Dr. Vivek D. PatkarM.D., D.G.O

Ex Honorary ProfessorLTMMC & LTMGH

Sion, Mumbai.

Definition of PPH

SHOCK: It is the failure of the circulatory system to maintain adequate cellular perfusion resulting in reduction of O2 and other nutrients to tissues

PPH: It is defined as a decrease in hematocrit by 10% points from the time of admission to post partum period or when there is need to give blood transfusion secondary to blood loss.

ACOG

Statistics ( L.T.M.G.H ) from 1999 to 2005 Average Confinements a year: 7500 to 9100

Maternal Mortality per year: 52 to 66

Maternal Mortality/ 1000 births 6.9 to 10.5

Maternal Mortality due to Obst. Haem 11 to 16

per year:

Statistics ( L.T.M.G.H ) from 1999 to 2005 Average Confinements a year: 7500 to 9100

APH per year: 89 to 142

PPH per year: 54 to 80

Intractable PPH per year: 17 to 21

Obstetric Hysterectomy’s per year: 11 to 16

Hypogastric Artery Ligation’s per year: 3 to 6

Uterine Artery Ligation’s per year: 12 to 16

CLASSES OF HAEMORRHAGE

Blood volume in pregnancy = 8.5 – 9 % of patients weight

Class III and Class IV = INTRACTABLE PPH William Roberts : Clinics of North America, 1995

Class I Class II Class III Class IV

% Blood Loss

15 20 - 25 30 - 35 40

Pulse Normal 100 120 > 140

Systolic BP Normal Normal 70 - 80 < 60

Mean arterial Pressure

80 - 90 80 - 90 50 – 70 < 50

Statistics Sample Years: 2001 & 2002PPH Causes No.

UTERINE :Atony

Retained placentaPlacenta praeviaAbruptio placenta Adherent placenta

Rupture Ut and Lacerations

Inversion of Uterus

56

28

14

1

NON UTERINE :Lower gen tr. Lacer

Br Lig Hematoma

Coagulopathy

10

2

5

Total 116

INTRACTABLE PPH Causes No.

UTERINE :Atony

Retained placentaPlacenta praeviaAbruptio placentaAdherent placenta

Rupture Ut and Lacerations

Inversion of Uterus

8

7

5

1

NON UTERINE :Lower gen tr. Lacer

Br Lig Hematoma

Coagulopathy

2

1

2

Total 26

PRELUDE TO SURGERY

It is assumed before going for surgical management that patient has been stabilized and basic resuscitation is carried out. An attempt at the medical management with oxytocin,

Methergin, PG, Ca+. Bimanual massage. Intrauterine douche with intrauterine and vaginal

packing for atony. DIC to be ruled out. Source and cause of bleeding identified with certainty.

In intractable PPH you have a limited time frame so may have to skip some of the above steps

Management of PPH is synonymous to

the working of a military operational head

quarters it requires:

* Quick reaction time (20 mins)

* Interactive team (Anesth, Intensivist, Bl bank)

* Well equipped OT (Controlled envioroment)

* Dedicated mission and objective depending on local scenario (suturing : vs ligation : hem evac : O.H.)

* Fall back options ( Uterine Art. & Hypogastric Art.)

* Collateral damage (bladder and bowel)

* Attrition rates (tissue trauma / septicaemia)

* Escape routes (packing / drain)

TACTICAL ANALOGUETACTICAL ANALOGUE

Uterine Artery LigationAs an alternative to obstetric hyterectomy in atonic PPH During pregnancy uterine artery forms about 90% of blood

supply to uterus It increases twice in size to help trumpeting of the spiral vessels

(luxuriant flow) The uterine artery turns upwards from the isthmus and enters

the uterus and gives out ascending and descending branch Occasionally the uterines may split up into

2 or 3 branches before entering the uterus

Hence for UAL to be successful

sometimes more ligatures may be required!!

71 UAL’s done Waters reported in 1952 bilateral uterine artery ligation as

anatomically sound, physiologically rational and surgically possible method to control non traumatic PPH

Classic Conservative Methods:

* Oxytocin

* Methargin

* Prostaglandins

* Bimanual Compression

* Intramyometral Prostaglandins

* Uterine Packing B-lynch suture

UAL

In case of vaginal Deliveries exploration of uterus and inspection of lower genital tract was done to exclude traumatic cause of PPH

Decision for uterine artery ligation was taken whenever it was prudent to conserve the uterus

Escape routes were charted and permission for obst hyst was taken

Procedure STEP I: Uterine artery was ligated at the level

of upper end of lower uterine segment, where it runs along uterine border.

