S. Monokoane Department of Obstetrics & Gynaecology

University of Limpopo Medunsa campus

SASOG CONGRESS 19 MAY 2014

Obstetric Haemorrhage- a killer!

Introduction Obstetric haemorrhage is a major cause of maternal

morbidity and mortality worldwide.

The Saving Mothers Report 2008-2010 showed Obstetric haemorrhage to be the 2nd most common cause of maternal death in South Africa at 14.1%.

The major causes of death from haemorrhage were similar to the 2005-2008 report

but worrying is the rising trend in the number of deaths associated with bleeding at or following caesarean section

The proportion of deaths is alarmingly high accounting for 26% of all haemorrhage deaths

An Editorial in SAMJ May 2011 ISSUES IN MEDICINE

Haemorrhage associated with caesarean section in South Africa – be aware

S Fawcus, J Moodley, for the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD

BJOG March 2014

It is often taken for granted that c/s is a safe procedure, however audits show otherwise!

Challenges :most hospitals are overwhelmed by the number of c/s, often done as emergencies by junior doctors with limited skills and no supervision

Type of cases with predisposing factors e.g previous c/s, prolonged labours, APH- praevia and abruptio placenta with DIC

Obesity and co-morbidities PET, DM, cardiac, HIV

Objective To assess rates and contributory factors to reasons for

bleeding at or after caesarean section and the outcomes, both morbidity and mortality in a teaching hospital.

Method: A retrospective 4 year study at Dr George Mukhari

Hospital Pretoria, tertiary hospital referral for Gauteng northern, NW , Limpopo

Review of patients & theatre records from January 2010- December 2013

Inclusive criteria: all patients that bled at or post caesarean section recorded in theatre as serious event that warranted intervention.

Exclusion criteria: patients with incomplete records

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RESULTS

Patients Number Percentage

Total deliveries 39 151

Total VD 20949 65%

Total C/S done 13208 33%

significant bleeding @ c/s >1000ml

187

1.4% (PPH4.3% in 2010)

ICU with serious morbidity/nearmiss

60

0.45%

who died 0 9

Interventions : Indications

Relap: repair TAH, Bakri, ICU, B-Lynch devascularisation Fetal distress, poor progress, HPT, prev cs, malpresentation twins

Blood/products transfusion.

2010 2011 2012 2013

Total Deliveries 9 226 9 745 10 120 10 060

NVD 5 916 63.10% 6 647 68.20% 7 017 67.33% 6 363 62.20%

C/S 3 310 35.80% 3 098 31.79% 3 103 30.26% 3 697 36.73%

Assisted Vaginal

Delivery 36 0.80% 62 1.01% 73 1.51% 88 1,17%

Vaginal Breech

Delivery 116 1.30% 308 3.16% 294 2.90% 204 2.02%

Bookings Status

Booked 8 893 96.40% 7 975 97.03% 9 786 96.69% 9 957 98.90%

Unbooked 333 3.60% 1 676 2.97% 1 987 3.30% 103 1.02%

Maternal Age

< 18 years 458 5,00% 702 7.20% 745 7.36% 745 7.40%

18 - 34 years 7 841 85.00% 2 543 26.09% 8 453 83.52% 8 154 81.05%

≥35 years 927 10.00% 1 841 18.89% 2 316 22.88% 1 988 0.19%

Preterm Deliveries 1 989 21,60% 2 514 25.79% 2 641 26.09% 1 719 17.08%

Deliveries at Term 7 237 78.40% 7 231 74.20% 9 654 95.39% 8 341 82.91%

Abortions 130 1,40% 213 2.18% 201 1.98% 214 2.12%

Fetal Weights (gm)

