Pph workshop 1 (9 2013)

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postpartum hemorrhage workshop part 1 by dr mohamed elsherbiny

postpartum hemorrhage workshop part 1 by dr mohamed elsherbiny

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  • 1. Dr. Mohamed El Sherbiny MD Ob.& Gyn Postpartum Hemorrhage (PPH) Guidelines for Immediate Action “Part I” Damietta Specialized Hospital Workshop 25-9-2013
  • 2. Pub Med. Cochrane library. SOGC Hemorrhagic Shock Guideline No 115 2002 RCOG Guideline P.Previa No.27 2005 Misoprostol Guidance WHO 2007&FIGO 2009 RCOG Guideline PPH No.52 May 2009 WHO Guidelines PPH 2009 SOGC PPH Guideline No 235 Octob.2009 UpToDate July 2013 Sources of Evidence
  • 3. 1. MetGhamr 23-6-2002 2. Aswan Syndicate scientific Meeting 3-2006 3. Dekrnes G Hospital 2006 4. El Sewas G Hospital Meeting 2006 5. Damietta Governorate meeting Syndicate 2008 6. Dakahlia COG Society 8-4-2010 7. El Manzalla G H Meeting 6-20010 8. Damietta Specialized Hospital 2011 9. Samnoud Meeting 3- 2011 10.El Mahlla Meeting 6-2011 11-17 Zamala 8- 2008 to 7-9-2013 6 Years Local Scientific Meeting
  • 4. 1. Annual Asute Ob Gyn Conference 2004 2. Annual Kasr Aini Conference 2006 PPH 3. Annual conference Ob Gyn Banha 2007 4. Bolak Dakror Ob Gyn Conference 2007 5. Annual Port Saied Ob Gyn Conference 29-3-2007 6. Annual Ismailia Conference Ob Gyn 26-7-2007 7. Annual Zagazig Ob Gyn Conference 1-11-2007 8. Annual Kasr Aini Ob Gyn Conference 3-4-2008 9. Pan Arab Ob Gyn Annual Confer. 6 -11 - 2008 o National Conference
  • 5. 10-Pan Arab Asnnual Conference 6 -11 - 2008 Cairo 11- Conference M C S Mansoura 9- 8 – 2007 12-Gy Obn 6 October Conference 19-3 – 2009 13-ERC RCOG Local Meeting 3-2010 Alexanderia 14- El Azhar Dumyat Annual Conference 2012 15-Clinical Society of Ob& Gyn, Conference Mansoura 18-4-2013 16- The 27th Anual Scientific M. of Ob.Gyn Alexandria 2-3 May 2013 National Conference
  • 6. 1 - The 7th World Congress of Perinatal Medicine in Devolving countries Alexanderia March 29th to 30th 2012 2 - The XX FIGO World Congress October Italy, 2012 3 - The 3rd Annual ERC/ELG (RCOG)March 2- 3-2013 International Conference
  • 7. Worldwide postpartum hemorrhage is the commonest cause of maternal mortality. (Especially in developing countries (
  • 8. 0 5 10 15 20 25 30 35 Postpartumhmorrhage Hypertensivedisease Antepartumhemrrhage Ruptureduterus Obstructedlabour CesareanS. Anesthesia Pulmonaryembolism Spontaneousabortion Inducedabortion Sepsis Ectopic Otherdirect Direct causes of maternal death National Maternal Study 2000
  • 9. Guidelines for Immediate Action Before : Prevention A.Identify B. Management Of Established PPH 1 - Communication 2 - Resuscitation 3 - Monitoring and investigation 4 - Arresting the bleeding
  • 10. Before : Prevention I - Risk Factors for PPH 2 - Management of Third Stage
