Pph work shop part ii 10 2013


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postpartum hemorrhage workshop part 2 by dr mohamed elsherbiny

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Pph work shop part ii 10 2013

  1. 1. Dr. Mohamed El Sherbiny MD Ob.& Gyn Postpartum Hemorrhage (PPH) Guidelines for Immediate Action “Part II ” Damietta Specialized Hospital Workshop 2-11-2013
  2. 2. Sources of Evidence PubMed Cochrane library SOGC Clinical Practice Guideline No. 189,2007 Committee, Society for Maternal-Fetal Medicine(SMFM), November 2010 RCOG Guideline 2005 & 2011( Placenta previa, & previa accreta) NICE Clinical Guideline, November 2011 (CS) Placenta Previa Accreta ACOG Committee 7-2012 Damietta Governorate experience (FIGO 10- 2012 ) UpToDate, Reaink , Augest 2013
  3. 3. What Is The Next Step if Balloon Tamponade Fails ? The following may be attempted, depending on clinical circumstances and available expertise: Haemostatic brace suturing (B-Lynch or modified compression sutures) Bilateral ligation of uterine arteries Bilateral ligation of internal iliac (hypogastric) arteries Selective arterial embolisation RCOG Guideline PPH No.52 May 2009 Grade C 4
  4. 4. Compression sutures, may be attempted as a first intervention, and if these fail, then uterine, utero-ovarian and hypogastric vessel ligation may be tried. If Balloon Tamponade Fails
  5. 5. Stepwise uterine artery ligation (SUAL) is the first-line surgical approach . If bleeding is not controlled by SUAL or no available expert to perform it, shift to use of uterine compression (Brace) suture technique is the second step. Jacob , UpToDate Aug. 2013 Grade C If Balloon Tamponade Fails
  6. 6. Intractable Atonic PPH Algorithm Vaginal delivery Failed Expertise Stepwise Uterine Arteries Ligation (SUAL) Balloon Tamponade Laparotomy ± Non-pneumatic anti-shock garment if available Failed : ±Internal iliac ligation -Hysterectomy Low experience or Failed SUAL : B-Lynch/Hayman ± sandwich
  7. 7. Uterine Compression (Brace) Sutures B-Lynch suture 1997 Hayman suture 2002 Sandwich 2007 (combined with Balloon tamponade)
  8. 8. Test For Uterine Compression Sutures  An assistant stands between the patient’s legs to determine and extent of the bleeding.  The uterus is then exteriorized and bimanual compression performed. • The Test is positive if the bleeding stops and the compression suture will work and stop the bleeding.
  9. 9. B-Lynch Suture
  10. 10. Anterior Posterior B-Lynch Suture
  11. 11. B-Lynch Suture Monocryl No.1 mounted on 90-cm curved blunt needle or other rapidly absorbable sutures B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd Ed.2012
  12. 12. It is recommended that a laminated diagram of the brace technique be kept in theatre. RCOG Guideline PPH No.52 May 2009 Grade C
  13. 13. B-Lynch Technique
  14. 14. Simple, effective (91-99%) and cost-saving Fertility preserved and proven Mortality avoided World-wide application(1300 cases) and successful (only 19 failures reports. The B-Lynch surgical technique B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd Ed.2012
  15. 15. Hayman Compression Suture Hayman et al Obst. Gynec. 2002,99;3;502-6 A number 2 Vicryl or Dexon suture on a straight, blunt needle is used to transfix the uterus from front to back, just above the reflection of the bladder and is then tied at the fundus of the uterus. This can be done as one suture on each side of the uterus, or more than one suture if the uterus is particularly broad,
  16. 16. Hayman Uterine Compression Suture Advantage  Uterine cavity not opened  Probably quicker and easier to apply Disadvantage  Uterine cavity not explored under direct vision  No feed-back data on fertility outcome  Morbidity feed-back data limited  Unequal tension leads may to segmented  Ischemia secondary to slippage of suture – ‘shouldering’ with venous obstruction B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd Ed.2012