500 - 999 257 2,80% 156 1.60% 316 3.12% 312 3.10%

1000 - 1499 368 4,00% 201 2.06% 198 1.95% 362 3.59%

1500 - 1999 503 5,50% 361 3.70% 533 5.26% 547 5.43%

2000 - 2499 861 9,30% 1 001 10.27% 867 8.56% 1.163 11.56%

≥2500 7 237 78,40% 8 026 82.36% 7 223 71.37% 7 453 74.08%

Macrosomic Babies

4000 - 4999 149 1,60% 205 2.10% 254 2.50% 203 2.00%

≥4500 36 0,40% 74 0.75% 56 0.55% 34 0.33%

Multiple Pregnancy

Twins 212 22/1000 156 16/1000 212 21/1000 165 16/1000

Multiple Pregnancy

Twins 212 22/1000 156 16/1000 212 21/1000 165 16/1000

Triplets 1 1 3 2

Syphilis Serology

Tested 8 390 90,90% 7 054 72.38% 9 453 93.40% 9 639 95.81%

Positive 93,1% 346 3.55% 361 3.81% 292 2.93%

Negative 8 297 98,90% 4 867 49.94% 8 096 85.64% 8 843 87.90%

Unknown 836 9,10% 1 841 18.89% 996 10.53% 742 7.37%

HIV Status

Tested 7 995 86,70% 8 845 90.76% 9 919 98.01% 9 608 95.50%

Positive 2 547 31,90% 3 023 31.02% 3548 35.76% 2 709 26.92%

Negative 5 448 68,10% 3 990 40.94% 5 821 58.68% 6 899 68.57%

Unknown 1 231 13,30% 1 832 18.79% 550 5.54% 325 3.23%

Foetal Outcomes

Live Babies 8 947 97,00% 9 296 95.39% 10 002 98.83% 9 987 99.27%

Fresh Still-

births 135 1,50% 185 1.89% 158 1.57% 203 2.01%

Macerated Still-

births 144 1,60% 264 2.70% 264 2.63% 211 2.09%

Perinatal

Deaths 435 449 572 521

Perinatal

Mortality Rate 45/1000 BIRTHS 45/1000 BIRTHS 57/1000 BIRTHS 52/1000 BIRTHS

Maternal

Deaths 19 38 42 21

Maternal

Mortality Rate 206/100,000 408/100,000 419/100,000 210/100,000

Results YEAR C/S done Bled@C/S Near miss Died

2010 3310 20 12 03

2011 3098 21 15 03

2012 3103 25 18 01

2013 3697 21 15 02

TOTAL 13208 87 60 09

What were the causes of bleeding encountered @C/S in this study

Previous c/s with adhesions: 56 Uterine atony: 70 Bleeding corners & margins: 28

retroperitoneal haematoma: 5 Uterine tears/ extension in prolonged 2nd stage: 23 Uterine rupture at CS: 8 Morbidly adherent placenta: 21 Bleeding placental bed: 30 Extra-uterine pregnancy: 3 Abruptio placentae with DIC (Grade IIIb): 4 Obesity: 15 (BMI >30) Over-anticoagulated Clexane :5

Method No of Cases Success rates

B-Lynch + other

Compression

sutures

14

Uterine Artery

ligation

28

Internal Iliac artery

ligation

4

Uterine balloon

tampona

5

Surgical Treatment for PPH Method applied No of patients (187)

Relap to arrest bleeders at corner or tears

52(27%)

Uterine artery ligation Internal Iliac artery ligation

33(25%) 03(1.6%)

Compression suture B-Lynch 18(9.6%)

Insert Bakri balloon +/- Blynch for placental bed if figure of 8 sutures failed

15(8%)

Peripartum TAH/ subtotal 40(21%)

Removal of morbidly adherent placenta+/- curretage

07(3.7%)

Outcome Maternal

Successfully managed on the table: 118

Admitted in ICU: 60

Had acute renal failure: 21

Had massive blood transfusion >10 units/24hrs: 60

Died of hypovoloemic shock due to uncontrolled bleeding: 7

Died of bleeding due to anticoagulation:2

Complications and outcomes Number (%)

Complications ICU admissions 60(32,08%)

Acute renal 23 (12,8%)

DIC 26 (13,09)

