POSTPARTUM HAEMORRHAGE STEPS TO AVOID HYSTERECTOMY

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POSTPARTUM HAEMORRHAGE STEPS TO AVOID
HYSTERECTOMY

• S.ARULKUMARAN
• Professor Head, Department of Obstetrics
  Gynaecology, St.Georges Hospital Medical School,
  University of London

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PPH - Old problem - new thoughts

• PG potentiates the action of oxytocin
• Tamponade test - Therapeutic Diagnostic
• Uterine Compression Sutures
• Severe Shock Golden Hour - Definitive Surgery
• Body weight Blood volume Hb
• Wash Out phenomenon - fibrinogen/
  r-Factor VII

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PPH - Emergency that kills(5th commonest cause
CIMD)

• Anticipate - high risk cases (e.g. twins,
  polyhydramnios, long labour, fibroids, APH,
  infection, past H/O PPH, retained tissue etc.)
• Prevent - Prophylactic oxytocics (e.g.
  Syntometrine, syntocinon, ergometrine,
  misoprostol)
• Manage - promptly - 90 uterine atony - 8 trauma
  and 2 coagulation disorders (e.g. Atony -
  Oxytocin infusion 40 units in 500ml - 80 mu/min
  -20 drops in a 20 drops/ml giving set)

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Prostaglandin potentiates the action of oxytocin

• Stepwise quick progression - syntometrine/ergometr
  ine/oxytocin infusion/prostaglandins
  IVIMIntraMyometrial
• Use misoprostol 400 ug rectally /orally whilst
  using oxytocin infusion

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Large bore IV cannulas (gauge 14 x 2) Crystalloids
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Emergency protocols
Endotracheal tube Laryngoscope
Essential drugs
Emergency Trolley
Crystalloids, giving sets, haemacel
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MANUAL REMOVAL OF PLACENTA
External hand steadies the uterine fundus
Uterus
Placenta
Internal hand along plane of cleavage
Anaesthesia Antibiotics IV line Oxytocics
Check placenta is complete Check the uterus is
empty Check for trauma of GT
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TAMPONADE TEST Therapeutic Prognostic For
severe PPH
Stomach balloon
Oesophageal balloon
Condous G, Arulkumaran S et.al. Obstetrics
Gynecology. 2003
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The Tamponade Test

• Therapeutic - No further intervention (14/16)
  Continue oxytocin infusion for 12 hrs, small
  vaginal pack, IV antibiotics, check fundal
  height, bleeding pv.
• Prognostic - No need to do a laparotomy - answer
  known in few minutes

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COMPRESSION SUTURESQuick, safe and effective

• B-Lynch
• Horizontal full thickness sutures
• Vertical full thickness sutures
• Square sutures
• Combination of sutures

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B-Lynch Suture
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COMPRESSION SUTURES
Cornu
Fallopian tube
Ovary
Hayman R, Arulkumaran S, Steer P Obstetrics
Gynecology. 2002
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Placental bed haemorrhage

• Through and through figure of eight or transverse
  sutures involving full thickness of the uterine
  wall
• Infiltration of placental bed with
  vasoconstrictors
• Hot packs and pressure

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COMPRESSION SUTURES
Vertical Compression Sutures
Horizontal Compression sutures
Hayman R, Arulkumaran S, Steer P Obstetrics
Gynecology 2002.
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• Combination of Compression Suture and the
  Tamponade

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LIGATION OF UTERO-OVARIAN VESSELS
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LIGATION OF UTERINE VESSELS
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LIGATION OF ANT.BRANCH OF INTERNAL ILIAC ARTERY
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• RADIOLOGICAL INTERVENTION EMBOLISATION

Point of ILA ligature
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PPH Coagulation disordersWash Out Phenomenon

• DIVC- FDP inhibits clotting
• Washout phenomenon - the coagulation factors
  are consumed and washed out at the site of
  bleeding
• The washout is the major phenomenon that
  prevents arrest of haemorrhage

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Reason for excessive uncontrolled bleeding

• Consumption coagulopathy
• Excessive fibrinolysis -
• Dilutional coagulopathy - haemodilution
• Hypothermia slow enzymatic process of
  cl.cascade imp.pl.let function
• Multitransfusion syndrome Depleted pl.lets and
  clotting factors
• Metabolic changes acidosis citrate

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Clinical classification of hypovolaemic shock

• Mild Shock - upto 20 blood volume loss
• Decreased perfusion of nonvital organs and
  tissues (skin, fat, skeletal muscle and bone)
• Pale cool skin, patient complains of feeling
  cold.

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Moderate Shock - 20-40 blood volume loss

• Decreased perfusion of vital organs (liver, gut,
  kidneys)
• Oliguria to anuria and slight to significant drop
  in blood pressure, mottling in extremities
  especially legs

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Severe Shock40 or more blood volume loss

• Decreased perfusion to heart and brain
• Restlessness, agitation, coma, cardiac
  irregularities, ECG abnormalities and cardiac
  arrest

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Haemorrhagic Shock

• Severe acute loss of blood produces failure of
  cardiovascular support for the bodys metabolic
  needs.
• Body weight - Blood loss - Shock
• Bodyweight in Kg /12 Blood volume in litres.
  E.g. 48 kg 4 L 84 kg 7 L
• 40 blood loss causes severe shock. 1.5 L blood
  loss may produce severe shock in a 48 Kg and mild
  shock in a 84 Kg lady

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THE GOLDEN HOUR

• As more time elapses between the point of severe
  shock and the start of resuscitation, the
  percentage of surviving patient decreases
• The Golden Hour is the time in which
  resuscitation must begin to achieve maximum
  survival

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PPH - Aggressive Surgery

• Systolic BP lt 70 mm Hg especially if there is no
  diastolic component
• Cold pale extremities/ pale conjunctiva
• Failure to raise BP despite infusion with
  crystalloids and blood
• Continuous blood loss despite medication
• Confused, coma, airhunger, ECG changes. Poor
  urinary output (takes time to establish)

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Subtotal or Total Hysterectomy

• Severe hypotension gt 20 to 30 min
• Continued blood loss (espgt3 L) despite other
  surgical measures (Int.iliac, uterine,
  infundibulo pelvic vessel ligatures)
• Inadequate response to blood replacement
• ECG changes
• Placenta praevia/acreta with bleeding
• DIVC/ washout phenomenon with difficulty in
  getting clotting factors /- clinical picture

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PPH - New thoughts ALGORITHM FOR ACTION

• Oxytocin infusion Misoprostol p.r/p.o
• Parenteral PG
• Tamponade test
• Compression sutures -Tamponade gtligation of
  vessels gt Hysterectomy
• Clotting factors - fibrinogen, Factor VII a
• Aggressive surgery (Degree of shock - Golden
  hour)
• Blood (blood products) replacement - start early
  and in adequate quantities
• ( Shock lung syndrome ARDS blood
  without leucocytes)

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Maternal mortality due to PPH

• CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS
• TOO LITTLE TOO LATE
• Too Little (IV fluids, oxytocics, BLOOD, Clotting
  factors)
• Too Late (PG, resuscitation - blood replacement,
  decision for surgery to get senior surgeon
  anaesthetist involved)

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