2. Surgical interventions in PPH
Dr,S-Borna , Perinatolgy Dep, Vali-e-Asr hospital ,TUMS

3. Tissue Retained placenta/ membrane/clot
Causes 4T
Tone
Previous PPH
Prolonged labour
Age > 40 years
Big baby
Multiple pregnancy
Placenta praevia
Obesity
Asian ethnicity
Tissue Retained placenta/ membrane/clot

4. Thrombin Abruption PET Pyrexia Intrauterine death Amniotic fluid embolism DIC
Trauma Caesarean section (emergency > elective) Perineal trauma Operative delivery Vaginal and cervical tears Uterine rupture

5. RECOGNISING SIGNIFICANT BLOOD LOSS
10 – 20% ml
Normal BP
No signs.
15-25% ml
BP ~ 100mmHg
Dizziness, tachycardia
25-35%
ml.
BP ~ 70-80mmHg.
Restlessness,pallor, oliguria.
35-45% ml
50-70mmHg
Collapse, air hunger, anuria

6. MANAGEMENT OF PPH

7. MANAGEMENT OF PPH

8. Management of Postpartum Hemorrhage
Determine the Cause
THE FOUR T’s
TONE
Soft “boggy” Uterus
TRAUMA
Laceration
Inversion
TISSUE
Retained placenta
THROMBIN
Blood not clotting
70 percent
20 percent
10 percent
1 percent
Oxytocin:* 20 IU/L, infuse
500 ml in 10 minutes then 250 ml/hr
Carboprost:
0.25 mg IM or into the myometrium
Misoprostol:* 800 mg SL, PO, or PR
Methylergonovine: 0.2 mg IM
Ergometrine: 0.5 mg IM
Inspect placenta
Explore uterus
Manual removal of placenta
Curettage
Observe clotting
Check coags
Replace factors
Fresh frozen plasma
Suture lacerations
Drain expanding hematoma
Replace inverted uterus
* See text for dosing options

9. pharmacological Management of postpartum hemorrhage
Oxytocin
10 to 40 units in 500 to 1000 mL saline infused at a rate sufficient to control atony or 10 units IM
Ergots
Methyl-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 hours
Carboprost
0.25 mg IM every 15 to 90 minutes up to eight doses or 500 mcg IM incrementally up to 3 mg or 0.5 mg intramyometrial
Misoprostol
800 to 1000 mcg rectally
Dinoprostone
20 mg vaginally or rectally every two hours
Recombinant human Factor VIIa
50 to 100 mcg/kg every two hours
pharmacological Management of postpartum hemorrhage

10. Uterine Contraction – non-pharm
Empty uterus
Foley catheter
Rub up a contraction
Bimanual compression
Balloon tamponade
Brace suture
Uterine artery ligation
Internal iliac artery ligation
Interventional radiology

11. Uterine tamponade 
 Uterine tamponade is effective in many patients with atony or lower segment bleeding
PacksThe 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 delivery
Pharmacologic interventions
Drug
Dosing
Oxytocin
10 to 40 units in 500 to 1000 mL saline infused at a rate sufficient to control atony or 10 units IM
Ergots
Methyl-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 hours
Carboprost
0.25 mg IM every 15 to 90 minutes up to eight doses or 500 mcg IM incrementally up to 3 mg or 0.5 mg intramyometrial
Misoprostol
800 to 1000 mcg rectally
Dinoprostone
20 mg vaginally or rectally every two hours
Recombinant human Factor VIIa
50 to 100 mcg/kg every two hours

16. Surgical interventions of postpartum hemorrhage at C/S
Uterine compression suture (eg, B-Lynch suture)
Uterine artery ligation
Utero-ovarian artery ligation or cross clamp
Pelvic packing
Uterine tourniquet
Focal myometrial excision
Use of fibrin glues and patches to cover areas of oozing and promote clotting
Placement of figure 8 sutures or other hemostatic sutures directly into the placental bed
Internal iliac artery (hypogastric artery) ligation
Aortic compression
Hysterectomy, supracervical
Hysterectomy, 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

25. Internal iliac artery ligation
HYSTERECTOMY
PELVIC PRESSURE PACK FOR PERSISTENT BLEEDING AFTER HYSTERECTOMY

26. Hysterectomy – before it’s too late

27. Uterine Inversion Rare Suspect if shock disproportionat to blood loss
Important to recognize quickly
Suspect if shock disproportionat to blood loss
Replace uterus immediately
Watch for vasovagal reflex

28. Goals ●Replace the uterus to its correct position
●Manage postpartum hemorrhage and shock, if present
●Prevent recurrent inversion
Initial 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 hepatotoxicity
laparotomy for correction of an otherwise refractory uterine inversion.)

33. 33

34. 34

35. Surgical managment
Huntington procedure
Haultain procedure