Surgical managment of PPH

1. Case Presentation on Surgical Mgt. of
PPH
Presenter: Dr.Anwar H.(Yr-4 OBGYN Resident)
May 2023
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2. Out line
1. Objective
2. Case summary
3. Discussion of surgical Mgt. of PPH
4. Comments
5. References
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3. Objective
1. To use the case as an entry point to discuss on the
Surgical mgt. of PPH & to improve Mgt. of our
patients care in the future carrier.
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4. CASA SUMMARY
• IDENTIFICATION
• Name: FMU
• Sex: Female
• Age:26yrs
• MRN:347842
• Region: Oromia
• Wareda: Kombolcha
• Religion: Muslim
• Ethnicity: Oromo
• Admission date: 30/08/2015
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5. CASE SUMMARY….
• HISTORY
Resident evaluation
Date 30/8/2015 @ 9:00pm
• C/C: Gush of fluid per vagina/1day
• HPP:
• She is G-VIII, p-VII(5 alive, 2END, 2SB, all by V/D.)
• She does not remembers her LNMP but claim to be amenorrhic
for the past 9 months.
• She has no ANC follow up.
5

6. Case summary…..
• She comes with referral from kombolcha HC. With diagnosis
of prolonged PROM + NRFHRB
• After she presented there with gush of clear non foul smelling
fluid per vagina of 1 day duration.
• But she has no history of pushing down pain or decreased fetal
movement.
• Other wise she has no other danger sign and symptom of
pregnancy.
• She has no hx of diagnosed DM, HTN, Cardiac & renal
disease.
6

7. Cont…
• Physical Examination
• G/A: Healthy looking
• V/S: Bp = 110/70mmHg , PR= 90 ,RR=22
• HEENT: Pink conjunctiva and NIS
• Chest : Clear and resonant
• CVS: S1 & S2 well heard, No murmur or gallop
• Abdomen:
– Term sized gravid uterus
– long lie & Cephalic presentation
– FHB +ve (138Bpm)
– Uterine contraction-2/10’/20-30”
7

8. cont….
• GUS:
– No vaginal bleeding
– Cervix: 2cm dilated & 60% effaced
– Membrane- ruptured, clear liquor
– Station- high(-2)
• MSSK/IGS: NAD
• CNS: COTPP
8

9. Cont…..
• INVESTIGATION DONE
• CBC(Hgb= 8.2gm/dl MCV=63fl plt=259 x10*9/L)
• BG & Rh= B(+ve)
• Obstetric U/S
 SIUP
 FHB +ve
 placenta fundal
 Cephalic presentation
 AGA= 37Wks + 4d
BPD=9.4CM= 38Wks + 2d
FL=6.3cm=33Wks + 4d
 EFW=2846gm
 SDP=1.5cm
INDEX: 3rd TMPx + ? R/O Skeletal dysplasia
9

10. cont….
• Asst.: 3rd TMPx + Unknown date + Grand MG + PROM + R/O
False labor + ? Skeletal dysplasia
• PLAN:
– Admit to labor ward
– Tracing with CTG
– follow with PROM Chart
– Ampicillin 2gm IV QID till delivery
– To ripen with 25mcg of misoprostol Q4hr if no spontaneous
onset of labor ensue.
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11. PROM CHART
Date Time BP PR R
R
Tem
p
FH
B
Foul
smelling
discharge
V.bleeding WBC
30/8/15 8:00pm 117/63 83 20 36.1 129 No No
8:30pm 130 No “
9:30pm 120 No “
10:00pm 110/60 78 20 36.4 139 No „
11:00pm 100/65 74 20 36.1 144 No “
1/9/15 12:00am 138 No “
1:00am 146 No “
2:00am 105/65 73 22 181 “ “
4:00am 106/60 70 20 142 “ “
6:00am 101/50 68 20 123 “ “
7:00am 136
11

