- The Triple-P procedure is a three step conservative treatment to prevent significant hemorrhage and peripartum hysterectomy involving obstetricians, anesthetists and interventional radiologists. - A sequence of conservative measures should be attempted before resorting to hysterectomy to control uterine hemorrhage. If one measure does not succeed, the next should be swiftly instituted. - Indecisiveness in treating hemorrhage can lead to potentially fatal excessive bleeding, while delay also increases blood loss and risks from complications like coagulopathy. Timing of hysterectomy is critical to outcome - it should be neither too early nor too late.

1. PERIPARTUM
HYSTERECTOMY

2. • Definition
• Incidence and trend
• Risk factors
• Management

3. Definition
Any woman giving birth and undergoing a hysterectomy in the
same clinical episode or within six weeks postpartum when the
indication for hysterectomy is related to the birth

4. History
• Peripartum hysterectomy was proposed in 1768 by
Joseph Cavallini in animal experiments.
• The first documented caesarean hysterectomy was
performed by Horatio Storer in 1869.
• In 1876, Eduardo Porro performed the first
caesarean hysterectomy in which both the mother
and baby survived.

5. INCIDENCE

6. TREND IN PGI

7. TREND IN PGI

8. RISK FACTORS
• Previous caesarean section
• Abnormal placentation including previa
• Multiple gestation
• Grand multipara
• Fetal macrosomia
• Previous PPH history
• Coagulopathy
• Chorioamnionitis

9. Elective Indication
• Invasive carcinoma cervix
Obsolete:
• Uterine leiomyoma
• Sterilisation
• Menstrual abnormalities
• Chronic pelvic pain
• Chorioamnionitis

10. Types peripartum hysterectomy
Classification of peripartum hysterectomy

11. EMERGENCY
INDICATIONS
Abnormal Placentation (30-60%)
Uterine atony(20-40%)
Uterine rupture(5-15%)
Extension of uterine incision(2-10%)
Leiomyoma (precluding closure)
Uterine infection

12. UTERINERUPTURE
• One of the most common indication in developing
countries
• Causes : unattended deliveries
: grand multipara
: obstructed labor
: rupture of previous cesarean

13. ABNORMAL PLACENTATION
mmon indication
e due to increased rate of C-Sections
e placenta accreta, inc eta or percreta
• Most co
• Incidenc
Could b
• With two or more prior cesarean deliveries and an existing
placenta previa, the risk for cesarean hysterectomy ranges
from 30 to 50 percent
Prev CS percentage
1 3
2 11
3 40
4 61
5 or more r67

14. The Triple-P procedure
• Perioperative location of the placenta and delivery of
the fetus by an incision above the upper border of
the placenta.
• Pelvic devascularisation by inflating radio logically
pre-placed occlusion balloons in both internal iliac
arteries.
• Placental non-separation with myometrial excision
and reconstruction of the uterine wall.
European society of radiology

15. UTERINE ATONY
• Atonic postpartum hemorrhage is a constant
bugbear of the obstetricians
• Failure of the sequence of all conservative
measures
• There is a relationship between the blood
loss and duration of time that passes prior to
decision for hysterectomy and the possibility
of the hysterectomy getting complicated

16. UTERINE ATONY
• incidence reduced due to the liberal use of
pharmacologic treatment
• Fetal macrosomia, twins, induction, prolonged labor
and augmentation, pre-eclampsia : risk factors for
atony

17. DECISION MAKING
TIMING IS CRITICAL!!!!
Hysterectomy should not be performed too early or
too late

18. • A sequence of conservative measures should be
attempted before resorting to more radical surgical
procedure
• Indecisiveness delays therapy and results in fatal
hemorrhage
• Increased duration of time increases the likelihood
that the hysterectomy will be seriously complicated
by coagulopathy, severe hypovolemia, tissue
hypoxia, hypothermia and acidosis, which further
compromise the patient’s status

19. • ACOG recommends that if hysterectomy is
performed for uterine atony, there should be
documentation of first attempting other therapies .
• In most cases of suspected placenta accreta,
however, hysterectomy should be the primary
management, especially when the woman does not
desire future fertility.

