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Surgical Management of Post Partum Haemorrhage

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Title: Tamponade technique Author: essam Last modified by: Created Date: 1/19/2012 4:53:45 PM Document presentation format: (4:3) – PowerPoint PPT presentation

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Title: Surgical Management of Post Partum Haemorrhage


1
Surgical Management of Post Partum Haemorrhage
2
Emeritus Professor C B-Lynch GORSL 2007
  • Consultant Obstetrician and Gynaecological
    Surgeon
  • Milton Keynes General Hospital (NHS Foundation
    Trust)
  • (Oxford Deanery, U.K.)

3
PPH - Essential Data (cont.)
  • Catastrophic haemorrhage is a persistent problem
    with substandard care as a regular event CEMACH
    Why Mothers Die UK 2000 2002
  • Approximately 25! of maternal deaths in
    developing countries are attributable to PPH
  • PPH is a worldwide problem and one of the three
    messengers of death

4
To Prevent the perils of PPH
  • an intrauterine balloon tamponade with or
    without the B-Lynch suture technique or
    modification should be tried first. e.g PPH
    following vaginal delivery

5
IS IT ONE OF THE BEST IDEAS IN OG?
  • Mention one surgical technique in obs gyn that
  • Saves life
  • Saves fertility
  • Simple
  • Quick
  • Cheap
  • Tested for success immediately before and after
    performance B-Lynch et al BJoG March 1997
    v104pp372-375

6
IS IT ONE OF THE BEST IDEAS IN OG?
  • gt4000 cases reported (1997 -2010) Reported
    postoperative complications e.g - Partial
    Ischemic necrosis - Joshi et al BJoG March
    2004 Uterine necrosis Treloar et all BJoG
    January 2006
  • Successful application in early pregnancy first
    trimester 13 weeks Hillaby K et all JoG
    Second Trimester 21 weeks - Price et al JoG
  • Known reported failure world wide 31/1827
    (0.016) - (CBL data collection and personal
    communications)

7
THE INVENTOR
  • Professor C B-Lynch GORSL 2007
  • Consultant Obstetrician and Gynaecological
    Surgeon
  • Milton Keynes General Hospital (NHS Trust)
  • (Oxford Deanery, U.K.)

8
THE IDEA
  • 27th November 1989
  • Massive PPH
  • Patient refusing hysterectomy

9
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10
The B-Lynch Suture Surgical Technique
  • Clinical Points

11
The B-Lynch Suture Compression Technique -
Clinical Points
  • The ten point principle
  • Lloyd Davis or Frog Legged Position Essential
  • The Uterus must be exteriorised
  • Basic surgical competence required
  • Bi-Manual Compression to test for potential
    success
  • Transverse lower segment incision made
  • Uterine cavity checked, explored evacuated.

12
The B-Lynch Suture Compression Technique -
Clinical Points
  • Apply monocryl No. 1 mounted on 90 cm
    curvedethiguard blunt needle (codeW3709)
    (Ethicon, Somerville, N.J.) suture correctly
    with even tension (no shouldering)
  • Allow free drainage of blood, debris
    inflammatory material.
  • Check bleeding control vaginally, including swabs
    and instruments
  • Wave to anaesthetists, offer a prayer and close
    the abdomen

13
UPDATE
  • Causes of failure
  • Placenta percreta (1)
  • Wrong technique (10) (uterine necrosis -2
    cases!)
  • Uncontrolled DIC (4)
  • No pre operative test done (6)
  • Not properly applied (6)
  • Delayed application (4)

14
B-Lynch Suture Technique Applied Correctly
Even Tension No Ischemia no necrosis
15
MRI B-Lynch Suture 6 Months Later
  • Normal Uterine characteristics C Tsitlakidis et
    al 10 year follow up of the effects of the
    b-lynch suture Int/fertill 51 (2006)

16
Cervical-isthmic apposition suture
  • Shouldering Ischemia

Anterior
Posterior
17
Partial ischemic necrosis of the uterus
following a uterine brace compression suture
  • The uterus as it appears at laparotomy, 24 hours
    following a uterine brace suture.
  • An example of poor technique
  • Without exploration and drainage of the uterine
    cavity

18
Haemostatic multiple square suture method
  • University of Seoul (Korea)
  • 23 cases
  • Didnt mention extent of bleeding
  • Pierce uterus 32 times
  • Does not close all transverse branches
  • ? Cavity Patency
  • Leading to pyometria Ochoa et al ObGy 99506-509
  • Obstet Gynecol 2000 Jul96(1)129-131

19
UPDATE (cont.)
  • Prophylactic Application
  • gt70 cases ? All No PPH (but high risk)
  • Complications (none reported)

20
Preventing the perils of PPH
  • Stepwise devascularisation or internal iliac
    vessel ligation should be done by a surgeon with
    appropriate experience expertise.
  • Arterial embolisation has established potential,
    but the logistics of arrangements with the
    radiology department has to follow strict
    obstetric radiological protocol.
  • Sub-total or total hysterectomy, may continue to
    rise with mortality morbidity if the rise in
    caesarean section rate is not controlled.
  • Trainees should have regular workshop fire
    drill training of the application of the Brace
    suture compression other conservative tamponade
    techniques.

21
Obstetric Trauma - PPH
  • Post Partum Haemorrhage Following Acute Uterine
    Inversion
  • Bleeding from lower genital tract

22
Acute Uterine Inversion
  • Acute inversion reported in 12,000 deliveries
  • May go unrecognised or misdiagnosed as uterine
    fibroid

23
  • In difficult cases, replacement may have to be by
    laparotomy followed by another B-Lynch technique
    stepwise atraumatic digital replacement (ref
    TEXTBOOK OF POSTPARTUM HEMORRHAGE sapiens
    publishing 2006)

24
  • Acute uterine inversion.

25
  • Acute uterine inversion. Finger tips placed below
    fundus of uterus to facilitate reduction.

26
  • Acute uterine inversion.
  • Progressive reduction with some ischaemia.

27
  • Acute uterine inversion.
  • Return of vascularity.

28
  • Acute uterine inversion. Complete reduction and
    revascularization with normal clinical features.

29
Post Partum Haemorrhage Following Genital Tract
Trauma
30
Below the Level of the Pelvic Floor
  • Lithotomy position
  • Adequately anaesthetised
  • Passive drainage should be encouraged
  • Local bleeding identified, transfixed and
    haemostased
  • Exploration of pudendal vessels
  • Transfixion haemostasis
  • Vaginal pack
  • Antibiotic cover

31
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32
Above the Level of the Pelvic Floor
  • Enlarge extend proximally between the 2 layers
    of the broad ligament
  • May enable conservative management
  • Laparotomy drainage may become necessary via
    subperitoneal approach
  • Time of presentation is variable
  • Clinical features may not fit
  • Low abdominal pain, tachycardia pallor
  • Conservative management failed laparotomy,
    evacuation retro-peritoneal drainage
  • Watchful of secondary haemorrhage
  • Consider embolisation

33
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34
More Complex Surgery for PPH Management
  • Stepwise Devascularisation
  • Internal Iliac (hypogastric) artery ligation
  • Complex pelvic surgery
  • Peripartum abdominal hysterectomy Subtotal/Total
    TF Baskett, Chapter 34 A TEXTBOOK OF POSTPARTUM
    HEMORRHAGE
  • Secondary PPH KM Groom, TZ Jacobson ,Chapter 35 -
    A TEXTBOOK OF POSTPARTUM HEMORRHAGE

35
Stepwise Devascularisation
36
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