POSTPARTUM HAEMORRHAGE POSTPARTUM HAEMORRHAGE

STEPS TO AVOID HYSTERECTOMYSTEPS TO AVOID HYSTERECTOMY

S.ARULKUMARANS.ARULKUMARANProfessor & Head, Department of Obstetrics Professor & Head, Department of Obstetrics & Gynaecology, St.George’s Hospital Medical & Gynaecology, St.George’s Hospital Medical

School, University of LondonSchool, University of London

PPH - PPH - Old problem - new thoughtsOld problem - new thoughts

PG potentiates the action of oxytocinPG potentiates the action of oxytocinTamponade test - Therapeutic & Tamponade test - Therapeutic &

DiagnosticDiagnosticUterine Compression SuturesUterine Compression SuturesSevere Shock & Golden Hour - Definitive Severe Shock & Golden Hour - Definitive

SurgerySurgeryBody weight – Blood volume & Hb%Body weight – Blood volume & Hb% ‘‘Wash Out’ phenomenon - fibrinogen/ Wash Out’ phenomenon - fibrinogen/

r-Factor VII r-Factor VII

PPH - Emergency that killsPPH - Emergency that kills(5’th commonest cause – CIMD)(5’th commonest cause – CIMD)

Anticipate - high risk cases Anticipate - high risk cases (e.g. twins, (e.g. twins, polyhydramnios, long labour, fibroids, APH, infection, polyhydramnios, long labour, fibroids, APH, infection, past H/O PPH, retained tissue etc.)past H/O PPH, retained tissue etc.)

Prevent - Prophylactic oxytocics Prevent - Prophylactic oxytocics (e.g. (e.g. Syntometrine, syntocinon, ergometrine, misoprostol)Syntometrine, syntocinon, ergometrine, misoprostol)

Manage - promptly - 90% uterine atony - Manage - promptly - 90% uterine atony - 8% trauma and 2% coagulation disorders 8% trauma and 2% coagulation disorders (e.g. Atony - Oxytocin infusion 40 units in 500ml - 80 (e.g. Atony - Oxytocin infusion 40 units in 500ml - 80 mu/min -20 drops in a 20 drops/ml giving set)mu/min -20 drops in a 20 drops/ml giving set)

Prostaglandin potentiates Prostaglandin potentiates the action of oxytocinthe action of oxytocinStepwise quick progression - Stepwise quick progression -

syntometrine/ergometrine/oxytocin syntometrine/ergometrine/oxytocin infusion/prostaglandins infusion/prostaglandins IV;IM;IntraMyometrialIV;IM;IntraMyometrial

Use misoprostol 400 ug rectally Use misoprostol 400 ug rectally /orally whilst using oxytocin /orally whilst using oxytocin

infusioninfusion

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids, giving sets, haemacel

Emergency protocols

Placenta

Uterus

External hand steadies the uterine fundus

Internal hand along plane of cleavage

MANUAL REMOVAL OF PLACENTA

AnaesthesiaAntibioticsIV lineOxytocics

Check placenta is completeCheck the uterus is emptyCheck for trauma of GT

TAMPONADE TESTTherapeutic & PrognosticFor severe PPH

Stomach balloon Oesophagealballoon

Condous G, Arulkumaran S et.al. Obstetrics & Gynecology. 2003

The “Tamponade Test”The “Tamponade Test”TherapeuticTherapeutic - No further intervention - No further intervention

(14/16); Continue oxytocin infusion (14/16); Continue oxytocin infusion for 12 hrs, small vaginal pack, IV for 12 hrs, small vaginal pack, IV antibiotics, check fundal height, antibiotics, check fundal height, bleeding pv.bleeding pv.

