s. monokoane department of obstetrics & gynaecology university … · 2019-04-18 ·...
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S. Monokoane Department of Obstetrics & Gynaecology
University of Limpopo Medunsa campus
SASOG CONGRESS 19 MAY 2014
Obstetric Haemorrhage- a killer!
Introduction Obstetric haemorrhage is a major cause of maternal
morbidity and mortality worldwide.
The Saving Mothers Report 2008-2010 showed Obstetric haemorrhage to be the 2nd most common cause of maternal death in South Africa at 14.1%.
The major causes of death from haemorrhage were similar to the 2005-2008 report
but worrying is the rising trend in the number of deaths associated with bleeding at or following caesarean section
The proportion of deaths is alarmingly high accounting for 26% of all haemorrhage deaths
An Editorial in SAMJ May 2011 ISSUES IN MEDICINE
Haemorrhage associated with caesarean section in South Africa – be aware
S Fawcus, J Moodley, for the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD
BJOG March 2014
It is often taken for granted that c/s is a safe procedure, however audits show otherwise!
Challenges :most hospitals are overwhelmed by the number of c/s, often done as emergencies by junior doctors with limited skills and no supervision
Type of cases with predisposing factors e.g previous c/s, prolonged labours, APH- praevia and abruptio placenta with DIC
Obesity and co-morbidities PET, DM, cardiac, HIV
Objective To assess rates and contributory factors to reasons for
bleeding at or after caesarean section and the outcomes, both morbidity and mortality in a teaching hospital.
Method: A retrospective 4 year study at Dr George Mukhari
Hospital Pretoria, tertiary hospital referral for Gauteng northern, NW , Limpopo
Review of patients & theatre records from January 2010- December 2013
Inclusive criteria: all patients that bled at or post caesarean section recorded in theatre as serious event that warranted intervention.
Exclusion criteria: patients with incomplete records
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RESULTS
Patients Number Percentage
Total deliveries 39 151
Total VD 20949 65%
Total C/S done 13208 33%
significant bleeding @ c/s >1000ml
187
1.4% (PPH4.3% in 2010)
ICU with serious morbidity/nearmiss
60
0.45%
who died 0 9
Interventions : Indications
Relap: repair TAH, Bakri, ICU, B-Lynch devascularisation Fetal distress, poor progress, HPT, prev cs, malpresentation twins
Blood/products transfusion.
2010 2011 2012 2013
Total Deliveries 9 226 9 745 10 120 10 060
NVD 5 916 63.10% 6 647 68.20% 7 017 67.33% 6 363 62.20%
C/S 3 310 35.80% 3 098 31.79% 3 103 30.26% 3 697 36.73%
Assisted Vaginal
Delivery 36 0.80% 62 1.01% 73 1.51% 88 1,17%
Vaginal Breech
Delivery 116 1.30% 308 3.16% 294 2.90% 204 2.02%
Bookings Status
Booked 8 893 96.40% 7 975 97.03% 9 786 96.69% 9 957 98.90%
Unbooked 333 3.60% 1 676 2.97% 1 987 3.30% 103 1.02%
Maternal Age
< 18 years 458 5,00% 702 7.20% 745 7.36% 745 7.40%
18 - 34 years 7 841 85.00% 2 543 26.09% 8 453 83.52% 8 154 81.05%
≥35 years 927 10.00% 1 841 18.89% 2 316 22.88% 1 988 0.19%
Preterm Deliveries 1 989 21,60% 2 514 25.79% 2 641 26.09% 1 719 17.08%
Deliveries at Term 7 237 78.40% 7 231 74.20% 9 654 95.39% 8 341 82.91%
Abortions 130 1,40% 213 2.18% 201 1.98% 214 2.12%
Fetal Weights (gm)
500 - 999 257 2,80% 156 1.60% 316 3.12% 312 3.10%
