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Pph moscow1

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Pph moscow1

  1. 1. MANAGEMENT OF POST-PARTUM HEMORRHAGEGC DI RENZO, MD, PHD, FRCOG, FACOGPERUGIA, ITALY
  2. 2. Why focus on preventing post-partum hemorrhage? Haemorrhage is the largest direct cause of maternal death PPH is mostly unpredictable Most PPH is caused by uterine atony Evidence-based, feasible, low-cost interventions exist Active management at the third stage of labour can prevent 60% of PPH
  3. 3. Difficulties associated with comparing post-partum hemorrhage studies Method to determine blood loss – Visual underestimation 70–80% Conduct during third stage of labour Confounding factors in epidemiological studies 58% of trials do not report their definition of PPH
  4. 4. Maternal Health: some ( underestimated) statistics 180–200 millions pregnancies per year 75 millions unwanted pregnancies 50 millions induced abortions 20 millions unsafe abortions 358,000 maternal deaths (1000 per day) 1 death every 1,5 min 20 maternal morbidities per minute 10-15 millions disabilities each year WHO, 2010
  5. 5. Maternal Death Clock  380 women become pregnantEvery Minute...  190 women face unplanned or unwanted pregnancy  110 women experience a pregnancy related complication  40 women have an unsafe abortion  1 woman dies from a pregnancy- related complication  20 women suffer of a disabilty related to childbirth WHO, 2010
  6. 6. About two thirds of maternal deaths are due to  Anemia-Hemorrhage  Obstructed delivery They can be  Eclampsia treated by a health  Sepsis professional  Unsafe abortion
  7. 7. Causes of maternal mortality
  8. 8. Maternal mortality from post- partum hemorrhage in the UK 6 Maternal mortality rate/million 5 4 3 2 1 0 85–87 88–90 91–93 94–96 97–99 00–02 YearHall M. 2004; Why mothers die (2000–2002) CEMACH. 88% received substandard care
  9. 9. Sub-standard care Organisational problems – Inappropriate booking – Inadequate blood transfusion – Intensive care facilities Poor quality of resuscitation – Inadequate transfusion – Blood products Equipment failure – Malfunctioning of specimen transport system Failure to recognise or treat antenatal medical conditions – Inherited bleeding disorders Failure of senior staff to attendHall M. 2004; Why mothers die (2000–2002) CEMACH. Concerns about the quality of surgical treatment
  10. 10. As with many problems, there seems to be two different kinds of emergencies... ...depending on whether the patient is in a developed or undeveloped country
  11. 11. Developed countries Sequence:  Diagnosis PPH  Protocol- management  Treatment  Success (>98%)
  12. 12. Undeveloped countries• Sequence: • Diagnosis PPH (?) • Emergency (?) • Transfer (?) • Centre (?) • Treatment (?) • Success (<60%)
  13. 13. Post-partum hemorrhageEqual opportunity Not equal occurrence opportunity killer 2/3 no risk factors  Poor  Malnourished  Unhealthy
  14. 14. What is post-partum hemorrhage?  Excess blood loss after the birth of a baby    PPH >500 ml (3.5– 30%)  Severe PPH >1000 ml (1.5–5.0%) Immediate PPH:  – Onset within 24 h of birthThese definitions are notPPH late:  accepted by all!! – Onset after 24 h of birth
  15. 15. One of the main problem……UNDERESTIMATION OF BLOOD LOSS
  16. 16. Methods used to diagnose post-partum hemorrhage Clinical methods – Physiological response to blood loss Quantitative methods – Visual assessment – Direct collection of blood into bedpan or plastic bags – Gravimetric method – Changes in hematocrit and haemoglobin – Others  Plasma volume  Tagged erythrocytes
  17. 17. Estimated blood loss 30 Visual Measured Estimated blood loss (%) 25 20 15 10 5 0 >500 ml >1,000 mlPrasertcharoensuk et al. IJGO 2000
  18. 18. Calibrated bag (Brass-V)
  19. 19. Risk factors1. placenta previa with or without previous uterine surgery.2. previous myomectomy.3. previous cesarean delivery.4. Ashermans syndrome. (treated surgically)5. submucous leiomyomata.6. maternal age of 36 years and older.
