Download PPH – Global and The UK Perspectives

PPH – Global and The UK
Perspectives
S Arulkumaran
Professor & Head
Obstetrics and Gynaecology
St George’s University of London
75% Of MM & third of NN mortality takes place
during labor/ birth or within 24 Hrs.
*Other direct causes include: ectopic pregnancy, embolism, anesthesia-related
** Indirect Causes include: anemia, malaria, heart disease
PPH Global Perspectives
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30-50% of maternal deaths due to PPH
Inadequate Health facilities
Inadequate skilled attendance
Inadequate medication or surgical facilities
Long delay in reaching facilities/ providing treatment
Solutions
Better communication and transport
Health facilities (affordable/ self respect & dignity
Health personal (no need for controlled traction)
Medications; PG/ Misprostol, Tranexamic acid, R Factor
VII a, 1;1 PCV to Plasma transfusion
Simpler techniques – Balloon Tamponade/
Compression sutures/ Anti-shock Garment
Strategies to Prevent Maternal Mortality
Basic Emergency Obstetric Functions (6)
THREE INJECTIONS
• Post partum Hemorrhage – Oxytocics (IV/ IM/ Oral) & active management
of the third stage of labor
• Hypertensive Disease > Eclampsia – Antihypertensive & Anticonvulsants
– Mg SO4 –IV/ IM
• Sepsis – post abortion or labor & delivery – Antibiotics IV/IM
THREE MANUAL FUNCTION
• Manual removal of placenta
• Evacuation of the uterus of retained placental tissue
• Vacuum Assisted Delivery in cases of second stage delay
Strategies to Prevent Maternal Mortality
Comprehensive Em Obstetric Functions (6 + 2)
• Basic Emergency Obstetric Functions
+
• Caesarean Section
• Blood Transfusion
• Four more to be added – Misoprostol, Anti Shock
Garment, Tamponade balloon & Compression
suture for post partum hemorrhage + latest – no
need for controlled cord traction with syntocinon;
need cord traction with misoprosotol??
Anti Shock Garment
•
Effective Easy to use, Re-usable
TAMPONADE TEST
Therapeutic & Prognostic
For severe PPH
Esophageal
balloon
Stomach balloon
Condous G, Arulkumaran S et.al.
Obstetrics & Gynecology. 2003
Glove catheter
No need for condom
Or suture material – S Africa
Condom Catheter –Bangaladesh,
Sri Lanka, India - 85% success rate
COMPRESSION SUTURES
Quick, safe and effective
B-Lynch
Horizontal full thickness
sutures
Vertical full thickness sutures
Square sutures
Combination of sutures
B- LYNCH COMPRESSION SUTURES
SIMPLE VERTICAL COMPRESSION SUTURES
Cornu
Fallopian tube
Ovary
Hayman R, Arulkumaran S, Steer P
Obstetrics & Gynecology. 2002
Conservative Surgical Treatment for
PPH
Method
B-Lynch + other
Compression
sutures
No of Cases
Success rates
94
90.4%
Arterial embolization
218
91%
Arterial ligation
264
83.7%
Uterine balloon
tamponade
135
83.7%
Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 20
UK – Direct deaths due to PPH
Years Pl Abr Pl Pr
‘85-’87
4
0
‘88-’90
6
5
‘91-’93
3
4
‘94-’96
4
3
‘97-’99
3
3
‘’00-’02 3 4
‘03-’05
2 3
‘06-’08
2
2
Karoshi et.al. 2012
PPH
6
11
8
5
1
10
9
5
GT tr
6
3
4
5
2
1
3
0
Total Rate/10 5
16
0.71
25
1.06
19
0.82
17
0.77
9
0.42
18
0.90
17
0.80
9
0.39
Karoshi et.al. 2012
TOP TEN
RECOMMENDATIONS
PPH in the UK (UKOSS)
• Major obstetric haemorrhage 3.7/1000 maternities
(370/ 100,000)
• Uterine atony was major cause of haemorrhage
• Feb 2005 - Feb 2006 – Postpartum Hysterectomy to
control haemorrhage -40.6 for 100,000 maternities
(CI – 36.3 – 45.4)
• Severe PPH – specific 24.4/100,000 – uterine
compression suture, pelvic vessel ligation,
embolisation. Factor VII a (CI - 21.7-27.3)
• The effect of balloon tamponade was not evaluated?
