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Postpartum haemorrhage
- the surgical aspectsSvensk förening för Obstetrik och Gynekologi, Tallberg14th April 2015P J Steer
Emeritus Professor of Obstetrics
Academic Department of Obstetrics and Gynaecology
Chelsea and Westminster Hospital
Imperial CollegeLondon
WITH
THANKS TO
PROFESSOR
MICHAEL
BELFORT
Baylor Medical College
Texas Children’s Hospital,
Houston,
USA
UTERINE ATONY -
SURGICAL APPROACH• Correction of uterine inversion
• Uterine compression and massage
• Packing / Balloon
• Uterine compression suture
• Uterine artery ligation
• Internal iliac ligation
• Hysterectomy
• Logethotopolous pack
• Arterial embolisation
CORRECTION OF UTERINE
INVERSION
• Vaginal approach
REPLACING AN INVERTED UTERUS
Acute uterine inversion: a new technique of hydrostatic replacement.
O. Ogueh and G. Ayida. Br J Obstet Gynaecol 104 (8):951-952, 1997.
VENTOUSE
CORRECTION OF UTERINE
INVERSION
• Abdominal approach
LAPAROTOMY - Another use for the
ventouse!
E. Antonelli, O. Irion, P. Tolck, and M. Morales. Subacute uterine inversion: description of a novel replacement technique using the obstetric ventouse.
BJOG. 113 (7):846-847, 2006.
LAPAROSCOPY - Use of counterpressure
R. Vijayaraghavan and Y. Sujatha. Acute postpartum uterine inversion with haemorrhagic shock: laparoscopic reduction
BJOG. 113 (9):1100-1102, 2006.
THE ATONIC UTERUS
• Anti-shock garment
• Bimanual compression
• Packing
• Balloons
• Compression sutures
Non-pneumatic anti-shock garment reduces average blood loss by 50%
S. Miller, S.et al. First aid for obstetric haemorrhage:
the pilot study of the non-pneumatic anti-shock garment in Egypt.
BJOG. 113 (4):424-429, 2006.
BIMANUAL COMPRESSION
PACKING
THE
UTERUS
S. Hsu, B. Rodgers, A. Lele, and J. Yeh.
Use of packing in obstetric hemorrhage of uterine origin.
J.Reprod.Med. 48 (2):69-71, 2003.
INTRAUTERINE BALLOON
Management of massive
postpartum haemorrhage:
use of a hydrostatic balloon
catheter to avoid laparotomy
R. Johanson, M. Kumar,
M. Obhrai, and P. Young.
BJOG 108 (4):420-422, 2001.
500 cc warm saline
in-situ for 24 hours
INTRAUTERINE BALLOON
Y. N. Bakri, A. Amri, and Jabbar F. Abdul.
Tamponade-balloon for obstetrical bleeding.
Int.J Gynaecol Obstet. 74 (2):139-142, 2001.
INTRAUTERINE BALLOON
Effectiveness of balloons
• 23 patients unresponsive to medical therapy
• 2 required hysterectomy
Dabelea V, Schultze PM, McDuffie RS Jr. Am J Perinatol. 2007 Jun;24(6):359-64.
Effectiveness of balloons
• Used in 27 cases at St George’s Hospital, London
• Sengstaken-Blakemore tube used
• Haemostasis achieved in 22 (81%)
• Four hysterectomies
• Removal at 24 hours – no further bleeding
S. K. Doumouchtsis, et al. Acta Obstet Gynecol Scand. 87 (8):849-855, 2008.
INTRAVAGINAL BALLOON
M. Tattersall and W. Braithwaite.
Balloon tamponade for vaginal lacerations causing
severe postpartum haemorrhage.
BJOG 2007; 114:647-8.
Belfort-Dildy device
Photograph courtesy of Gary Dildy, M.D.
Belfort MA, Dildy GA, Garrido J, White GL. Intraluminal pressure in a uterine tamponade balloon is curvilinearly related to the volume of fluid infused. Am J Perinatol 2011;28(8):659-66
Uterine Balloon Tamponade� Compression and decreased flow within the uterine
arteries can be demonstrated on ultrasound
� Flow rapidly returns to normal after removal
Flow within uterine artery during tamponade
Before Placement Balloon in place After Removal
Uterine Balloon Tamponade
• Post-marketing surveillance study
– 57 enrolled, 55 had PPH, 51 placed
• Study population:
– C/S 45% & Twins 24%
– EBL 2,000 (855 - 8,700) mL
• Delivery-to-Placement was 2.2 (0.3 – 210) hours
– Bleeding decreased or stopped 98% of cases
– Hysterectomy avoided in 92% of cases
• Uterine balloon volume >500 mL in 45% of cases
Dildy GA, Belfort MA, Adair CD et al. Initial experience with a dual-
balloon catheter for the management of postpartum hemorrhage.
