Download Surgical Management Of PPH - Challenges in Obstetrics

Tips & Tricks in dealing with a surgical
bleeding field
Ismail A. Al-Badawi, FRCSC
Section Head, Gynecology/Oncology & MIS
King Faisal Specialist Hospital& Research Center
Associate Professor, Alfaisal University
Pelvic Vascularity !
Introduction

150,000 women worldwide bleed to death each year
while giving birth !
10 deaths per 100,000 deliveries in developed countries !
In Developing countries = 1000: 100,000 delivery !

1/3 of women with PPH have no identified risk factors !

80 – 93 % of all deaths due to bleeding are avoidable!


Global Maternity Death – WHO 2006
Causes Of Maternal Mortality
Etiology
M. M.
Hemorrhage
28.7%
Embolism
19.7%
P.I.H.
17.6%
Infection
13.1%
Cardiomyopathy
5.6%
Anesthesia complic
2.5%
Others
12.7%
Confidential Enquiry Of Maternal Death In UK 2007
http://www.moh.gov.sa/statistics/M2005/Book%202005.pdf
Why Obstetrical bleeding ?
56 422 deliveries 16 maternal deaths
overall MMR of 28.4/100 000 total births
81.25% direct obstetrical causes
18.75% indirect causes
MMR due to direct causes was 23.4/100 000 deliveries.
The trend in MMR in the unit remained almost the same over the years
Obstetric haemorrhage was responsible for 43.75% maternal deaths
Journal of Obstetrics and Gynaecology (April 2004) Vol. 24, No. 3, 259–263
Types Of Bleeding
Types Of Bleeding
Surgical :
1.
2.
3.
4.
5.
6.
Premature Placental Separation ( Abruptio Placenta ) .
Uterine Atony .
Uterine Rupture .
Placenta Praevia .
Placenta Accreta / Percreta .
Emergency LSCS .
Types Of Bleeding
Medical :




D. I. C ( Disseminated Intravascular Coagulopathy ) .
HELLP Syndrome !
Amniotic Fluid Embolus !
Oncology cases !
Obstetrical Hemorrhage
Maternal Deaths
1.
2.
3.
4.
5.
6.
7.
Abruptio placenta – 19 percent .
Uterine rupture – 16 percent .
Uterine Atony – 15 percent .
Coagulation disorder – 14 percent .
Placenta previa – 7 percent .
Placenta accreta – 6 percent .
Retained placenta – 4 percent .
Chichaki, et al, 1999
Causes of 763 Deaths due to hemorrhage
Practical Issues
Primary PPH

No Universally Accepted Definition !
Blood loss within 24 hours of delivery :
>500 mL following vaginal delivery !
>1000 mL following caesarean delivery !


Decrease in haematocrit level >10 % of prenatal value !

Any bleeding that results (or could result, if untreated) in
signs of maternal haemodynamic instability !
Obstetric Hemorrhage


If Hemorrhage is not controlled by
medications, massage, manual uterine
exploration, or suturing lacerations in
the birth canal, then surgical or
radiological options must be considered.
IN general, avoid a “watch and wait”
approach to the bleeding patient.
- Obstetrical Hemorrhage Failed Medical Rx
Significant PPH
Atony/Tears/ Rupture
-B-Lynch procedure
-Uterine a. ligation
-Stepwize devascularization
-Uterine repair
-U.A.E.
-Internal Iliac artery ligation

TAH
PL Previa / Accreta
-Local mattress sutures
-Hemostatic balloons / Packing
-U.A.E.
- Stepwize devascularization
-Internal Iliac artery ligation