Contd

Procedure Contd Incase of LSCS it was done just below or at the

angle of incision of CS. Bladder was dissected down in case of

vaginal delivery.

Contd

Procedure Contd For left uterine artery ligation. Uterus was

grasped and elevated anteriorly to the right by left hand.

Contd

• The palm was put over the left uterine border with thumb anteriorly over the lower uterine segment and four fingers posterior to broad ligament protecting the intestines.

Procedure Contd A large mayo needle with no 1 CCG: a suture was

passed through the myometrium from anterior to posterior and then brought forward through the broad ligament lateral to uterine vessels and the suture was tied.

The procedure was repeated on other side.

Contd

Procedure Contd After bilateral uterine artery ligation myometrium

assumed a pinkish hue secondary to ischaemia. The decrease in bleeding was directly assessed

from LSCS incision in case of CS and in case of vaginal delivery by observing per vaginal bleeding

Contd

Procedure Contd STEP II: If decrease in bleeding was

inadequate, additional lower stitches (cervico vaginal branch) and ascending branch on either side were taken.

STEP III: If bleeding still continues, bilateral ovarian arteries were ligated in infundibulopelvic ligament.

UAL success rate 85 to 95%

Simple, less blood loss

Surgical time less

Effective with less complications (hematoma and uretric damage)

No compromisation of future pregnancy and menstruation

Can be combined with OAL

ANATOMY of HAL God – Omnipotent ,

Omni – knowledgeable,

Omni – present BUT

OMNI PROTECTIONIST! Covered the great

Vessels with a shroud (POST.PERITONEUM) Beyond Visual Range (ANAT DISECTION HALL & OT) What you don’t see , you don’t perceive and hence ignore Anat not as nice and orderly ( GRAY, GRANT, CUN) but

occasionally mutilated and mayhem

ANATOMY of HA Aorta divides into common

iliacs at fourth lumbar The CIA divides into EIA and

IIA (HA) at sacrum

EIA goes along psoas to form femoral

HA drops medio inf into the pelvic fossa

Bony landmark for bifurcation of CIA is sacral prom

Left CIA division fractionally higher (sigmoid)

ANATOMY of HA HA is a retro peritoneal structure Anterio medially covered by

peritoneum and fibrous fascia

Ureters cross from lateral to medial at bifurcation

Anterio laterally lie EIA and obturator nerve

Posterio medially is the Internal iliac vein

To the right terminal end of ileum and ceacum overlap

To the left lower Inf border of sigmoid colon

Division of Hypogastric Artery (Gross CM)

Post Division Ant Division

Parietal Parietal Visceral

Ilio lumbar Obturator Obl. Umbelical

Lateral sacral Int pudendal Uterine

Superior Gluteal Inf Gluteal Vaginal

Sup. Vesical

Inf. Vesical

M. Haemorrhoidal

Collateral Circulation ( Gross)

Areas of Anastomosis

I. Lumbar Art (Aorta)

Circumflex Iliac (EIA) ↔ Ilio Lumbar

II. Middle Sacral (Aorta) ↔ Lateral Sacral

III. Superior Heamorrhoidal ↔ Middle Heamorrhoidal

(Br of Inf Mesentric)

Anastomosis is ipsilateral (vertical) and horizontal along midline. In bilateral HAL horizontal coll. Ceases

HaemodynamicsAortography (OLSON) Collaterals present but flow from HA

forwards gradient 50 to 70 After HA ligation reverse flow from Lumbar/ Middle

Sacral and Sup. Heamorrhoidal In HA Major Reduction in pulse pressure helps

stabilize the clot formation Collaterals have smaller diameter ( 40 to 50%) which

inhibits rapid gradient and blood flow, thus avoiding trip hammer effect ( BURCHELL)

Haemodynamics On cessation of TRIP HAMMER effect the pelvic

arterial system is converted to a Venus like system.

