Management of postpartum hemorrhage at cesarean deliver y INITIAL MANAGEMENT Ongoing bleeding may not be recognized when retroperitoneal including vaginal and vulvar ID: 930277
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Slide1
In
t
he name of GOD
Slide2ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts
Management of postpartum
hemorrhage
at cesarean
deliver
y
Slide3INITIAL MANAGEMENT
●Ongoing bleeding may not be recognized when :
retroperitoneal
(including vaginal and vulvar
hematomas)
hidden under surgical drapes or thick dressing
confined to the uterine cavity after closure of the
hysterotomy
these
sites should be actively
evaluated when
compensated shock is present (normal blood
pressure
with increasing heart rate).
Retroperitoneal
enlargement or bulging of the broad ligament can
be
signs of retroperitoneal hemorrhage; the
abdomen
should not be closed until the possibility of
ongoing
retroperitoneal bleeding has been excluded.
Slide4On recognition of ongoing
bleeding
the anesthesia team should be alerted
immediately
vital
signs, hemodynamic and respiratory parameters
,
and hematologic and biochemical indices should
be
closely monitored
Thromboelastography and
thromboelastometry
,
where
available, may be useful for guiding plasma and
coagulation product therapy
Fluid and blood products, as appropriate, are administered for resuscitation and correction of coagulation
and
electrolyte abnormalities.
Slide5When hemorrhage is suspected
as the cause of hemodynamic
instability, initial (and expedited) management with blood and
blood
products is advised (as opposed to large
volume
crystalloid infusion), and early activation of a massive
transfusion
protocol should be considered.
●Acidosis is corrected using bicarbonate, if necessary.
●Body temperature should be maintained and hypothermia
prevented
.
●The source of bleeding should be addressed:
•If
atony
is present or suspected, fundal massage and
uterotonic
drugs are used to contract the uterus.
Slide6Serious hemorrhage
from the uterine incision is generally caused by lateral extension of the incision.
Bleeding
from a
hysterotomy
incision can generally be
controlled
by suture ligation.
The
angles of a transverse incision should be clearly
visualized
to ensure that they, and any retracted vessels
,
are
completely ligated. This generally requires
exteriorization
of the uterus with gentle traction and
adequate
lateral retraction.
Given
the proximity of the ureter to the vaginal angle
and
bladder reflection, the placement of hemostatic
sutures
laterally to control bleeding from an extension of
a
hysterotomy
laceration should be carried out
with
extreme caution
.
If possible, the
ipsilateral
ureter should be identified before the bleeding is controlled and, once the hemorrhage has
been
controlled, the integrity of the ureter should be
ensured
•
Slide7Baseline electrolyte analysis
is important to check ionized calcium and potassium levels since, in the event
of
multiple units of blood transfusion
, these electrolytes can reach critical thresholds very
quickly
.
Aggressive management of electrolyte levels is crucial in modern massive transfusion protocols, and the institution of standardized management protocols is recommended.
●Use of specific clotting factor therapies can be
useful
and have some advantages in cases of
intractable
hemorrhage and coagulopathy.
Slide8CONSERVATIVE SURGICAL INTERVENTIONS
Slide9Local techniques for managing focal bleeding from the placental site
Local techniques for the management of focal bleeding from the placental implantation site include the placement of figure 8 sutures or other hemostatic sutures directly into the placental bed, and the use of fibrin glues and patches to cover areas of oozing and promote clotting. Focal areas of bleeding can also be excised if they are small and easily accessible, particularly in cases of placenta
accreta
with persistent
bleeding.
Application of
ferric
subsulfate
(
Monsel's
solution) to oozing areas may be helpful and is not
harmful
.
Slide10Uterine artery and
utero-ovarian artery ligation
Bilateral ligation of the uterine vessels (O’Leary stitch) to
control
PPH has become a first-line procedure for controlling
uterine
bleeding at laparotomy
. It
is preferable to internal
iliac
artery ligation because the uterine arteries are more
readily
accessible, the procedure is technically easier, and there
is
less risk to major adjacent vessels and the ureters.
