1. ALTERNATIVE METHODS FOR MANAGEMENT OF ATONIC POSTPARTUM HAEMORRHAGE
DR. MURWAN IBRAHIM OMER
DGO, MOG, ABOG, FRCOG, FICS
Consultant Obstetrician and Gynaecologist

2. Can we change our practice to improve outcome of PPH?
When conventional methods fail to control atonic PPH, there are interventions which are being ignored that should be considered before opting for major surgical procedures.

3. Postpartum Haemorrhage
Is a leading cause of maternal mortality and morbidity.
Too Little (IV fluids, oxytocics, BLOOD, Clotting factors)
Too Late (resuscitation - blood replacement, misopristol decision for surgery + to get senior surgeon & anaesthetist involved)

4. PPH
Anticipate - high risk cases (e.g. twins, polyhydramnios, prolonged 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
FIGO/ ICM STATEMENT ON AMTSL + WHO+ COCHRANE 4 4 4

5. Guidelines by the Scottish Executive Committee of the RCOG
COMMUNICATE.
RESUSCITATE.
MONITOR / INVESTIGATE
STOP THE BLEEDING

6. STOP THE BLEEDING Uterine compression IV syntocinon 10 units
IV ergometrine 500 mg
Syntocinon infusion (30 units in 500 ml)
Surgery / Hysterectomy
Misoprostol/ Intrauterine pack / Intrauterine balloon / Compression Sutures

7. Misoprostol Synthetic analog of prostaglandin E1 Low cost
Shelf life of several years if kept in their packets
Low cost
Can be administered orally, rectally, vaginally and by sublingual route
Being selective for the PGE1 receptors: Hence fewer systemic side-effects
Misoprostol could play an important
role in saving lives of thousands of women, particularly in low-resource settings 7 7 7

12. A study in Pakistan on the outcome of Utero-vaginal Packaging in Primary Postpartum Hemorrhage on 34 patients
Pelvic infection was seen in 5 cases i.e., 14.7% (but pre- existing risk factors for infection such as prolonged rupture of membranes, obstructed labour and home delivery were present in all these cases)

13. Therapeutic & Prognostic For severe PPH
TAMPONADE TEST
Therapeutic & Prognostic
For severe PPH
Oesophageal
balloon
Stomach balloon 13 13 13 13

14. The “Tamponade Test” Condous G, Arulkumaran S et.al.
Obstetrics & Gynecology. 2003

15. St George’s Series
27 consecutive cases of Sengstaken – Blakemore Esophageal catheter tamponade
Bleeding arrested in 22 cases
Tamponade failed in 5 cases. Of them:
4 underwent a subtotal hysterectomy
1 was managed with Haemabate and Misoprostol (concomitant use)
Doumouchtsis S, Papageorghiou A, Arulkumaran S. Acta Scand 2008

16. The Sengstaken-Blakemore oesophageal catheter
The main disadvantage is that it is not purpose-designed for PPH.
Therefore, it may not easily adapt to the shape of the uterine cavity.

21. “Women are not dying because of diseases we cannot treat
“Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.”
Mahmoud Fathalla,MD, PhD, 1997

23. Uterine balloon tamponade
Authors
Year
Type of study
Method
No of women
Success Rates
Goldrath
1983
Case series
Foley catheter 20
19/20 (95%)
Bakri et al
2001
Silicone Balloon 5
3*/5 (60%)
Condous et al
2003
Sengstaken -Blakemore 16
14/ %
Akhter et al
Condom 23
23/23 (100%)
Penney et al (Scottish Audit)****
Audit
Balloon 6
5/6 (83.3%)
2004 21
15/21 (71.4%)
Seror et al
2005 17
12/17 (70.6%)
St George’s current series
2006 27
22/27 (81.5%)
Total
135
83.7% 23 23 23 23

24. COMPRESSION SUTURES Quick, safe and effective
B-Lynch
Modified B-Lynch sutures
Combination of sutures 24 24 24

28. 28 28 28

29. Comparison between Original method & its modification
B- Lynch brace suture.
Modified B-Lynch brace suture.
1. Requires expertise.
1. Easy to perform.
2. Transverse LUS incision required.
2. LUS incision not required.
3. Time consuming.
3. Less time consuming (can be completed in 2-3 min).
4. Cervical stenosis.
4. No cervical stenosis
5. Haematometra formation.
5. No Haematometra formation.
6. Bleeding from LUS due to multiple bites.
6. No bleeding from LUS.

30. B-Lynch or Compression sutures
Authors
Year
Type of study
Method
No of women
Success Rates
B-Lynch et al
1997
Case series
B-Lynch 5
5/5 (100%)
Cho et al
2000
Square sutures 23
23/23 (100%)
Pal et al
2003 6
6/6 (100%)
Smith et al 7
6/7 (85.7%)
Penney et al (Scottish Audit)
Audit*** 10
9/10 (90%)
Penney at al (Scottish Audit)
2004 19
13/19 (68.4%)
Wohlmuth et al
2005 12
11/12 (91.6%)
Pereira et al
Compressive sutures
7/7 (100%)
Nelson et al
2006
Modified B- Lynch sutures
5/5 (100%)
Total 94
85/94 (90.4 %) 30 30 30

31. Conservative Treatment for PPH
Method
No of Cases
Success rates
B-Lynch + other Compression sutures 94
90.4%
Arterial embolization
218
91%
Arterial ligation
264
83.7%
Uterine balloon tamponade
135
Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007 31 31 31

32. “It is not the strongest of the species that survives, nor the most intelligent, but the one most responding to change.”
Charles Darwin

33. No of Deliveries

34. Maternal Mortality Rate

36. Are you all shocked? That’s good, because I’m here to talk to you about Shock..36

37. And here we are… 37

38. Conclusion
When conservative measures fail to control bleeding in post partum haemorrhage, uterovaginal packing, internal uterine tamponade and B-lynch sutures can be used before resorting to hysterectomy. These uterine preserving methods have been used in various countries and have proven to be effective, with minimal maternal morbidity.
They are feasible in this country and should be considered by Obstetricians when managing PPH. However, they require training and experience.

39. Emergency Trolley GENERAL MANAGEMENT Emergency protocols
Endotracheal tube
Laryngoscope
GENERAL MANAGEMENT
Essential drugs
Crystalloids, giving sets, haemacel 39 39 39

42. Thank You