TAH
- Obstetrical Hemorrhage -
Identify
Patients at
Risk
Multidisciplinary
“Hemorrhage
protocol”
Clinical
Management
of PPH
- Obstetrical Hemorrhage -Pl previa/accreta
-Anticoagulation Rx
-Coagulopathy
1. Identify pat.
at risk
-Overdistended uterus
-Grand multiparity
-Abn labor pattern
-Chorioamnionitis
-Large myomas
-Previous history of PPH
Maternal Mortality
- Obstetrical Hemorrhage -
1. Prepare for PPH
Personnel
-Nursing
-Anesthesia
- Surgical assistance
- Blood Bank
- ICU Team
Drugs/Equipment
-Methergine
-Hemabate
- Mesopristol
-Cytotec
-Colloids
- Blood products
-Surgical Instruments
-Hemostatic balloons
( Cook, S-B, Foley)
Maternal Mortality
- Obstetrical Hemorrhage Patients at
risk
Pre-delivery
management
1.- Prepare for PPH
2.- Optimize patient’s hemodynamic status
3.- Timing of Delivery
4.- Surgical planning
5.- Anesthesia /I.V. access/ invasive monitoring
6.- Modify obstetrical management
7.- Increased postpartum/post op surveillance
- Obstetrical Hemorrhage 2.
Optimize hemodynamic status
1. Acute isovolemic hemodilution !
2. Preoperative transfusion !
3. Cell Saver !
- Obstetrical Hemorrhage -
Identify
Patients at
Risk
Multidisciplinary
“Hemorrhage
protocol”
1.- How/Who triggers the “H.P.”
2.- Identify “The response team”
3.- Transfusion protocol
4.- Define the logistics involved
5.- Conduct drills
6.- Post-op care
Clinical
management of
PPH
Maternal Mortality
- Obstetrical Hemorrhage -
Identify
Patients at
Risk
Multidisciplinary
“Hemorrhage
protocol”
Clinical
management of
PPH
1. How/Who triggers the “H.P.” ???
The OB Consultant on call for L+D !
The Head Nurse of L+D Initiate the H.P !
A single number paging system !
Over Head Calling System !
Maternal Mortality
- Obstetrical Hemorrhage Identify
Patients at
Risk
Multidisciplinary
“Hemorrhage
protocol”
Clinical
management of
PPH
2 - The “Response Team”
-Nursing
-Anesthesia
-Ob surgery (MFM, Gyn Onc, Ob-Gyn,)
-Intervention Radiology
-Hematology
Maternal Mortality
- Obstetrical Hemorrhage Identify
Patients at
Risk
Multidisciplinary
“Hemorrhage
protocol”
Clinical
management of
PPH
3 - Transfusion Protocol
-Immediate release of O neg Blood if required
- How fast can Crossmatched blood be made available !
-Physical transport of Blood  O.R. and samples from O.R. 
Lab / Blood Bank !
- Availability of different products !
Requesting of blood products
Immediately
15 min after receipt
Emergency group O Rh D negative units can be given while the
patient’s blood group is being determined.
Un-crosshatched ABO group specific blood can be provided.
of sample in blood bank
As soon as thepatient’s blood group has been determined a switch should be made from O
Rh (D) negative blood to ABO group specific blood. Medical staff must accept full responsibility for
administration of un-crosshatched blood– the patient may have
unidentified / undetected antibodies – the use of un-crosshatched blood in these patients may result in a
life threatening Haemolytic Transfusion Reaction.
45 min after receipt
of sample in blood bank
Fully crosshatched blood can be provided in most cases.
Tips & Tricks
Uterine Packing
The Re-emergence
of uterine packing

Although uterine packing was advocated for treating PPH
in the past, it fell out of use largely due to concerns of
concealed hemorrhage and uterine over distension.

In recent years, however, several modifications of this
procedure have allayed these concerns.

Balloon tamponade has been shown to effectively control
some types of postpartum bleeding, and may be useful in
several settings: placental Praevia and placenta accreta.
The re-emergence
of uterine packing
The Foley catheter procedure.
 A Foley catheter with a 30-mL balloon capacity is easy
to acquire and may routinely be stocked on labor and
delivery suites.

Using 24F Foley catheter, the tip is guided into the
uterine cavity and inflated with 30 mL of saline.

Additional Foley catheters can be inserted if necessary up
to 5 catheters. If bleeding stops, the patient can be
observed with the catheters in place and then removed
after 12 to 24 hours.
The re-emergence
of uterine packing
The Sengstaken-Blakemore tube.

Originally developed for the tamponade of bleeding esophageal
varices, the Sengstaken-Blakemore tube has the advantage over the
Foley catheter due to the larger capacity of its balloon !

The Sengstaken-Blakemore tube has an open tip that permits
continuous drainage.

Like the Foley catheter, the Sengstaken-Blakemore tube should be
guided through the cervix into the uterus and the balloon can then be
inflated up to 150 cc to achieve the desired tamponade and can be
removed in 12 to 24 hours.
The re-emergence
of uterine packing
Bakri SOS Balloon.

