Dep Valie Asr hospital TUMS Surgical interventions in PPH Causes 4T Tone Previous PPH Prolonged labour Age gt 40 years Big baby Multiple pregnancy Placenta praevia Obesity ID: 1039157
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2. Dr,S-Borna , Perinatolgy Dep, Vali-e-Asr hospital ,TUMSSurgical interventions in PPH
3. Causes 4TTonePrevious PPHProlonged labourAge > 40 yearsBig babyMultiple pregnancyPlacenta praeviaObesityAsian ethnicityTissueRetained placenta/membrane/clot
4. ThrombinAbruptionPETPyrexiaIntrauterine deathAmniotic fluid embolismDICTraumaCaesarean section(emergency > elective)Perineal traumaOperative deliveryVaginal and cervical tearsUterine rupture
5. RECOGNISING SIGNIFICANT BLOOD LOSS10 – 20%500-1000mlNormal BPNo signs.15-25%1000-1500mlBP ~ 100mmHgDizziness, tachycardia25-35%1500-2000ml.BP ~ 70-80mmHg.Restlessness,pallor, oliguria.35-45%2000-3000ml50-70mmHgCollapse, air hunger, anuria
6. MANAGEMENT OF PPH
7. MANAGEMENT OF PPH
8. Management of Postpartum Hemorrhage21Determine the CauseSuture lacerationsDrain expanding hematomaReplace inverted uterusInspect placentaExplore uterusManual removal of placenta CurettageObserve clottingCheck coagsReplace factors Fresh frozen plasmaOxytocin:* 20 IU/L, infuse 500 ml in 10 minutes then 250 ml/hrCarboprost: 0.25 mg IM or into the myometriumMisoprostol:* 800 mg SL, PO, or PRMethylergonovine: 0.2 mg IMErgometrine: 0.5 mg IMTHE FOUR T’sTONESoft “boggy” UterusTRAUMALacerationInversionTISSUERetained placentaTHROMBINBlood not clotting70 percent20 percent10 percent1 percent* See text for dosing options
9. pharmacological Management of postpartum hemorrhageOxytocin10 to 40 units in 500 to 1000 mL saline infused at a rate sufficient to control atony or 10 units IMErgotsMethyl-ergonovine 0.2 mg IM every two to four hours or ergometrine 0.5 mg IV or IM or ergonovine 0.25 mg IM or IV every two hoursCarboprost0.25 mg IM every 15 to 90 minutes up to eight doses or 500 mcg IM incrementally up to 3 mg or 0.5 mg intramyometrialMisoprostol800 to 1000 mcg rectallyDinoprostone20 mg vaginally or rectally every two hoursRecombinant human Factor VIIa50 to 100 mcg/kg every two hours
10. Uterine Contraction – non-pharmEmpty uterusFoley catheterRub up a contractionBimanual compressionBalloon tamponadeBrace sutureUterine artery ligationInternal iliac artery ligationInterventional radiology
11. Uterine tamponade Uterine tamponade is effective in many patients with atony or lower segment bleedingPacksThe gauze can be impregnated with 5000 units of thrombin in 5 mL sterile saline to enhance clotting,
12. Insertion of Uterine Tamponade Balloon
13. A regimen of intravenous broad spectrum antibiotics, such as gentamicin, 1.5 mg/kg every eight hours, and either metronidazole, 500 mg every eight hours, or clindamycin, 300 mg every six hours, are administered while the pack is in place (typically 24 hours). If packing does not control hemorrhage, repacking is not advised
14. INDICATIONS FOR LAPAROTOMY Laparotomy is indicated for management of uterine atony unresponsive to the conservative interventions described above. The uterine vessels are ligated and/or uterine compression sutures are placed.
15. Management of postpartum hemorrhage at cesarean deliveryPharmacologic interventionsDrugDosingOxytocin10 to 40 units in 500 to 1000 mL saline infused at a rate sufficient to control atony or 10 units IMErgotsMethyl-ergonovine 0.2 mg IM every two to four hours or ergometrine 0.5 mg IV or IM or ergonovine 0.25 mg IM or IV every two hoursCarboprost0.25 mg IM every 15 to 90 minutes up to eight doses or 500 mcg IM incrementally up to 3 mg or 0.5 mg intramyometrialMisoprostol800 to 1000 mcg rectallyDinoprostone20 mg vaginally or rectally every two hoursRecombinant human Factor VIIa50 to 100 mcg/kg every two hours
16. Surgical interventionsof postpartum hemorrhage at C/SUterine compression suture (eg, B-Lynch suture)Uterine artery ligationUtero-ovarian artery ligation or cross clampPelvic packingUterine tourniquetFocal myometrial excisionUse of fibrin glues and patches to cover areas of oozing and promote clottingPlacement of figure 8 sutures or other hemostatic sutures directly into the placental bedInternal iliac artery (hypogastric artery) ligationAortic compressionHysterectomy, supracervicalHysterectomy, total
17. Local techniques for managing focal bleeding from the placental site placement of figure 8 sutures or other hemostatic sutures directly into the placental bed, 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
18. Although it will not control bleeding from uterine atony or placenta accreta, it may decrease blood loss while other interventions are being attempted.
19. Uterine compression sutures B-Lynch suture Hayman, Pereiralarge Mayo needle with #1 or #2 chromic catgut Cho described a technique using multiple squares/rectangles 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,
20. B-Lynch Suture
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25. Internal iliac artery ligationHYSTERECTOMYPELVIC PRESSURE PACK FOR PERSISTENT BLEEDING AFTER HYSTERECTOMY
26. Hysterectomy – before it’s too late
27. Uterine InversionRareImportant to recognize quicklySuspect if shock disproportionat to blood lossReplace uterus immediatelyWatch for vasovagal reflex
28. Goals●Replace the uterus to its correct position●Manage postpartum hemorrhage and shock, if present●Prevent recurrent inversionInitial interventions — Interventions for the management of acute uterine inversion should begin promptly and simultaneously. ●Discontinue uterotonic drugs,.
29. ●Call for immediate assistance, ●Establish adequate intravenous access and aggressive fluid resuscitation. infusion of crystalloid to support blood pressure. Treat bradycardia due to increased vagal tone with atropine (0.5 mg IV). Draw blood for baseline laboratory tests, Blood should be administered, as needed,. ●Do not remove the placenta●Immediately attempt to manually replace the inverted uterus to its normal position
30. Give uterine relaxants.•Nitroglycerin (glyceryl trinitrate) is an excellent uterine relaxant [50 micrograms administered intravenously, followed by up to four additional doses of 50 micrograms, •Terbutaline (0.25 milligrams intravenously or subcutaneously) or magnesium sulfate (4 to 6 grams intravenously over 15 to 20 minutes)
31. Inhalational anesthetic agents, such as sevoflurane, desflurane, and isoflurane, are also excellent uterine relaxants Halothane and enflurane are also effective, but these drugs are not used in adults in the United States because of concerns about serious side effects (, halothane-related hepatotoxicitylaparotomy for correction of an otherwise refractory uterine inversion.)
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35. Surgical managmentHuntington procedure Haultain procedure