  17. 17. Hayman Uterine Compression Suture El Sherbiny
  18. 18. Combination of External Compression & Internal Tamponade “ Uterine Sandwich”  Indicated for patients with persistent bleeding from uterine atony refractory to medical therapy and has negative or unsatisfactory compression suture test .  The balloon is inflated with median volume of (range 60 to 250 mL) to avoid "undue blanching at the compression suture sites," which might lead to uterine laceration or necrosis Bakri ,UpToDate,Mar.,2013
  19. 19. Intrauterine balloon (Bakri) in combination with a B-Lynch uterine compression suture Nelson &O'Brien , Am J Obstet Gynecol. 2007;196(5): Diemert et al.Am J Obstet Gynecol. 2012;206(1):65.e1 Uterine Sandwich Bakri balloon tamponade combining with Hayman external compression suture . Yoong et al. Acta Obstetricia et Gynecologica Scandinavica , 91 (2012) 147–1512011
  20. 20. Uterine Sandwich Nelson &O'Brien , Am J Obstet Gynecol. 2007;196(5):
  21. 21. Hayman Uterine Sandwich Yoong et al. Acta Obstetricia et Gynecologica Scandinavica , 91 (2012) 147–1512011
  22. 22. Stepwise Devascularization
  23. 23. Stepwise Uterine Devascularization This technique entails five successive steps, so if bleeding is not controlled by one step the next step is taken until bleeding stops. The steps are (1)unilateral uterine vessel ligation, (2) bilateral uterine vessel ligation (3) low uterine vessel ligation (4) unilateral ovarian vessel ligation (5) bilateral ovarian vessel ligation. AbdRabbo ,Am J Obstet Gynecol. 1994 Sep;171(3):694-
  24. 24. Advantages over internal iliac ligation: Easier dissection. Lower complication rates. More distal occlusion of arterial supply with less potential for rebleeding because of collaterals High reported rates of success in controlling haemorrhaging. (SOGC ) Clinical Practice Guidelines 2000 Stepwise Uterine Devascularization
  25. 25. 12 45 3 Stepwise Uterine Devascularization
  26. 26. 1 3 2 Stepwise Uterine Devascularization
  27. 27. Each suture: Starts in a vascular area just lateral to the outer margin of the uterus, then encompasses 2cm of uterine walls medially encircling the blood vessels within it.
  28. 28. PPH After CS 35
  29. 29. 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 36
  30. 30. 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. 37
  31. 31. Intractable Atonic PPH Algorithm Cesarean Section Expertise Stepwise Uterine Arteries Ligation(SUAL) Low experience or Failed SUAL: B-Lynch/Hayman ± sandwich Failed : ± Internal iliac ligation Hysterectomy Excluding the other 3 Ts ( Extension , C. tears ,PP accreta Upper S Atony
  32. 32. Intractable Atonic PPH Algorithm Cesarean Section Expertise Stepwise Uterine Arteries LIG. (± Prophylactic) Total Hysterectomy Excluding the other 3 Ts ( U .S.atony , Trauma or thrombin Lower S Atony Major P. Previa or Focal PP accreta Low Experience Balloon Tapenade Dissectible Bladder Longitudinal Lateral .Uterine Sutures Non -Dissectible Bladder
  33. 33. Management of Placenta Previa Accreta “The New Nightmare”
  34. 34. Morbid Adherent Placenta : Accreta 79% Increta 14% Percreta 7% 79% 14% 7% Attach to the myomet. penetrate to serosa invade into the myometrium UpToDate , Resink , Aug 2013
  35. 35. 1-Placenta previa : 9.3% Vs 1/22,154 without PP 2-Uterine scare: 29% with placenta over the scar Versus 6.5% not over the scar 3-Raised Maternal Age The most important and the commonest risk factor is placenta previa after a prior CS. Silver et al.. Obstet Gynecol 2006; 107:1226–1232. Stafford I, et alContemp Obstet Gynecol 2008;82-53:76 Risk Factors For placenta Accreta Ferrazzani et al,. Fetal Diagnosis and Therapy; 2009. 25:400–403.
