Download - Pph drill
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Dr. Monika Madaan
Specialist
Dept. Of Obstetrics & Gynaecology
ESI HospitalManesar
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PPHSingle most important cause of maternal
mortality worldwide.Accounts for 34% of maternal deaths in
developing countries.
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DefinitionAny blood loss than has potential to
produce or produces hemodynamic instability
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DefinitionBlood loss > 500 ml after deliveryPrimary : Loss within 1st 24 hours after deliverySecondary : 24 hours till 12 weeks postnatally
Minor : 500-1000 mlModerate : 1000-2000 mlSevere : > 2000 ml
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PREDICTION AND PREVENTION
Identify pt. at risk
- Pl previa/accreta
- Anticoagulation Rx
- Coagulopathy
- Overdistended uterus
- Grand multiparity
- Abn labor pattern
- Chorioamnionitis
- Large myomas
- Previous history of PPH
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PREDICTION AND PREVENTIONActive Management Of Third Stage Of Labor
(AMTSL): Should be offered routinely and includes:
1.Administration of uterotonics soon after birth.
2.Delayed cord clamping.
3.Delivery of placenta by controlled cord traction followed by uterine massage.
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PPH DrillClear and logical sequence of steps
essential in the management of PPH.
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CALL FOR HELP
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Team Effort
•Skilled Obstetric Team•Trained Anaesthesiologist•Clinical hematologist •Supporting staff
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ResuscitationAssessA : AirwayB : Breathing C : Circulation Secure 2 wide bore i.v. lines:- 14-16 gauge Draw blood for grouping & cross matching,
CBC, LFT/KFT, SE & Coagulogram.
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Position flatKeep the patient warmAdminister oxygen by mask ( @ 10-15 litres/
min)Catheterize the patient for emptying bladder &
monitoring output
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Fluid Replacement
RAPID WARMED infusion of fluidsCrystalloids : Fluids of choice until
compatible blood is arranged1 ml of blood loss= 3 ml of crystalloidsTotal volume of 3.5 litres of clear fluids
(upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood.
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If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given
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FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal
(ie 12-15 ml/kg or total of 1 litres.)Platelet Concentrate: if Platelet count< 50,000/
microlitre.Cryoprecipitate: if fibrinogen < 1 g/ l.
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Continuous vital monitoring.Monitor adequacy of replacement with urine
output (0.5 ml/kg/hr) and CVP (4-8 cm water)Main therapeutic goals are to maintain:Haemoglobin > 8gm/dlPlatelet count > 75 × 109 / lProthrombin < 1.5 × mean controlAPTT < 1.5 × mean controlFibrinogen > 1 gm/ l
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Establish Etiology Simultaneously4 T’s
Tone (abnormalities of uterine contraction) :70 – 80%
Trauma (of the genital tract) : 20 %Tissue (retained products of conception) : 10
%Thrombin (abnormalities of coagulation) : 1 %
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Contd…
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Bimanual Compression
If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions
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Administer Uterotonic DrugsFIRST LINE
Oxytocin:
Start with 5 units slow iv or im.
Infusion of 20 units in 1 L@ 60 dr/min.
Continue same dose @ 40 dr/min until bleeding stops.
Maximum upto 3 L.SECOND LINE
Ergometrine/ methyl ergometrine:
Dose: 0.2 mg im or slow iv
Repeat 0.2 mg after 15 min.
Maximum 5 doses (1 mg)
Syntometrine im
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THIRD LINE PGF 2α: Dose: 0.25 mg im. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. Misoprostol: 200-800 µg sublingually. Do not exceed 800 µg
WHO GUIDELINES FOR MANAGEMENT OF PPH 2009
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Uterine Tamponade• Bakri balloon• Sengstaken Blakemore oesophageal catheter• Condom catheter• Urological Rusch balloon
Success depends upon Positive Tamponade test
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Procedure of condom Balloon insertion
Initial Assembly Condoms-2
Foley’s catheter-no.16 Saline with iv set Speculum Sponge holding
forceps
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ProcedureLithotomy positionIndwelling Foley’s
catheter.Explore uterus, cervix and
vagina.Inflate balloon with 100-
300 ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test).
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Compression sutures
B Lynch Suture•Fundal compression suture•Apposes anterior & posterior wall
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Contd…Parallel Vertical compression sutures for placenta praevia
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Stepwise Uterine Devascularization
•Uterine arteries
•Tubal branch of ovarian artery
•Internal iliac artery
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Uterine Artery EmbolizationPossible only if internal artery ligation has not been done and facility for interventional radiology available
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HysterectomyResort to hysterectomy “SOONER RATHER
THAN LATER”High maternal morbidityTiming and adequate replacement is of
utmost importance
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Documentation and DebriefingImportant to record:Sequence of eventsTime and sequence of admn of
pharmacological agents, fluids, blood productsThe time of surgical interventionThe condition of mother throughout .
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Newer DevelopmentsTranexamic acid : 1 gm i.v slow. Can be
repeated after 30 min if bleeding continues./Recombinant activated factor VII
(Novoseven): 90 µg/ kg . May be repeated within 15-30 minutes. No clear consensus on efficacy.
Carbetocin (oxytocin agonist) : 100 µg i.v or i.m. Produces tetanic uterine contractions.
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HAEMOSTASIS ALGORITHMH – Ask for helpA – Assess and resuscitateE – Establish etiologyM – Massage the uterusO – Oxytocic administrationS – Shift to OTT – Tissue n trauma to be excluded and
proceed to tamponadeA – Apply compression suturesS – Systematic pelvic devascularisationI – Interventional radiologyS – Subtotal or total hysterectomy
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To Conclude, Management of PPH Has Evolved From:PanicPanicHysterectomy
PitocinProstaglandinsHappiness
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ADDRESS 35 , Defence Enclave, Opp. Preet Vihar Petrol Pump, Metro pillar no. 88, Vikas
Marg , Delhi – 110092
CONTACT US 011-22414049, 42401339
WEBSITE : www.lifecarecentre.in
www.drshardajain.com www.lifecareivf.com
E-MAIL ID
[email protected]@gmail.com
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