Pph workshop 1 (9 2013)

Dr. Mohamed El Sherbiny
MD Ob.& Gyn
Postpartum
Hemorrhage (PPH)
Guidelines for Immediate
Action “Part I”
Damietta Specialized Hospital Workshop 25-9-2013

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

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

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

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

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

Worldwide
postpartum
hemorrhage is the
commonest cause of
maternal mortality.
(Especially in
developing countries (

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

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

Before :
Prevention
I - Risk Factors for PPH
2 - Management of Third Stage

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

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

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

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 *

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

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

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

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

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.

25
The peak of action of misoprostol is not consistent with the
3rd
stage ,so it is not as effective as oxytocin

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?

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

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

What Are the Degrees of Shock?
Compensated Hemorrhagic Shock
Mild Hemorrhagic Shock
Moderate Hemorrhagic Shock
Severe Hemorrhagic Shock
31

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

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

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:

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

1-Minor PPH
Estimated blood
loss 500- 1000 ml &
shock
(Compensated Shock)

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

3-Monitoring and Investigation
Minor PPH <1000 ml
&Compensated)
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

Estimated blood
loss 500- 1000 ml &
shock
(Compensated Shock)
1-Minor PPH
II-Estimated blood
loss >1000 ml or
clinical signs of
shock
2-Major PPH
If not at a Hospital, it
must be referred
urgently

1.Communication
2.Resuscitation
41

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.

2-Resusetation
Minor PPH <1000
ml &Compensated
ØIntravenous
access one 14-
gauge cannula
ØCrystalloid
infusion.
ØAB,C : Assess: Airway,
ØO2 by mask at 10–15 L/M
Ø14-gauge cannula x2
ØTransfuse blood rapidly
ØUntil blood is available, IV up
Ringer (± one L of it is colloid)
ØKeep patient& infusions warm

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.

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

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

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

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

• 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

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.

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

Minor PPH <1000
ml &Compensated
Venepuncture
(20 ml) for:
Grouping
CBC
Coagulation
screen
Pulse and
BP/15m
Venepuncture (20 ml) for:
Crossmatch (≥4 units)
Basal renal and liver functions
Continuous: Pulse , BP & RR
Temperature /15 m
Foley catheter: urine output
2 cannulae: 14 or 16 gauge

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

1.Communication
2.Resuscitation

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).

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

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

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

First Line Uterotonics
For management of PPH, oxytocin should
be preferred over :
Ergometrine alone
Fixed-dose combination of ergometrine
and oxytocin,
Carbetocin
Prostaglandins.

• 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.

Carbetocin (Pabal®) , 100µg given
as an IV bolus over 1 minute
(Can be repeated )is an
alternative

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

Third Line Uterotonics
If the bleeding does not respond
to the 2nd-line treatment:
Prostaglandin / Misoprostol
should be offered.

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%)

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.

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.

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.

rFVIIaRecombinant human coagulation
Factor VIIa (rFVIIa): NovoSeven®
90 μg/kg given/2 hours bolus
infusion
Unproven Effect

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.

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

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

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

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

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

Intractable PPH
•Uterine atony
•Placenta Previa accretes at CS scar (PP accreta)
•Coagulopathy

Intractable Postpartum Hemorrhage Algorithm
Vaginal delivery
Garment
balloon tampnade
Arterial embolization
Local
Control
Garment
Suellen Miller, 2005

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

Intractable Postpartum Hemorrhage Algorithm
Vaginal delivery
Local
Control
Garment
Gauze Pack or Balloon
Tamponade
Arterial embolization
Bakri
Tamponade Balloon
Sengstaken-Blakemore Tube
Condom

Sengstaken–Blakemore tube
Three lumen tube
(one for drainage)
Volume > 500ml

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.

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

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

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 ?

Condom Balloon Tamponade
Akhter et al . MedGenMed.2003 Sep 11;5(3):38. Bangladesh

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

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

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

Mohamed El Sherbiny MD Ob.& Gyn.
Damietta Egypt
Use of a Surgical
Glove to Control
Severe Postpartum
Hemorrhage
XX FIGO World Congress
October 2012

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

The Inverted
Glove Balloon
Tapenade
El Sherbiny et al FIGO 2012

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

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.

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

Beside the glove ,other Foleys catheter is also
inserted as a drainage channel to monitor
ongoing bleeding.

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

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

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.

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.

Conclusion
The Intrauterine tamponade with a
surgical glove is a simple, safe,
inexpensive, readily available and
effective means of treating massive
atonic postpartum hemorrhage.

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

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.

2-Resusetation
Minor PPH <1000
ml &Compensated
Intravenous
access one 14-
gauge cannula
Crystalloid
infusion.
AB,C : Assess: Airway,
O2 by mask at 10–15 L/M
14-gauge cannula x2 orange
Transfuse blood rapidly
Until blood is available, IV up
Ringer )± one L of it is colloid(
Keep patient& infusions warm

Minor PPH <1000
ml &Compensated
Venepuncture
)20 ml( for:
Grouping
CBC
Coagulation
screen
Pulse and
BP/15m
Venepuncture )20 ml( for:
Crossmatch )≥4 units(
Basal renal and liver functions
Continuous: Pulse , BP & RR
Temperature /15 m
Foley catheter: urine output
2 cannulae: 14 or 16 gauge

Intractable PPH
•Uterine atony
•Placenta accreta at CS scar
•Coagulopathy
124

Pph workshop 1 (9 2013)

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