  36. 36. Women with placenta accreta/percreta are at very high risk of major PPH. If placenta accreta or percreta is diagnosed antenatally, there should be consultant-led multidisciplinary planning for delivery. RCOG Guideline PPH No.52 May 2009 (Grade C)
  37. 37. Complication of 109 Cases Of Placenta Percreta Bl.transfusion of > 10 units 40% Maternal death 7% Infection 29% Perinatal death 9% ureteral ligation 5% Fistula formation 5% Uterine rupture 3%. O'Brien,. Am J Obstet Gynecol 1996; 175:1632.22.
  38. 38. Progressive increase 1950 : 1/30,000 1980s : 1 /2500 2002 : 1 / 535 2006 : 1/210 An increase of 142 Fold !! mainly due to the marked ↑ in CS rate worldwide . The incidence of Morbid Adherent Placenta Stafford & Belfort, Contemp Ob/Gyn April:77, 2008 UpToDate , Resink , Aug 2013
  39. 39. Frequency of Placenta Accreta According To Number of CS Deliveries And Presence of Placenta Previa Cesarean delivery Placenta previa No Placenta previa First (primary) 3.3 0.03 Second 11 0.2 Third 40 0.1 Fourth 61 0.8 Fifth 67 0.8 ≥ Sixth 67 4.7 SMFM. Placenta accreta. Am J Obstet Gynecol 2010. UpToDate , Resink , Aug 2013
  40. 40. Prenatal detection of placenta previa accreta is associated with decreased in: Feto-maternal morbidity & Feto-maternal mortality Warshak., et al Obstet Gynecol 2010;115:65–9 CHOU et al Ultrasound Obstet Gynecol 2002; 15: 28–35.
  41. 41. Diagnosis of placenta accreta before delivery allows multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality. ACOG Committee 7-2012
  42. 42. Diagnosis of Placenta Previa Accreta (PPA)
  43. 43. Clinical Manifestations of Placenta Accreta AP Hemorrhage :In focal accreta Interapartum hemorrhage : Profuse, life-threatening at the time of manual placental separation The usual first manifestation of diffuse accreta . Hematuria :During pregnancy :With bladder invasion.
  44. 44. RCOG Guideline PP PPA No. 27 October 2005 SOGC Clinical Practice Guideline No. 189,2007 RCOG Guideline PPH No.52 ,2009 RCOG Guideline PP PPA No. 27 , 2011 ACOG Committee 7-2012 Recommendations For Prenatal Diagnosis of PP Accreta Early counseling Proper Decision :1-Conservative Vs hysterectomy 2-Elective rather than emergency
  45. 45. PP. With previous CS are at high risk of having a morbidly adherent placenta and should have been imaged antenatally. Colour flow Doppler U/S should be performed . PP. With previous CS RCOG Guideline No. 27 October 2005 Grade C
  46. 46. Women with a placenta previa and a prior CS are at high risk for placenta accreta. If there is imaging evidence of pathological adherence of the placenta, delivery should be planned in an appropriate setting with adequate resources. PP. With Previous CS SOGC CLINICAL PRACTICE GUIDELINE 2007(II-2B)
  47. 47. All women who have had a previous CS must have their placental site determined by U/S. RCOG Guideline PPH No.52 May 2009 (Grade C) Placenta previa With Previous CS Antenatal sonographic imaging can be complemented by MRI in equivocal cases RCOG Green-top Guideline PP PPA No. 27 2011
  48. 48. Diagnosis Of A Morbidly Adherent Placenta Woman and her family can be counseled early Ghourab et al .Ann Saudi Med 2000;20:382–5. Dashe et al. Obstet Gynecol 2002;99:692–7. Evidence level III U/S at 20-24 weeks: Why? Placental migration is less likely if There has been a previous CS.