* The drop in pulse pressure

84% --- B/L HAL

75% --- U/L HAL

* The Mean arterial pressure ↓ 25% --- B/L HAL

↓ 22% --- U/L HAL

THIS HELPS STABLE CLOT FORMATION

CRISIS !!! 36 Cases The situation is grim and tense The scenario is unnerving The patients condition is precarious The relatives have a look of disbelief and

foreboding The OT scene is chaotic The residents/ para medical staff are running

helter skelter YOU are in a dilema

“Too Early to say YES to Late to say No”

Indications for HAL Atonic PPH Traumatic PPH Placenta previa and

adherant placenta Broad ligament hematoma Rupture Uterus Following a Obstetric

Hyterectomy, UAL Deep Vault or Vaginal

tears or Hematoma

Procedure Large adequate incision

preferably midline vertical

( Decreases op time and improves success rate) Vis peritoneum opened between RL and IPL Identify ureter, EIA, EIV and obturator nerve If hematoma, destruction, edema proceed carefully Generally dipping HA not seen Trace Common Iliac and follow medially into pelvis

fossa ( Ureteric crossing a GIVE AWAY) Contd.

Procedure (Contd) Dissect fascia anterior to HA

generally 1 to 2 layers Tease it vertically Visualize HA and lift gently with

babcock about 1 to 2 cms below bifurcation Areolar tissue that connects HA and HV posterio-medially blunt

dissected carefully. A right angled clamp (MIXTER,

ADSONS) passed posteriorly

preferable lateral to medial Care not to damage EIV and HV

.

Procedure (Contd) Feed a silk or linen (40)

(non- absorbable) long, single or

doubled into the tip of the Mixter

by holding the suture taut on an artery forceps Either retake the same suture around or take a second

suture below the first Lift the suture and check for pulsations in EIA Recheck ureter EIA, CI and bleeding from Venus plexus

and then tie Recheck pulsations in EIA ( Rule out Spasm) Do not transect vessel

Complications< 1 to 9 % depending on experience of

surgeon and condition of pt ( Lecoq,

Reich, Sagara, Siegel, Tajes) EIA Spasm, thrombosis Injury to HV, EIV Tying wrong structures– ureter, EIA, CI Necrosis of buttocks, perineum, bladder mucosa Bladder Atony Circulatory disturbances of lower extremities

In BREENS Series of 334 cases hypogastric vein laceration (16) current series (out of 36, 2)

Contd.

Int. Iliac/Success rate

Authors Year Method No of Women

Success Rates

Evans et al 1985 Internal iliac artery ligation

14 6/14 (42.8%)

Fernandez et al 1988 Internal iliac artery ligation

8 8/8 (100%)

Chattopadhyay et al

1990 Bilateral Hypogastric artery ligation

29 19/29 ( 65%)

Ledee et al 2001 Bilateral Hypogastric artery ligation

48 43/48 (89.5%)

Failures (2% -- 8%) Presence of large aberrant BL VS Dislodging of clots after BL Pressure rises Concomitant severe venous bleeding Necrosis of BL VS causing bleed Coagulopathy and DIC intervening Irreversible hypovolumic shock (Time Factor)

We had 3 failures ( not due to procedure)

* Couvelaries UT due to coagulopathy

* Vault, paracervical tears due to

abberant vsl

* Rupture Uterus due to hypovolumic

shock

Incase of Failures Ovarian Art Ligation (↓ collateral by 12-15%) Gravity suit if available Selective arterial transcatheter embolization (by

autologous blood clot/ gel foam/

oxidized cellulose, CO2

Wire coils / Baloon catheter / IBS

Monomer Look out for coagulopathy

Return of Mensis in 98% (Gregori, Kindziersk)

Return of fertility with normal pregnancy ( Given, Gates, Morgan, Mengert) (Noiugr)

Ovarian Artery Ligation Direct branch of Aorta. Take off after renals Bl.Supply about 2 to 8% in pregnancy Window under IPL Take selectively 2 to 3 cms from fimbria Right side beware of ureter Left side beware of sigmoid

Indications

* Atonic PPH stepwise devascularization

* After HAL fails

* After Obst. Hyst if bleed continues

Before HAL You can attempt COMPRESSION OF

AORTA by Harris’s compressor or Debakey clamp

Temporary tamponade decreases pressure by 60 to 70%

You can attempt COMPRESSING COMMON ILIACS or pinching uterine arteries for tamponade and helping clot formation

HAL HAL is an EMERGENCY, LIFE

SAVING, SALVAGE Surgery

“Go in Quick and come Out Fast”

Procrastinate and

* Lose the plot

* Conqueror to Vanquished

* Savior to Executioner

In Surgical Impasse and Intractable PPH the best defense is swift offense, viz. HAL - Michael Smith