12. Case summary…..
• On the same day:
• False labor was diagnosed and misoprostol 25mgm was
started @ 4:00 am
• labor started after 5hr of misoprostol @ 8:00 am(3c/10’/40-
50”).
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13. Progress note(by senior Resident)
• Date 1/9/2015 @ 9:00am
• Subjectively:
• She has pushing down pain
• Objectively:
• G/A: ASL(in labor pain)
• V/S: Bp= 110/ 70 PR = 104 RR= 20 T=36.6C
• Abdomen:
– Term sized gravid uterus
– Long lie and cephalic presentation
– FHB +ve (60-90bpm)
– Uterine Cx: 4/10’/45-50”
13

14. Progress…
• GUS:
– Cervix : fully dilated
– G-III MSAF
– Station 2
– Brow presentation
– Grossly adequate pelvis
• Asst. Same +persistent Brow presentation + severe fetal
bradycardia + BOH
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15. Plan
• To take consent and prepare for Emergency C/S
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16. Operation note
• Under GA, abdomen entered through pfennenstiel skin incision.
• Finding:
– Intact gravid uterus
– Healthy looking ovaries and tubes
– G-III MSAF
– 30% Retro placental clot
• What is Done & out come:
• LUSTCS done to effect a delivery of alive male newborn
weighing 3kg with APGAR score of 4,2, 0 on the 1st , 5th & 10th
minute respectively
• EBL 500ml, mother leave OR with stable V/S
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17. Post op order
• Date: 1/9/15
• Dx- Immediate post op after LUSTCS done for Severe
bradycardia
• C-Subcritical
• D-NPO
• A- Encourage early ambulation
• I-Post op Hgb.
• NC- Routine
• V/S & Ux massage: Q15’ for 2hr then Q30’ for 4hr
• Mf(DNS,RL,NS)1Bag tid x 24hr
• Diclofenac 75mg im bid & tramadol 50mg iv QID X24hr
• Keep urine catheter for 8hr
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18. Post OP V/S
Date Time BP PR RR T InPut UOP SPO2 VB MEDICA
TION
1/9/15 11:00am 95/65 82 20 36.5 98% No Tramadol
50mg IV
11:15am 90/60 88 20 36.4 87% No
11:30am 85/50 99 22 2 NS 95%
11:45 80/55 105 22 96% No
12:00 90/60 „‟
12:15 102/64 78 22 96% „‟
12:30 105/65 80 20 98% No
12:45 105/63 82 22 98% No
01:00 104/62 80 22 98% No
01:15 78/42 105 22 96% No
01:30 74/38 108 22 94% No
01:45 74/45 110 20 95% No
02:00 78/46 128 22 98% No
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19. Post op evaluation
• Date 1/9/15 @ 1:15pm
• P-immediate post op after LUSTCD was done for indication of
severe fetal Bradycardia
• On-Mf. & Oxytoxin drip
• Subj:-no new complaint
• Obj:-GA-ASL
• V/S BP=78/42 PR=96 RR=22 T=
• HEENT: pale conjunctiva & NIS
• Abdomen:
– full and moves with respiration
– clean surgical wound dressing
– shifting dullness +ve
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20. Progress…
• GUS:
– no active Vx bleeding
– cervix 3cm dilated
– no blood clots in vagina & uterus
• CNS: COTPP
• Ultrasound
– Uterus is empty
There is 4.2 x 3cm posterior cul-de-sac collection
INDEX: Intra abdominal collection
• Asst. = Same + PPH 2⁰ to intra-abdominal collection +
hypovolemic shock 2⁰ ABL
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21. Progress…
• Plan
• To Prepare x-matched blood
• To Resuscitate with iv crystalloid
• To apply NASG
• Prepare for relaparatomy
• To consult duty senior
21