  20. 20. Risk factors (multivariable analysis)  Retained placenta, OR=3.5  Failure to progress to second stage, OR=3.4  Placenta accreta, OR=3.3  Lacerations, OR=2.4  Instrumental delivery, OR=2.3  Newborn large for gestational age, OR=1.9  Hypertensive disorders, OR=1.7  Induction of labour, OR=1.4  Augmentation of labour with oxytocin, OR=1.4Sheiner E, et al. J Matern Fetal Neonatal Med 2005.
  21. 21. Obstetrics & Gynecology 1985;66:89-92Placenta Previa/Accreta and Prior Cesarean SectionSTEVEN L. CLARK Et al The risk of placenta previa was 0.26% with an unscarred uterus and increased almost linearly with the number of prior cesarean sections to 10% in patients with four or more. With a placenta previa and one previous cesarean section, the risk of placenta accreta was 24%; this risk continued to increase to 67% (two of three) with a placenta previa and four or more cesarean sections.
  22. 22. MANAGEMENT Ch. B- Lynch 1° ed 2006 2° ed 2012
  23. 23. ( FIGO 2009 – Cape Town)
  24. 24. COMPREHENSIVEMedical Mechanical Surgical
  25. 25. Joint statement management of the third stage of labour to prevent post-partum hemorrhage Active management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atony – Consists of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony. The usual components include:  Administration of uterotonic agents  Controlled cord traction  Uterine massage after delivery of the placenta, as appropriate Every attendant at birth needs to have the knowledge, skills and critical judgment needed to carry out active management of the third stage of labour and access to needed supplies and equipment
  26. 26. Maternal outcomes of active management trials Active management 30 Physiological management Patients (%) 20 10 0 Transfusion Prolonged Therapeutic Low Retained third stage uterotonic haemoglobin placenta drugsMcCormick et al, IJGO 2002
  27. 27. POSTPARTUM HEMORRHAGE need of “ action” in the “golden hour” in order to increase the probability of patient survival:The mnemonic HAEMOSTASIS can assist in rememberingthe sequence of events to confront
  28. 28. HAEMOSTASIS H: Get HELP
  29. 29. HAEMOSTASISA: evaluate the vital parameters of the patient and the amount of bloodloss
  30. 30. HAEMOSTASISE: identify the cause (ethiology) and the appropriatetreatment (4T) Tone Tissue Trauma Trombin
  31. 31. Causes of post-partum hemorrhage (4T) TONE (70%) TRAUMA CAUSE TISSUE (19%) (10%) THROMBIN (1%)Anderson et al. Am Fam Physician 2007.
  32. 32. RISK FACTORS Etiology Process Clinical Risk Factors Tone Overdistended Uterus Polyhydramnios, Multiple Gestation Macrosomia Uterine Muscle Fatigue Rapid Labor, Prolonged Labor High Parity Intra Amniotic Infection Fever, Prolonged ROM Functional/Anatomic Distortion of the Fibroid Uterus Uterus Placenta Previa Uterine Anomalies Tissue Retained Products Incomplete Placenta at Delivery Abnormal Placenta Previous Uterine Scar High Parity Retained Blood Clots Atonic UterusTrauma Lacerations Precipitous or Operative Delivery Extensions at C/S Malposition, Deep Engagement Uterine Rupture Previous Uterine Surgery Uterine Inversion High Parity, Fundal PlacentaThrombin Pre-existing Coagulopaties, Liver Disease Acquired in Pregnancy ITP, DIC Therapeutic Anti-coag History of DVT or PE
  33. 33. HAEMOSTASISO: proceed with oxytocin infusion, prostaglandins ( via rectal, intramuscolar, IV, intramyometrial) First line Second line Third line (off label)
  34. 34. Drugs to prevent and treat uterine atony•Prophylactic syntometrine versus oxytocin•Prophylactic use of oxytocin•Carbetocin•Injectable prostaglandins•Misoprostol