It is 250 – 500 cc capacity silicon- made balloon,
designed specifically to take the shape of the
uterine cavity to act as a tamponade with a drainage
hole in the tip of the balloon catheter to allow blood
drainage if collected above the balloon.
The re-emergence
of uterine packing
After C- Section:




When the balloon is placed at the time of cesarean delivery, an
assistant working from below helps pull the distal end of the
balloon shaft through the cervix into the vagina.
The hysterotomy incision is closed
The balloon is filled with 250 to 500 mL of sterile isotonic
fluid
The distal end of the balloon is attached to a weight, such as a
liter intravenous fluid bag, to ensure that a tamponade effect is
maintained.
The re-emergence
of uterine packing
After vaginal delivery :





A Foley catheter is inserted in the bladder to monitor urine
output and reduce bladder volume !
The uterus is examined to ensure that there are no retained
placental fragments !
The balloon is inserted into the uterus so that the entire
balloon is past the internal cervical os !
Using a syringe, the balloon is filled with sterile saline to the
desired volume—again, typically, 250 to 500 mL
Gentle downward traction is placed on the balloon stem to
ensure that a tamponade effect is maintained
Selective Arterial Embolization
Selective Arterial Embolization
If the patient is stable and bleeding is not
excessive, and if interventional radiology is
available, then pelvic arteriography may
show the site of blood loss and therapeutic
arterial embolization may suffice to stop the
bleeding.

Uterine Artery Embolization
Uterine Artery Embolization
Selective arterial embolization

With gelfoam pledgets, coils, or a balloon catheter,
the targeted artery is occluded.

Unlike other interventions, SAE can be highly
effective when coagulopathy is present.

Although long-term follow-up is unavailable for
most of the reported cases, menses typically returns
within 3 months, and subsequent normal pregnancies
have resulted.
Selective arterial embolization

When women are at increased risk for PPH
(suspected accreta, previa), catheters can be placed
prophylactically, prior to a planned C/S delivery in
anticipation of need.

Many studies found that prophylactically placed
catheters reduced the total blood loss and incidence
of coagulopathy, compared with catheterization
performed in an emergent setting.
Surgical Compression Suture
Surgical Compression Suture

In recent years, interest has surged in the surgical
compression suture for treating PPH brought on by
uterine atony.

B-Lynch suture initially described by Christopher
B-Lynch in 1997 has gained the most popularity .
Surgical Compression Suture
The theory behind each technique is the same:

The mechanical compression of uterine
vascular sinuses prevents further
engorgement with blood and continued
hemorrhage.
Surgical Compression Suture
A woman meets the criteria for the
B-Lynch compression suture if bimanual
compression decreases the amount of
uterine bleeding by abdominal
inspection.

Surgical Compression Suture



Although originally described using No. 2 chromic
catgut, variations using No.1 Vicryl suture have been
equally successful.
In our experience, we have also used No. 1 chromic
catgut and 0 loop PDS suture with no complications
noted.
There are theoretical concerns about bowel
complications with PDS suture because the suture
material may not completely degrade for up to 6
months.
Uterine Devascularization
Uterine Devascularization
Uterine Devascularization
Success Rates :



Step 1: 8.7 % .
Step II : 74.8 % .
Step III : 93 % .
Internal Iliac Artery Ligation
Internal Iliac Artery Ligation

Burchell has put forward the mechanism responsible
for controlling pelvic hemorrhage following ligation
of internal iliac artery !

The ligation of internal iliacs greatly decreased the
pulse pressure and transformed the pelvic arterial
system into a venous like system with slow and
sluggish blood flow.
Internal Iliac Artery Ligation

Burchell also proved that with bilateral ligation, the
drop in pulse pressure was around 85 – 90 % ,
whereas with unilateral ligation it was 77% on the
same side and 14% on the opposite side.

The rate of blood flow dropped to about 48% after
ligation.
Internal Iliac Artery Ligation

Possible delayed complications like ischaemic
necrosis of the gluteal muscles, weakness of gluteal
muscles or bladder atony can occur up to 20 % of
the cases.

Full term pregnancies with no complications like
intrauterine growth retardation have been reported
after bilateral internal iliac and ovarian artery
ligation.
CesareanHysterectomy
Peripartum hysterectomy



often in conjunction with cesarean delivery !
In the United States, it is performed in 0.05 to 0.1
percent of all deliveries and 0.5 percent of all
cesarean deliveries !
Similar results are found in Europe and Canada !
Cesarean Hysterectomy

Must be discussed with all high risk
patients before delivery !