22. ReLaparotomy
• Findings:
– 300ml of blood sucked out
– Lt. side broad ligament hematoma expansion
• Done:
• Abdominal hysterectomy + Rt. salphyngo Oophorectomy
done.
• EBL =900ml
• Patient leave OR table with V/S(BP=118/64, PR=130,
Spo2=94%, UOP=400ml).
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23. Post op order
• Date: 1/9/15
• Dx- Immediate post op after laparotomy was done for intra-
abdominal collection
• V/S : Q15’ for 2hr then Q30’ for 4hr
• Mf(DNS,RL,NS)1Bag TID x 24hr
• Ceftriaxone 1gm iv BID
• Metronidazole 500mg iv TID
• Diclofenac 75mg IM BID & Tramadol 50mg iv QID X24hr
• Keep urine catheter for 12hr
• Transfuse with at least 3 unit of blood
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24. Post operatively
• Transfused with 1 unit of (o+ve) blood
• Post op Hgb:
– Date 2/09/15=7gm/dl
– Date 5/9/15=5.8gm/dl
– Date 9/9/2015= 5.9gm/dl
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25. Post op follow up
Date Time BP PR RR T⁰ INPU
T
UOP SPO2 VB MED.
1/9/15 4:30pm 115/70 104 22 36.3 92% no tramadol
4:45 ” 113/65 98 22 36.4 94%
5:00 ” 100/65 86 22 36.4 95%
9:00 ” 100/70 90 20 36.2 94%
9:30 ” 105/65 91 22 36.1 93%
10:00 ” 100/70 92 20 36.2 92%
10:30 100/65 94 20 36.1 95%
11:00 100/70 90 22 36.2 96%
11:30 105/65 89 26 36.1 95%
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26. Date Time BP PR RR T⁰ INPU
T
UOP SP
O2
VB MED.
2/9/15 1:00 am 105/62 86 24 98%
1:30 “ 108/60 80 24
2:00 “ 110/62 78 22
2:30 “ 114/66 90 22
3:00 115/65 100 20
3:30 120/60 100 20 96%
4:30 120/60 100 20 97%
5:30 115/70 98 20 98%
6:30 125/70 92 20 99%
7:00 115/66 101 20 98
8:00 123/69 94 20 96%
9:00 115/66 104 20 97%
10:00 115/70 102 20 96%
11:00 110/66 94 20 97%
12:00 112/68 100 20
2:30pm 117/65 100 20 36.2 91%
2:45 109/56 116 21 1000ml/8hr 26

