PPH – Global and The UK Perspectives

S ArulkumaranProfessor & Head

Obstetrics and GynaecologySt George’s University of London

*Other direct causes include: ectopic pregnancy, embolism, anesthesia-related ** Indirect Causes include: anemia, malaria, heart disease

75% Of MM & third of NN mortality takes place 75% Of MM & third of NN mortality takes place during labor/ birth or within 24 Hrs.during labor/ birth or within 24 Hrs.

PPH Global Perspectives• 30-50% of maternal deaths due to PPH• Inadequate Health facilities• Inadequate skilled attendance• Inadequate medication or surgical facilities• Long delay in reaching facilities/ providing treatment Solutions• Better communication and transport• Health facilities (affordable/ self respect & dignity• Health personal (no need for controlled traction)• Medications; PG/ Misprostol, Tranexamic acid, R

Factor VII a, 1;1 PCV to Plasma transfusion• Simpler techniques – Balloon Tamponade/

Compression sutures/ Anti-shock Garment

Strategies to Prevent Maternal MortalityBasic Emergency Obstetric Functions (6)

THREE INJECTIONS

•Post partum Hemorrhage – Oxytocics (IV/ IM/ Oral) & active management of the third stage of labor

•Hypertensive Disease > Eclampsia – Antihypertensive & Anticonvulsants – Mg SO4 –IV/ IM

•Sepsis – post abortion or labor & delivery – Antibiotics IV/IM

THREE MANUAL FUNCTION

•Manual removal of placenta

•Evacuation of the uterus of retained placental tissue

•Vacuum Assisted Delivery in cases of second stage delay

Strategies to Prevent Maternal MortalityComprehensive Em Obstetric Functions (6 + 2)

• Basic Emergency Obstetric Functions+

• Caesarean Section• Blood Transfusion

• Four more to be added – Misoprostol, Anti Shock Garment, Tamponade balloon & Compression suture for post partum hemorrhage + latest – no need for controlled cord traction with syntocinon; need cord traction with misoprosotol??

Anti Shock Garment

• Effective Easy to use, Re-usable

TAMPONADE TESTTherapeutic & PrognosticFor severe PPH

Stomach balloon

Esophagealballoon

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

Glove catheterNo need for condom Or suture material – S Africa

Condom Catheter –Bangaladesh, Sri Lanka, India - 85% success rate

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 COMPRESSION SUTURES

SIMPLE VERTICAL COMPRESSION SUTURES

Cornu

Fallopian tube

Ovary

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

Conservative Surgical Treatment for Conservative Surgical Treatment for PPHPPH

MethodMethod No of CasesNo of Cases Success ratesSuccess rates

B-Lynch + other B-Lynch + other Compression Compression suturessutures

9494 90.4%90.4%

Arterial embolizationArterial embolization 218218 91%91%

Arterial ligationArterial ligation 264264 83.7%83.7%

Uterine balloon Uterine balloon tamponadetamponade

135135 83.7%83.7%

Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007

UK – Direct deaths due to PPHYears Pl Abr Pl Pr PPH GT tr Total Rate/10 5

‘85-’87 4 0 6 6 16 0.71‘88-’90 6 5 11 3 25 1.06‘91-’93 3 4 8 4 19 0.82‘94-’96 4 3 5 5 17 0.77‘97-’99 3 3 1 2 9 0.42‘’00-’02 3 4 10 1 18 0.90‘03-’05 2 3 9 3 17 0.80‘06-’08 2 2 5 0 9 0.39

Karoshi et.al. 2012

Karoshi et.al. 2012

TOP TEN RECOMMENDATIONS

PPH in the UK (UKOSS)• Major obstetric haemorrhage 3.7/1000 maternities

(370/ 100,000)• Uterine atony was major cause of haemorrhage• Feb 2005 - Feb 2006 – Postpartum Hysterectomy to

control haemorrhage -40.6 for 100,000 maternities (CI – 36.3 – 45.4)

• Severe PPH – specific 24.4/100,000 – uterine compression suture, pelvic vessel ligation, embolisation. Factor VII a (CI - 21.7-27.3)

• The effect of balloon tamponade was not evaluated?

CONFIDENTIAL ENQUIRY CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHSINTO MATERNAL DEATHS TOO LITTLE – TOO LATETOO LITTLE – TOO LATE

Too Little (IV fluids, oxytocics, Too Little (IV fluids, oxytocics, BLOOD, Clotting factors)BLOOD, Clotting factors)

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

Placenta Accreta – special problemPlacenta Accreta – special problem

Response of the Professional BodiesRCOG/ NPSA/ RCA/ RCR

RCOG Green top guidelines 1. Postpartum haemorrhage; Prevention and Management2. Blood transfusion in Obstetrics3. Placenta Praevia, Placenta Praevia accreta, vasa praveia; Diagnosis and management

RCOG Good Practise guidelines1. The role of Interventional radiology in Obstetrics2. Responsibility of consultant on call3. The maternity dashboard

NPSA – Care bundle for the management of placenta Accreta

www.rc.og.org.uk Google – Greentop guidelines

GREEN TOP GUIDELINES‘THE PREVENTION & MANAGEMENT OF PPH’

Algorithm for management of Atonic PPH Algorithm for management of Atonic PPH ‘HAEMOSTASIS ‘HAEMOSTASIS’’

HH - - Ask for HelpAsk for Help

AA - Assess vital parameters & blood loss - Assess vital parameters & blood loss and Resuscitate – (Rule of 30)and Resuscitate – (Rule of 30)

EE -Establish etiology + Ecbolics -Establish etiology + Ecbolics (syntometrine, ergometrine, bolus syntocinon) (syntometrine, ergometrine, bolus syntocinon) + Ensure availability of blood. + Ensure availability of blood.

