POSTPARTUM HAEMORRHAGE STEPS TO AVOID HYSTERECTOMY S.ARULKUMARAN Professor & Head, Department of Obstetrics & Gynaecology, St.George’s Hospital Medical School, University of London

PPH - Old problem - new thoughts PG potentiates the action of oxytocin Tamponade test - Therapeutic & Diagnostic Uterine Compression Sutures Severe Shock & Golden Hour - Definitive Surgery Body weight – Blood volume & Hb% ‘Wash Out’ phenomenon - fibrinogen/ r-Factor VII

PPH - Emergency that kills (5’th commonest cause – CIMD) Anticipate - high risk cases (e.g. twins, polyhydramnios, long labour, fibroids, APH, infection, past H/O PPH, retained tissue etc.) Prevent - Prophylactic oxytocics (e.g. Syntometrine, syntocinon, ergometrine, misoprostol) Manage - promptly - 90% uterine atony - 8% trauma and 2% coagulation disorders (e.g. Atony - Oxytocin infusion 40 units in 500ml - 80 mu/min -20 drops in a 20 drops/ml giving set)

Prostaglandin potentiates the action of oxytocin Stepwise quick progression - syntometrine/ergometrine/oxytocin infusion/prostaglandins IV;IM;IntraMyometrial Use misoprostol 400 ug rectally /orally whilst using oxytocin infusion

Large bore IV cannulas (gauge 14 x 2) Crystalloids

Emergency Trolley Emergency protocols Endotracheal tube Laryngoscope Essential drugs Emergency Trolley Crystalloids, giving sets, haemacel

MANUAL REMOVAL OF PLACENTA External hand steadies the uterine fundus Uterus Placenta Internal hand along plane of cleavage Anaesthesia Antibiotics IV line Oxytocics Check placenta is complete Check the uterus is empty Check for trauma of GT

Therapeutic & Prognostic For severe PPH TAMPONADE TEST Therapeutic & Prognostic For severe PPH Stomach balloon Oesophageal balloon Condous G, Arulkumaran S et.al. Obstetrics & Gynecology. 2003

The “Tamponade Test” Therapeutic - No further intervention (14/16); Continue oxytocin infusion for 12 hrs, small vaginal pack, IV antibiotics, check fundal height, bleeding pv. Prognostic - No need to do a laparotomy - answer known in few minutes

COMPRESSION SUTURES Quick, safe and effective B-Lynch Horizontal full thickness sutures Vertical full thickness sutures Square sutures Combination of sutures

B-Lynch Suture

COMPRESSION SUTURES Cornu Fallopian tube Ovary Hayman R, Arulkumaran S, Steer P Obstetrics & Gynecology. 2002

Placental bed haemorrhage Through and through figure of eight or transverse sutures involving full thickness of the uterine wall Infiltration of placental bed with vasoconstrictors Hot packs and pressure

COMPRESSION SUTURES Vertical Compression Sutures Horizontal Hayman R, Arulkumaran S, Steer P Obstetrics & Gynecology; 2002.

Combination of Compression Suture and the Tamponade

LIGATION OF UTERO-OVARIAN VESSELS

LIGATION OF UTERINE VESSELS

LIGATION OF ANT.BRANCH OF INTERNAL ILIAC ARTERY

RADIOLOGICAL INTERVENTION – EMBOLISATION Point of ILA ligature

PPH Coagulation disorders ‘Wash Out Phenomenon’ DIVC- FDP inhibits clotting “Washout phenomenon” - the coagulation factors are consumed and washed out at the site of bleeding The “washout” is the major phenomenon that prevents arrest of haemorrhage

Reason for excessive uncontrolled bleeding Consumption coagulopathy Excessive fibrinolysis - Dilutional coagulopathy - haemodilution Hypothermia – slow enzymatic process of cl.cascade + imp.pl.let function Multitransfusion syndrome – Depleted pl.lets and clotting factors Metabolic changes – acidosis + citrate

Clinical classification of hypovolaemic shock Mild Shock - upto 20% blood volume loss Decreased perfusion of nonvital organs and tissues (skin, fat, skeletal muscle and bone) Pale cool skin, patient complains of feeling cold.

Moderate Shock - 20-40% blood volume loss Decreased perfusion of vital organs (liver, gut, kidneys) Oliguria to anuria and slight to significant drop in blood pressure, mottling in extremities especially legs

Severe Shock 40% or more blood volume loss Decreased perfusion to heart and brain Restlessness, agitation, coma, cardiac irregularities, ECG abnormalities and cardiac arrest

Haemorrhagic Shock Severe acute loss of blood produces failure of cardiovascular support for the body’s metabolic needs. Body weight - Blood loss - Shock Bodyweight in Kg /12 = Blood volume in litres. E.g. 48 kg = 4 L; 84 kg = 7 L 40% blood loss causes severe shock. 1.5 L blood loss may produce severe shock in a 48 Kg and mild shock in a 84 Kg lady

THE GOLDEN HOUR As more time elapses between the point of severe shock and the start of resuscitation, the percentage of surviving patient decreases The “Golden Hour” is the time in which resuscitation must begin to achieve maximum survival

PPH - Aggressive Surgery Systolic BP < 70 mm Hg especially if there is no diastolic component Cold pale extremities/ pale conjunctiva Failure to raise BP despite infusion with crystalloids and blood Continuous blood loss despite medication Confused, coma, airhunger, ECG changes. Poor urinary output (takes time to establish)

Subtotal or Total Hysterectomy Severe hypotension > 20 to 30 min Continued blood loss (esp>3 L) despite other surgical measures (Int.iliac, uterine, infundibulo pelvic vessel ligatures) Inadequate response to blood replacement ECG changes Placenta praevia/acreta with bleeding DIVC/ washout phenomenon with difficulty in getting clotting factors +/- clinical picture

PPH - New thoughts – ALGORITHM FOR ACTION Oxytocin infusion + Misoprostol p.r/p.o Parenteral PG Tamponade test Compression sutures +-Tamponade >ligation of vessels > Hysterectomy Clotting factors - fibrinogen, Factor VII a Aggressive surgery (Degree of shock - Golden hour) Blood (+blood products) replacement - start early and in adequate quantities ( Shock lung syndrome – ARDS – blood without leucocytes)

Maternal mortality due to PPH CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS TOO LITTLE – TOO LATE Too Little (IV fluids, oxytocics, BLOOD, Clotting factors) Too Late (PG, resuscitation - blood replacement, decision for surgery + to get senior surgeon & anaesthetist involved)