SURGICAL MANAGEMENT OF PPHAT TERTIARY CENTERPROF. (Dr ) M.C. BansalMBBS, MS , FICOG , MICOG .
Pregnancythe most dangerous journey of mankind…
DefinitionWHO defines PPH as blood loss of more than 500ml following vaginal delivery or more than 1000 mlafter caesarean section. In Asian women even lossof 300 ml can have sinister effect due to smallerbuilt, lesser blood volume, lower Hb & poornutrition. However, various authors suggest thatPPH should be diagnosed with any amount ofblood loss that threatens the hemodynamicstability of the woman.
Causes of Maternal Death Haemorrhage 24.8% Infection 14.9% HaemorrhageIndirect is the biggest causes and fastest 19.8% killer Eclampsia 12.9%Other direct causes Obstructed labour Unsafe 7.9% 6.9% abortion 12.9%
Postpartum Hemorrhage PPH is a serious, Life-threatening obstetric problem. One of the leading causes of maternal morbidity andmortality. In developing countries mainly due to three delays: -1. Delay in seeking care.2. Delay in reaching care.3. Delay in receiving care.
Maternal Mortality following PPHWHO estimated5,29,000 maternal death / year in world1,36,000 maternal death/ year in India i.e. 30%29.6% maternal deaths due of PPH.In India, about 15.15% - 25.8% mothers die due to PPH.
Additional burden of PPH• > 50% of births in India take place at home without the help of trained/ qualified Birth attendant .• 83% of rural deliveries occur at home• 80% of women are anaemic
Incidence of PPH• 11% women with live birth i.e. 14 million women / year• 3.9% in vaginal deliveries• 6.4% in Cesarean section .• Higher with high risk factor• 10% overall.• Mismanagement of III stage results in higher incidence of PPH
The Four Ts Mnemonic – Causes of PPH Four Ts Causes Incidence (%) 1st Tone Atonic uterus 70 2nd Lacerations, hematomas, 20 Trauma inversion, rupture 3rd Tissue Retained tissue, 10 Invasive placenta 4th Coagulopathies 1 ThrombinAm Fam Physician 2007;75:875-82.
MMR & MORBIDITY DUE TO OBSTETRICAL HAEMORRHAGE
Prevention of PPH ??? It can be achieved by Active management of 3 rd stage of labour
Active Management – Why? 30 20 Percent 10 0 Transfusion Prolonged 3rd Therapeutic Low Retained Stage Uterotonic Hemoglobin Placenta Active Management Physiological Management McMormick, Sanghvi, Kinzie, McIntosh, IJGO20031. Reduces length of time of 3rd stage2. Reduces amount of blood loss3. Reduces need for blood transfusions
Prevention Universalization of Spancer’s Modification of Brand- Andrew’s technique of placental delivery e.g. prophylactic injection of uterotonics at the time of delivery of anterior shoulder followed by traction and counter traction maneuver for placental delivery. Prompt recognition and aggressive management according to the cause of PPH.
Prevention (contd) Shout for help 1. Blood bank , relative, donors, blood and blood components. 2. Anesthetist 3. Prepare Operation Theater. 4. Immediate Communication with nearest/ dependent Tertiary center, 5. Quick transportation to Tertiary Centre (summon obstetrical flying squad /108 Ambulance)
Treatment Protocol Of Primary Atonic PPH (1st T) Management Management of of Shock Uterine atonicityReplacement of blood * Conservative medical or itscomponent management * Surgical management - Conservative surgery - Radical surgery
Stepwise Management of Atonic PPHStep I - Bleeding continues - 15 methyl PGF2 250g every 15-30 mint.Step II - a) Bimanual compression b) Aortic compressionStep III - Transvaginal options - Uterine packing - TamponadeStep IV - Compression sutures B.Lynch, Hayman, Cho SquareStep V -Other surgical measures - stepwise uterine devascularisationStep VI - Hysterectomy
Conservative Surgical ManagementMode of Actions: Controls PPH Preserves reproductive functions Avoids hysterectomy and related complications and consequences
UTERINE PACCKING PLASTC BAG INFUSED WITH SALINE
Balloon Tamponade Two-way catheter - temporary control of PPH Feasible in a scenario of atonic PPH following a vaginal delivery, unresponsive to medical management & before interventional radiological procedures or surgical interventions Simple, cheap, easy to use & effective measure
Procedure Balloon portion is placed directly into uterus [entire balloon (500ml capacity) has to be inserted past the cervical canal & internal os]. Gentle traction on balloon shaft ensures proper contact between balloon & tissue surface & enhances tamponade effect Success is judged by a declining loss of blood from cervix & that seen through drainage port Mean time for leaving the tamponade balloon - 8 to 48 hours Gradual deflation of the balloon is advised to reduce the potential risk of further bleeding
Step-Wise Devascularisation Of The Uterus 1st reported from Egypt Effective in controlling PPH in 80% of cases Unilateral uterine artery ligation Bilateral uterine artery ligation at the upper part of the lower uterine segment Low uterine vessels ligation after mobilization of the bladder Unilateral ovarian vessel ligation Bilateral ovarian vessel ligation
Ovarian Artery Ligation Ovarian artery directly arises from the aorta Anastomosis with the uterine artery in the region of the uterine aspect of the utero-ovarian ligament
