Surgical management of pph at tertiary center

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  • Surgical management of pph at tertiary center

    1. 1. SURGICAL MANAGEMENT OF PPHAT TERTIARY CENTERPROF. (Dr ) M.C. BansalMBBS, MS , FICOG , MICOG .
    2. 2. Pregnancythe most dangerous journey of mankind…
    3. 3. 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.
    4. 4. 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%
    5. 5. 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.
    6. 6. Maternal Mortality following PPHWHO estimated5,29,000 maternal death / year in world1,36,000 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.
    7. 7. 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
    8. 8. 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
    9. 9. 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.
    10. 10. MMR & MORBIDITY DUE TO OBSTETRICAL HAEMORRHAGE
    11. 11. ‘Prevention iseasier and better than cure’
    12. 12. Prevention of PPH ??? It can be achieved by Active management of 3 rd stage of labour
    13. 13. 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
    14. 14. 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.
    15. 15. 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)
    16. 16. Recognition Referral Responsiveness
    17. 17. “No matter where a woman delivers, giving birth should be a moment of joy, not a sentence to death”
    18. 18. “While managing PPHTime lapsed should notbe counted in a minute---one has not lost oneminute ,but 60 seconds” Ian Donald
    19. 19. “No amount of Blood from anyblood bank is safer and betterthan Her own blood.” Hence be prompt insaving each second and everydrop of blood of bleeding womanin her 3rd stage of labour,
    20. 20. PPH Treatment Protocol
    21. 21. PPH Treatment Protocol
    22. 22. 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
    23. 23. Stepwise Management of Atonic PPHStep I - Bleeding continues - 15 methyl PGF2 250g 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
    24. 24. Conservative Surgical ManagementMode of Actions: Controls PPH Preserves reproductive functions Avoids hysterectomy and related complications and consequences
    25. 25. Bimanual Compression of Relaxed Uterus
    26. 26. Conservative Surgical Management Options In Atonic PPH Manual removal of placenta Exploration of uterus Uterine Packing by Roller gauze, Condom, Foley Catheter, Sengstaken Blackmore tube, Surgical Glove distention,Balloon tamponade Step-wise devascularization of uterus B-Lynch suture, Hayman suture, Gun Sheela, Cho multiple square suture Internal iliac (hypogastric) artery ligation Postpartum Arterial embolisation
    27. 27. MRP
    28. 28. MRP
    29. 29. UTERINE PACCKING PLASTC BAG INFUSED WITH SALINE
    30. 30. 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
    31. 31. 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
    32. 32. 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
    33. 33. 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
    34. 34. 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
    35. 35. Uterine ArteryLigationABDOMINAL ROUTE
    36. 36. Vaginal Route for Uterine Artery Ligation Indicated in atonic PPH following vaginal delivery
    37. 37. 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
    38. 38. B- LYNCHSUTURE
    39. 39. B-LYNCH SUTURE
    40. 40. B-LYNCHSUTURE
    41. 41. B-LynchSuture
    42. 42. B-LINCH SUTURE
    43. 43. Cho Multiple Square Compression Sutures Multiple square sutures are used to cover the whole body of uterus using a straight 10-cm needle May be useful in placenta previa
    44. 44. Sketch of pelvic blood vessels
    45. 45. Internal Iliac Artery(Anatomy-Surgical dissection)
    46. 46. INTERNAL ILLIAC ARTERY (ANATOMY) SURGICAL DISSECTION
    47. 47. 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
    48. 48. 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
    49. 49. INTERNAL ILLIAC ARTERY LIGATION
    50. 50. 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
    51. 51. ANGIOGRAPHY – UTERINE ARTERY
    52. 52. BLOCKED uterine ARTERY afterEMBOLIZ ATION
    53. 53. 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
    54. 54. PPH in CASE of ABRUPTIO PLACENTA ( Covouliare Uterus)
    55. 55. 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
    56. 56. Cervical Tear Repair Recognition - unilateral / bilateral Stitching under good light,
    57. 57. VulvaL hematoma
    58. 58. Spntaneous rupture uterus
    59. 59. Treatment Protocol for Rupture
    60. 60. Treatment protocol of Uterine rupture
    61. 61. 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
    62. 62. Retention of PlacentaRetention of Retention ofDetached Placenta Adherent PlacentaUterine Hour glass contraction Simple Adhesion Morbid AdhesionInertia ( constriction ring ) Placenta Accreta Placenta Inccreta Placenta Perccreta
    63. 63. 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.
    64. 64. A hysterectomy specimen of placenta Percreta
    65. 65. Placenta Perccreta( A case of Placenta Previa & rupture Uterus)
    66. 66. 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.
    67. 67. 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.
    68. 68. Faulty Technique of placental delivery leading to Inversion Uterus(a,b,,c)
    69. 69. Acute complete Inversion of Uterus with Attached Cord
    70. 70. Diagramatic Staging Of Inversion OF Uterus
    71. 71. Abdominal view of Inversion Of Uterus
    72. 72. Manual Reposition Of Inverted Uterus
    73. 73. Treatment Protocol for Inversion Uterus
    74. 74. Treatment Protocol for Inversion Uterus
    75. 75. Saving life of the one giving birthto a new life…
    76. 76. THANKS

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