  • 11. I - Risk Factors for PPH
  • 12. Known Antenatal Risk Substantial Risk O.R Significant Risk O.R Suspected or proven Placental abruption 13 Previous PPH 3 Known placenta praevia tone 12 Asian ethnicity 2 Multiple pregnancy 5 Obesity ( BMI>35( 2 Pre- eclampsia/gestational hypertension 4 Anaemia ( <9 g/dl( 2
  • 13. Intra-Partum / Postartum risk Significant risk O.R Significant risk O.R Delivery by emergency C.S 4 Operative vaginal delivery 2 Delivery by elective C.S 2 Prolonged labour (>12 hours( 2 Induction of labour 2 Big baby ( >4kg( 2 Retained placenta 5 Pyrexia in labour 2 Mediolateral episiotomy 5 Age ( >40yeares, not multipa-rous( 1.4
  • 14. 2 - Management of Third Stage
  • 15. Active management of the 3rd stage of labour lowers maternal blood loss and reduces the risk of PPH by about 60%. It should be offered to all women Management of 3rd Stage
  • 16. Low-risk Vaginal Deliveries: Oxytocin 10 iu (IM) or Oxytocin 30 iu IV infusion in1000 mL,150 mL/h * Management Of Third Stage High risk V. Deliveries or CS : Oxytocin 5 iu IV over 5 minutes .Or Carbetocin (Oxytocin analogue) 100 µg IV bolus over 1 minute *
  • 17. Oxytocin 5-10 iu + Methergin 0.2mg (Syntometrine ) may be used in the absence of hypertension (for instance, antenatal low haemoglobin) as it reduces the risk of minor PPH (500-1000 ml) but increases vomiting. Management of Third Stage
  • 18. A single 100 µg IV injection of carbetocin is as effective as a continuous 2-h infusion of oxytocin Carbetocin Vs oxytocin for the prevention of PP following CS: Carbetocin is associated with a reduced use of additional oxytocics
  • 19. Oxytocics Comparison Methyle Ergometrine (Methergine Oxytocin Carbetocin Pabal Oxytocin analogue Amp 1m :0.1 mg IV IM IV IM IV IM Onset of action 2-3 m 2-5m < 1 m 3 m < 1 m < 2 m Contraction Time 60m 3 H 1 6 m 30 m 67 m 120 m Storage < 25°C Dark storage < 25°C 2-8°C (refrigerator( 22 Clinically IV only
  • 20. Carbetocin :Pabal At CS, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of PPH. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for at vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed for the cost- effectiveness of carbetocin as a uterotonic gent. Su et al Cochrane Systematic Review Apr.2012
  • 21. Misoprostol is not as effective as oxytocin but it may be used when oxytocin is not available, such as the home-birth setting. Management Of Third Stage Recommended Dosages 600 µg orally or sublingually.
  • 22. 25 The peak of action of misoprostol is not consistent with the 3rd stage ,so it is not as effective as oxytocin
  • 23. Route Onset of action Duration of action Oral 8 min ∼2 h Sublingual 11 min ∼3 h Highest area under the curve Vaginal 20 min ∼4 h Rectal 20-100 min ∼4 h Lowest area under the curve Pharmacokinetic Profiles of Misoprostol Why Orally Or Sublingually?