Uterine
artery ligation is primarily indicated when bleeding is
due
to laceration of the uterine or utero-ovarian
artery branches
, but can also temporarily decrease bleeding from other
etiologies
by reducing perfusion pressure in the uterine tissue. Although it will not control bleeding from uterine
atony
or
placenta
accreta
, it may decrease blood loss while other
interventions
are being attempted.
After identification of the ureter, a large curved needle with
a #0
polyglycolic
acid suture is passed through the lateral aspect of the lower uterine segment as close to the cervix
as
possible and then back through the broad ligament
just
lateral to the uterine vessels
.
If this does not
control
bleeding, the vessels of
the
utero-ovarian arcade are similarly ligated just distal to
the
cornua
by passing a suture ligature through the myometrium just medial to the vessels, then back through the broad
ligament
just lateral to the vessels, and then tying
to
compress the vessels (
figure 4
).
Bilateral ligation of the arteries and veins (uterine and utero-ovarian) is successful in controlling hemorrhage in over 90
percent
of patients
.
Slide12Slide13Uterine compression sutures
Uterine compression sutures are an effective
method
for reducing uterine blood loss related to
atony
.
Procedure-related complications, such as uterine necrosis, erosion, and
pyometra
, have been reported but are rare
.
Uterine
synechiae
have been reported on postpartum hysteroscopy or
hysterosalpingogram
, although some of these women may have had curettage as well
.
Limited follow-up of women who have had a
uterine compression suture suggests that there are no adverse effects on fertility or future pregnancy outcome.
The B-Lynch suture is the most common technique for uterine compression
Slide14B-Lynch suture
The B-Lynch suture envelops and compresses the uterus, similar to the result achieved with manual uterine
compression.
The
technique is relatively simple to learn, appears safe, preserves future reproductive
potential.
It should only be used in cases of uterine
atony
; it will not control hemorrhage from placenta
accreta
. It will not prevent postpartum hemorrhage in future pregnancies
.
A
large Mayo needle with #1 or #2 chromic catgut is used to enter and exit the uterine cavity laterally in the lower uterine segment (
figure 5
). A large suture is used to prevent breaking and a rapid absorption is important to prevent a herniation of bowel through a suture loop after the uterus has
involuted
.
The
technique has been used alone and in combination with balloon
tamponade
. This combination has been called the "uterine sandwich
."
Slide15Slide16Balloons
The exact mechanism of action of these devices is unclear, but is likely related to a
reduction in uterine artery perfusion pressure .
Whether this is the result of direct compression of the uterine artery in the lower segment or due to wall conformational changes has not been determined .
Continued excessive bleeding indicates that
tamponade
is not effective and surgery or
embolization
should be performed.
Slide17TYPES OF BALLOON CATHETERS
Bakri
tamponade
balloon catheter
The
Bakri
tamponade
balloon catheter consists of a silicone balloon maximum recommended
fill volume 500 mL
The collapsed balloon is inserted into the uterus .
when filled with fluid, the balloon adapts to the configuration of the uterine cavity to
tamponade
endometrial bleeding. The central lumen of the catheter allows drainage and is designed to monitor ongoing bleeding above the level of the balloon .
The device is intended for one-time use.
Slide18Slide19Slide20Slide21Slide22Slide23Indications
Intrauterine balloon
tamponade
is indicated when
uterotonic
drugs and bimanual compression of the uterus fail to control bleeding.
Intrauterine balloon catheters have also been used with variable success to
control or reduce bleeding after cesarean delivery
with placenta
previa
, low lying placenta, or a focally invasive or adherent placenta.
A small number of cases
of delayed (secondary) postpartum hemorrhage
have been successfully managed with balloon catheters .
