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

2. 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

3. 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)

6. 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

7. Large bore IV cannulas (gauge 14 x 2)
Crystalloids

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

9. 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

10. 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

11. 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

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

13. B-Lynch Suture

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

15. 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

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

17. Combination of Compression Suture and the Tamponade

18. LIGATION OF UTERO-OVARIAN VESSELS

19. LIGATION OF UTERINE VESSELS

20. LIGATION OF ANT.BRANCH OF
INTERNAL ILIAC ARTERY

21. RADIOLOGICAL INTERVENTION – EMBOLISATION
Point of ILA
ligature

25. 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

26. 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

32. 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.

33. 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

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

35. 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

36. 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

38. 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)

39. 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

40. 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)

41. 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)