  • 24. A:Identify
  • 25. I -Estimated blood loss 500- 1000 ml & No clinical signs of shock Measures to facilitate resuscitation should it become necessary. Close monitoring  IV access CBC ,Blood group and screen  Primary PPH: Definition Management dependent definition Minor PPH
  • 26. II-Estimated blood loss >1000 ml or clinical signs of shock Protocol of measures to achieve resuscitation and haemostasis. Primary PPH: Definition Management dependent definition Major PPH
  • 27. What Are the Degrees of Shock? Compensated Hemorrhagic Shock Mild Hemorrhagic Shock Moderate Hemorrhagic Shock Severe Hemorrhagic Shock 31
  • 28. Compensated Hemorrhagic ShockLoss of ≤ 15% of blood volume may not be associated with any change in blood BP, pulse, or capillary refill. As symptoms usually precedes the sign, these symptoms may be presented : Anxiety Restlessness Feeling of breathlessness . Urinary output > 30 mL/h 32
  • 29. Degree of shock Blood loss Signs & symptoms Mild <20% Anxiety , Sweating & Palpitation Increased capillary refilling Cool extremities Moderate 20% to 40% + Tachycardia& Tachypnea Postural hypotension Oliguria (< 20 mL/h) Severe >40% + Hypotension Agitation/confusion Collapse& Anuria Signs And Symptoms Of Shock NB. Blood volume at term: ± 100 ml/kg
  • 30. 1.Communication 2.Resuscitation 3.Monitoring and investigation 4.Arresting the bleeding Treatment of the underlying disorder (4Ts) Management of Intractable PPH Management of Established PPH 4 components: undertaken simultaneously:
  • 31. 1-Minor PPH Estimated blood loss 500- 1000 ml & No clinical signs of shock (Compensated Shock) 2-Major PPH II-Estimated blood loss >1000 ml or clinical signs of shock Management Of Established PPH Depends On Degree of Blood Loss If not at a Hospital, it must be referred urgently
  • 32. 1-Minor PPH Estimated blood loss 500- 1000 ml & No clinical signs of shock (Compensated Shock) Management Of Established PPH Depends On Degree of Blood Loss
  • 33. 2-Resusetation Minor PPH <1000 ml &Compensated Major PPH >1000 ml or Shock Intravenous access one 14- gauge cannula Crystalloid infusion. AB,C : Assess: Airway, Breathing& Circulation O2 by mask at 10–15 L/M 14-gauge cannula x2 orange Transfuse blood rapidly Until blood is available, IV up to 3.5 L crystalloid lactated Ringer (± one L of it is colloid) Keep patient& infusions warm She had received one L lactated Ringer solution
  • 34. 3-Monitoring and Investigation Minor PPH <1000 ml &Compensated) Major PPH >1000 ml or Shock Venepuncture (20 ml) for: Group CBC Coagulation screen Pulse and BP/15m Venepuncture (20 ml) for: Crossmatch (≥4 units) CBC & Coagulation screen Basal renal and liver F Ts. Continuous:P ,BP,RR Temperature /15 m Foley C. : urine output 2 cannulae, 14- or 16-gauge All recorded on a flow chart
  • 35. Estimated blood loss 500- 1000 ml & No clinical signs of shock (Compensated Shock) 1-Minor PPH II-Estimated blood loss >1000 ml or clinical signs of shock Management Of Established PPH Depends On Degree of Blood Loss 2-Major PPH If not at a Hospital, it must be referred urgently
  • 36. 1.Communication 2.Resuscitation 3.Monitoring and investigation 4.Arresting the bleeding Treatment of the underlying disorder (4Ts) Management of Intractable PPH Management Of Established PPH 4 components: undertaken simultaneously: 41
  • 37. 1-Communication Minor PPH <1000 ml &Compensated Major PPH >1000 ml or Shock Alert first-line obstetric and anaesthetic staff trained in the management of PPH. ØCall obstetric middle grade & alert consultant ØCall anaesthetic middle grade & alert consultant. ØAlert consultant clinical haematology ØAlert blood transfusion laboratory.
  • 38. 2-Resusetation Minor PPH <1000 ml &Compensated Major PPH >1000 ml or Shock ØIntravenous access one 14- gauge cannula ØCrystalloid infusion. ØAB,C : Assess: Airway, Breathing& Circulation ØO2 by mask at 10–15 L/M Ø14-gauge cannula x2 ØTransfuse blood rapidly ØUntil blood is available, IV up to 3.5 L crystalloid lactated Ringer (± one L of it is colloid) ØKeep patient& infusions warm
  • 39. 2-Resusetation •Volume replacement must be undertaken on the basis that blood loss is often grossly underestimated. • Compatible blood (supplied in the form of packed RBCs) is the best fluid as soon as available, •If necessary Rh negative O blood.