  35. 35. Ancient Oxytocics• Egyptian Papyrus Ebers, 1500 BC contract uterus: speed birth, stem haemorrhage hemp in honey celery in milk juniper berries fly excrement (in many ancient pharmacopoeias)• Dioscorides: cyclamen, 100 AD• Ergot (Claviceps purpurea), 1582 AD 40
  36. 36. 1953: Synthesis of Oxytocin Vincent du Vigneaud – American biochemist – discovery, isolation, and synthesis together with ADH/vasopressin• Nobel prize in chemistry 1955 sulphur compounds of high importance first synthesis of a polypeptide hormone The Nobel Foundation 1955 http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/oxytocin.gif T Reinheimer, 2009 41
  37. 37. Oxytocin Today – oxytocin (sometimes combined with ergometrin)• Labour induction/augmentation• Prophylaxis and Treatment of Postpartum haemorrhage retained placenta: umbilical vein injection milk ejection/lactation: oxytocin nasal spray Martindale 2008 http://www.appdrugs.com/ProdJPGs/OxytocinLg.jpg T Reinheimer, 2009 42
  38. 38. Oxytocin Agonists Carbetocin (DURATOCIN, PABAL) – long-acting synthetic analogue – indication: prevention of uterine atony – veterinary medicine• Non-peptide agonists patented for erectile dysfunction WAY-262464: patented for anxiety, schizophrenia Pritt et al. 2004, Manning et al. 2008 http://www.bcnpeptides.com/images/products/carbetocina.jpg WO/2003/000692, US/20070117794 T Reinheimer, 2009 43
  39. 39. Mean arterial pressure (MAP) changes with oxytocin • 30 women with elective Mean change of MAP (mmHg) caesarean section • 5 u of oxytocin either as a bolus injection or an infusion over 5 min • Heart rate and intra- arterial blood pressure recorded every 5 s Study period (s)Thomas JS, et al. Br J Anaesth 2007
  40. 40. Carbetocin – Pharmacodynamics Oxytocin Carbetocin
  41. 41. N=240Study design: Prospective double-blind randomized controlled studyDrugs: Carbetocin 100 µg i.m. vs. syntometrine (5 IU of oxytocin and0.5 mg of ergometrine) i.m.Primary outcome: postpartum hemorrhage requiring additional uterotonictherapySecondary outcome: incidences of postpartum hemorrhage (>500 ml) and severepostpartum hemorrhage (>1,000 ml) as well as adverse effects profile
  42. 42. Authors Conclusion:A single dose of intramuscular carbetocin 100µg may be more effective as compared to a single intramuscular dose of syntometrine (5 IU of oxytocin and 0.5 mg of ergometrine) in reducing postpartum blood loss Lower incidence of adverse effects.
  43. 43. N=377Study design: double-blind randomised single centre studyDrugs: carbetocin 100 µg or oxytocin 5 IU, both i.v.Primary outcome: Need of additional pharmacological oxytocic interventions.Secondary outcomes: Estimated blood loss, difference in preoperative andpostoperative haemoglobin, incidence of blood transfusion and adverse effects
  44. 44. Authors conclusion:Carbetocin reduces the use ofadditional oxytocics followingcaesarean section when compared withthe licensed dose of oxytocin (5 IU)
  45. 45. Carbetocin versus oxytocin • REVIEW: Oxytocin agonists for preventing PPH • COMPARISON: 01 Carbetocin versus oxytocin • OUTCOME: 02 Use of additional uterotonic therapy Carbetocin Oxytocin RR (Fixed) Weight RR (Fixed) Study n/N n/N 95% CI (%) 95% CI 01 Caesarean delivery Boucher 1998 0/29 3/28 100 0.14 (0.01, 2.56) Dansereau 1999 15/317 32/318 900 0.47 (0.26, 0.85) Subtotal (95% CI) 346 346 100.0 0.44 (0.25, 0.78) Total events: 15 (carbetocin), 35 (oxytocin) Test for heterogeneity chi-square=0.66; df=1; p=0.42; I 2=0.0% Test for overall effect z=2.81; p=0.005 02 Vaginal delivery Boucher 2004 12/83 12/77 100.0 0.93 (0.44, 1.94) Subtotal (95% CI) 83 77 100.0 0.93 (0.44, 1.94) Total events: 12 (carbetocin), 12 (oxytocin)Su LL, et for Cochrane Database Syst Rev. 2007 Test al. heterogeneity not applicable 0.001 0.1 1 10 100 1000 Favours carbetocin Favours oxytocinJul Test for overall effect z=0.20; p=0.8 18;(3):CD005457
