Postpartum Hemorrhage Second part دكتور محمد توفيق الشربينى دكتوراة وإستشارى النساء و التوليد مستشفى دمياط التخصصى - مستشفى دمياط العام Dr.Mohamed El Sherbiny MD Obstetrics&Gynecology drsherbiny@hotmail.com

Intractable Postpartum hemorrhage About 10 % of women will not respond to the initial management steps and are considered as intractable PPH. They are caused mainly by Uterine atony Placenta accretes at CS scar

A multi-disciplinary team, Hemodynamic Stablization Local Control Intractable Postpartum Hemorrhage A multi-disciplinary team, Hemodynamic Stablization Local Control Surgery (SOGC ) Clinical Practice Guidelines 2000 (III)

The approach to intractable PPH will be individualized depending on : Intractable Postpartum hemorrhage The approach to intractable PPH will be individualized depending on : The clinical situation The skill of the operator. The technology available. (SOGC ) Clinical Practice Guidelines 2000 III

The B-Lynch technique (brace suture) for intractable hemorrhage It may be particularly useful because of its simplicity of application, life saving potential, relative safety, and its capacity for preserving the uterus and thus fertility. The B-Lynch, 1997 B J of Obstet and Gynaecol, 104: 372-375

B-Lynch technique

Hayman Compression Suture A number 2 Vicryl or Dexon suture on a straight, blunt needle is used to transfix the uterus from front to back, just above the reflection of the bladder and is then tied at the fundus of the uterus. This can be done as one suture on each side of the uterus, or more than one suture if the uterus is particularly broad, Hayman et al Obst. Gynec. 2002,99;3;502-6

Hayman Compression Suture Vicryl® or Dexon® are strong and unlikely to cause external adhesions to the uterus. It does not appear to be necessary to open the uterus or avoid crossing the uterine cavity. Hayman et al Obst. Gynec. 2002,99;3;502-6

Stepwise uterine devascularization for intractable atonic hemorrhage This technique entails five successive steps (using chromic catgut 1 with Mayos needle), if bleeding is not controlled by one step the next step is taken until bleeding stops. The procedure was effective in all 103 (100%) cases. Abdrabbo , 1994, Am J Obstet Gynecol.171:694-700

Mov443

Mov471

Stepwise Uterine Devascularization Advantages over internal iliac ligation: Easier dissection. Lower complication rates. More distal occlusion of arterial supply with less potential for rebleeding because of collaterals High reported rates of success in controlling haemorrhaging. (SOGC ) Clinical Practice Guidelines 2000

Placenta accreta, increta and percreta A placenta previa with previous CS should be considered of having a morbidly adherent placenta. Particular attention should be focused to confirming or excluding this diagnosis using U/S. When present, senior anaesthetic and obstetric input are vital in planning the delivery. RCOG guidelines Grade B Evidence base.Level III

Placenta accreta Women who have had 2 or more CS deliveries with anterior or central placenta previa have nearly a 40% risk of developing placenta accreta. The patient should be counseled about the likelihood of hysterectomy and blood transfusion. ACOG Guideline 2002

Placenta previa accreta (Increta or Percreta) with severe bleeding 1-Low &high bilateral uterine vessels ligation (Stepwise) ,the Best. 2- Longitudinal lateral sutures 3-Bilateral Internal iliac ligation. 4- Hysterectomy : almost total 5-Tight uterine packing.

Bilateral Internal Iliac Artery Ligation It was recommended for many decades to control PPH It has fallen out of favor because of: The prolonged operating time Technical difficulties Inconsistent clinical response. High hazard if internal or external iliac veins are injured.

Bilateral Internal Iliac Artery Ligation It is indicated mainly for: Large broad ligament or lateral pelvic hematoma Multiple cervical tears. L. segment bleeding or atonic pp as a last resort. It is less effective than Bilateral uterine artery ligation for atonic postpartum hemorrhage

. After the covering sheath has been opened and the artery has been carefully freed from the immediately adjacent veins. A ligaure is carried beneath the artery- 3.0 cm distal to the bifurcation- with a right angle clamp and firmly tied. Passing the tips of the clamp from lateral to medial is crucial to prevent injuries to the underlying veins .

Internal Iliac Artery Ligation 50% failure rate in placenta accreta and uterine tears

Peripartum hysterectomy Emergency hysterectomy is the most common treatment modality when massive postpartum haemorrhage requires surgical intervention mainly for Placenta acretta or percreta ( 50%) Uterine atony Rupture uterus CS extension or broad ligament hematoma Thomas Br J Obstet Gynaecol 1998;105:127-8.

Post Hysterectomy Bleeding Diffuse post hysterectomy bleeding may be controlled by abdominal packing to allow time for normalization of the woman’s haemodynamic and coagulation status. (II-3) The pack composed of gauze in a sterile plastic bag brought out through the vagina and placed under tension. This pack is also known as a parachute, mushroom, or umbrella pack. S O G C C L I N I C A L P R AC T I C E G U I D E L I N E S 2000 II