ARDS 05 (2.6%)

Hysterectomy 44 (23%)

Maternal outcomes: Discharged 178

Demised 9

Fetal outcomes [n = 112]: Born alive 1 71(81,2%)

FSB 15 (13,4%)

MSB 6 (5,%)

Discussion: Risk factors for bleeding at C/S Prolonged labour +/-CPD

Previous caesarean section

- Adhesions

- Morbidly adherent placentae and Preavia

Obesity and co-morbidity PET cardiac

Distended uterus: macrosomia, twins

Induction of labour

Technique and skill of the surgeon at c/s

Who should do these C/S??

Saving Mothers Report 2008-10 Bleeding associated with caesarean section was 26.2%

Uterine rupture 17.9%

Abruptio placentae 16%

Retained placenta 9.0%

Uterine atony 6.4%

In this audit there was a combination of above

Scope of the problem 2002-4 report • In South Africa the causes of PPH are:

– Ruptured Uterus (commonly associated with VBAC) 27%

– Uterine Atony 24%

– Retained Placenta 21%

– Other Uterine Trauma 25%

• In Gauteng PPH is responsible for 13% of the maternal deaths.

Findings in this study Inadequate surgical haemostasis esp. at the corners (?not using

Green Armitage) -should use blunt technique for cs!

Missed lateral lower tears/extensions-exposure

Undiagnosed Morbidly adherent placentae in previous CS and extrauterine pregnancies as ELCS- do scan

Adhesiolysis on entry into abdomen overlying lower segment in previous CS- call senior

Difficulty in delivery of the head /impacted in CPD resulting in lateral tears esp in Prolonged 2nd stage

Undermined/under-estimated blood loss delay resuscitation

Refused advised from experienced scrub sister!

Delay in instituting definitive measures as TAH

Uterine Vascular Bundle Ligation

Safe method of passing right-angled clamp from lateral to medial side below the internal iliac artery

Uterine Bracing B-Lynch Suture

A

Broad Ligament

Round Ligament

Bladder reflected caudally

A. Positioning of closed artery forceps. This maintains a patent cervical canal on tightening lower sutures

Anterior view

Fallopian Tube

Anterior view of Completed sutures

ARULKUMARAN MODIFICATION R. G. Hayman, S. Arulkumaran, and P. J. Steer.

Uterine compression sutures: surgical management of postpartum hemorrhage.

Obstet Gynecol 99 (3):502-506, 2002.

A A

Balloon catheters available

PARALLEL VERTICAL COMPRESSION SUTURES

Y. M. Hwu, C. P. Chen, H. S. Chen, and T. H. Su. Parallel vertical compression sutures:

a technique to control bleeding from placenta praevia or accreta during caesarean section.

BJOG. 112 (10):1420-1423, 2005.

Case 1 delay! • 24 yr POG1 with poor progress due to CPD

• C/S commenced at 18h00

• Head impacted/jammed in the pelvis

• Lower segment ballooned thinned out

• After delivery of the head noted welling up/ bleeding from an extension in the cervix

• Tried for 2hours to repair

• Called for help of consultant at 20h00

• Consultant wasted time trying repair, did TAH at 22h00

• Abdomen was closed with BP 60/30 -50/20

died on arrival in ICU

CASE 2 • 28yrs P2G3 at 38weeks previous C/S X2

• ELCS done by registrar noted bluish tumour, cut above it delivered a live baby 3.4kg Percreta!

• Tried to remove the placenta, it was encroaching into the bladder

• Experienced torrential bleeding

• Called consultant out urgently, then called senior consultant

• Proceeded to do TAH, continued bleeding

• Opened the bladder cystostomy & oversew the bleeding varicosities area with figures of 8

• Packed the pelvis, made uneventful recovery

Case 3 26yr P1G2 C/S 1 with prolonged latent phase On 09/09/12 at 05H30, still in labour since last night (1cm dilated)

Plan: book for c/s ,done at 14H11,

BP 169/94 P= 128

Intraoperatively: adhesions+++ lysis done then a lower segment transverse incision on the uterus

3550g neonate delivered MSL II observed ,placenta manually delivered

Uterus repaired in layers, no reported tears nor vascular injuries .