27. Date Time BP PR RR T⁰ INPU
T
UOP SPO2 VB MED
2/9/15 3:30pm 125/58 111 21 97%
4:00 118/67 98 20 96%
5:00 121/58 96 20 96%
6:00 117/72 90 20 97%
7:00 115/60 100 20 96%
3/9/15 6:00am 110/70 100 20 95%
7:00 112/70 90 22 95%
8:00 110/72 98 20 97%
9:30 112/68 90 20 98%
10:30 104/58 86 20 97%
11:30 102/60 78 22 96%
12:00 108/58 72 20 96%
1:00 100/60 70 20 36.5 95%
2:00 110/60 72 20
4/9/15 9:00am 125/70 90 21
11:00am 115/70 88 21
2:00pm 120/70 105 20
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28. Cont…
• Date 8/9/15
• Patient transferred to maternity ward with stable vital sign
for further transfusion
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29. DISCUSSION
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30. Introduction
• Postpartum hemorrhage (PPH) is an obstetric emergency
• It is the 1st -leading cause of maternal morbidity and mortality
worldwide.
• PPH- Defined as cumulative blood loss ≥ 1000ml or
• Blood loss accompanied by sign and symptoms of hypovolemia
within 24 hours after birth process regardless of route of
delivery.
• Clinically also defined as a decrease in Hct. of 10% from the
base line.
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31. Classification & Etiology
• Primary or early PPH: in the first 24 hours
after delivery
• etiologies: Uterine atony, Retained placenta,
Genital tract lacerations, Uterine rupture, Uterine inversion,
Coagulopathy
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32. Classification & Etiology of PPH
• 2⁰ or delayed(late) PPH:
• occurs from 24 hours to 12 weeks after delivery
• Etiology -Endometritis, Placental site sub involution, Retained
placental fragments, Coagulopathy, Gestational choriocarcinoma
• Our patients it is 1⁰ PPH 2⁰ to lateral extension of hysterotomy
incision
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33. Management of PPH
• The management depends on the etiology of PPH and
hemodynamic status of the pt.
• In addition to fluid administration and transfusion of blood
products;
• Temporizing maneuvers should be attempted prior to
performing any surgical procedures in hemodynamically
unstable pts.
• so every effort should be made to reverse contributing factors
such as hypothermia, acidosis and coagulopathy;
• Cessation of hemorrhage depends on reversal of any
coagulopathy acidosis
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34. Mgt…
• Quick assessment of the etiology & the source of bleeder is
important 1st steps b/c the mgt. vary(4T’s).
• Generally, in treatment of PPH, less invasive method should be
used initially if possible.
• The initial mgt. Depends on the etiology
– medical mgt.
– Radiological mgt.
– Surgical mgt.
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35. Laparotomy
• Laparotomy is best performed through a vertical midline
incision to provide exposure of both the pelvis and
abdomen
• In patients at or post cesarean delivery, the existing
incision is used.
• In our pts the existing Pfenninstiel incision
is used for relap.
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36. Laparotomy….
• The abdominal cavity is irrigated to remove blood and clots and
inspected for the source of bleeding.
• These sites should be actively evaluated in patients with
compensated shock (normal blood pressure with increasing heart
rate).
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37. TEMPORARY MEASURES FOR STABILIZING HEMODYNAMICALLY
UNSTABLE PATIENTS
• Patients at imminent risk of exsanguination
- Manual aortic compression
- Resuscitative endovascular balloon
occlusion of the aorta
- Intermittent intraaortic balloon occlusion
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38. Temporizing maneuver…….
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39. Myometrial laceration
• Serious hemorrhage is caused by lateral extension of the incision.
• Generally, Bleeding from a hysterotomy incision is controlled by
suture ligation.
• The angle of transverse incision should be clearly visualized for
retracted vessels.
• . Deterioration of maternal vital sign without obvious bleeding
should alert intraperitoneal or retro-peritoneal bleeding
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40. Laceration…..
• An Enlarging hematoma beyond the end of the incision (or
swelling beneath the surface of broad ligament) suggest
retracted blood vessel with ongoing bleeding.
• On lateral lacerations, placement of hemostatic sutures should
be made with caution to avoid injury to the ureters.
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41. Laceration of uterine artery or utero-
ovarian artery branches
• Bilateral ligation of uterine vessels (O’ Leary stitch) is the
preferred approach for controlling PPH from Uterine artery or
branches of utero-Ovarian artery.
• Bleeding adjacent to the uterus without clear bleeding points
can be managed by ligation of uterine vessels
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42. Hysterectomy
• It is Definitive treatment of uterine bleeding
• If the fertility preserving procedures do not reduce the
bleeding to the manageable level.
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43. Post laparotomy inspection
• The need for ≥2 units of blood(packed RBC) per hour for
3hour is a sign of significant ongoing bleeding & a need to
return to OR or
• Arterial embolization by an interventional vascular
specialist.
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44. Comment
• Poor follow up of labor progress(incomplete
partograph)
• Referral diagnosis of NRFHRP was undermined
• Lack of blood is a challenging in rescesitation.
• Clear observation of the two lateral age for active
bleeding or for placement of suture before closure of
the abdomen should be made in lateral extension;
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45. REFERRANCE
1. ACOG PRACTICE BULLETIN VOL.130 NO
183 October 2017 (P1-19)
2. Gabbe Obstetrics, 7th edition, Chapter 18 p406
PPH
3. Williams Obstetrics, 25th edition, PPH p758
4. Up to date -2018 topic on PPH,
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