  46. 46. ConclusionsPrevention of PPHVaginal birth: active management, Oxytocin (3-5 IU), noprostaglandins, no ergometrinCaesarean section: Carbetocin (Pabal®), Oxytocin 5IU 2-3min –no bolus, no PGs, no ergometrinTherapy of PPHOT (10-40 IU/liter), ergometrin (0.2mg every 2-3 hours)PGE2/PGF2alpha (0.25 mg i.m. every 15-90 min)Misoprostol 800-1000mcg rectally (off label)Carbetocin (off label)
  47. 47. HAEMOSTASISS: transfer the patient to the operating room( exclude trauma or retained products, proceed with bimanual compression)
  48. 48. HAEMOSTASIST: “Balloon Tamponade”;
  49. 49. HAEMOSTASIST: “Balloon Tamponade”; Uterine packing (2009)
  50. 50. Traditionalmethod Bakri balloon
  51. 51. TAMPONADE WITH BAKRI BALLOON– Simple and efficient (87-95 % success rate)– Applicable after cesarean and vaginal births– Used as method of prevention in “cesareans at high hemorrhagic risk” (placental pathologies, uterine over-distension, preeclampsia, precedent hysterotomy, coagulopathy, etc) and in the case of contraindications for prostaglandins (asthma, glaucoma, important hepatic and renal dysfunction)– Easy to insert and remove– Continuous monitoring of blood loss
  52. 52. BAKRI BALLOON The Bakri is a balloon in silicon, latex-free, which is filled with physiological solution (500 cc max) and is able to create a real intrinsic compression on the myometrial walls: the filling volume can be varied in relation to the dimension of the uterus and the contractile response Additionally to the ease of insertion it has the possibility to monitor the amount of blood loss thanks to the drainage holes located in the distal part of the catheter, which is attached to a sac in order to collect the fluids. This access is used also to perform washings of the uterine cavit y. Associate adequate antibiotic coverage Removal of the balloon within 24 hrs administering uterotonics/uterokinetics before deflating
  53. 53. Bakri balloon
  54. 54. The intrauterine balloon Ultrasound Bladder Bakri balloon Bakri balloon myoma Catetere vescicale BAKRI BALLOON
  55. 55. HAEMOSTASISA: apply “sutures”
  56. 56. HAEMOSTASISA: apply “ compression sutures”
  57. 57. B-Lynch suture
  58. 58. HAEMOSTASIS A: apply “compressive sutures”Hayman uterine compressive sutures Cho multiple quadrate sutures Does not necessitate to open the uterine cavity
  59. 59. HAEMOSTASIS A: perform “ sutures”Suture of Hayman
  60. 60. HAEMOSTASIS S: Systematic pelvic devascularization Rescue Surgery: Ligation uterine artery and ovarian arteryTriple ligation of Tsiruinikov : ligation of the uterine arteries, round ligament and the uterine-ovarian.
  61. 61. Vascular ligation – Uterine – Ovarian – Int iliac
  62. 62. Vascular ligation
  63. 63. HAEMOSTASIS Rescue Surgery Ligation hypogastric artery Underneath the superior gluteal artery
  64. 64. Hypogastric artery ligation success 84% Hansch E, etal. AJOG 1999
  65. 65. HAEMOSTASIS I: Interventional radiologist –”Uterine Artery Embolization”(Limiting factors: hemodinamically stable cases - presence of angiographist - transport toradiology) Fragments of gelfoam are injected (gelatin sponge resorbable in 10-30 days)
  66. 66. HAEMOSTASISI: Interventional radiologist –”Uterine Artery Embolisation”
