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

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.

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)

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

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

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

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

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)

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

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

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

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.

“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

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 14/16 87.50% 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

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

28 28 28

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.

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

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

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

No of Deliveries

Maternal Mortality Rate

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

And here we are… 37

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.

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

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