Am J Obstet Gynecol 2013 Sep 18.
B-LYNCH SUTURE
C. B-Lynch, A. Coker, A. H. Lawal,
J. Abu, and M. J. Cowen.
The B-Lynch surgical technique
for the control of massive
postpartum haemorrhage:
an alternative to hysterectomy?
Five cases reported.
Br J Obstet Gynaecol 104 (3):372-375, 1997.
Square suturing
J. H. Cho, H. S. Jun, and C. N. Lee.
Hemostatic suturing technique for uterine bleeding during cesarean delivery.
Obstet Gynecol. 96 (1):129-131, 2000.
FURTHER MODIFICATIONSR. G. Hayman, S. Arulkumaran, and P. J. Steer.
Uterine compression sutures: surgical management of postpartum hemorrhage.
Obstet Gynecol 99 (3):502-506, 2002.
FRONT VIEW SIDE VIEW
ANTERIOR VIEW
POSTERIOR VIEW
HAYMAN SUTURE
11 cases, 1 hysterectomy –F. Ghezzi, A. Cromi, S. Uccella, L. Raio, P. Bolis, and D. Surbek.
The Hayman technique: a simple method to treat postpartum haemorrhage.
BJOG. 114 (3):362-365, (March) 2007.
Dealing with bleeding from the
lower segment
A
Broad Ligament
Round Ligament
Bladderreflectedcaudally
A. Positioning of closed artery forceps.This maintains a patent cervical canalon tightening lower sutures
Anterior view
Fallopian Tube
Anterior view of Completed sutures
ARULKUMARAN MODIFICATIONR. G. Hayman, S. Arulkumaran, and P. J. Steer.
Uterine compression sutures: surgical management of postpartum hemorrhage.
Obstet Gynecol 99 (3):502-506, 2002.
AA
PARALLEL VERTICAL
COMPRESSION SUTURES
Y. M. Hwu, C. P. Chen, H. S. Chen, and T. H. Su. Parallel vertical compression sutures:
a technique to control bleeding from placenta praevia or accreta during caesarean section.
BJOG. 112 (10):1420-1423, 2005.
PARALLEL VERTICAL
COMPRESSION SUTURES
Y. M. Hwu, C. P. Chen, H. S. Chen, and T. H. Su. Parallel vertical compression sutures:
a technique to control bleeding from placenta praevia or accreta during caesarean section.
BJOG. 112 (10):1420-1423, 2005.
B Dawlatly, I Wong, K Khan,
& S Agnihotria Department of Obstetrics and
Gynaecology,
Whipps Cross University Hospital,
London.
BJOG: 114; 502 (April 2007)
Using the cervix to stop bleeding in a woman
with placenta accreta: a case report
Multiple U suture
Hackethal A et al (2008)
Hum Reprod. 2008
23:74-79
Compression suture and balloon
Combined B-lynch suture with
intrauterine balloon catheter
triumphs over massive postpartum haemorrhage.
D. Danso and P. Reginald.
BJOG. 109 (8):963, 2002.
Compression suture and balloon
• 5 patients with compression suture and balloon
• 11 hours median use (range 10-24)
• Effective in all cases
• No complications seen
Nelson WL, O'Brien JM.
Am J Obstet Gynecol. 2007 May;196(5):e9-10.
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
Uterine compression suture
without hysterotomy -
why a non-absorbable suture
should be avoided.
– C. Cotzias and J. Girling. J Obstet Gynaecol 25 (2):150-152,
2005.
Removable sutures
Matsubara S, Acta Obstet Gynecol Scand 2014; 93:1069-70
Removable sutures
Zhang ZW et al, BJOG 2014; 122:429-433
Removable sutures
Aboulfalah A et al, Frontiers in Surgery, 2014; 1: article 43
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
• Pyometria after hemostatic square suture
technique
– M. Ochoa, A. D. Allaire, and M. L. Stitely.
– Obstet Gynecol. 99 (3):506-509, 2002.
• Uterine cavity synechiae after hemostatic
square suturing technique.
– H. H. Wu and G. P. Yeh.
– Obstet Gynecol. 105 (5 Pt 2):1176-1178, 2005.
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
• Partial ischemic
necrosis of the
uterus following a
uterine brace
compression
suture.
– V. M. Joshi and M. Shrivastava. BJOG.111 (3):279-280, 2004.
