DR. MURWAN IBRAHIM OMERDGO, MOG, ABOG, FRCOG, FICS

Consultant Obstetrician and Gynaecologist

ALTERNATIVE METHODS FOR

MANAGEMENT OF ATONIC POSTPARTUM

HAEMORRHAGE

Can we change our practice Can we change our practice to improve outcome of to improve outcome of

PPH?PPH?

When conventional methods fail When conventional methods fail to control atonic PPH, there are to control atonic PPH, there are interventions which are being interventions which are being ignored that should be ignored that should be considered before opting for considered before opting for major surgical procedures.major surgical procedures.

Postpartum Postpartum HaemorrhageHaemorrhage

Is a leading cause of maternal Is a leading cause of maternal mortality and morbidity. mortality and morbidity.

Too LittleToo Little (IV fluids, oxytocics, BLOOD, (IV fluids, oxytocics, BLOOD, Clotting factors)Clotting factors)

Too LateToo Late (resuscitation - blood (resuscitation - blood replacement, misopristol decision for replacement, misopristol decision for surgery + to get senior surgeon & surgery + to get senior surgeon & anaesthetist involved)anaesthetist involved)

PPHPPH

AnticipateAnticipate - high risk cases - high risk cases (e.g. twins, (e.g. twins, polyhydramnios, prolonged labour, fibroids, APH, polyhydramnios, prolonged labour, fibroids, APH, infection, past H/O PPH, retained tissue etc.)infection, past H/O PPH, retained tissue etc.)

PreventPrevent - Prophylactic Oxytocics - Prophylactic Oxytocics (e.g. (e.g. Syntometrine, syntocinon, ergometrine, misoprostol)Syntometrine, syntocinon, ergometrine, misoprostol)

ManageManage - Promptly - 90% uterine - Promptly - 90% uterine atony - 8% trauma and 2% coagulation atony - 8% trauma and 2% coagulation disordersdisorders

FIGO/ ICM STATEMENT ON AMTSL + WHO+ COCHRANE

Guidelines Guidelines by the Scottish Executive by the Scottish Executive Committee of the RCOGCommittee of the RCOG

COMMUNICATE. COMMUNICATE. RESUSCITATE.RESUSCITATE. MONITOR / INVESTIGATE MONITOR / INVESTIGATE STOP THE BLEEDINGSTOP THE BLEEDING

STOPSTOP THETHE BLEEDINGBLEEDING

Uterine compression Uterine compression IV syntocinon 10 units IV syntocinon 10 units IV ergometrine 500 IV ergometrine 500 g g Syntocinon infusion (30 units in 500 Syntocinon infusion (30 units in 500

ml)ml) Surgery / HysterectomySurgery / Hysterectomy

Misoprostol/ Intrauterine pack / Misoprostol/ Intrauterine pack / Intrauterine balloon / Compression Intrauterine balloon / Compression SuturesSutures

MisoprostolMisoprostol

Synthetic analog of prostaglandin E1Synthetic analog of prostaglandin E1

• Shelf life of several years if kept in their packets• Low cost• Can be administered orally, rectally, vaginally and by sublingual route• Being selective for the PGE1 receptors: Hence fewer systemic side-effects

Misoprostol could play an important role in saving lives of thousands of women, particularly in low-resource

settings

A study in Pakistan on the outcome of Utero-vaginal A study in Pakistan on the outcome of Utero-vaginal Packaging in Primary Postpartum Hemorrhage Packaging in Primary Postpartum Hemorrhage

on 34 patientson 34 patients

Pelvic infection was seen in 5 cases i.e., 14.7% (but pre- existing risk factors for infection such as prolonged rupture of membranes, obstructed labour and home delivery were present in all these cases)

TAMPONADE TESTTherapeutic & PrognosticFor severe PPH

Stomach balloon

Oesophagealballoon

The “Tamponade Test”The “Tamponade Test”

Condous G, Arulkumaran S et.al. Obstetrics & Gynecology. 2003

St George’s SeriesSt George’s Series

27 consecutive cases of Sengstaken – Blakemore 27 consecutive cases of Sengstaken – Blakemore Esophageal catheter tamponadeEsophageal catheter tamponade

Bleeding arrested in 22 cases Bleeding arrested in 22 cases Tamponade failed in 5 cases. Of them:Tamponade failed in 5 cases. Of them:

4 underwent a subtotal hysterectomy4 underwent a subtotal hysterectomy1 was managed with Haemabate and Misoprostol 1 was managed with Haemabate and Misoprostol

(concomitant use)(concomitant use) Doumouchtsis S, Papageorghiou A, Arulkumaran S. Acta Scand 2008

The Sengstaken-Blakemore The Sengstaken-Blakemore oesophageal catheteroesophageal catheter

The The mainmain disadvantage is that it disadvantage is that it is not purpose-designed for PPH.is not purpose-designed for PPH.

Therefore, it may not easily adapt Therefore, it may not easily adapt to the shape of the uterine cavity.to the shape of the uterine cavity.

“Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.”