  • 40. Massive Blood Loss : What Are The Main Goals Of Management ? The Main Goals is to maintain: • Haemoglobin > 8g/dl • Platelet count > 75 x 109 /l • Prothrombin T < 1.5 x mean control • Activated prothrombin times (APT) < 1.5 x mean control • Fibrinogen > 100mg/dl
  • 41. Component Usual Indication starting dose Packed RBC Replacement of oxygen-carrying capacity 2– 4 Units IV Fresh frozen plasma Documented coagulopathy 2–6 Units IV Cryoprecipitate Coagulopathy with low fibrinogen 10–20 Units IV Platelets Thrombocytopenia / thrombasthenia with bleeding 6–10 Units IV Indications For Blood Component Therapy Packed RBC : Fresh frozen plasma: Platelets = 6:4:1
  • 42. Intravenous fluid replacement with isotonic crystalloids should be used in preference to colloids for resuscitation of women with PPH. High doses of colloids : More expensive May cause adverse effects Colloids versus crystalloids ? 2-Resusetation
  • 43. Coagulopathy Fresh frozen plasma 4 units for: Every 6 units of red cells or Prothrombin time > 1.5 x normal Activated partial thromboplastin time > 1.5 x normal (12–15 ml/kg or total 1 litres) Platelets : if PLT count < 50 x 109 /L
  • 44. • During the wait lactated Ringer :3mI for every one mI of blood lost (*) • Ringer’s lactate is preferred over normal saline to avoid hyperchloremic acidosis(**) • There is no place for hypotonic dextrose solutions (**) Hypovolumeic Shock
  • 45. Whole blood is needed when acute hemorrhage is catastrophic. Whole Blood Vs Component therapy Component therapy provides better treatment because only the specific component needed is given.
  • 46. Donor Compatible plasma Compatible red cells Compatible platelets Compatible platelets Recipient ABO group 1st choice 2nd choice A A,AB A,O A,AB B,O B B,AB B,O B,AB A,O O O,A,B, AB O O A,B,AB AB AB AB,A,B, O AB A,B,O Blood Component : Recipient & Donor
  • 47. 3-Monitoring and Investigation Minor PPH <1000 ml &Compensated Major PPH >1000 ml or Shock Venepuncture (20 ml) for: Grouping CBC Coagulation screen Pulse and BP/15m Venepuncture (20 ml) for: Crossmatch (≥4 units) CBC & Coagulation screen Basal renal and liver functions Continuous: Pulse , BP & RR Temperature /15 m Foley catheter: urine output 2 cannulae: 14 or 16 gauge All recorded on a flow chart
  • 48. Poor Man's" Fibrinogen Assay • If a clot does not form within 6 m or • Clot forms and lyses within 30 m. A coagulation defect is probably present and the fibrinogen level is < 150 mg/dl
  • 49. 1.Communication 2.Resuscitation 3.Monitoring and investigation 4.Arresting the bleeding Treatment of the underlying disorder (4Ts) Management of Intractable PPH Management Of Established PPH 4 components: undertaken simultaneously:
  • 50. Arresting The Bleeding Causes for PPH may be considered to relate to one or more of ‘the four Ts’: ● Tone (abnormalities of uterine contraction) ● Tissue (retained products of conception) ● Trauma (of the genital tract) ● Thrombin (abnormalities of coagulation).