1000 - 1499 368 4,00% 201 2.06% 198 1.95% 362 3.59%
1500 - 1999 503 5,50% 361 3.70% 533 5.26% 547 5.43%
2000 - 2499 861 9,30% 1 001 10.27% 867 8.56% 1.163 11.56%
≥2500 7 237 78,40% 8 026 82.36% 7 223 71.37% 7 453 74.08%
Macrosomic Babies
4000 - 4999 149 1,60% 205 2.10% 254 2.50% 203 2.00%
≥4500 36 0,40% 74 0.75% 56 0.55% 34 0.33%
Multiple Pregnancy
Twins 212 22/1000 156 16/1000 212 21/1000 165 16/1000
Multiple Pregnancy
Twins 212 22/1000 156 16/1000 212 21/1000 165 16/1000
Triplets 1 1 3 2
Syphilis Serology
Tested 8 390 90,90% 7 054 72.38% 9 453 93.40% 9 639 95.81%
Positive 93,1% 346 3.55% 361 3.81% 292 2.93%
Negative 8 297 98,90% 4 867 49.94% 8 096 85.64% 8 843 87.90%
Unknown 836 9,10% 1 841 18.89% 996 10.53% 742 7.37%
HIV Status
Tested 7 995 86,70% 8 845 90.76% 9 919 98.01% 9 608 95.50%
Positive 2 547 31,90% 3 023 31.02% 3548 35.76% 2 709 26.92%
Negative 5 448 68,10% 3 990 40.94% 5 821 58.68% 6 899 68.57%
Unknown 1 231 13,30% 1 832 18.79% 550 5.54% 325 3.23%
Foetal Outcomes
Live Babies 8 947 97,00% 9 296 95.39% 10 002 98.83% 9 987 99.27%
Fresh Still-
births 135 1,50% 185 1.89% 158 1.57% 203 2.01%
Macerated Still-
births 144 1,60% 264 2.70% 264 2.63% 211 2.09%
Perinatal
Deaths 435 449 572 521
Perinatal
Mortality Rate 45/1000 BIRTHS 45/1000 BIRTHS 57/1000 BIRTHS 52/1000 BIRTHS
Maternal
Deaths 19 38 42 21
Maternal
Mortality Rate 206/100,000 408/100,000 419/100,000 210/100,000
Results YEAR C/S done Bled@C/S Near miss Died
2010 3310 20 12 03
2011 3098 21 15 03
2012 3103 25 18 01
2013 3697 21 15 02
TOTAL 13208 87 60 09
What were the causes of bleeding encountered @C/S in this study
Previous c/s with adhesions: 56 Uterine atony: 70 Bleeding corners & margins: 28
retroperitoneal haematoma: 5 Uterine tears/ extension in prolonged 2nd stage: 23 Uterine rupture at CS: 8 Morbidly adherent placenta: 21 Bleeding placental bed: 30 Extra-uterine pregnancy: 3 Abruptio placentae with DIC (Grade IIIb): 4 Obesity: 15 (BMI >30) Over-anticoagulated Clexane :5
Method No of Cases Success rates
B-Lynch + other
Compression
sutures
14
Uterine Artery
ligation
28
Internal Iliac artery
ligation
4
Uterine balloon
tampona
5
Surgical Treatment for PPH Method applied No of patients (187)
Relap to arrest bleeders at corner or tears
52(27%)
Uterine artery ligation Internal Iliac artery ligation
33(25%) 03(1.6%)
Compression suture B-Lynch 18(9.6%)
Insert Bakri balloon +/- Blynch for placental bed if figure of 8 sutures failed
15(8%)
Peripartum TAH/ subtotal 40(21%)
Removal of morbidly adherent placenta+/- curretage
07(3.7%)
Outcome Maternal
Successfully managed on the table: 118
Admitted in ICU: 60
Had acute renal failure: 21
Had massive blood transfusion >10 units/24hrs: 60
Died of hypovoloemic shock due to uncontrolled bleeding: 7
Died of bleeding due to anticoagulation:2
Complications and outcomes Number (%)
Complications ICU admissions 60(32,08%)
Acute renal 23 (12,8%)
DIC 26 (13,09)
ARDS 05 (2.6%)
Hysterectomy 44 (23%)
Maternal outcomes: Discharged 178
Demised 9
Fetal outcomes [n = 112]: Born alive 1 71(81,2%)
FSB 15 (13,4%)
MSB 6 (5,%)
Discussion: Risk factors for bleeding at C/S Prolonged labour +/-CPD
Previous caesarean section
- Adhesions
- Morbidly adherent placentae and Preavia
Obesity and co-morbidity PET cardiac
Distended uterus: macrosomia, twins
Induction of labour
Technique and skill of the surgeon at c/s
Who should do these C/S??