MM -Massage Uterus – bimanual compression -Massage Uterus – bimanual compression

OO -Oxytocin infusion -Oxytocin infusion / prostaglandins / prostaglandins - - intravenous / per rectal / intramuscular / intra-intravenous / per rectal / intramuscular / intra-myometrial/ myometrial/ Tranexamic acidTranexamic acid

Algorithm for management of Atonic PPH Algorithm for management of Atonic PPH ‘ ‘HAEMOSTASISHAEMOSTASIS’’

SS - Shift to OT - Shock Garment (anti) - Aortic - Shift to OT - Shock Garment (anti) - Aortic compression/ Bimanual compressioncompression/ Bimanual compression

TT - (4 T’s) Tissue/ Trauma/Tone/Thrombin > - (4 T’s) Tissue/ Trauma/Tone/Thrombin > Tamponade (before coagulopathy)– Balloon / packingTamponade (before coagulopathy)– Balloon / packing

AA - Apply compression sutures – B- Lynch / - Apply compression sutures – B- Lynch / modified/ +/- Balloonmodified/ +/- Balloon

SS - Systematic Pelvic devascularisation – Uterine / - Systematic Pelvic devascularisation – Uterine / Ovarian / Quadruple / internal iliac Ovarian / Quadruple / internal iliac

II - Interventional Radiology – If appropriate, - Interventional Radiology – If appropriate, Uterine artery embolisationUterine artery embolisation

SS - Subtotal / Total abdominal hysterectomy- Subtotal / Total abdominal hysterectomy

Conservative Surgical Tr. for PPHConservative Surgical Tr. for PPHMethodMethod No of CasesNo of Cases Success ratesSuccess rates

B-Lynch + other B-Lynch + other Compression suturesCompression sutures

9494 90.4%90.4%

Arterial embolizationArterial embolization 218218 91%91%

Arterial ligationArterial ligation 264264 83.7%83.7%

Uterine balloon Uterine balloon tamponadetamponade

135135 83.7%83.7%

Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007

Massive PPH - Surgical TechniquesMassive PPH - Surgical TechniquesNear Miss Enquiries - ScotlandNear Miss Enquiries - Scotland

Use of Balloon techniques – 6 in Use of Balloon techniques – 6 in ’’03 > 42 in 03 > 42 in ’’0606Haemostatic compression sutures – 10 in Haemostatic compression sutures – 10 in ’’03 03

>24 in >24 in ’’06.06.Over 4 years; 106 balloon techniques - 95% Over 4 years; 106 balloon techniques - 95%

success rate; 76 brace sutures – 83% success success rate; 76 brace sutures – 83% success raterate

Peripartum hysterectomy – 15% in 2003 > 8% in Peripartum hysterectomy – 15% in 2003 > 8% in 20062006

Avoidable delay in diagnosis & management –8%Avoidable delay in diagnosis & management –8%Failure to follow protocol/plan – 6%Failure to follow protocol/plan – 6%

From April 2010 – CNST audit requirement - PilotCQC – building risk profile of Hospitals

Responsibility of Consultant on Call (RCOG advice – 2009)

• Labour ward duties (safer childbirth)• Must attend

– Major Post Partum Haemorrhage– Eclamptic fit– Collapsed patient– Major placenta praevia– Return to theatre -Laparotomy– When trainee asks for it

• Be present (depending upon trainee’s experience)– Trial of instrumental delivery– Twins/preterm labour C/S / vaginal Breech delivery– C/S at full dilatation/ for Transverse lie/ BMI >40

Maternity DashboardRoyal College of Obstetricians and Gynaecologists

The Maternity Dashboard – Tool to monitor implementation of principles of clinical governance ‘on the ground’.

A powerful, visible way of continually monitoring and assessing how a unit is doing.

Enables teams to respond in a timely and appropriate manner to ensure a safe and responsive high-quality service.

Helps to develop an ethos of total quality improvement.

www.rcog.org.uk/womens-health/clinical-guidance/maternity-dashboard-clinical-performance-and-governance-score-card

Performance & Governance Score Card ‘Maternity

Dashboard’

• Designed by Prof. Arulkumaran & Team –Northwick Park

• Recommended by CMO’s Report

• Looks at Activity, Staffing, Clinical Risk indicators, User feedback (e.g. complaints)

Maternity Dashboard - Ensures high quality safe care.- Tool for Commissioners, Providers,

Consumers and Regulators

Massive PPH, blood transfusion, hysterectomies, admission to ICU

KNOWLEDGE TRANSFER N MEOWS CHART

More Medical and Simpler Surgical Techniques shouldhelp to reduce morbidity & mortality

THANK YOU