  49. 49. Diagnostic Modalities of The Morbidly Adherent Placenta Ultrasound Gray scale U/S Colour flow Doppler  3D power Doppler MRI Ultrasound is the most useful modalities for evaluating placental position and implantation Resnilk ,UpToDate , Aug 2013ACOG Committee 7-2012
  50. 50. A Non Adherent Placenta Previa 1-Normal subplacental Hypoechoic Zone(myometrial vasculature 2-Normal posterior bladder wall 3-Normal placental vascular pattern Gray scale U/S
  51. 51. 1-Normal subplacental Hypoechoic Zone (myometrial vasculature ) 2-Normal posterior bladder wall A Non Adherent Placenta Previa
  52. 52. Greyscale : Loss of the retroplacental sonolucent zone Irregular retroplacental sonolucent zone Thinning or disruption of the hyperechoic serosa–bladder interface. Abnormal placental lacunae. Presence of focal exophytic masses invading the urinary bladder RCOG Green-top Guideline No. 27 2011 What Are The U/S Criteria for Diagnosis of P Accreta?
  53. 53. A Morbidly Adherent Placenta Previa 1-Loss or Irregularity of the retroplacental sonolucent zone 2- Thinning or disruption of the hyperechoic serosa–bladder interface
  54. 54. 3-Vascular lacunae"swiss chess appearance”+ve Pred.v :95% A Morbidly Adherent Placenta
  55. 55. Abnormal placental lacunae. "swiss cheese appearance” Positive perdictive value +ve Pred.v :95% A Morbidly Adherent Placenta Turbulence
  56. 56. Diffuse or focal lacunar flow Vascular lakes with turbulent flow (peak systolic velocity over 15 cm/s) Hypervascularity of serosa–bladder interface Markedly dilated vessels over peripheral subplacental zone. RCOG Green-top Guideline No. 27 2011 What Are The Colour Doppler Criteria for Diagnosis of PPA ?
  57. 57. Diffuse or focal lacunar flow
  58. 58. Hypervascularity of serosa–bladder interface
  59. 59. Markedly dilated vessels over peripheral subplacental zone
  60. 60. Multiple large vessels extending through the bladder wall of PP. percreta.
  61. 61. At least one diagnostic criterion was present. Multiple diagnostic criteria : Higher prediction Diagnostic Performance of U/S Modalities RCOG Green-top Guideline No. 27 January 2011 Shih et al . Ultrasound Obstet Gynecol,203-33:193 ;2009.
  62. 62. Overall, grayscale U/S is sufficient to diagnose PPA , with a sensitivity of 77–87%, specificity of 96–98%, a positive predictive value of 65–93%). The use of power Doppler, color Doppler, or 3D imaging does not significantly improve the diagnostic sensitivity compared with that achieved by grayscale U/S alone ACOG Committee 7-2012 Positive Doppler data confirm the diagnosis
  63. 63. It is still debated. Sensitivity & specificity are comparable with U/S MRI was better at detecting the depth of infiltration or when U/S findings are inconclusive The main MRI features of placenta accreta : ● Uterine bulging ● Heterogeneous signal intensity within the placenta ● Dark intraplacental bands on t2-weighted imaging. The Role Of MRI In Diagnosing PPA RCOG Green-top Guideline No. 27 January 2011
  64. 64. Sagittal T2WI MR of a placenta percreta :placental invasion into the bladder
  65. 65. Prenatal Care Correction of iron deficiency anemia, if present Antenatal corticosteroids between 23 and 34 weeks of gestation for pregnancies at increased risk of delivery within seven days (eg, antepartum bleeding) Anti-D immune globulin if vaginal bleeding occurs and the patient is Rh(D)-negative Serial U/S assessment of the placenta is generally not useful after the diagnosis of accreta, increta, or percreta has been made Resnilk ,UpToDate , Aug 2013
  66. 66. Decision Making U/S Guided
  67. 67. Counseling & Consent Any woman with suspected placenta praevia accreta should be counseled clearly in a consent form. This should include:  The anticipated skin and uterine incisions  Whether conservative management or proceeding straight to hysterectomy if accreta is confirmed at surgery RCOG Green top Guideline No. 27 January 2011