The consent must include it !
DECISION MAKING

Though , the decision to proceeds to hysterectomy
should not be delayed till the patient reach critical
stage or she bleed too much till she goes to DIC.

The proper timing to move to hysterectomy is
vital for the well being of the patient and it must not
be delayed beyond the right time in order to preserve
the women fertility!
Challenges !

Anatomical changes !

Increased Vascularity !

Other Complications !
Pelvic Packing
Pelvic Packing

Very effective for wide spread oozing , raw
services or for venous bleeding !

Must be done correctly to be successful !

Pack and Go back !
Packing
o
Transient compression of the aortic bifurcation
against the sacral prominence can increase arterial
perfusion pressure to the maternal heart, brain, and
kidneys; also this will decrease loss of blood into
the operative field.
Tricks are NOT only
Surgical
Three avoidable factors in most Massive Obstetric
Hemorrhage related maternal deaths
Delays in:



correction of hypovolaemia
surgical control of bleeding
diagnosis and treatment of
defective coagulation
Fresh frozen plasma (FFP)


volume 200 to 250ml
contains
 all


coagulation factors, except FVIII(rapidly decays)
dose 15 mL/kg
Solvent detergent prepared FFP has a lower risk of
transfusion transmitted infection
PHARMACOLOGICAL AGENTS THAT REDUCE
BLEEDING
Recombinant VIIa
Antifibrinolytics
Recombinant activated factor VII

off-label use
 1999 first ‘off-label’ successful use: perioperative bleeding in
a wounded soldier without a preexisting hemostasis disorder
 2001: successful in a parturient during CS delivery
 2003–2004: more case reports and small series in obstetrics
 Dose: 20-120 µg/kg
 No clear evidence of a dose– response relationship
Recombinant activated rFVII Registries


North European registry [Northern European FVIIa in Obstetric Haemorrhage (NEFOH)

108 cases in 9 countries -65 hospitals

5-year period (2000 -2004)

single dose of rFVIIa in
81%

dose ≤7.2mg
91%

no change in bleeding or worsening
14%

TED
4 cases

MI
1 case
The Australian and New Zealand registry:

105 cases in 38 hospitals

assessment of efficacy possible in only 94 cases

median dose of 92mgkg1

single dose
78%

Positive response
76% (64% to the first dose)

hysterectomy
41% before or 21% after rFVIIa therapy

TED
2 cases

encephalopathy
1 (severe anoxic insults)
Registry UniSeven in the Czech Republic

80 Czech patients with life threatening PPH

2004-2009

DESIGN: Retrospective, observational, multicentre study.

RESULTS:

97.5%
treatment was able to control the bleeding

66.3%
only 1 dose of rFVIIa was sufficient

mortality rate: 2.5%

VTE

74.3% was administered before considering hysterectomy was able to avoid
hysterectomy
non
Seidlová D et al Ceska Gynekol. 2010 Aug;75(4):297-305
Anti-Fibrinolytic Drugs:
Tranexamic acid
Inhibition of fibrinolysis by TXA
Plasmin
Tranexamic Acid
Fibrin
Lysine Binding Site
●
Tranexamic Acid (TXA) is a synthetic derivative of the amino acid lysine.
●
It has a very high affinity for the lysine binding sites of plasminogen.
●
It blocks these sites and prevents binding of activated plasminogen to
the fibrin surface, thus exerting its antifibrinolytic effect.
TXA in elective surgery
Reduced need for transfusion
RR (95% CI)
TXA
0.61 (0.54-0.69)
0
0.4
0.8
TXA better
1.2
1.6
TXA worse
2.0
TXA already recommended for use in
some treatment protocols
Page 56: 1.16.13:
“Additional therapeutic options for the treatment of
postpartum haemorrhage include tranexamic acid
(intravenous)…”
http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf
The most recently updated WHO treatment guidelines
for PPH state that TXA may be used, but that the
quality of evidence on which this recommendation is
based is low, and recommend further clinical trials of
TXA in PPH.
Dr Metin Gülmezoğlu
WHO Reproductive Health Library
Post-hemorrhage care

Once bleeding has stopped
 remember
that the most common cause of maternal
direct deaths is thromboembolism
 Thromboprophylaxis:
 LMWH:
ASAP