azienda ospedaliera universitaria integrata di verona ... · before closing the abdomen total...

Azienda Ospedaliera Universitaria Integrata di Verona Ginecologia e Ostetricia

La chirurgia nelle emorragie ostetriche massive M. Franchi & Co

Incidence

Technique

Total vs Subtotal

Introduction

Elective vs Emergency

Conclusions


Medical Education

Simulation

Author Type of Study PH (n) Delieveries (n) PH per 1000 Kastner et al R 48 32.241 1.4

Forna et al. R 58 70.449 0.8

Kwee et al. P 48 110.937 0.33

Whiteman et al. Population-based estimate

18.339 28.816.883 0.77

Eniola et al. R 22 48.865 0.45

Jou et al. R 287 214.237 1.33

Smith & Mousa R 18 40.524 0.36

Sakse et al. R 181 653.582 0.24

Knight et al. Population-based descriptive

318 775.186 0.41

Rahman et al. R 43 67.668 0.64

Glaze et al. R 87 108.154 0.8 Kayabasoglu et al. R 28 74.462 0.37

Flood et al. R 358 872.379 0.4 AOUI Vr 2005-12

R 14 16593 0.8


First Author

Year n Accreta (%)

Atony (%)

Extension (%)

Uterine Rupture (%)

Other (%)

Kastner 2002 48 49 30 4 2 15

Glaze 2008 87 33 37 3 1 29

Knight 2007 315 38 53 9 8 20

Kwee 2006 48 50 27 0 8 15

Shellhaas 2009 186 38 34 1 5 19

Indications


Rossi et al Obstet Gynecol 2010;115:637–44

Repeat CS X

Multiple Birth X

9 CS X

Age t40 y X 12

6.5

1.4

Peripartum Hystrectomy Adjusted OR*

Whiteman et al. Obstet Gynecol 2006;108:1486-92

1998-2003 HCUPNIS - USA

Peripartum Hysterectomy (H and delivery during same hospitalization)

18,339 (0.77x1000 deliveries)

*Maternal and Hospital Characteristics


Silver et al Obstet Gynecol 2006; 108:1486-92 Grobman et al Obstet Gynecol 2007;110:1249-55

1999-2002 NICHHDMFMUNetwork - USA

19 Academic Medical Centers 70,442 CS

(900 pts: 1.3% p praevia)


Incidenza TC


Incidenza taglio cesareo

27%


23,384 deliveries (55.2 % CS deliveries) 51 pts of 2.2/1,000

2000-2013

19,936 deliveries 34 pts of 1.7/1,000

2005-15

Cromi A et al Fertil Steril 2016;106:624-8

D’Arpe S et al Arch Gynecol Obstet 2015; 291:3-841-7


http://images.google.ca/imgres?imgurl=http://www.33ff.com/flags/XL_flags/Italy_flag.gif&imgrefurl=http://www.33ff.com/flags/worldflags/Italy_flag.html&h=240&w=360&sz=3&hl=en&start=5&tbnid=Ase506m5LxQ8uM:&tbnh=81&tbnw=121&prev=/images?q%3DItaly%2Bflag%26gbv%3D2%26svnum%3D10%26hl%3Den%26sa%3DG

Hysterectomy

Elective hysterectomy is associated with lower morbidity Orbach et al J Matern Fetal Neonatal Med 2010;24:480-84

Placenta Accreta Cervical Pregnancy

Infection Cancer

PPH/Atony/Accreta Placental Abruption

Utering Inversion Utering Rupture

Elective Emergency

“Save the Uterus”

“Save the Mother”


Elective Hysterectomy 14 (9%)

Emergency Hysterectomy 144 (91%)

Imudia et al Arch Gynecol Obstet 2009;280:619–623

Emergency vs Elective

From 1991 to 2007 202.356 deliveries

158 cesarean hysterectomy 0,78 per 1000


34 pts Hyst > 24 h postpartum

Knight BJOG 2007;114:1380-87


89% within the first 24 h after delivery

Criteria have never been developed to aid the decision to remove the uterus after delivery

O’Brien et al EJGRB 2010;153:165-69



Knight BJOG 2007;114:1380-87

Unità di sangue trasfuse in pz sottoposte a PPHyst

Proposed Performance Measure If hysterectomy is performed for uterine atony, there should be documentation of other therapy attempts.


