Presentation on theme: "Postpartum Hemorrhage"— Presentation transcript:
1Postpartum Hemorrhage Second partدكتور محمد توفيق الشربينىدكتوراة وإستشارى النساء و التوليدمستشفى دمياط التخصصى - مستشفى دمياط العامDr.Mohamed El SherbinyMD Obstetrics&Gynecology
2Intractable Postpartum hemorrhage About 10 % of women will not respond to the initial management steps and are considered as intractable PPH They are caused mainly byUterine atonyPlacenta accretes at CS scar
3A multi-disciplinary team, Hemodynamic Stablization Local Control Intractable Postpartum HemorrhageA multi-disciplinary team,Hemodynamic StablizationLocal ControlSurgery(SOGC ) Clinical Practice Guidelines 2000 (III)
4The approach to intractable PPH will be individualized depending on : Intractable Postpartum hemorrhageThe approach to intractable PPH will be individualized depending on :The clinical situationThe skill of the operator.The technology available.(SOGC ) Clinical Practice Guidelines III
10The B-Lynch technique (brace suture) for intractable hemorrhage It may be particularly useful because of its simplicity of application, life saving potential, relative safety, and its capacity for preserving the uterus and thus fertility.The B-Lynch, 1997 B J of Obstet and Gynaecol, 104:
12Hayman Compression Suture A number 2 Vicryl or Dexon suture on a straight, blunt needle is used to transfix the uterus from front to back, just above the reflection of the bladder and is then tied at the fundus of the uterus.This can be done as one suture on eachside of the uterus, or more than one suture ifthe uterus is particularly broad,Hayman et al Obst. Gynec. 2002,99;3;502-6
15Hayman Compression Suture Vicryl® or Dexon® are strong and unlikely to cause external adhesions to the uterus.It does not appear to be necessary to open the uterus or avoid crossing the uterine cavity.Hayman et al Obst. Gynec. 2002,99;3;502-6
17Stepwise uterine devascularization for intractable atonic hemorrhage This technique entails five successive steps (using chromic catgut 1 with Mayos needle), if bleeding is not controlled by one step the next step is taken until bleeding stops.The procedure was effective in all 103 (100%) cases.Abdrabbo , 1994, Am J Obstet Gynecol.171:
22Stepwise Uterine Devascularization Advantages over internal iliac ligation:Easier dissection.Lower complication rates.More distal occlusion of arterial supply with less potential for rebleeding because of collateralsHigh reported rates of success in controlling haemorrhaging.(SOGC ) Clinical Practice Guidelines 2000
24Placenta accreta, increta and percreta A placenta previa with previous CS should be considered of having a morbidly adherent placenta. Particular attention should be focused to confirming or excluding this diagnosis using U/S. When present, senior anaesthetic and obstetric input are vital in planning the delivery.RCOG guidelines Grade B Evidence base.Level III
25Placenta accretaWomen who have had 2 or more CS deliveries with anterior or central placenta previa have nearly a 40% risk of developing placenta accreta.The patient should be counseled about the likelihood of hysterectomy and blood transfusion.ACOG Guideline 2002
26Placenta previa accreta (Increta or Percreta) with severe bleeding 1-Low &high bilateral uterine vessels ligation (Stepwise) ,the Best.2- Longitudinal lateral sutures3-Bilateral Internal iliac ligation.4- Hysterectomy : almost total5-Tight uterine packing.
29Bilateral Internal Iliac Artery Ligation It was recommended for many decades to control PPHIt has fallen out of favor because of:The prolonged operating timeTechnical difficultiesInconsistent clinical response.High hazard if internal or external iliac veins are injured.
30Bilateral Internal Iliac Artery Ligation It is indicated mainly for:Large broad ligament or lateral pelvic hematomaMultiple cervical tears.L. segment bleeding or atonic pp as a last resort.It is less effective than Bilateral uterine artery ligation for atonic postpartum hemorrhage
32. After the covering sheath has been opened and the artery has been carefully freed from the immediately adjacent veins A ligaure is carried beneath the artery- 3.0 cm distal to the bifurcation- with a right angle clamp and firmly tied.Passing the tips of the clamp from lateral to medial is crucial to prevent injuries to the underlying veins .
34Internal Iliac Artery Ligation 50% failure rate in placenta accreta and uterine tears
35Peripartum hysterectomy Emergency hysterectomy is the most common treatment modality when massive postpartum haemorrhage requires surgical intervention mainly forPlacenta acretta or percreta ( 50%)Uterine atonyRupture uterusCS extension or broad ligament hematomaThomas Br J Obstet Gynaecol 1998;105:127-8.
36Post Hysterectomy Bleeding Diffuse post hysterectomy bleeding may be controlled by abdominal packing to allow time for normalization of the woman’s haemodynamic and coagulation status. (II-3)The pack composed of gauze in a sterile plastic bag brought out through the vagina and placed under tension. This pack is also known as a parachute, mushroom, or umbrella pack.S O G C C L I N I C A L P R AC T I C E G U I D E L I N E S II