Pph drill

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Pph drill

  1. 1. Dr. Monika Madaan Specialist Dept. Of Obstetrics & Gynaecology ESI Hospital Manesar
  2. 2. PPH Single most important cause of maternal mortality worldwide. Accounts for 34% of maternal deaths in developing countries.
  3. 3. Definition Any blood loss than has potential to produce or produces hemodynamic instability
  4. 4. Definition Blood loss > 500 ml after delivery Primary : Loss within 1st 24 hours after delivery Secondary : 24 hours till 12 weeks postnatally Minor : 500-1000 ml Moderate : 1000-2000 ml Severe : > 2000 ml
  5. 5. PREDICTION AND PREVENTION - Pl previa/accreta - Anticoagulation Rx - Coagulopathy - Overdistended uterus Identify pt. at risk - Grand multiparity - Abn labor pattern - Chorioamnionitis - Large myomas - Previous history of PPH
  6. 6. PREDICTION AND PREVENTION Active Management Of Third Stage Of Labor (AMTSL): Should be offered routinely and includes: 1.Administration of uterotonics soon after birth. 2.Delayed cord clamping. 3.Delivery of placenta by controlled cord traction followed by uterine massage.
  7. 7. PPH Drill Clear and logical sequence of steps essential in the management of PPH.
  8. 8. CALL FOR HELP
  9. 9. Team Effort •Skilled Obstetric Team •Trained Anaesthesiologist •Clinical hematologist •Supporting staff
  10. 10. Resuscitation Assess A : Airway B : Breathing C : Circulation  Secure 2 wide bore i.v. lines:- 14-16 gauge  Draw blood for grouping & cross matching, CBC, LFT/KFT, SE & Coagulogram.
  11. 11. Position flat Keep the patient warm Administer oxygen by mask ( @ 10-15 litres/ min) Catheterize the patient for emptying bladder & monitoring output
  12. 12. Fluid Replacement RAPID WARMED infusion of fluids Crystalloids : Fluids of choice until compatible blood is arranged 1 ml of blood loss= 3 ml of crystalloids Total volume of 3.5 litres of clear fluids (upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood.
  13. 13. If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given
  14. 14. FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal (ie 12-15 ml/kg or total of 1 litres.) Platelet Concentrate: if Platelet count< 50,000/ microlitre. Cryoprecipitate: if fibrinogen < 1 g/ l.
  15. 15. Continuous vital monitoring. Monitor adequacy of replacement with urine output (0.5 ml/kg/hr) and CVP (4-8 cm water) Main therapeutic goals are to maintain: Haemoglobin > 8gm/dl Platelet count > 75 × 109 / l Prothrombin < 1.5 × mean control APTT < 1.5 × mean control Fibrinogen > 1 gm/ l
  16. 16. Establish Etiology Simultaneously 4 T’s Tone (abnormalities of uterine contraction) : 70 – 80% Trauma (of the genital tract) : 20 % Tissue (retained products of conception) : 10 % Thrombin (abnormalities of coagulation) : 1 %
  17. 17. Contd…
  18. 18. Bimanual Compression If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions
  19. 19. Administer Uterotonic Drugs FIRST LINE Oxytocin: Start with 5 units slow iv or im. Infusion of 20 units in 1 L@ 60 dr/min. Continue same dose @ 40 dr/min until bleeding stops. Maximum upto 3 L. SECOND LINE Ergometrine/ methyl ergometrine: Dose: 0.2 mg im or slow iv Repeat 0.2 mg after 15 min. Maximum 5 doses (1 mg) Syntometrine im
  20. 20. THIRD LINE PGF 2α: Dose: 0.25 mg im. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. Misoprostol: 200-800 µg sublingually. Do not exceed 800 µg WHO GUIDELINES FOR MANAGEMENT OF PPH 2009
  21. 21. Uterine Tamponade • Bakri balloon • Sengstaken Blakemore oesophageal catheter • Condom catheter • Urological Rusch balloon Success depends upon Positive Tamponade test
  22. 22. insertion Initial Assembly  Condoms-2  Foley’s catheter-no.16  Saline with iv set  Speculum  Sponge holding forceps
  23. 23. Procedure Lithotomy position Indwelling Foley’s catheter. Explore uterus, cervix and vagina. Inflate balloon with 100300 ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test).
  24. 24. Compression sutures B Lynch Suture •Fundal compression suture •Apposes anterior & posterior wall
  25. 25. Contd… Parallel Vertical compression sutures for placenta praevia
  26. 26. Stepwise Uterine Devascularization •Uterine arteries •Tubal branch of ovarian artery •Internal iliac artery
  27. 27. Uterine Artery Embolization Possible only if internal artery ligation has not been done and facility for interventional radiology available
  28. 28. Hysterectomy Resort to hysterectomy “SOONER RATHER THAN LATER” High maternal morbidity Timing and adequate replacement is of utmost importance
  29. 29. Documentation and Debriefing Important to record: Sequence of events Time and sequence of admn of pharmacological agents, fluids, blood products The time of surgical intervention The condition of mother throughout .
  30. 30. Newer Developments Tranexamic acid : 1 gm i.v slow. Can be repeated after 30 min if bleeding continues./ Recombinant activated factor VII (Novoseven): 90 µg/ kg . May be repeated within 15-30 minutes. No clear consensus on efficacy. Carbetocin (oxytocin agonist) : 100 µg i.v or i.m. Produces tetanic uterine contractions.
  31. 31. HAEMOSTASIS ALGORITHM H – Ask for help A – Assess and resuscitate E – Establish etiology M – Massage the uterus O – Oxytocic administration S – Shift to OT T – Tissue n trauma to be excluded and proceed to tamponade A – Apply compression sutures S – Systematic pelvic devascularisation I – Interventional radiology S – Subtotal or total hysterectomy
  32. 32. To Conclude, Management of PPH Has Evolved From: Panic Panic Hysterectomy  Pitocin  Prostaglandins  Happiness
  33. 33. & ADDRESS 35 , Defence Enclave, Opp. Preet Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092 CONTACT US 011-22414049, 42401339 WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com

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