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
E. J. Treloar, R. S. Anderson, H. S. Andrews, and J. L. Bailey. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage.
BJOG. 113 (4):486-488, 2006.
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
• Partial necrosis following Cho sutures– Reyftmann L et al (2009) Gynecol Obstet Fertil 37:579-582
• Partial necrosis following local compression suture– Gottlieb AG et al (2008) Obstet Gynecol 112:429-431
• Partial necrosis following B-Lynch plus Cho suture– Akoury H, Sherman C. (2008) J Obstet Gynaecol Can.
30:421-4
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
• 8 cases of uterine necrosis
• 3 cases of uterine rupture in subsequent pregnancy
• Two cases of pyometra
• One case of haematometra
• Two cases of Asherman’s syndrome
• Synechiae
Amorim-Costa et al, Acta Obstet Gynecol Scand. 2011 Jul;90(7):701-6
Synechiae
• Study 1 (Hackethal technique):
– Uterine compression sutures successful in
26/33
– 15 later had hysteroscopy and/ or HSG
– 4 had synechiae (27%)
• Study 2 (B-Lynch’s or Cho’s technique):
– 13/37 subsequent hysteroscopy
– 3 had Asherman’s, 7 had synechiae
Poujade O, BJOG 2011;118:433-439
Rathat G, Fertil Steril 2011; 95:405-9
49 pregnancies after uterine
compression suturing• Outcome similar to controls:
– 34 (81%) term delivery
– 2 (4.7%) preterm
– 4 (9.5%) miscarriage
• One perinatal loss
– Twins , placenta praevia, ruptured uterus
(previous classical)
• 34% had pelvic adhesions compared with 17.5%
controls
Hyeong G, et al Obstet Gynecol 2013; 122: 565-570
Matsubara S, et al
Acta Obstet Gynecol Scand. 2013 Apr;92(4):378-85.
UTERINE ARTERY LIGATION
O'Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage.
J Reprod Med 1995;40:189-93.
INTERNAL ILIAC LIGATION
Main danger is damage to the internal iliac vein: Success rates 43-90%
SHOULD ONLY BE DONE BY EXPERIENCED SURGEON
Das BN,.Biswas AK. Ligation of internal iliac arteries in pelvic haemorrhage.
J Obstet Gynaecol Res. 1998;24:251-4.
V. Joshi, S. Otiv, R. Majumder,
Y. Nikam, and M. Shrivastava.
Internal iliac artery ligation for
arresting postpartum haemorrhage.
BJOG. 114 (3):356-361, 2007.
Correct Way
IF THE BLEEDING IS
HEAVY, CONSIDER
AORTIC
COMPRESSION
Caesarean hysterectomy
Caesarean Hysterectomy
• Don’t leave it too late
• Do subtotal first
• Leave the vault open initially as it helps to find the cervix
• Stop once the bleeding is controlled
• Involve vascular surgeons prn
• Consider Logethotopolous pack
Logethotopolous pack
Preparation
of
Logethoto-
polous
pack
USE A SCRIBE
ARTERIAL EMBOLISATION
• First described in 1979
• up to 95% success
• Requires angiography facilities
C. Boulleret, et al.
Hypogastric arterial selective and superselective embolization for
severe postpartum hemorrhage: a retrospective review of 36 cases.
Cardiovasc.Intervent.Radiol. 27 (4):344-348, 2004.
C. Boulleret, et al.
Hypogastric arterial selective and superselective embolization for
severe postpartum hemorrhage: a retrospective review of 36 cases.
Cardiovasc.Intervent.Radiol. 27 (4):344-348, 2004.
ARTERIAL EMBOLISATION
• Gelfoam is material of choice (Vedantham 1997)
• Preoperative placement of catheters - calculate radiation dosage and inform patient of risks to fetus if > 5 Rads
• Potential complications of embolisation:
– Angiography (haematoma, contrast nephrotoxicity)
– Pelvic infection (low-grade fever, pelvic abscess)
– Ischaemic phenomena (necrosis, buttock claudication)
Complications of Embolisation
Al-Thanyan et al. Obstet Gynecol 2012;120:468–70
DON’T PANIC
• If you rush,
you will make
silly mistakes
SPECIAL POINT
https://drive.google.com/file/d/0B2zXNlGDKFDEV0QxSHBnYWF5Mmc/view
Summary
• Balloon tamponade is effective first-line management
• Uterine compression sutures should usually be tried
next
• Compression sutures have significant complications,
associated mainly with uterine ischaemia
• Hysterectomy may still be necessary
• The Logethotopolous pack can be life-saving as a
last resort
• Embolisation can be useful
• Real-time guidance by computer may be valuable