  68. 68. 1- Consultant obstetrician planned and directly supervising delivery 2- Consultant anaesthetist planned and directly supervising anaesthetic at delivery 3-Blood and blood products available 4- Multidisciplinary involvement in pre-op planning What Preparations Should Be Made Before Surgery? RCOG Green-top Guideline No. 27 January 2011
  69. 69.  At least two large bore intravenous catheters should be placed.  A 3-way Foley catheter and ureteral stents should be available in case they are needed to assess integrity of the urinary tract.  Balloon catheterization of the internal iliac arteries may resulted in significantly less blood loss, lower blood transfusion requirements, and shorter duration of surgery. Others investigator have not documented significant benefits What Preparations Should Be Made Before Surgery? Resnilk ,UpToDate , Aug 2013
  70. 70. 5-Discussion and consent includes possible interventions (Such as hysterectomy, leaving the placenta in place, Cell salvage and intervention radiology) 6-Local availability of a level 2 critical care bed. What Preparations Should Be Made Before Surgery? RCOG Green-top Guideline No. 27 January 2011
  71. 71. At what gestation should elective delivery occur? Elective CS delivery in asymptomatic women is not recommended before 36–37 weeks GA for suspected placenta accreta. RCOG Green top Guideline No. 27 January 2011 A course of corticosteroid at 34 ws gestation and deliver after 48 hours. This is supported by reported outcomes, as well as a decision analysis UpTODate ,Resink, Aug 2013ACOG Committee 7- 2012
  72. 72. Opening the uterus at a site distant from the placenta, and delivering the baby without disturbing the placenta. Going straight through the placenta to achieve delivery is associated with more bleeding and a high chance of hysterectomy and should be avoided. RCOG Green-top Guideline No. 27 2011 What Surgical Approach Should Be Used For Suspected PPA ? Grade C/D
  73. 73. Guided U/S Opening the uterus at a site distant from the placenta UpTODate ,Resink, Aug 2013
  74. 74. Preoperative or intraoperative sonographic localization of the placental edge is helpful for determining the best position for the hysterotomy incision UpTODate ,Resink, Aug 2013
  75. 75. Strong evidence of of diffuse PP accreta Focal or No strong evidence of of PPevia accreta No incision at the placental site (USCS) Don’t separate the placenta even if the uterus is conserved Separation of the placenta may be allowed if the uterus is to be conserved
  76. 76. Focal PP Accreta
  77. 77. Focal accreta : TAH is recommended If future fertility is strongly desired : Conservatism Separation of the placenta may be allowed if the uterus is to be conserved
  78. 78. Transient Packing &Stepwise Uterine A ligation 1&2 Stepwise Longitudinal lateral sutures Total Hysterectomy No Strong fertility need Fertility need Focal or Unexpected PP Accreta Faild Non Dissectible Bladder If still bleeding (50%) Separation of the Placenta Dissectible Bladder Balloon inverted Glove Tamponade ??Opening the bladder
  79. 79. Mohamed El Sherbiny MD Ob.& Gyn. Damietta Egypt Conservative Management of Placenta Previa-Accreta by Prophylactic Uterine Arteries Ligation and Stepwise Vertical Compression Sutures. XX FIGO World Congress October 2012
  80. 80. Materials This protocol was followed in 13 women undergoing CS for placenta previa with focal accreta suspected or diagnosed by ultrasound, color and power Doppler studies. All patients were recruited from ultrasound scanned women with previous CS
  81. 81. Materials The exclusion criteria were: 1-Posterior placenta previa 2-Placental implantation away from the scar 3- Diffuse PP accreta that either : a-Wide area of accreta or B-Deep penetration to the bladder
  82. 82. Setting Damietta General Hospital Damietta Specialized Hospital and Dr. El.Sherbiny Hospital Between April 2004 and December 2011.