Mahmoud Fathalla,MD, PhD, 1997

Uterine balloon tamponadeUterine balloon tamponadeAuthorsAuthors YearYear Type of Type of

studystudyMethodMethod No of No of

womenwomenSuccess Success RatesRates

GoldrathGoldrath 19831983 Case seriesCase series Foley catheterFoley catheter 2020 19/20 19/20 (95%)(95%)

Bakri et alBakri et al 20012001 Case seriesCase series Silicone BalloonSilicone Balloon 55 3*/5 (60%)3*/5 (60%)

Condous et Condous et alal

20032003 Case seriesCase series Sengstaken -Sengstaken -BlakemoreBlakemore

1616 14/16 14/16 87.50%87.50%

Akhter et Akhter et alal

20032003 Case seriesCase series CondomCondom 2323 23/23 23/23 (100%)(100%)

Penney et Penney et al (Scottish al (Scottish Audit)Audit)********

20032003 AuditAudit BalloonBalloon 66 5/6 (83.3%)5/6 (83.3%)

Penney Penney et et al al (Scottish (Scottish Audit)Audit)********

20042004 AuditAudit BalloonBalloon 2121 15/21 15/21 (71.4%)(71.4%)

Seror et alSeror et al 20052005 Case seriesCase series Sengstaken -Sengstaken -BlakemoreBlakemore

1717 12/17 12/17 (70.6%)(70.6%)

St George’s St George’s current current seriesseries

20062006 Case seriesCase series Sengstaken -Sengstaken -BlakemoreBlakemore

2727 22/27 22/27 (81.5%)(81.5%)

TotalTotal 135135 83.7%83.7%

COMPRESSION SUTURESCOMPRESSION SUTURESQuick, safe and effectiveQuick, safe and effective

B-LynchB-LynchModified B-Lynch suturesModified B-Lynch suturesCombination of suturesCombination of sutures

Comparison between Original method & its modification

B- Lynch brace B- Lynch brace suture.suture.

Modified B-Lynch brace Modified B-Lynch brace suture.suture.

1. Requires 1. Requires expertise.expertise.

1. Easy to perform.1. Easy to perform.

2. Transverse LUS 2. Transverse LUS incision required.incision required.

2. LUS incision not 2. LUS incision not required.required.

3. Time consuming.3. Time consuming. 3. Less time consuming 3. Less time consuming (can be completed in 2-3 (can be completed in 2-3 min).min).

4. Cervical stenosis. 4. Cervical stenosis. 4. No cervical stenosis4. No cervical stenosis

5. Haematometra 5. Haematometra formation.formation.

5. No Haematometra 5. No Haematometra formation.formation.

6. Bleeding from LUS 6. Bleeding from LUS due to multiple bites. due to multiple bites.

6. No bleeding from 6. No bleeding from LUS.LUS.

B-Lynch or Compression suturesB-Lynch or Compression suturesAuthorsAuthors YearYear TyTyppe of e of

studystudyMethodMethod No of No of

womenwomenSuccess RatesSuccess Rates

B-Lynch et al B-Lynch et al 19971997 Case seriesCase series B-LynchB-Lynch 55 5/5 (100%)5/5 (100%)

Cho et alCho et al 20002000 Case series Case series Square suturesSquare sutures 2323 23/23 (100%)23/23 (100%)

Pal et alPal et al 20032003 Case seriesCase series B-LynchB-Lynch 66 6/6 (100%)6/6 (100%)

Smith et alSmith et al 20032003 Case seriesCase series B-LynchB-Lynch 77 6/7 (85.7%)6/7 (85.7%)

Penney et aPenney et al (Scottish l (Scottish Audit)Audit)

20032003 AuditAudit****** B-LynchB-Lynch 1010 9/10 (90%)9/10 (90%)

Penney at alPenney at al (Scottish (Scottish Audit)Audit)

20042004 AuditAudit****** B-LynchB-Lynch 1919 13/19 (68.4%)13/19 (68.4%)

Wohlmuth et alWohlmuth et al 20052005 Case seriesCase series B-LynchB-Lynch 1212 11/12 (91.6%)11/12 (91.6%)

Pereira et al Pereira et al 20052005 Case seriesCase series Compressive Compressive suturessutures

77 7/7 (100%)7/7 (100%)

Nelson Nelson et alet al 20020066 Case seriesCase series Modified B-Modified B-Lynch Lynch suturessutures

55 5/5 (100%)5/5 (100%)

TotalTotal 9494 85/94 85/94 ((90.490.4 %) %)

Conservative Treatment for PPHConservative Treatment for PPHMethodMethod No of CasesNo of Cases Success ratesSuccess rates

B-Lynch + other B-Lynch + other Compression Compression suturessutures

9494 90.4%90.4%

Arterial Arterial embolizationembolization

218218 91%91%

Arterial ligationArterial ligation 264264 83.7%83.7%

Uterine balloon Uterine balloon tamponadetamponade

135135 83.7%83.7%

Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007

““It is not the strongest of It is not the strongest of the species that survives, the species that survives, nor the most intelligent, nor the most intelligent, but the one most but the one most responding to change.”responding to change.”

Charles DarwinCharles Darwin

No of Deliveries

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ConclusionConclusion When conservative measures fail to When conservative measures fail to

control bleeding in post partum control bleeding in post partum haemorrhage, uterovaginal packing, haemorrhage, uterovaginal packing, internal uterine tamponade and B-lynch internal uterine tamponade and B-lynch sutures can be used before resorting to sutures can be used before resorting to hysterectomy. These uterine preserving hysterectomy. These uterine preserving methods have been used in various methods have been used in various countries and have proven to be countries and have proven to be effective, with minimal maternal effective, with minimal maternal morbidity.morbidity.

They are feasible in this country and They are feasible in this country and should be considered by Obstetricians should be considered by Obstetricians when managing PPH. However, they when managing PPH. However, they require training and experience.require training and experience.

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids, giving sets, haemacel

Emergency protocols

GENERAL MANAGEMENT