Intrauterine balloon catheters have also been successful in management of
acute, recurrent uterine inversion
and prophylactically or as an adjuvant therapy to control bleeding in women with
cesarean scar pregnancy or cervical pregnancy.
Slide24Contraindications
Intrauterine balloon
tamponade
is contraindicated in postpartum patients
allergic
to any component of the device.
Clinical settings where
tamponade
is
unlikely to be effective
(
eg
, bleeding from pelvic vessels or cervical or vaginal trauma; uterine abnormalities that prevent effective balloon
tamponade
; suspected uterine rupture; cervical cancer; and purulent infection of the vagina, cervix or uterus).
These devices should not be used when a large amount of
placenta is adherent to the uterus
and immediate hysterectomy may be life-saving.
Slide25Internal iliac artery ligation
Bilateral ligation of the internal iliac arteries (
hypogastric
arteries
) has been used to control uterine hemorrhage by
reducing the
pulse pressure of blood flowing to
the uterus.
The utility of
internal
iliac artery ligation may
be
compromised when there are
extensive
collateral
vessels (such as in placenta
percreta
).
The
technique is challenging even for an experienced pelvic
surgeon
, especially when there is a large uterus, a transverse lower abdominal incision, ongoing pelvic hemorrhage, or the patient has a high body mass index
.
Successful and safe bilateral
hypogastric
ligation becomes even more difficult when attempted by a surgeon who rarely operates deep in the pelvic retroperitoneal space
.
For these reasons, uterine compression sutures and, less commonly, uterine artery ligation, have largely replaced this procedure as first-line surgical options. The internal iliac ligation procedure is described separately.
Slide26HYSTERECTOMY
Hysterectomy
is generally the last resort for treatment of
atony
, but should not be delayed in women who require prompt control of uterine hemorrhage to prevent death. By comparison, in women with placenta
accreta
/
increta
/
percreta
or uterine rupture, early resort to hysterectomy is one of the best approaches for controlling hemorrhage
.
With improving prenatal diagnosis of placental attachment disorders, hysterectomy can often be anticipated and discussed with the patient before cesarean delivery.
Slide27POST-LAPAROTOMY
INSPECTION
At the completion of the laparotomy and before closing the abdomen, the operative field should be inspected carefully for hemostasis.
Microvascular
bleeding usually can be
controlled
using topic hemostatic agents.
Slide28PELVIC PRESSURE PACK
FOR PERSISTENT BLEEDING
AFTER
HYSTERECTOMY
Patients with continued severe hemorrhage after hysterectomy can enter a lethal downward spiral characterized by hypothermia, coagulopathy, and metabolic acidosis
.
Criteria
proposed for this "in extremis" state
include pH <
7.30, temperature <35 degrees Celsius,
combined
resuscitation and procedural time >90 minutes,
nonmechanical
bleeding, and transfusion requirement >10 units packed red blood cells (RBCs)
.
Slide29MANAGEMENT OF HEMORRHAGE FIRST RECOGNIZED AFTER THE PATIENT HAS
LEFT THE OPERATING ROOM
If
excessive vaginal bleeding is present, the cervix and vagina
should
be inspected and lacerations repaired under adequate
anesthesia.
If the uterus is boggy, the diagnosis of uterine
atony
is made.
The
initial management of uterine
atony
after cesarean delivery is similar to that after vaginal delivery and consists of:
●Uterine massage to contract the uterus
●Administration of
uterotonic
drugs
●Fluid resuscitation and transfusion
●Laboratory tests to evaluate blood loss and coagulopathy and type and cross for multiple units of packed red blood cells
●Balloon
tamponade
Slide30If excessive bleeding persists, uterine artery embolization is an option for stable patients in whom volume status can be maintained until the procedure can be completed (approximately two hours). Many clinicians use both balloon
tamponade
and uterine artery embolization in this situation. These procedures are discussed in detail separately.
Laparotomy
is indicated in patients with massive bleeding and those who are unstable since it is unlikely that replacement of blood products will match blood loss in these patients.
Slide31