20. Sequential steps in managing postpartum hemorrhage

21. PREPLANNING
• Proper consent and explain the possibility in high risk patients
• Adequate blood arrangement
• Prophylactic antibiotics
• Arrange for general anesthesia
• Multidisciplinary team consisting of obstetricians, obstetric
anesthesiologists, urologists, vascular surgeons, and interventional
radiologists.
• Appropriate instrumentation should be available.

22. Supplies for peripartum
hystserectomy

23. care bundle
• consultant obstetrician planned and directly supervising
delivery
• consultant anesthetist planned and directly supervising
anesthetic at delivery
• blood and blood products available
• multidisciplinary involvement in pre-op planning
• discussion and consent includes possible interventions
(such as hysterectomy, leaving the placenta in place, cell
salvage and intervention radiology)
• local availability of a critical care bed.

24. TAKE HELP
• Urologist – in cases of placenta percreta involving
posterior bladder wall - partial cystectomy may be
required
• Interventional radiology – in cases of suspected
accreta. Preop placement of hypogastric artery
balloons bilaterally to decrease the blood loss,
avoiding the need for embolisation

25. POINTS TO CONSIDER….
• The normal pelvic anatomy might be distorted
• Vascular pedicles are thicker and more oedematous
than in the non-pregnant state
• The vascular pedicles should be doubly clamped
to avoid slippage of ligatures.
• Small pedicles should be secured and knots tied when
they are in the correct anatomical plane, without
torsion or twisting of the pedicle

26. • Bladder might be adherent to the lower segment,
especially in previous cesarean section
• Presence of uterine tears or extensions of the uterine
angles might increase the risks of ureteric injuries,
during placement of sutures.
• Unintended oophorectomy due to shortening of
ovarian pedicles.

27. Cont.…
• There may be a difficulty in identifying the cervix,
especially if hysterectomy follows a caesarean
section done at full dilatation.
• The tissues might be very friable and this can pose
added difficulties

28. PROCEDURE
• Incision-midline vertical/ Pfannensteil
• Vertical midline is preferred in emergency situations and if hypogastric
artery ligation is anticipated
• Enter by the earliest method
• Delivery is best accomplished by a classical low vertical inscision, which
can be made hemostatic using towel clip or single running layer of suture.

29. Contd…
• Exposure is best obtained with cephalad traction on
the uterus, along with hand held retractors such as
Deaver, doyens’
• Steps are similar to abdominal hysterectomy with
some precautions

30. TRANSECTION OF ROUND LIGAMENT

31. TRANSECTION OF TUBOOVARIAN LIGAMENT

32. TRANSECTION OF THE UTERINES

33. CLAMPING THE CARDINALS

34. IF THE CERVIX IS FULLY
EFFACED
• Palpating the upper vagina, pinching to palpate the
cervix
• Hooking the finger between the cervical rim and the
vaginal wall through the caesarean incision

37. VAULT REPAIR
• Each of the lateral vaginal fornix is secured to the cardinal
and uterosacral ligaments
• Achieve hemostasis by running lock stitch of vicryl 1-0 placed
through the mucosa and the endopelvic fascia
• Some prefer to close the vagina using figure of eight chromic
catgut.
• Indwelling bladder drain and suction drain if required

38. VAULTCLOSURE

39. SUBTOTAL HYSTERECTOMY

40. STABLE PATIENTS
• Keep pedicles small and ensure that they are carefully
and doubly ligated
• Engorged and edematous tissues that exist following
delivery can cause vessels tied within large pedicles to
slip and retract
UNSTABLE PATIENTS
• Quick clamping and cutting until bleeding is
controlled/uterus is removed
• Pedicles are tied off after ensuring hemostasis