  83. 83. Methods After delivery of the fetus, the uterine cavity was temporarily packed by gauze till prophylactic bilateral double ligation of the uterine arteries is performed, then the placenta was
  84. 84. Uterine cavity is temporarily packed by gauze
  85. 85. 1 2 Stepwise Uterine Devascularization Prophylactic bilateral double ligation of the uterine arteries
  86. 86. Prophylactic bilateral double ligation of the uterine arteries
  87. 87. Stepwise Longitudinal Lateral Sutures Anatomy: Branches of the uterine arteries pass transversely to anastomose with the opposite side
  88. 88. Tow lines of longitudinal number 1 chromic catgut sutures are taken through anterior and posterior uterine wall perpendicular to the vessels and 2 cm medial to the outer borders of the lower uterine segment . Stepwise Longitudinal Lateral Uterine Sutures: First Step
  89. 89. Stepwise Longitudinal Lateral Uterine Sutures: First Step 1 1
  90. 90. Stepwise Longitudinal Lateral Uterine Sutures: Second Step If still there is bleeding, other 2 medial similar lines of number 1 catgut sutures are taken leaving free central area.
  91. 91. 1 1 2 2 Stepwise Longitudinal Lateral Uterine Sutures: First Step
  92. 92. Longitudinal lateral sutures at the site of bleeding suturing both uterine walls
  93. 93. R E S U L T S E S U L T S
  94. 94. Suspected Focal PPA (n:13) 10 cases evidence of focal accreta Double UAs Ligation and removal of the Placenta 2 cases No evidence of accreta 1 cases evidence of Diffuse accreta Treated outside this protocol by leaving the placenta in situ &closing the uterus Compression sutures protocol All successful 1 cases Bleeding stopped One cases Need Compress -ion sutures protocol
  95. 95. Results All 10 women with focal accreta later resumed normal menstrual flow.
  96. 96. Results All of them underwent diagnostic office hysteroscopy 2 months after the surgery, nine of them showed normal uterine cavity . Only one had mild synechia and was corrected in the same hysteroscopic setting
  97. 97. Results The mean surgical time was 50 minutes and The mean transfused blood volume was 750 mL.
  98. 98. Conclusion Placental site bleeding due to adherent focal placenta accreta can be safely controlled by prophylactic double bilateral uterine artery ligation followed by stepwise vertical compression sutures in women who desire preservation of fertility.
  99. 99. Balloon Tamponade After CS Balloon catheters have been used with variable success to control bleeding after CS delivery with :  Placenta Previa Or  Adherent Placenta Frenzel et al ,Br J Obstet Gynaecol 2005;112: 7-676 Bakri et al . Int J Gynaecol Obstet 2001;74:139–42 Vitthala et al. Aust N Z J Obstet Gynaecol. 2009;49(2):191. (Success R.: 56%) Ishii et al , J. Obstet. Gynaecol. Res. January 2012 ,Vol. 38, No. 1: 102–107,
  100. 100. Inverted finger knotted glove
  101. 101. Inserting the end of the 2 catheters through the open uterine incision to the cervix and then into the vagina
  102. 102. After closure, assistants infate the balloon with sterile saline while inspecting the uterus from above
  103. 103. Diffuse PP Accreta
  104. 104. Strong evidence of diffuse PP accreta 1 -T AH is recommended 2- ± Conservatism (Placenta left "in situ") Only if  Hemodynamic stability Normal coagulation Strong desire for fertility Accept the risks involved No incision at the placental site (USCS) No separate the placenta even if the uterus is planned to be conserved ACOG Committee 7- 2012
