In t he name of GOD ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts - PowerPoint Presentation

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In

t

he name of GOD

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ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts

Management of postpartum

hemorrhage

at cesarean

deliver

y

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INITIAL 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.

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On 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.

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When 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.

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Serious 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

•

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Baseline 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.

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CONSERVATIVE SURGICAL INTERVENTIONS

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Local 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

.

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Uterine 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.

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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

.

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Uterine 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

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B-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

."

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Balloons

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.

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TYPES 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.

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Indications

 

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.

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Contraindications

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.

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Internal 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.

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HYSTERECTOMY

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.

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POST-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.

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PELVIC 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)

.

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MANAGEMENT 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

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If 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.

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