Proceed directly to hysterectomy to prevent morbidity and blood loss

Knight et al BJOG 2007;114:1380-87

Nei casi che non rispondano alle terapie sopra indicate, organizzare per tempo manovre chirurgiche di

devascolarizzazione (arterie uterine,ovariche o iliache interne) o di compressione dell’utero (suture B-Lynch o tecnica

semplificata proposta da Hayman);

Aprile 2007, www.ministerosalute.it



“… hysterectomy should not be delayed until the patient is

in extremis or while less definitive procedures with which

the surgeon has little experience are attempted. …”

RCOG, “Scottish Obstetric Guidelines”, March 2002




For each woman who die following Hysterectomy

(PPH) More than 150 survive

Knight et al BJOG 2007;114:1380-87

http://images.google.ca/imgres?imgurl=http://www.modernlifeisrubbish.co.uk/images/screenshots/piechart-tutorial/uk-flag.jpg&imgrefurl=http://www.modernlifeisrubbish.co.uk/article/howto-add-edit-custom-fills-in-illustrator&h=400&w=800&sz=40&hl=en&start=1&tbnid=GScoVt1d_PcR2M:&tbnh=72&tbnw=143&prev=/images?q=UK+FLAGS&gbv=2&svnum=10&hl=en&sa=G

Taglio Cesareo

Trattamenti chirurgici per PPH

Parto Vaginale

Compressione bimanuale Catetere Intrauterino

Compressione bimanuale Catetere Intrauterino

Embolizzazione Laparotomia

Sutura Compressiva Embolizzazione

Legatura art ut/ipogastrica Isterectomia

Tamponamento Pelvico

Sutura Compressiva Legatura art ut/ipogastrica

Isterectomia Tamponamento Pelvico


A B D

E

A “dome” of the pack

B-C-D “neck” of the pack

E gauze rolls

F intavenous tubing

G one liter intravenous fluid bag

Pressure pack- Logothetopoulos


Dildy AG et al Obstet Gynecol 2006;108:1222-6

Usta et al Acta Obstet Gynecol Scand 2007;86:172

Uterine Rupture

Complete all layers of the uterine wall are separated

Incomplete (dehiscence)

uterine muscle is separated-visceral peritoneum intact

37 pts with prior complete uterine rupture

11 pts hysterectomy 26 pts repair of the rupture

12 pts had 24 subsequent pregnancies

1/3 recurrent uterine rupture


34anni, 7 precedenti tagli cesarei. EG 32 w Algie addominali ingravescenti. TAC addome (nel sospetto di appendicopatia)

Taglio Cesareo 12 ore dopo per iniziale rifiuto del consenso da parte della paziente

Rottura d’utero

Grosvenor e Fisher NEJM 2009;360:2



Nascita di neonato: Apgar 7/9 Isterorrafia

Decorso post-operatorio non complicato.

Grosvenor e Fisher NEJM 2009;360:2


Rottura d’utero



Prima Dopo

Primipara 38 aa TC non complicato per distress fetale

Emoperitoneo in IIa g post-op (Hb 13.8 Æ 6.4 Æ 5.8 g/dL)



Placentzione Anomala

GV Para 3003 - 3 Tc pregressi - Pl praevia, sospetto RMN Percretismo, (TC 37 sett)



Versamento imbibisce le fasce pararenali sia anteriore che posteriore di destra, e lo spazio lateroconale omolaterale. Utero post-gravidico, globoso, latero-deviato a sinistra da grossolana

formazione espansiva iperdensa in fase precontrastografica, con significato di ematoma di recente insorgenza, esso divarica i foglietti del legamento largo con maggior asse sagittale e

trasversale di 10 cm. In fase arteriosa un vaso di piccolo calibro che decorre lungo il miometrio della porzione laterale destra dell’utero, si dispone a contornare ventralmente l’ematoma

(possibile rifornimento); versamento ematico si dispone anche lungo la faccia mesorettale destra e nella fossetta ischiorettale omolaterale contornando il retto.


Ia giornata anemizzazione

7a giornata (Trasfuse 3 GRC)

Dimissione, in buone condizioni generali, stazionarietà della raccolta confermata da una seconda TAC

14-15a giornata Febbre domiciliare trattata con paracetamolo

Massa ascessuale con bolle gassose

Utero infarcito con bolle gassose


Quadro laparotomico iniziale


Deiscenza precedente sutura uterina


Isterectomia

DX SX


Isterectomia


Parete Ascessuale


Precedente sutura uterina Ovaio destro

Tuba destra

Ovaio e tuba uterina con marcato edema stromale, periviscerite talora a carattere ascessuale e presenza di trombi fibrino-

granulocitari nel lume dei vasi.


2500 cc Cristalloidi 1000 cc Colloidi

4U GRC 1200 cc Plasma


Dimessa in 11° giornata

Need to call senior staff “early”

Senior Surgeons Consultant with specific experience in

Advanced Obstetric Surgery


90% of scottish consultant/senior trainer

obstetricians have personal experience of postpartum hysterectomy

whereas only 40% have such experience of internal

iliac ligation


1998

Which Hysterectomy

Subtotal Hysterectomy Lower degree of haemorrage and speed of operation.

Total Hysterectomy to be certain of achieving haemostasis.