  105. 105. 1-No further Treatment (Expectant) 2- Uterine artery embolization 3-Methotrexate therapy 4-Hemostatic sutures 5-Arterial ligation 6- Balloon tamponade Placenta Left "in Situ “ What is the Further Treatment ? UpTODate ,Resink, Aug 2013
  106. 106. Risks of Uterine Conservation With the Placenta Left in Situ UpTODate ,Resink, Aug 2013  Severe vaginal bleeding: 53 %  Sepsis: 6 %  Secondary hysterectomy: 20% percent (range 6 to 31 %)  Death: 0.3 % (range 0 to 4 %)  Subsequent pregnancy: 67 % (range 15 to 73 %)
  107. 107. Cunningham et al, Williams Obstetrics, 23rd edit. 2010 Elective Versus Emergency Peripartum Hysterectomy Complications Elective (n=345) Emergency (n=644) Transfusion 28% 83% Urinary T. injuries 1.8% 6.5% Surgical infection 21% 25% Death 0% 1.4% Briery (2007), Castaneda (2000), Glaze (2008), Kastner (2002), Kwee (2006), Sakse (2008
  108. 108. Conservative management of placenta accreta when the woman is already bleeding is unlikely to be successful and risks wasting valuable time.. RCOG Green-top Guideline No. 27 2011 What Surgical Approach Should Be Used For PPA Already in Bleeding? GPP
  109. 109. Peripartum Hysterectomy Key Points
  110. 110. Peripartum Hysterectomy Abnormal placentation is the main indication for peripartum hysterectomy. Glaze et al Obstet Gynecol. 2008 Mar; 111(3):732-8 ( 87 case 8 years Canadian) LEVEL OF EVIDENCE: III.
  111. 111.  A vertical skin incision is optimal, Pfannenstiel incision is not sufficient.  Classical CS-Hysterectomy  After delivery of the infant, the cord is cut, the uterine incision is oversewn circumferentially to decrease blood loss, and hysterectomy is performed. Hysterectomy: The Technique
  112. 112. Peripartum Hysterectomy  The hysterectomy Should be Total  It should be simple , rapid, with minimal dead space and raw surfaces (fear of coagulopathy).  Tow to three drainages
  113. 113. Inadequate exposure or traction may lead to vascular or ureteral injury Balfour abdominal retractor Hysterectomy: The Technique
  114. 114. Hysterectomy: The Technique  If the bladder does not dissected easily, it should be opened at the dome. Palpation and inspection of the posterior bladder from the interior makes it easier to find the dissection plane  Consultation with a gynecologic oncologist or urologist is warranted if the surgeon is not familiar with bladder surgery.
  115. 115. Post Hysterectomy Bleeding • Diffuse post hysterectomy bleeding may be controlled by abdominal packing to allow time for normalization of the woman’s haemodynamic and coagulation status. (II-3) • The pack composed of gauze in a sterile plastic bag brought out through the vagina and placed under tension. This pack is also known as a parachute, mushroom, or umbrella pack. S O G C C L I N I C A L P R AC T I C E G U I D E L I N E S 2000 II
  116. 116. Assembly of a pelvic pressure pack to control hemorrhage. A sterile x- ray cassette cover drape (plastic bag) is filled with gauze rolls tied end-to-end. The length of gauze is then folded into a ball (A) and placed within the cassette bag in such a way that the gauze can be unwound eventually with traction on the tail (D). Intravenous tubing (E) is tied to the exiting part of the neck (C) and connected to a 1-liter bag (G). Once in place, the gauze pack (A) fills the pelvis to tamponade vessels and the narrow upper neck (B) passes to exit the vagina (C). The IV bag is suspended off the foot of the bed to sustain pressure of the gauze pack on bleeding sites.
  117. 117. pelvic pressure pack, as constructed from an X-ray cassette drape, sterile gauze rolls, and an intravenous infusion set-up
  118. 118. the pelvic pressure pack in situ
  119. 119. Thank You