  • 51. Postpartum Hemorrhage Emptying the bladder 40 iu oxytocin in 1000 mL lactated Ringer Firm fundal massage Before delivery of the placenta After delivery of the placenta Contracted cervix Partial separation Placenta Accreta Uterine Atony Genital Tract Trauma Coagulation Disorders
  • 52. Postpartum Hemorrhage Before Delivery Of The Placenta Brandt-Andrwes (Controlled cord traction) Succeeded Fundal massage &Oxytocin infusion Continuo oxytocin infusion& fundal massageIntra-umbilical cord injection Misoprostol (800 g) Manual Removal Contracted cervix Nitroglycerin 500ug iv Partial separation Peeling Placenta Accreta Hysterectomy Piece meal removal ± Methotrexate / Anti progestrone / EmbolizationIn all cases continue fundal massage &oxytocin infusion
  • 53. Postpartum Hemorrhage after delivery of the placenta Firm fundal massage &Oxytocin infusion Bleeding stopped Conservative T: Massage & oxytocin infusion Bleeding not stopped Firm uterus Exploration 1-Trauma Repair of lower & upper GT up to Hysterectomy 2-Remnant: Removal 3-Coagulopathy: Reverse Emptying the bladder Bimanual compression Atonic uterus Uterotonics + Bleeding stopped Bleeding not stopped Intractable PPH Bleeding not stopped
  • 54. Bimanual Compression
  • 55. Aortic Compression
  • 56. Uterotonics (3 lines) 62
  • 57. First Line Uterotonics For management of PPH, oxytocin should be preferred over : Ergometrine alone Fixed-dose combination of ergometrine and oxytocin, Carbetocin Prostaglandins.
  • 58. First Line Uterotonics • Oxytocin (Syntocinon®) 5 units IV over 5 m (± repeated) then • Infusion (40 u in 500 ml L Ringer at 125 ml/hour). • Not more than 3 L of IV fluids containing oxytocin.
  • 59. First Line Uterotonics Carbetocin (Pabal®) , 100µg given as an IV bolus over 1 minute (Can be repeated )is an alternative
  • 60. Second Line Uterotonics If the bleeding does not respond to the 1st- line, Ergometrine will be the second line: • Ergometrine (Methergin®) IM / IV (slowly): 0.2 mg • Repeat 0.2 mg IM after 15 minutes • If required, give 0.2 mg IM or IV slowly / 4 H Maximum dose :5 doses (Total 1.0 mg) Contraindications :Pre-eclampsia, hypertension, heart disease
  • 61. Third Line Uterotonics If the bleeding does not respond to the 2nd-line treatment: Prostaglandin / Misoprostol should be offered.
  • 62. Misoprostol Cytotic®,Mesotac® ,Mesoprost® The recommended dose: 600 µg oral or sublingual 1000 µg rectal my be used if these routes are not suitable (efficacy < 50%)
  • 63. Misoprostol Versus IV Oxytocin Sublingual misoprostol (800 µg) is clinically equivalent to IV oxytocin (40iu) when used to stop atonic PPH in women who have received oxytocin during the 3rd stage of labour.
  • 64. Misoprostol Versus IV Oxytocin In settings in which use of oxytocin is not feasible, misoprostol might be a suitable first-line treatment alternative for post-partum haemorrhage.
  • 65. Misoprostol • A repeated dose should not be given unless at ≥ 2 h since the first dose. • If the initial dose was associated with pyrexia or marked shivering, then at least 6 hours should lapse before the second dose is given.
  • 66. rFVIIaRecombinant human coagulation Factor VIIa (rFVIIa): NovoSeven® 90 μg/kg given/2 hours bolus infusion Unproven Effect
  • 67. Tranexamic Acid For The Treatment Of Postpartum Haemorrhage • Tranexamic acid decreases postpartum blood loss after vaginal birth and after CS based on two RCTs of unclear quality which reported only few outcomes. • Further investigations are needed on efficacy and safety of this regimen for preventing PPH.