Saving Mothers Report 2008-10 Bleeding associated with caesarean section was 26.2%
Uterine rupture 17.9%
Abruptio placentae 16%
Retained placenta 9.0%
Uterine atony 6.4%
In this audit there was a combination of above
Scope of the problem 2002-4 report • In South Africa the causes of PPH are:
– Ruptured Uterus (commonly associated with VBAC) 27%
– Uterine Atony 24%
– Retained Placenta 21%
– Other Uterine Trauma 25%
• In Gauteng PPH is responsible for 13% of the maternal deaths.
Findings in this study Inadequate surgical haemostasis esp. at the corners (?not using
Green Armitage) -should use blunt technique for cs!
Missed lateral lower tears/extensions-exposure
Undiagnosed Morbidly adherent placentae in previous CS and extrauterine pregnancies as ELCS- do scan
Adhesiolysis on entry into abdomen overlying lower segment in previous CS- call senior
Difficulty in delivery of the head /impacted in CPD resulting in lateral tears esp in Prolonged 2nd stage
Undermined/under-estimated blood loss delay resuscitation
Refused advised from experienced scrub sister!
Delay in instituting definitive measures as TAH
Uterine Vascular Bundle Ligation
Safe method of passing right-angled clamp from lateral to medial side below the internal iliac artery
Uterine Bracing B-Lynch Suture
A
Broad Ligament
Round Ligament
Bladder reflected caudally
A. Positioning of closed artery forceps. This maintains a patent cervical canal on tightening lower sutures
Anterior view
Fallopian Tube
Anterior view of Completed sutures
ARULKUMARAN MODIFICATION R. G. Hayman, S. Arulkumaran, and P. J. Steer.
Uterine compression sutures: surgical management of postpartum hemorrhage.
Obstet Gynecol 99 (3):502-506, 2002.
A A
Balloon catheters available
PARALLEL VERTICAL COMPRESSION SUTURES
Y. M. Hwu, C. P. Chen, H. S. Chen, and T. H. Su. Parallel vertical compression sutures:
a technique to control bleeding from placenta praevia or accreta during caesarean section.
BJOG. 112 (10):1420-1423, 2005.
Case 1 delay! • 24 yr POG1 with poor progress due to CPD
• C/S commenced at 18h00
• Head impacted/jammed in the pelvis
• Lower segment ballooned thinned out
• After delivery of the head noted welling up/ bleeding from an extension in the cervix
• Tried for 2hours to repair
• Called for help of consultant at 20h00
• Consultant wasted time trying repair, did TAH at 22h00
• Abdomen was closed with BP 60/30 -50/20
died on arrival in ICU
CASE 2 • 28yrs P2G3 at 38weeks previous C/S X2
• ELCS done by registrar noted bluish tumour, cut above it delivered a live baby 3.4kg Percreta!
• Tried to remove the placenta, it was encroaching into the bladder
• Experienced torrential bleeding
• Called consultant out urgently, then called senior consultant
• Proceeded to do TAH, continued bleeding
• Opened the bladder cystostomy & oversew the bleeding varicosities area with figures of 8
• Packed the pelvis, made uneventful recovery
Case 3 26yr P1G2 C/S 1 with prolonged latent phase On 09/09/12 at 05H30, still in labour since last night (1cm dilated)
Plan: book for c/s ,done at 14H11,
BP 169/94 P= 128
Intraoperatively: adhesions+++ lysis done then a lower segment transverse incision on the uterus
3550g neonate delivered MSL II observed ,placenta manually delivered
Uterus repaired in layers, no reported tears nor vascular injuries .
