dr.mohamed el sherbiny md obstetrics&gynecology [email protected] دكتور محمد...
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Dr.Mohamed El SherbinyMD Obstetrics&Gynecology
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