  • 68. Tranexamic Acid For The Treatment Of Postpartum Haemorrhage “The WOMAN Trial” : Waiting the result An international randomised, double blind placebo controlled trial. The trial will be a large, pragmatic, randomised, double blind, placebo controlled trial among 15,000 women with a clinical diagnosis of PPH
  • 69. The patient received : 1-Syntocinon 5 units IV over -5iu & (40 u in 500 ml L Ringer at 125 ml/hour). 2-Methergin 0.2 mg/slow IV and other 0.2 mg IM and repeated after 15 minutes 3-600µg misoprostol sublingually The bleeding subsided for 30 minutes Then the uterus was not responding to treatment or massage and other ± 500 ml of blood were lost. The case is now categorized as “Major PPH” What is the best line of management? Return to The case Scenario
  • 70. 1.Communication 2.Resuscitation 3.Monitoring and investigation 4.Arresting the bleeding Treatment of the underlying disorder (4Ts) Management of Intractable PPH Management Of Established PPH 4 components: undertaken simultaneously:
  • 71. PPH After CS : Causes 1- uterine atony 2-Placent previa &placenta accreta/ increta/percreta 3- Trauma: bleeding from the uterine incision or extensions of this incision or bleeding from vaginal or cervical tears or uterine rupture 4- Retained placenta 77
  • 72. PPH After CS : Management Uterine atony: Fundal massage and uterotonic drugs (including intrauterine injection ) Truma:Inspection for and repair of lacerations and incisional bleeding. The angles of a transverse incision should be clearly visualized and any retracted vesselsare ligated. The ipsilateral ureter should be identified before bleeding is controlled. 78
  • 73. Intractable PPH About 10 % of women will not respond to the initial management steps and are considered as intractable PPH. They are caused mainly by •Uterine atony •Placenta accreta at CS scar • Difficult trauma repair •Coagulopathy 79
  • 74. Bimanual Compression
  • 75. Intractable PPH About 10 % of women will not respond to the initial management steps and are considered as intractable PPH. They are caused mainly by •Uterine atony •Placenta Previa accretes at CS scar (PP accreta) • Difficult trauma repair •Coagulopathy
  • 76. Intractable Postpartum Hemorrhage Algorithm Vaginal delivery Garment balloon tampnade Arterial embolization Local Control Garment Suellen Miller, 2005
  • 77. Management of Uterine Atony If pharmacological measures fail : “Intrauterine balloon tamponade “ is the first-line ‘surgical’ intervention RCOG Guideline PPH No.52 May 2009 Grade C
  • 78. Intractable Postpartum Hemorrhage Algorithm Vaginal delivery Local Control Garment Gauze Pack or Balloon Tamponade Arterial embolization Bakri Tamponade Balloon Sengstaken-Blakemore Tube Condom
  • 79. Sengstaken–Blakemore tube Three lumen tube (one for drainage) Volume > 500ml
  • 80. Rüsch Hydrostatic Balloon Catheter Capacity >500 ml A 60-ml bladder syringe can be used But It does not have a drainage channel to monitor ongoing bleeding after placement. Available in some urology center for controlling prostatic bleeding.
  • 81. Bakri Balloon A silicone balloon It was designed as obstetric tamponade Capacity 500 cc of sterile saline It has a drainage channel FDA approved Bakri et al . Int J Gynaecol Obstet 2001;74:139–42
  • 82. Bakri Balloon
  • 83. In contrast to the Bakri balloon, the balloon end of the catheter is flush with the end of the balloon BT-Cath Balloon A silicone balloon It was designed as obstetric tamponade Capacity 500 cc of sterile saline FDA approved
  • 84. Condom Balloon Tamponade First used by Akhter et al. 2003 at Bangladesh A 20 women with PPH using the B-Lynch A 23 were managed using the condom catheter with success rate 100% Simple to use, inexpensive and safe. Akhter et al . MedGenMed.2003 Sep 11;5(3):38. Bangladesh Condom has no drainage channel to monitor ongoing bleeding. It is clean but not sterile  Availability at theater ?