However uterus was bleeding from placental bed, EBL=2300ml
Pt received 5000ml R/L, 2x voluven , urinary output 100ml,
Pitocin 20u in R/L infusion, 800mg cytotec PR clots expelled & pt transferred to high care labour ward
HIGH CARE
BP range: 80/60- 110/70, pulse : 105-130
At 18H00, active bleeding was observed on the pt’s operation & per vagina
She was wheeled back to theatre for exploratory laparotomy, emergency blood products ordered
Before laparotomy BP =67/38,P =171, blood transfusion & surgery were commenced
Findings: 2000ml haemoperitoneum
- bleeding from right uterine artery
- bleeding from raw areas over the uterine wound
Proceeded to do: subtotal hysterectomy, 4 large abdominal swabs used to pack the pelvic cavity, abdomen closed and patient transferred to ICU
Pt received 3FFP, 4u packed cells & 2 mega units platelets
3rd case continued
Taken back to theatre (re-laparatomy) for removal of swabs commenced
Under general anaesthesia and aseptic conditions the abdomen was opened
Findings: 2000ml haemoperitoneum, swabs removed
Bleeding found to be from the right corner of the uterine stump , oozing seen over the bladder
Procedure bleeding was arrested with sutures, abdominal cavity washed out , 2 pencil drains inserted.
The abdominal cavity closed & pt transferred back to ICU at 17H00
At the time BP=100/69, Pulse=160 temp=38
At 19h00 pt arrested and resuscitation commenced & was certified dead at 21H30.
Case 4 • Called for a patient with extra-uterine pregnancy
• Taken in as Prev C/Sx1 with ? Abruptio live baby
• At C/S registrar failed to notice an extrauterine pregnancy
• Delivered a live 1,85kg baby with good Apgar's but mutilated the uterus( fetus was in PoD behind the uterus!)
• Placenta was adherent to the bowel & bleeding profusely
• Blood supply from R infundibulopelvic ligament
• Below it was adherent to peritoneum above the ureter
• After clamping the blood supply we dissected it free above the ureter, made good recovery’
Avoidable factors Delayed and inappropriate correction of hypovolemia
Delay in diagnosis of the problem and treatment thus allowing massive blood loss resulting in defective coagulation
Delay in surgical control of bleeding
Degree of hypotension with tachycardia is 1st sign of significant blood loss
Failure to evaluate response to treatment by pulse BP CVP urine output & ABG
Rapid transfer between facilities & train junior drs from level 1 centres on rotational basis
Anaesthetic side
Inadequate resuscitation with blood products
Often give too much crystalloids :dilutional effect worsening coagulopathy
Use of spinal in unstable or potential problematic cases & rely too much on machines than finger pulse
Allowed abdominal closure with low BP<100 systole
Poor communication with the surgeon
Conclusion We need to restructure teaching: should we introduce
surgical skills at 5th and 6th yr medical students?
Supervision of interns/new medical officers
Resuscitation: implemented correctly Put C/S skill requirement as a MUST before you can practice plus ESMOE certificate
Use of plastic drapes for collection of blood
Senior doctors to be involved in doing previous C/S as in UK
Facilities: have 2 emergency theatres running 24hours
THANK YOU!
RESUSCITATION major PPH >1L IV access - 14 G cannula x 2 Head down tilt In 20ml syringe take blood FBC, x-match 4units, clotting
profile & U+E Oxygen by mask at 8 litres / minute Infuse 2 litres of crystalloid and 1 -2 litre of colloid Start blood transfusion as soon as possible Give 2units O Rhesus negative uncrossed blood urgently If bleeding is unrelenting then give emperical FFP unit for
3 packed cells transfused or 10 units of cryoprecipitate Fluids should be warmed Keep the patient WARM as well