CONFIDENTIAL ENQUIRY
INTO MATERNAL DEATHS
TOO LITTLE – TOO LATE
Too Little (IV fluids, oxytocics,
BLOOD, Clotting factors)
Too Late (PG, resuscitation - blood
replacement, decision for surgery +
to get senior surgeon &
anaesthetist involved)
Placenta Accreta – special problem
Response of the Professional Bodies
RCOG/ NPSA/ RCA/ RCR
RCOG Green top guidelines
1. Postpartum haemorrhage; Prevention and Management
2. Blood transfusion in Obstetrics
3. Placenta Praevia, Placenta Praevia accreta, vasa praveia;
Diagnosis and management
RCOG Good Practise guidelines
1. The role of Interventional radiology in Obstetrics
2. Responsibility of consultant on call
3. The maternity dashboard
NPSA – Care bundle for the management of placenta Accreta
www.rc.og.org.uk
Google – Greentop guidelines
GREEN TOP GUIDELINES
‘THE PREVENTION &
MANAGEMENT OF PPH’
Algorithm for management of Atonic PPH
‘HAEMOSTASIS’
 H - Ask for Help
 A - Assess vital parameters & blood loss and
Resuscitate – (Rule of 30)
 E -Establish etiology + Ecbolics
(syntometrine, ergometrine, bolus syntocinon)
+ Ensure availability of blood.
 M -Massage Uterus – bimanual compression
 O -Oxytocin infusion / prostaglandins intravenous / per rectal / intramuscular / intramyometrial/ Tranexamic acid
Algorithm for management of Atonic PPH
‘HAEMOSTASIS’
 S - Shift to OT - Shock Garment (anti) - Aortic
compression/ Bimanual compression
 T - (4 T’s) Tissue/ Trauma/Tone/Thrombin >
Tamponade (before coagulopathy)– Balloon / packing
 A - Apply compression sutures – B- Lynch / modified/
+/- Balloon
 S - Systematic Pelvic devascularisation – Uterine /
Ovarian / Quadruple / internal iliac
 I - Interventional Radiology – If appropriate, Uterine
artery embolisation
S
- Subtotal / Total abdominal hysterectomy
Conservative Surgical Tr. 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
135
tamponadeS, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007
Doumouchtsis
83.7%
Massive PPH - Surgical Techniques
Near Miss Enquiries - Scotland
 Use of Balloon techniques – 6 in ’03 > 42 in ’06
 Haemostatic compression sutures – 10 in ’03
>24 in ’06.
 Over 4 years; 106 balloon techniques - 95%
success rate; 76 brace sutures – 83% success
rate
 Peripartum hysterectomy – 15% in 2003 > 8% in
2006
 Avoidable delay in diagnosis & management –8%
 Failure to follow protocol/plan – 6%
From April 2010 – CNST audit requirement - Pilot
CQC – building risk profile of Hospitals
Responsibility of Consultant on
Call (RCOG advice – 2009)
• Labour ward duties (safer childbirth)
• Must attend
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–
–
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Major Post Partum Haemorrhage
Eclamptic fit
Collapsed patient
Major placenta praevia
Return to theatre -Laparotomy
When trainee asks for it
• Be present (depending upon trainee’s experience)
– Trial of instrumental delivery
– Twins/preterm labour C/S / vaginal Breech delivery
– C/S at full dilatation/ for Transverse lie/ BMI >40
Maternity Dashboard
Royal College of Obstetricians and Gynaecologists
The Maternity Dashboard – Tool to
monitor implementation of principles
of clinical governance ‘on the ground’.
A powerful, visible way of continually
monitoring and assessing how a unit
is doing.
Enables teams to respond in a timely
and appropriate manner to ensure a
safe and responsive high-quality
service.
Helps to develop an ethos of total
quality improvement.
www.rcog.org.uk/womens-health/clinicalguidance/maternity-dashboard-clinicalperformance-and-governance-score-card
Performance & Governance Score
Card ‘Maternity Dashboard’
• Designed by Prof. Arulkumaran & Team –
Northwick Park
• Recommended by CMO’s Report
• Looks at Activity, Staffing, Clinical Risk
indicators, User feedback (e.g. complaints)
Maternity Dashboard - Ensures high quality safe care.Tool for Commissioners, Providers,
Consumers and Regulators
Massive PPH, blood transfusion, hysterectomies, admission to ICU
KNOWLEDGE TRANSFER
N
MEOWS CHART
More Medical and Simpler
Surgical Techniques should
help to reduce morbidity &
mortality
THANK YOU