  • 85. Condom Balloon Tamponade Akhter et al . MedGenMed.2003 Sep 11;5(3):38. Bangladesh
  • 86. Mechanism of Action of Balloon Tamponade I- Exertion of inward to outward hydrostatic pressure against the uterine wall.  This pressure may or may not be in excess of systemic arterial pressure .  The net result is reduction in persistent capillary and venous bleeding from the endometrium and myometrium. Sinha ,Obstet Gynecol. 2003;102(3):641 Georgiou , BJOG. 2010;117(3):295 Bakri,UpToDate,Aug,2013
  • 87. Mechanism of Action II-Direct uterine artery (UA) compression Decreased UA blood flow has been observed on ultrasound examination in patients with an intrauterine Sengstaken-Blakemore tube Cho et al ,Ultrasound Obstet Gynecol. 2008;32(5):711. Bakri,UpToDate,Mar.,2013
  • 88. Indications of Balloon Tamponade In Management of PPH 1- After vaginal delivery for “Atonic PPH”. (Success R. :80-100%) 2- After CS with placenta previa / accreta . (Success R.: 56%) 3-Secondary PPH
  • 89. Mohamed El Sherbiny MD Ob.& Gyn. Damietta Egypt Use of a Surgical Glove to Control Severe Postpartum Hemorrhage XX FIGO World Congress October 2012
  • 90. Mohamed El Sherbiny MD Ob.& Gyn. Hafez Gewely Egyptian Board Ob Gyn El Saeid Hammoda : Egyptian Board Ob Gyn Mohamed El Hennawy MS Ob-Gyn Ahmad Mohamed El Serbiny MS Ob. Gyn Damietta Egypt
  • 91. The Inverted Glove Balloon Tapenade El Sherbiny et al FIGO 2012
  • 92. The Inverted Glove Tapenade With aseptic precautions knots are mad on all fingers of a surgical glove to render it a single cavity Then the glove is inverted to have a smooth outer surface. 98 finger knotted Inverted Glove El Sherbiny et al FIGO 2012
  • 93. El Sherbiny et al FIGO 2012
  • 94. The Inverted Glove Tapenade A sterile Foleys catheter is inserted within the glove and tied near the mouth of the glove with a silk thread, and the outer end of the catheter is connected to a saline set. El Sherbiny et al FIGO 2012
  • 95. Then the glove is introduced into the uterine cavity. The cervix is grasped with ring forceps. A long dressing forceps is used to insert the glove balloon catheter into the uterine cavity. Alternatively, the catheter can be inserted manually )±U/S Guided( Glove Tapenade: Insertion El Sherbiny et al FIGO 2012
  • 96. Beside the glove ,other Foleys catheter is also inserted as a drainage channel to monitor ongoing bleeding. El Sherbiny et al FIGO 2012
  • 97. El Sherbiny et al FIGO 2012
  • 98. El Sherbiny et al FIGO 2012
  • 99. Glove Inflation The glove is inflated with 200-500 mL normal saline, according to need. A roller gauze is introduced into the vaginal cavity to keep the uterine balloon in place. The glove and the catheters were kept for 24 hours, and gradually deflated when bleeding ceased El Sherbiny et al FIGO 2012
  • 100. How To Keep The Tamponade In Situ ? 1-A roller gauze is introduced into the vagina for packing it. Other alternative 2-Other glove is introduced into the vagina and inflated by warm saline. or 3-Placement of adjunct cervical cerclage
  • 101. Results Within 20 minutes the bleeding was stopped in 22 out of 24 women (92%) in which the glove tamponade was used . In 2 cases, hysterectomy was required despite successful placement of the catheter .The fertility of these 2 patient was not desired.
  • 102. Results None of the patients went into irreversible shock or death . There was no clinical evidence of intrauterine infection. Nine patients were followed up for subsequent pregnancy and 7 (78%) of them got pregnant within 2 years.
  • 103. Conclusion The Intrauterine tamponade with a surgical glove is a simple, safe, inexpensive, readily available and effective means of treating massive atonic postpartum hemorrhage.
