Presentation on theme: "Dept. Of Obstetrics & Gynaecology"— Presentation transcript:
1Dept. Of Obstetrics & Gynaecology PPH DrillDr. Monika MadaanSpecialistDept. Of Obstetrics & GynaecologyESI Hospital Manesar
2PPH Single most important cause of maternal mortality worldwide. Accounts for 34% of maternal deaths in developing countries.
3DefinitionAny blood loss than has potential to produce or produces hemodynamic instability
4Definition Blood loss > 500 ml after delivery Primary : Loss within 1st 24 hours after deliverySecondary : 24 hours till 12 weeks postnatallyMinor : mlModerate : mlSevere : > 2000 ml
5PREDICTION AND PREVENTION - Pl previa/accretaAnticoagulation RxCoagulopathyOverdistended uterusGrand multiparityAbn labor patternChorioamnionitisLarge myomasPrevious history of PPHIdentify pt. at risk
6PREDICTION AND PREVENTION Active Management Of Third Stage Of Labor (AMTSL): Should be offered routinely and includes:Administration of uterotonics soon after birth.Delayed cord clamping.Delivery of placenta by controlled cord traction followed by uterine massage.
7PPH DrillClear and logical sequence of steps essential in the management of PPH.
9Skilled Obstetric Team Trained Anaesthesiologist Clinical hematologist Team EffortSkilled Obstetric TeamTrained AnaesthesiologistClinical hematologistSupporting staff
10Resuscitation Assess A : Airway B : Breathing C : Circulation Secure 2 wide bore i.v. lines: gaugeDraw blood for grouping & cross matching, CBC, LFT/KFT, SE & Coagulogram.
11Position flatKeep the patient warmAdminister oxygen by mask litres/ min)Catheterize the patient for emptying bladder & monitoring output
12Fluid Replacement RAPID WARMED infusion of fluids Crystalloids : Fluids of choice until compatible blood is arranged1 ml of blood loss= 3 ml of crystalloidsTotal volume of 3.5 litres of clear fluids (upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood.
13If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given
14FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1 FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal(ie ml/kg or total of 1 litres.)Platelet Concentrate: if Platelet count< 50,000/ microlitre.Cryoprecipitate: if fibrinogen < 1 g/ l.
15Continuous vital monitoring. Monitor adequacy of replacement with urine output (0.5 ml/kg/hr) and CVP (4-8 cm water)Main therapeutic goals are to maintain:Haemoglobin > 8gm/dlPlatelet count > 75 × 109 / lProthrombin < 1.5 × mean controlAPTT < 1.5 × mean controlFibrinogen > 1 gm/ l
16Establish Etiology Simultaneously 4 T’sTone (abnormalities of uterine contraction) : 70 – 80%Trauma (of the genital tract) : 20 %Tissue (retained products of conception) : 10 %Thrombin (abnormalities of coagulation) : 1 %
17Explore cervix and vagina Contd…Check tone of uteruswell contractedSuspect traumaExplore cervix and vagina
18Bimanual CompressionIf uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions
19Administer Uterotonic Drugs FIRST LINEOxytocin:Start with 5 units slow iv or im.Infusion of 20 units in 1 60 dr/min.Continue same 40 dr/min until bleeding stops.Maximum upto 3 L.SECOND LINEErgometrine/ methyl ergometrine:Dose: 0.2 mg im or slow ivRepeat 0.2 mg after 15 min.Maximum 5 doses (1 mg)Syntometrine im
20Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. THIRD LINEPGF 2α:Dose: 0.25 mg im.Can be repeated every 15 min.Maximum upto 2 mg or 8 doses.Misoprostol:µg sublingually.Do not exceed 800 µgWHO GUIDELINES FOR MANAGEMENT OF PPH 2009
21Uterine Tamponade Sengstaken Blakemore oesophageal catheter Bakri balloonSengstaken Blakemore oesophageal catheterCondom catheterUrological Rusch balloonSuccess depends upon Positive Tamponade test
22Procedure of condom Balloon insertion Initial AssemblyCondoms-2Foley’s catheter-no.16Saline with iv setSpeculumSponge holding forceps
23Procedure Lithotomy position Indwelling Foley’s catheter. Explore uterus, cervix and vagina.Inflate balloon with ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test).
27Uterine Artery Embolization Possible only if internal artery ligation has not been done and facility for interventional radiology available
28Hysterectomy Resort to hysterectomy “SOONER RATHER THAN LATER” High maternal morbidityTiming and adequate replacement is of utmost importance
29Documentation and Debriefing Important to record:Sequence of eventsTime and sequence of admn of pharmacological agents, fluids, blood productsThe time of surgical interventionThe condition of mother throughout .
30Newer DevelopmentsTranexamic acid : 1 gm i.v slow. Can be repeated after 30 min if bleeding continues./Recombinant activated factor VII (Novoseven): 90 µg/ kg . May be repeated within minutes. No clear consensus on efficacy.Carbetocin (oxytocin agonist) : 100 µg i.v or i.m. Produces tetanic uterine contractions.
31HAEMOSTASIS ALGORITHM H – Ask for help A – Assess and resuscitate E – Establish etiology M – Massage the uterus O – Oxytocic administration S – Shift to OT T – Tissue n trauma to be excluded and proceed to tamponade A – Apply compression sutures S – Systematic pelvic devascularisation I – Interventional radiology S – Subtotal or total hysterectomy
32To Conclude, Management of PPH Has Evolved From: PanicHysterectomyPitocinProstaglandinsHappiness