Dr.Mohamed El SherbinyMD Obstetrics&Gynecology

drsherbiny@hotmail.com

توفيق محمد دكتورالشربينى

و النساء وإستشارى دكتوراةالتوليد

مستشفى - التخصصى دمياط مستشفىالعام دمياط

Postpartum

HemorrhageSecond part

Intractable Postpartum hemorrhage

About 10 % of women will not respond to the initial management steps and are considered as intractable PPH. They are caused mainly by

•Uterine atony

•Placenta accretes at CS scar

Intractable Postpartum Hemorrhage

(SOGC ) Clinical Practice Guidelines 2000 (III)

A multi-disciplinary team,

Hemodynamic Stablization

Local Control

Surgery

Intractable Postpartum hemorrhage

The approach to intractable PPH will be individualized depending on :

The clinical situation

The skill of the operator.

The technology available. (SOGC ) Clinical Practice Guidelines 2000 III

The B-Lynch, 1997 B J of Obstet and Gynaecol, 104: 372-375

The B-Lynch technique (brace suture) for intractable hemorrhage

It may be particularly useful because of its simplicity of application, life saving potential, relative safety, and its capacity for preserving the uterus and thus fertility.

B-Lynch technique

Hayman Compression Suture

Hayman et al Obst. Gynec. 2002,99;3;502-6

A number 2 Vicryl or Dexon suture on a straight, blunt needle is used to transfix the uterus from front to back, just above the reflection of the bladder and is then tied at the fundus of the uterus.

This can be done as one suture on each

side of the uterus, or more than one suture if

the uterus is particularly broad,

Hayman Compression Suture

Hayman et al Obst. Gynec. 2002,99;3;502-6

Vicryl® or Dexon® are strong and unlikely to cause external adhesions to the uterus.

It does not appear to be necessary to open the uterus or avoid crossing the uterine cavity.

This technique entails five successive steps (using chromic catgut 1 with Mayos

needle), if bleeding is not controlled by one step the next step is taken until bleeding stops.

The procedure was effective in all 103 (100%) cases.

Abdrabbo , 1994, Am J Obstet Gynecol.171:694-700

Stepwise uterine devascularization for

intractable atonic hemorrhage

Mov443

Mov471

Advantages over internal iliac ligation: Easier dissection.Lower complication rates.More distal occlusion of arterial supply with less potential for rebleeding because of collateralsHigh reported rates of success in controlling haemorrhaging.

(SOGC ) Clinical Practice Guidelines 2000

Stepwise Uterine Devascularization

Placenta accreta, increta and percreta

A placenta previa with previous CS should

be considered of having a morbidly

adherent placenta. Particular attention

should be focused to confirming or

excluding this diagnosis using U/S. When

present, senior anaesthetic and obstetric

input are vital in planning the delivery.

RCOG guidelines Grade B Evidence base.Level III

Placenta accreta

Women who have had 2 or more CS deliveries

with anterior or central placenta previa have

nearly a 40% risk of developing placenta accreta.

The patient should be counseled about the

likelihood of hysterectomy and blood

transfusion.

ACOG Guideline 2002

Placenta previa accreta (Increta or Percreta) with severe bleeding

1-Low &high bilateral uterine vessels

ligation (Stepwise) ,the Best.

2- Longitudinal lateral sutures

3-Bilateral Internal iliac ligation.

4- Hysterectomy : almost total

5-Tight uterine packing.

Bilateral Internal Iliac Artery Ligation

It was recommended for many decades to control PPH

It has fallen out of favor because of:

The prolonged operating time

Technical difficulties

Inconsistent clinical response.

High hazard if internal or external iliac veins are injured.

Bilateral Internal Iliac Artery Ligation

It is indicated mainly for:

Large broad ligament or lateral pelvic hematoma

Multiple cervical tears.

L. segment bleeding or atonic pp as a last resort.

It is less effective than Bilateral uterine artery ligation for atonic postpartum hemorrhage

50% failure rate in

placenta accreta

and uterine tears

Internal Iliac Artery Ligation

Peripartum hysterectomyEmergency hysterectomy is the most

common treatment modality when massive postpartum haemorrhage requires surgical intervention mainly for

• Placenta acretta or percreta ( 50%)

• Uterine atony

• Rupture uterus

• CS extension or broad ligament hematoma

Thomas Br J Obstet Gynaecol 1998;105:127-8.

Post Hysterectomy Bleeding

• Diffuse post hysterectomy bleeding may be

controlled by abdominal packing to allow

time for normalization of the woman’s

haemodynamic and coagulation status. (II-3)

• The pack composed of gauze in a sterile

plastic bag brought out through the vagina

and placed under tension. This pack is also

known as a parachute, mushroom, or

umbrella pack. S O G C C L I N I C A L P R AC T I C E G U I D E L I N E S 2000 II