  67. 67. HAEMOSTASIS S : Subtotal or total abdominal hysterectomyRescue Surgery : total hysterectomy / subtotal 1.55 % births 0.24% and 0.90% of all cesarean sectionsISTAT 2006 between 1480 and 1800 hysterectomies/year associated with cesarean section
  68. 68. The ideal treatment should be: intuitive and easy to apply secure and effective in the“prevention” and the arrest of hemorrhages has an immediate result avoids hysterectomy
  69. 69. Our Philosophy…
  70. 70. Team work EFFICACY & EFFICIENCY
  71. 71. •TEAM- Obstetricians, Anesthetists,Blood bank, Interventional Radiologists Max therapeutic efforts within 2-3 hrs Contemporary involvement of all professional figures Liberal use of all therapeutic agents
  72. 72. Follow in a stepwise way the guidelines
  73. 73. BASICS INFORMED CONSENT1. INTERVENTIONAL RADIOLOGISTS IN THE THEATRE2. CLAMPING UTERINE VESSELS BEFORE PLACENTAL DELIVERY3. ASSOCIATION OF COMPRESSIVE SUTURES AND BAKRI BALLOON
  74. 74. B-Lynch + Bakri Balloon “ SANDWICH EFFECT“
  75. 75. B-Lynch + Bakri Balloon IT LOOKS LIKE THE LUGGAGES OF IMMIGRANTS….. NO RISK OF ISCHEMIA
  76. 76. Prevention of Postpartum Hemorrhage( cases with elevated hemorrhagic risk: i.e., placenta previa post-C.S.) PRELIMINARY PROPHYLACTIC STEP 1 CATHETERIZATION OF THE DESCENDING AORTA EXTRACTION OF THE FETUS BY C.S. AND STEP 2 PLACENTAL DELIVERY MULTIPLE QUADRATE ENDOUTERINE STEP 3 HEMOSTATIC SUTURES PREPARATION OF B-LYNCH COMPRESSIVE STEP 4 SUTURES APPLICATION OF HYDROSTATIC BALLOON STEP 5 (BAKRI-BALLOON) REPOSITIONING OF UTERUS –UTERINE SUTURES- HYDROSTATIC BALLOON INFLATION-B-LYNCH STEP 6 LIGATURE IF THESE MANEUVRES FAIL DEVASCOLARIZATING LIGATURE /SELECTIVE EMBOLIZATION /HYSTERECTOMY
  77. 77. transomeral/transfemoral pre-carefourSTEP 1 Angiography
  78. 78. STEP 2 DELIVERY OF THE FETUS ADMINISTRATION OF CARBETOCIN
  79. 79. STEP 2 CLAMPING UTERINE VESSELS
  80. 80. Prevention of postpartum hemorrhage ( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. ) Assistance Plan STEP 2 Squared hemostatic endouterine suturesRationale: at the level of the inferior uterine segment reduced muscularcomponent ; incomplete mechanical hemostasis after placental delivery;conspicuous hemorrhage multiple quadrate sutures in the IUS of 2-3 cm, transdecidual. (Dexon n.1- 2,needle with large curvature ) Retraction of the muscular fibers with clamping and e occlusion of the vasculature m s Affront i
  81. 81. STEP 3 Squared hemostatic endouterine sutures
  82. 82. Prevention of postpartum hemorrhage( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. ) Assistance Plan STEP 3 B-Lynch compressive sutures The ligature of the sutures follows after STEP 4
  83. 83. PREPARATION OFSTEP 4 B-LYNCH SUTURE
  84. 84. STEP 4
  85. 85. Prevention of postpartum hemorrhageSTEP 4 Application of hydrostatic balloon (Bakri balloon) Uterine closure Hydrostatic balloon inflation B-Lynch suture ligature
  86. 86. BAKRI-BALLOON POSITIONINGSTEP 5
  87. 87. MILD INFLATION OF THE BALLOONSTEP 5
  88. 88. REPOSITIONING THE UTERUS;STEP 6 FULL INFLATION OF BALLOON; B-LINCH SUTURE APPLIED
  89. 89. postpartumhemorrhage ( Ex adiuvantibus )
  90. 90. postpartum hemorrhage ( Ex adiuvantibus ) Separatore cellulare a flusso continuo Unità di gestione della temperatura corporea
  91. 91. postpartum hemorrhageADULT INTENSIVE CARE UNIT POSTPARTUM
  92. 92. ONGOINGEND POINT :SURGICAL CONSERVATIVE TREATMENTREACHED 95% ( 78 OUT OF 82 )• 4 HYSTERECTOMIES
  93. 93. DIFFICULT CASES……. US SCAN
  94. 94. DIFFICULT CASES…. RMN
  95. 95. DIFFICULT CASES …. US SCAN CHECK AFTER 30 DAYS
  96. 96. ( 02.09.2011)DIFFICULT CASES...
  97. 97. DIFFICULT CASES...... ( 02.09.2011)
  98. 98. ( 02.09.2011)DIFFICULT CASES...
  99. 99. DIFFICULT CASES...
