Surgical Management of postpartum hemorrhage - PowerPoint Presentation

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Surgical Management

of postpartum hemorrhage

Dr

Maryam

Zarekhafri

perinatologist

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Postpartum hemorrhage obstetric

emergencyManaged by medical surgical interventionsSurgical intervention : conservative : apply compressive suture systemic pelvic devascularisation subtotal \ total hysterectomy

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The

Source Of Bleeding Is Often:Atony

Retained

placental

fragments

Uterine

laceration

Retroperitoneal

hematoma

Vaginal

and

vulvar

hematomas

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Transfer To OR :

If urgent transfer to OR required: Transfer woman flat with face mask oxygen Apply bimanual compression Assess need for analgesia

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Surgical Treatment Of Intractable Bleeding :

coagulopathy Weigh benefits of conservative versus aggressive managementquicker and safer to do subtotal hysterectomy based on surgeon’s skill/maternal condition

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Compressive suture :

They are Easy , quick , safe and effective control of bleedingPreserve patient fertility Efficacy 60-100% ( 80 % )B –lynch 1997 CHO – sutureHayman PereiraReduction of blood flow in the uterine arteries

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B-lynch

Suture:(Re) open the abdomen and (re) open the uterus Uterus must be exteriorised Check the uterine cavity for bleeding sites , explore and evacuate Placement of the suture, as demonstrated, requires surgical expertiseFrog leg position 1 or 2 chromic catgut or vicryl ( absorbable suture )

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B-lynch

Suture Complications :

Uterine

necrosis,

erosion,

and

pyometra,

rarely

.

No

adverse

effects

on

fertility

or

future

pregnancy.

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Modified

B-lynch Suture :

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Hayman

stich:

2

to

4

vertical

compression

sutures

from

the

anterior

to

posterior

uterine

wall

without

hysterotomy.

A

transverse cervicoisthmic suture to control bleeding from the lower uterine segment.

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Makino- Takeda Suture :

Placenta Previa Focal accreta Lower segment atony

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Matsubara – Yano ( MY ) Suture :

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Cho

stich:

multiple

squares/rectangles

through

and through sutures

extend

from

the

serosa

of

the

anterior

wall

to

the

serosa

of

the posterior wall and tied down as tight as possible to compress the myometrium.

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Ouahba

Suture :

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Pereira:

Series

of

transverse

and longitudinal

sutures suture are

placed

around

the

uterus

via

subserosal

myometrium

,

without

entering

the

uterine

cavity to completely compress the uterus. The myometrium should be manually compressed to facilitate

maximal

compression

.

Avoid Damaging :

ureter, Blood Vessel ,Fallopian Tube.

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Uterine

tourniquet

Tourniquets

have

been used

to control

bleeding

at

myomectomy,

may

be

useful

in

PPH

.

A

Penrose

drain

or

urinary catheter is placed as low as possible around the lower uterine segment without

incorporating

the

urinary

bladder,

to

mechanically

occlude

the

vascular supply.A second or third tourniquet can also be applied, as needed. The tourniquet(s) can be held in place with a clamp and removed and the surgical procedure is completed.

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Ligation

of

uterine

and

utero-ovarian

arteriesDecrease

uterine

bleeding

by

reducing

perfusion

pressure

in

the

myometrium.

It

not

completely

control

bleeding from uterine atony or placenta accreta but may decrease blood loss while

other

interventions

are

being

attempted.

Does

not

harm

the uterus and does not appear to impact reproductive function.Placing a large clamp across the utero-ovarian ligaments bilaterally is a rapid and simple means

of

occluding uterine blood flow through ovarian artery collaterals.

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Trauma :

Second most common cause of PPH (uterus, cervix, vagina or perineum )Genital trauma : Clamping of obvious arterial bleeding prior to repair Position woman to maximise visualisation and maternal comfort Repair ensuring bleeding at the apex of the laceration is secured Transfer To OR

Maximise

lighting and position in lithotomy

Under

anaesthetic Check uterine cavity is empty and uterus is intact

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Cervical Trauma

:Optimise assessment with positioning, lighting, retractors and assistantsEnsure bleeding at the apex of the laceration is securedAvoid suture placement cephalad to the anterior fornix due to risk of ureteral ligationIf extensions (e.g. lower uterine, high vaginal, cardinal ligament), consider performing a laparotomy to enable simultaneous vaginal and abdominal routes for repairRunning locked #0 absorbable suture

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Uterine Rupture :

Spontaneouslyprevious obstetric surgeryseverity of the haemorrhage depends upon the extent of the ruptureUrgently transfer to ORConfirm diagnosis during surgeryUnder anaesthetic: Palpate uterine cavity to identify rupture site Rpair rupture using multiple layers and absorbable suturesConsider hysterectomy if : Defect is large or difficult to close

Haemodynamic

stability is threatened

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Hysterectomy

:

Before it is too late

Hysterectomy is a definitive treatment of uterine bleeding when fertility preserving procedures have

not reduced

the bleeding to a manageable

level

Ideally

, it should be performed before severe hypovolemia, tissue

hypoxia, hypothermia

, electrolyte abnormalities, and acidosis have developed

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Thank You For Your Attention