PrognosticPrognostic - No need to do a - No need to do a laparotomy - answer known in few laparotomy - answer known in few minutesminutes

COMPRESSION SUTURESCOMPRESSION SUTURESQuick, safe and effectiveQuick, safe and effective

B-LynchB-LynchHorizontal full thickness Horizontal full thickness

sutures sutures Vertical full thickness suturesVertical full thickness suturesSquare suturesSquare suturesCombination of suturesCombination of sutures

B-Lynch Suture

COMPRESSION SUTURES

Cornu

Fallopian tube

Ovary

Hayman R, Arulkumaran S, Steer PObstetrics & Gynecology. 2002

Placental bed haemorrhagePlacental bed haemorrhageThrough and through figure of eight Through and through figure of eight

or transverse sutures involving full or transverse sutures involving full thickness of the uterine wallthickness of the uterine wall

Infiltration of placental bed with Infiltration of placental bed with vasoconstrictors vasoconstrictors

Hot packs and pressureHot packs and pressure

COMPRESSION SUTURES

VerticalCompressionSutures

HorizontalCompressionsutures

Hayman R, Arulkumaran S, Steer PObstetrics & Gynecology; 2002.

Combination of Compression Combination of Compression Suture and the TamponadeSuture and the Tamponade

LIGATION OF UTERO-OVARIAN VESSELS

LIGATION OF UTERINE VESSELS

LIGATION OF ANT.BRANCH OFINTERNAL ILIAC ARTERY

Point of ILAligature

RADIOLOGICAL INTERVENTION – EMBOLISATIONRADIOLOGICAL INTERVENTION – EMBOLISATION

PPH Coagulation disordersPPH Coagulation disorders‘Wash Out Phenomenon’‘Wash Out Phenomenon’

DIVC- FDP inhibits clottingDIVC- FDP inhibits clotting ““Washout phenomenon” - the Washout phenomenon” - the

coagulation factors are consumed and coagulation factors are consumed and washed out at the site of bleedingwashed out at the site of bleeding

The “washout” is the major The “washout” is the major phenomenon that prevents arrest of phenomenon that prevents arrest of haemorrhagehaemorrhage

Reason for excessive uncontrolled Reason for excessive uncontrolled bleedingbleeding

Consumption coagulopathyConsumption coagulopathyExcessive fibrinolysis - Excessive fibrinolysis - Dilutional coagulopathy - haemodilutionDilutional coagulopathy - haemodilutionHypothermia – slow enzymatic process of Hypothermia – slow enzymatic process of

cl.cascade + imp.pl.let functioncl.cascade + imp.pl.let functionMultitransfusion syndrome – Depleted Multitransfusion syndrome – Depleted

pl.lets and clotting factorspl.lets and clotting factorsMetabolic changes – acidosis + citrateMetabolic changes – acidosis + citrate

Clinical classification of Clinical classification of hypovolaemic shockhypovolaemic shock

Mild ShockMild Shock - upto 20% blood - upto 20% blood volume lossvolume loss

Decreased perfusion of nonvital Decreased perfusion of nonvital organs and tissues (skin, fat, organs and tissues (skin, fat, skeletal muscle and bone)skeletal muscle and bone)

Pale cool skin, patient complains of Pale cool skin, patient complains of feeling cold.feeling cold.

Moderate Shock - Moderate Shock - 20-40% blood volume loss20-40% blood volume loss

Decreased perfusion of vital Decreased perfusion of vital organs (liver, gut, kidneys)organs (liver, gut, kidneys)

Oliguria to anuria and slight to Oliguria to anuria and slight to significant drop in blood significant drop in blood pressure, mottling in pressure, mottling in extremities especially legsextremities especially legs

Severe ShockSevere Shock40% or more blood volume loss40% or more blood volume loss

Decreased perfusion to Decreased perfusion to heart and brainheart and brain

Restlessness, agitation, Restlessness, agitation, coma, cardiac irregularities, coma, cardiac irregularities, ECG abnormalities and ECG abnormalities and cardiac arrestcardiac arrest

Haemorrhagic Shock Haemorrhagic Shock Severe acute loss of blood produces failure of Severe acute loss of blood produces failure of

cardiovascular support for the body’s cardiovascular support for the body’s metabolic needs.metabolic needs.