  100. 100. CESAREANHYSTERECTOMY
  101. 101. CESAREANHYSTERECTOMY
  102. 102. CESAREANHYSTERECTOMY
  103. 103. CESAREANHYSTERECTOMY
  104. 104. Considerations All pregnancies are at risk of hemorrage in the post partum even if at the moment of birth there were no risk factors.Because our goal is to improve maternal health and prevent the possibility of death during the pregnancy or birth it is fundamental to possess, other than a solid preparation, a trustworthy and well trained team and the necessary instruments. ( Bakri balloon;Cell sorter with continuous flow; FloSeal)
  105. 105. New conservative approach in the management of PPH G. Clerici, G. Epicoco, E. Bottaccioli, S. Arena, I. Giardina, G. C. Di Renzo, G. Affonti University Hospital of Perugia, Perugia, Italy CONSERVATIVE MANAGEMENT PROTOCOL METHODS A retrospective study of 49 patients (since October STEP 1 –Preliminary prophylactic 2007) with placenta previa/accreta who underwent a catheterization of the descending aorta conservative management protocol (see table). STEP 2 –Extraction of the fetus by C.S. and RESULTS placental delivery E M S Conservative management of PPH was successfully Affronti achieved in 48 patients (98%). In only one case it was STEP 3 –Multiple quadrate endouterine necessary to perform post-partum hysterectomy for haemostatic sutures massive bleeding due to severe placental accretism. In another case it was necessary selective STEP 4-Preparation of B-Lynch compressive embolization of the right uterine artery due to the sutures presence of hematoma in the right part of the lower uterine segment and in the right paracolpus. STEP 5 –Application of hydrostatic balloon The mean estimated blood loss was 1620 ml (range (Bakri balloon) 1100-2340 ml). The mean hospital stay was 5.5 days (range 4-10 days). 22 patients (45%) underwent STEP 6 –Repositioning of uterus - uterineINTRODUCTION sutures - hydrostatic balloon inflation – B- intraoperative and postoperative blood transfusionsPostpartum hemorrhage (PPH) is the leading Lynch ligature and the mean transfused volume was 700 ml. 18cause of maternal death worldwide. Most patients (37%) were admitted for 24-48 h to intensivedeaths occur within the first 4 hours after If the maneuvers fail the next step is care unit for intensive monitoring. 30% of patientsdelivery, often as a consequence of placental devascolarizating ligature/selective experienced moderate fever in the first 24-48 h anddelivery. Treatment option for PPH include embolization of the uterine arteries. they were treated with antibiotics.conservative management (uteritonic drugs, If all procedures fail, proceed withselective devascularization by ligation or hysterectomy.embolization of the uterine artery, external CONCLUSIONScompression with uterine sutures and • Monitoring of maternal hematologic All pregnancies are at risk of PPH. Its management isintrauterine packing). Failure of these parameters 24 hrs before C.S. and 2 h after dictated by several considerations includingoptions necessitates hysterectomy. the procedure, than every 2-4 h for the hemodynamic status and desire to preserve fertility.The objective of the study is to report our following 24 hrs in relation to clinical Conservative interventions should representexperience with a conservative management conditions. mandatory step for treatment of PPH in high riskprotocol to treat PPH in high risk patients • Blood transfusion if the hemoglobin level patients with placenta previa/accreta. The results ofdiagnosed with placenta previa/accreta. decreases more than 7 g/dl and the this conservative protocol are encouraging . hematocrit value is less than 21% ; • The Bakri balloon is removed 24 h after delivery.
  106. 106. CONCLUSIONS
  107. 107. FACTS:All pregnancies are at risk ofPPH even if no predisposing factors are presentLuis G. Keith 2007
  108. 108. BOTTOM LINE Averting maternal death is based on having a prepared mind, a prepared team and a full range of possible therapiesLuis G. Keith, 2007
  109. 109. Postpartum HemorrhageRecommendations: •Every department needs to have a protocol for management of O.E., with periodic re-evaluation (Life Support training) •Cases at risk of E.O. need to give birth in a II-III level structure •Uncontrollable hemorrhages may necessitate hysterectomy: an expert surgeon needs to be avaliable quickly 24 hrs a day •Activate the multidisciplinary team early in the management of a case at risk •Institutional guidelines for the treatment of hemorrhages with periodic simulation training (skills and drills)
  110. 110. THANK YOU

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