We have described the use of a

pelvic pack delivered transvaginally to successfully provide

pelvic tamponade and arrest the haemorrhage.

The pelvic pack was first described by Logothetopulos in

19262. He proved the effectiveness of sustained pelvic

pressure in arresting bleeding by performing a hysterec-

tomy without ligating vessels and inserting a pack into the

pelvis. The classical Logothetopulos pack is a mushroom-

shaped dressing with an umbrella, or parachute, surround-

ing the mushroom of tamponading gauze3. The pack is then

inserted into the pelvis and the tail is grasped through the

vagina from below with the use of forceps. The tails are

secured by passing them through a ring pessary, thus

providing traction4. Since then, variations of the pelvic

pack for securing haemostasis have been described1,3 – 9.

Some have used large gauze pressure packs tied end to end

Fig. 1. Bowel bag brought through the vaginal vault and through a ring

pessary at the introitus. To prevent retraction of the pack and its contents

and to maintain pelvic tamponade, a surgical clamp grasps the end of the

bowel bag and is placed across the ring pessary.

Fig. 2. The surgical clamp and ring pessary have been removed. The purse-

string of the end of the bowel bag is opened and the packs removed one by

one. The bowel bag is then removed.

CASE REPORT708

D RCOG 2003 Br J Obstet Gynaecol 110, pp. 707–709

and inserted into the pelvis with the tail of the last pack

passed through the vagina5. The three cases underwent

pelvic surgery for gynaecologic cancer, which can be

associated with pelvic haemorrhage6. Bleeding can also

be difficult to control when it occurs from multiple sites of a

tumour bed and from venous plexuses3. Surgery is also

hampered when the bleeding points are at inaccessible sites

of the pelvis or abdomen and when disseminated intra-

vascular coagulation develops. In such situations, timely

intra-operative decisions are crucial in determining when to

stop attempts at securing haemostasis by surgical means

and when to use pelvic packing.

We used a sterile bowel bag and large moist pressure

packs with their ends tied end to end. These packs and the

bowel bag were then removed vaginally within 48 hours

when the patient was haemodynamically stable and with a

stable coagulation profile. The patients were then observed

for 10 minutes to determine whether there was further

bleeding which might warrant a further laparotomy, which

none of the cases described required. We believe the tech-

nique we describe has several advantages 1. It is simple and

easy to perform. 2. The bowel bag is inert and in our expe-

rience is not associated with adhesion formation, so that its

removal is less likely to disturb recently formed thrombi

(further bleeding is often provoked when abdominal/pelvic

packs placed at the site of bleeding are removed). When we

have used abdominal packs to control haemorrhage (for

example, when the vagina is not open) we have also placed

the abdominal packs inside a bowel bag. 3. Packs placed in

the pelvis through the abdominal route may fail to provide

sustained tamponade once the abdomen is closed (although

closure itself may provide some measure of tamponade).

When the abdomen is opened to retrieve the packs, which are

often loosely applied to the bleeding area, further packing

may be required. Finan et al.6 have described a means of

applying and maintaining tamponade transabdominally for

pelvic haemorrhage. In contrast, the technique in our three

cases provides continued tamponade to the pelvis. 4. It is not

necessary to open the abdomen to remove the packs. Argu-

ments that there may be concealed haemorrhage with trans-

vaginal removal are not supported by our experience. If the

vagina is not open, then the choice is to open the vagina

(which may not be practical) or to place the packs in a bowel

bag and close the abdomen.

Some complications have been reported with the use of

the pelvic pack although we did not experience these in our

patients. For example, infection can occur with the intro-

duction of a foreign body into the pelvis6. However, this

does not pose a great problem as the patients are main-

tained on intravenous antibiotics until after the packs are

removed. In our practice, the packs are isolated in the

bowel bag, which may reduce the inflammatory response. It

has been reported that the tied ends of the gauze packs can

be tangled up and removing them can cause disruption of

the clots resulting in further bleeding but this does not

occur when the ends of the packs are tied together and a

bowel bag is used3. Other complications reported include

neuropathy as a result of nerve compression or ischaemia

and acute renal failure arising from excessive compression

of the inferior vena cava—although these problems rarely

develop if the pack is removed within 24–48 hours5,6.

In summary, persistent and large intra-operative pelvic

haemorrhage can be managed successfully by transvaginal

tamponade using pelvic packs placed inside a bowel bag,

delivered through the vagina and secured in position. We

believe this method has a number of advantages over the

traditional abdominal route of placing pelvic packs.

References

1. Agostini A, Mazza D, Bereder JM. Value of pelvic tamponade in

persistent haemorrhage after haemostasis hysterectomy. Gynecol

Obstet Fertil 2001;29:613– 615.

2. Logothetopulos K. Eine absolut sichere Blutstillungsmethode bei

vaginalen und abdominalen gynakologischen Operationen. Zentralbl

Gynakol 1926;50:3202.

3. Burchell CR. The Umbrella pack to control pelvic haemorrhage. Conn

Med 1968;32:734– 736.

4. Cassels Jr JW, Greenberg H, Otterson WN. Pelvic tamponade in puer-

peral haemorrhage: a case report. J Reprod Med 1985;30:689– 692.

5. Edwards WR. Hysterectomy, massive transfusion and packing to con-

trol haemorrhage from pelvic veins in the course of bilateral oopho-

rectomy. Aust N Z J Obstet Gynaecol 1996;36:82– 84.

6. Finan MA, Fiorica JV, Hoffman MS, et al. Massive pelvic haemor-

rhage during gynaecologic cancer surgery: ‘Pack and go back’. Gynecol

Oncol 1996;62:390 –395.

7. Hallak M, Dildy III GA, Hurley TJ, Moise Jr KJ. Transvaginal pres-

sure pack for life-threatening pelvic haemorrhage secondary to pla-

centa accreta. Obstet Gynecol 1991;78:938– 941.

8. Robie GF, Morgan MA, Payne Jr GG, Wasemiller-Smith L. Logothe-

topulos pack for the management of uncontrollable postpartum haem-

orrhage. Am J Perinatol 1990;7:327– 328.

9. Shen GK, Rappaport W. Control of nonhepatic intra-abdominal hae-

morrhage with temporary packing. Surg Gynecol Obstet 1992;174:

411– 413.

Accepted 6 February 2003

CASE REPORT 709

D RCOG 2003 Br J Obstet Gynaecol 110, pp. 707–709