Uterine Artery Ligation 90% blood supply of uterus in pregnancy is from uterine vessels Ligation of uterine arteries result into significant reduction in blood flow to the uterus
Vaginal Route for Uterine Artery Ligation Indicated in atonic PPH following vaginal delivery
B-Lynch Suture Exerts continuous vertical compression on uterine vascular system Before proceeding to place the suture into uterus, potential efficacy of B-Lynch suture should be tested for by performing open bimanual compression to see if bleeding stops The assistant performs compression & maintains it with 2 hands during the placement of the suture by the surgeon Monocryl suture or Vicryl number 2 should be used
Internal Iliac Artery LigationConditions indicating ligation – Atonic uterus refractory to other measures Abruptio placentae with uterine atony Abdominal pregnancy with pelvic implantation of the placenta & placenta accreta
Internal Iliac Artery LigationT Therapeutic indications Before or after hysterectomy for PPH Continuous bleeding from the broad ligament base; profuse bleeding from pelvic side-wall or vaginal angle Diffuse bleeding without , clearly identifiable vascular bed Ruptured uterus in which uterine artery may be torn at its origin from internal iliac artery Where extensive lacerations of cervix have occurred following difficult instrumental delivery
Uterine Artery Embolization Highly feasible, safe & beneficial procedure, possibly precluding further laparotomy & hysterectomy If successful, not only saves the patient’s life, but also preserves the functions of uterus ,tubes and ovaries. Should be the procedure of choice for PPH prior to surgical intervention
Hysterectomy Best immediate option When uterine atony is unresponsive to uterotonics Where facilities for embolization are not available Obstetrician not well versed with technical aspects of conservative surgical procedures or iliac artery ligation Indications Uterine rupture secondary to obstructed labor Previous Caesarean section If rupture is extensive & hemorrhage cannot be contained by suture of ruptured area
PPH in CASE of ABRUPTIO PLACENTA ( Covouliare Uterus)
2nd T Surgical Treatment of Traumatic PPHCauses 1.CervicalTear-Lateral, annular, bucket handle type detachment. 2. Vaginal Tear - Circular / Vertical, colporrhaxis. 3. Extended Episiotomy — upwards towards posterior fornix, downwards involving anus and rectum. 4. Vulval Hematoma . 5. Perineal lacerations. 6. Para Urethral tear , clitoral tear. 7. Uterine Rupture – complete / incomplete 8. Broad Ligament hematoma
Cervical Tear Repair Recognition - unilateral / bilateral Stitching under good light,
3rd T - TISSUE FACTOR Retained Placenta 1. With Active Bleeding---MRP - Partially Separated.-----MRP - Retained Cotyledons.----Uterine Exploration and E&C - Retained piece of Membranes.—Uterine Exploration and E&C 2. With No Bleeding. - Active Retention ( Hour Glass Contraction)-G.A., Placental Delivery. - Placenta Accreta - Placenta Inccreta -Placenta Perccreta. Acute inversion of Uterus--Protocol
Retention of PlacentaRetention of Retention ofDetached Placenta Adherent PlacentaUterine Hour glass contraction Simple Adhesion Morbid AdhesionInertia ( constriction ring ) Placenta Accreta Placenta Inccreta Placenta Perccreta
Morbid Adherent Placenta Placenta Accreta Rare occurs in 1: 500 to 1: 700 deliveries. Placenta adhers to uterine wall because the Decidua and the Nitabuch layer , the physiological cleavage in decidua is lacking or incomplete. Inccreta placenta penetrates the uterine myometrium to variable3 depth. Perccreta Very rare occurring in1 : 6,000 to 1: 40,000 deliveries. Placenta perforates the entire thickness of uterine wall and serosa even., -- entire placenta or part of it maybe morbidly adherent.
Placenta Perccreta( A case of Placenta Previa & rupture Uterus)
Rx of Morbid Adherent Placenta Once the diagnosis is made , counseling the woman and her relatives regarding possible need of Hystere ctomy will avoid psychological and medicolegal problems. Medical Management Umbilical cord is cut close to placenta and left in situ. A course of 6 doses of Methotrexate is given orally or parenterly in a dose of 50 mg Methotrexate and 6mg Folinic acid on alternate days. Follow up with USG and Beta HCG estimation weekly indicates the need for further courses of the medicine. Woman can have normal Delivery in future.
Inversion Of Uterus “Turning inside out of the uterus” Acute Inversion is extremely rare ---In India its incidence is reported ----1: 23,0000 deliveries. Management 1. Resuscitation measures must be promptly instituted , Blood transfusion , I.V.fluids and sedation given. 2.Immediate manual reposition in labour room under sedation ( 2- 4.gm MgSo4 in 10ml iv or Terbutalin o.25 in5ml saline iv.)without administration of utero -tonics . 3.O “ Sullivan ‘s technique of intra vaginal hydrostatic pressure. 4. Surgical Technique---usually required in chronic case3s.
Faulty Technique of placental delivery leading to Inversion Uterus(a,b,,c)
Acute complete Inversion of Uterus with Attached Cord