Body weight - Blood loss - ShockBody weight - Blood loss - Shock Bodyweight in Kg /12 = Blood volume in litres. Bodyweight in Kg /12 = Blood volume in litres.

E.g. 48 kg = 4 L; 84 kg = 7 LE.g. 48 kg = 4 L; 84 kg = 7 L 40% blood loss causes severe shock. 1.5 L 40% blood loss causes severe shock. 1.5 L

blood loss may produce severe shock in a 48 blood loss may produce severe shock in a 48 Kg and mild shock in a 84 Kg ladyKg and mild shock in a 84 Kg lady

THE GOLDEN HOURTHE GOLDEN HOURAs more time elapses between the As more time elapses between the

point of severe shock and the start point of severe shock and the start of resuscitation, the percentage of of resuscitation, the percentage of surviving patient decreasessurviving patient decreases

The “Golden Hour” is the time in The “Golden Hour” is the time in which resuscitation must begin to which resuscitation must begin to achieve maximum survivalachieve maximum survival

PPH - Aggressive SurgeryPPH - Aggressive Surgery Systolic BP < 70 mm Hg especially if there Systolic BP < 70 mm Hg especially if there

is no diastolic componentis no diastolic component Cold pale extremities/ pale conjunctivaCold pale extremities/ pale conjunctiva Failure to raise BP despite infusion with Failure to raise BP despite infusion with

crystalloids and bloodcrystalloids and blood Continuous blood loss despite medicationContinuous blood loss despite medication Confused, coma, airhunger, ECG changes. Confused, coma, airhunger, ECG changes.

Poor urinary output Poor urinary output (takes time to establish)(takes time to establish)

Subtotal or Total HysterectomySubtotal or Total Hysterectomy

Severe hypotension > 20 to 30 minSevere hypotension > 20 to 30 min Continued blood loss (esp>3 L) despite other Continued blood loss (esp>3 L) despite other

surgical measures (Int.iliac, uterine, infundibulo surgical measures (Int.iliac, uterine, infundibulo pelvic vessel ligatures)pelvic vessel ligatures)

Inadequate response to blood replacementInadequate response to blood replacement ECG changesECG changes Placenta praevia/acreta with bleedingPlacenta praevia/acreta with bleeding DIVC/ washout phenomenon with difficulty in DIVC/ washout phenomenon with difficulty in

getting clotting factors +/- clinical picturegetting clotting factors +/- clinical picture

PPH - New thoughts – PPH - New thoughts – ALGORITHM ALGORITHM FOR ACTIONFOR ACTION

Oxytocin infusion + Misoprostol p.r/p.oOxytocin infusion + Misoprostol p.r/p.o Parenteral PGParenteral PG Tamponade testTamponade test Compression sutures +-Tamponade >ligation of Compression sutures +-Tamponade >ligation of

vessels > Hysterectomyvessels > Hysterectomy Clotting factors - fibrinogen, Factor VII aClotting factors - fibrinogen, Factor VII a Aggressive surgery Aggressive surgery (Degree of shock - Golden hour)(Degree of shock - Golden hour)

Blood (+blood products) replacement - start early Blood (+blood products) replacement - start early and in adequate quantitiesand in adequate quantities

( Shock lung syndrome – ARDS – blood without leucocytes)( Shock lung syndrome – ARDS – blood without leucocytes)

Maternal mortality due to PPHMaternal mortality due to PPH

CONFIDENTIAL ENQUIRY INTO CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS MATERNAL DEATHS

TOO LITTLE – TOO LATETOO LITTLE – TOO LATEToo Little (IV fluids, oxytocics, BLOOD, Too Little (IV fluids, oxytocics, BLOOD,

Clotting factors)Clotting factors)

Too Late (PG, resuscitation - blood Too Late (PG, resuscitation - blood replacement, decision for surgery + to get replacement, decision for surgery + to get senior surgeon & anaesthetist involved) senior surgeon & anaesthetist involved)