41. SUBTOTAL/TOTAL???
• Total hysterectomy is the operation of choice in cases of
central placenta praevia .
• Subtotal hysterectomy
- unstable patient
- when removal of cervix is not essential for hemostasis
- bleeding is due to uterine atony

42. Advantages of Sub-total Hysterectomy
• Less operation time
• Reduced hospitalization
• Reduced risk of bladder and ureteral injury
Disadvantages
• Potential risk of malignancy in the cervical stump
• Need for regular cytology
• Bleeding or discharge associated with the residual cervical
stump.

43. POST OPERATIVE
• Record the indication for the surgery
• Have a discussion with the patient when she recovers,
especially in primiparous woman
• Tackle postnatal symptoms that require counseling
• Bladder drainage for 7-10 days in case of bladder injury

44. COMPLICATIONS
• febrile morbidity 1/3rd (M.C)
• Blood transfusion (75 - 88%)
• Coagulopathy
• Urologic injury(5-22%)
• Reoperation ( 2-4%) intra-abdominal hemorrhage, other
organ damage
• ICU requirement ( mechanical ventilation 7-13%)

45. Incidental Bladder Injury
Gush of clear fluid in the operating field,
Repair at primary surgery preferred, lowers risk of postop
vesicovaginal fistula.
After confirmation of ureteral patency, bladder closure done by 2
or 3 layered running closure
Continuous bladder drainage in post-op period

46. Oophorectomy
• Due to inadvertent clamping of ovarian ligament
• At times to stop bleeding from infundibulo-pelvic vessels
• 5% of peripartum hysterectomies, one adnexa was removed to
stop bleeding.

47. CHANGINGTRENDS….
• Increasing CS rate(risk of placenta accreta): becoming
commoner
• Hemorrhage/atony has decreased: due to increased
success of treatment with uterotonic agents, PGs,
embolization, uterine catheters and surgical procedures
• Reduction in elective procedures
• Downward trend in the incidence of uterine rupture with
modern obstetrics and reduced parity

48. Role of UAE
• No randomized clinical trials to prove its efficacy
• In situations where stabilization can occur and an inter-
ventional radiology suite is nearby, UAE is an important
consideration before proceeding with peripartum
hysterectomy.
• UAE is a safe, minimally invasive procedure with a reported
success rate of more than 90% in the treatment of postpartum
hemorrhage.

49. To Summarize….
• A dilemma, where decision regarding emergency
hysterectomy, as a last resort to save the life of the mother, the
fetus being already lost and the mother still young, often a
primigravida or of low parity with no living child.
• Can be made rarer by -good antenatal care
- active management of labor
-early recognition of complications
-timely performance of c -section

51. THANK YOU

52. • The Triple-P procedure is a three step conservative
treatment involving obstetricians, anesthetists and
interventional radiologists to prevent significant
hemorrhage and peri- partum hysterectomy. The three
steps are:
• Perioperative location of the placenta and delivery of the
fetus by an incision above the upper border of the
placenta.
• Pelvic devascularisation by inflating radio logically pre-
placed occlusion balloons in both internal iliac arteries.
• Placental non-separation with myometrial excision and
reconstruction of the uterine wall.

53. • A sequence of conservative measures to control uterine
hemorrhage should be attempted before resorting to more
radical surgical procedureIf an intervention does not
succeed, the next treatment in the sequence should be
swiftly instituted.
• Indecisiveness delays therapy and results in possibly fatal
excessive hemorrhage. Moreover, there is increased
blood loss with increased duration of time before
performance of hysterectomy. This, in turn, increases the
likelihood that the hysterectomy will be seriously
complicated by coagulopathy, severe hypovolemia, tissue
hypoxia, hypothermia, and acidosis, which further
compromise the patient's status. Timing is critical to an
optimal outcome: hysterectomy should not be performed
too early or too late.