However uterus was bleeding from placental bed, EBL=2300ml

Pt received 5000ml R/L, 2x voluven , urinary output 100ml,

Pitocin 20u in R/L infusion, 800mg cytotec PR clots expelled & pt transferred to high care labour ward

HIGH CARE

BP range: 80/60- 110/70, pulse : 105-130

At 18H00, active bleeding was observed on the pt’s operation & per vagina

She was wheeled back to theatre for exploratory laparotomy, emergency blood products ordered

Before laparotomy BP =67/38,P =171, blood transfusion & surgery were commenced

Findings: 2000ml haemoperitoneum

- bleeding from right uterine artery

- bleeding from raw areas over the uterine wound

Proceeded to do: subtotal hysterectomy, 4 large abdominal swabs used to pack the pelvic cavity, abdomen closed and patient transferred to ICU

Pt received 3FFP, 4u packed cells & 2 mega units platelets

3rd case continued

Taken back to theatre (re-laparatomy) for removal of swabs commenced

Under general anaesthesia and aseptic conditions the abdomen was opened

Findings: 2000ml haemoperitoneum, swabs removed

Bleeding found to be from the right corner of the uterine stump , oozing seen over the bladder

Procedure bleeding was arrested with sutures, abdominal cavity washed out , 2 pencil drains inserted.

The abdominal cavity closed & pt transferred back to ICU at 17H00

At the time BP=100/69, Pulse=160 temp=38

At 19h00 pt arrested and resuscitation commenced & was certified dead at 21H30.

Case 4 • Called for a patient with extra-uterine pregnancy

• Taken in as Prev C/Sx1 with ? Abruptio live baby

• At C/S registrar failed to notice an extrauterine pregnancy

• Delivered a live 1,85kg baby with good Apgar's but mutilated the uterus( fetus was in PoD behind the uterus!)

• Placenta was adherent to the bowel & bleeding profusely

• Blood supply from R infundibulopelvic ligament

• Below it was adherent to peritoneum above the ureter

• After clamping the blood supply we dissected it free above the ureter, made good recovery’

Avoidable factors Delayed and inappropriate correction of hypovolemia

Delay in diagnosis of the problem and treatment thus allowing massive blood loss resulting in defective coagulation

Delay in surgical control of bleeding

Degree of hypotension with tachycardia is 1st sign of significant blood loss

Failure to evaluate response to treatment by pulse BP CVP urine output & ABG

Rapid transfer between facilities & train junior drs from level 1 centres on rotational basis

Anaesthetic side

Inadequate resuscitation with blood products

Often give too much crystalloids :dilutional effect worsening coagulopathy

Use of spinal in unstable or potential problematic cases & rely too much on machines than finger pulse

Allowed abdominal closure with low BP<100 systole

Poor communication with the surgeon

Conclusion We need to restructure teaching: should we introduce

surgical skills at 5th and 6th yr medical students?

Supervision of interns/new medical officers

Resuscitation: implemented correctly Put C/S skill requirement as a MUST before you can practice plus ESMOE certificate

Use of plastic drapes for collection of blood

Senior doctors to be involved in doing previous C/S as in UK

Facilities: have 2 emergency theatres running 24hours

THANK YOU!

RESUSCITATION major PPH >1L IV access - 14 G cannula x 2 Head down tilt In 20ml syringe take blood FBC, x-match 4units, clotting

profile & U+E Oxygen by mask at 8 litres / minute Infuse 2 litres of crystalloid and 1 -2 litre of colloid Start blood transfusion as soon as possible Give 2units O Rhesus negative uncrossed blood urgently If bleeding is unrelenting then give emperical FFP unit for

3 packed cells transfused or 10 units of cryoprecipitate Fluids should be warmed Keep the patient WARM as well