  • 104. Combination of External Compression & Internal Tamponade Intrauterine balloon (Bakri) can be used in combination with a B-Lynch uterine compression suture to create a "uterine sandwich," whereby the uterus is compressed between the balloon internally and the compression suture externally Nelson &O'Brien , Am J Obstet Gynecol. 2007;196)5(: Diemert et al.Am J Obstet Gynecol. 2012;206)1(:65.e1
  • 105. B-Lynch Technique
  • 106. Periprocedure Monitoring And Care  Patients with a negative test (ie, bleeding is not controlled) should proceed to laparotomy  Broad spectrum antibiotic prophylaxis  Uterotonics  Adequate analgesia  Monitor for blood loss( pallor, dizziness, hypotension, tachycardia, confusion)  Periodic flushing of the drainage port to ensure that it has not become occluded by blood and to remove clots.
  • 107. Thank You
  • 108. Thank You Egypt
  • 109. 1-Minor PPH Estimated blood loss 500- 1000 ml & No clinical signs of shock (Compensated Shock) 2-Major PPH II-Estimated blood loss >1000 ml or clinical signs of shock Management Of Established PPH Depends On Degree of Blood Loss If not at a Hospital, it must be referred urgently
  • 110. 2-Resusetation Minor PPH <1000 ml &Compensated Major PPH >1000 ml or Shock Intravenous access one 14- gauge cannula Crystalloid infusion. AB,C : Assess: Airway, Breathing& Circulation O2 by mask at 10–15 L/M 14-gauge cannula x2 orange Transfuse blood rapidly Until blood is available, IV up to 3.5 L crystalloid lactated Ringer )± one L of it is colloid( Keep patient& infusions warm
  • 111. 3-Monitoring and Investigation Minor PPH <1000 ml &Compensated Major PPH >1000 ml or Shock Venepuncture )20 ml( for: Grouping CBC Coagulation screen Pulse and BP/15m Venepuncture )20 ml( for: Crossmatch )≥4 units( CBC & Coagulation screen Basal renal and liver functions Continuous: Pulse , BP & RR Temperature /15 m Foley catheter: urine output 2 cannulae: 14 or 16 gauge All recorded on a flow chart
  • 112. Arresting The Bleeding Causes for PPH may be considered to relate to one or more of ‘the four Ts’: ● Tone (abnormalities of uterine contraction) ● Tissue (retained products of conception) ● Trauma (of the genital tract) ● Thrombin (abnormalities of coagulation).
  • 113. Postpartum Hemorrhage after delivery of the placenta Firm fundal massage &Oxytocin infusion Bleeding stopped Conservative T: Massage & oxytocin infusion Bleeding not stopped Firm uterus Exploration 1-Trauma Repair of lower & upper GT up to Hysterectomy 2-Remnant: Removal 3-Coagulopathy: Reverse Emptying the bladder Bimanual compression Atonic uterus Uterotonics + Bleeding stopped Bleeding not stopped Intractable PPH Bleeding not stopped
  • 114. 1.Communication 2.Resuscitation 3.Monitoring and investigation 4.Arresting the bleeding Treatment of the underlying disorder (4Ts) Management of Intractable PPH Management Of Established PPH 4 components: undertaken simultaneously:
  • 115. Intractable PPH About 10 % of women will not respond to the initial management steps and are considered as intractable PPH. They are caused mainly by •Uterine atony •Placenta accreta at CS scar • Difficult trauma repair •Coagulopathy 124
  • 116. Management of Uterine Atony If pharmacological measures fail : “Intrauterine balloon tamponade “ is the first-line ‘surgical’ intervention RCOG Guideline PPH No.52 May 2009 Grade C
  • 117. Beside the glove ,other Foleys catheter is also inserted as a drainage channel to monitor ongoing bleeding. El Sherbiny et al FIGO 2012