Knight BJOG 2007;114:1380-7

Subtotal hysterectomy is the operation of choice unless there is trauma to cervix or lower segment

the risk of neoplasia developing in the cervical stump is not relevant in the context of life-threatening haemorrhage RCOG Guideline N°52 2011

Total Hysterectomy

Subtotal Hysterectomy


Which Hysterectomy

“… .In an emergency situation, in the hand of surgeon

who has had little experience with the operation,

Subtotal Hysterectomy, is an acceptable alternative. …”

Total Hysterectomy



Mosby 1993

Which Hysterectomy

“… .if the bleeding is due to uterine atony or trauma in the upper uterine segment …and

there is not bleeding from the cervix subtotal hysterectomy

should suffice. …” It is advisable to clean out the vagina and check for continued blood loss

before closing the abdomen

Total Hysterectomy



Saunders 2014


Li GT et al BJOG 2015 10-1111/1471-058.13685

2006/2012 22 pts PPH from

LUS ± accreta

Successful 82%*

*4 pts: Hemorrhage >3000ml-TAH

Blood loss 2000-4000 ml

Emergency peripartum hysterectomy


Place hypogastric artery baloons pre-op

Cell saving technique in the operating room

Availability in op room topical hemostatic agents

Litothomy position to allow access to the vagina


Hysterectomy in pregnant patient

The tissues are soft and pliable

Ut and parevesical veins are distended

Constant tension on uterus attenuates the very engorged ut vessels

Up to five times normal calibre

Constant tension on uterus allows sharp dissection throughout

Mosby 1993

Wright et al Obstet Gynecol 2010; 116:492-33

Clamp-cut-drop technique

The delayed ligation technique is well suited to nonemergency cases

and can be used for many emergency cases

Dyer et al AJOG 1953;65:517-21

Often prudent to use midline laparotomy


Laboratorio Analisi

Centro Trasfusionale

Anestesista Ostetrico Esperto

Patologo Neonatale

Ch Addominale Ch Urologo

Radiologo Interventista

Esperto

Chirurgo Ostetrico Esperto

Il buon esito in Ostetricia «drammatica» è correlata alla integrazione di differenti Specialisti


ACOG Committee 266 2002 RCANZCOG C-Obs 20 2003 CMACE BJOG Suppl 1 2011 RCOG GTG N 27 2011


www.rcoa.ac.uk/system/files/GPAS-2015-09-OBSTETRICS.pdf

https://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiR_bSFy93JAhULXhQKHTj0CoEQjRwIBw&url=https://www.rcog.org.uk/en/departmental-catalog/Departments/postgraduate-and-scientific-meetings/1402---4lb---mbrrace-uk-maternal-mortality-and-sepsis-morbidity-report-launch---joint-mbrrace-ukrcog/&bvm=bv.110151844,d.d24&psig=AFQjCNHF9yzIqsR9lIV45lF5bCB2ji99ew&ust=1450259282703284

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiZirTUz93JAhVDORQKHQVIBY4QjRwIBw&url=http://www.rcoa.ac.uk/erp&psig=AFQjCNECqiHG7K0XC8ARV3qvP9pxOuPA7Q&ust=1450260538265796

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwik85W-yt3JAhXJzxQKHeBBDAgQjRwIBw&url=http://www.ugsa.org.au/&bvm=bv.110151844,d.d24&psig=AFQjCNHm5-8RmIqRVO4oJI4ovlZkz-tzSg&ust=1450259143632153

https://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiV_-3_y93JAhUBOxQKHXwCARwQjRwIBw&url=https://www.rcog.org.uk/&psig=AFQjCNEwY9Z537lGzaAuXehLSxpHXD8HDQ&ust=1450259382409201

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjDh7iB0d3JAhVCTBQKHcR9B9YQjRwIBw&url=http://www.bio-medical.co.uk/cmace&bvm=bv.110151844,d.d24&psig=AFQjCNEQ3q9fNfIiTFNSXrFFiTHGhwbvpw&ust=1450260871948344

http://images.google.ca/imgres?imgurl=http://ec.europa.eu/education/img/flags/usa.gif&imgrefurl=http://ec.europa.eu/education/programmes/eu-usa/index_en.html&h=329&w=492&sz=6&hl=en&start=1&tbnid=Rk5l56U0QzbEqM:&tbnh=87&tbnw=130&prev=/images?q%3DUSA%2BFLAGS%26gbv%3D2%26svnum%3D10%26hl%3Den%26sa%3DG

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiYhc-C5d3JAhVFVxQKHSJ_AIoQjRwIBw&url=http://www.ilpost.it/2015/09/01/bandiera-nuova-zelanda/&psig=AFQjCNGzF96FzBYRDW6R7MnTf4kHkJXb0w&ust=1450266251326931

http://images.google.ca/imgres?imgurl=http://www.modernlifeisrubbish.co.uk/images/screenshots/piechart-tutorial/uk-flag.jpg&imgrefurl=http://www.modernlifeisrubbish.co.uk/article/howto-add-edit-custom-fills-in-illustrator&h=400&w=800&sz=40&hl=en&start=1&tbnid=GScoVt1d_PcR2M:&tbnh=72&tbnw=143&prev=/images?q%3DUK%2BFLAGS%26gbv%3D2%26svnum%3D10%26hl%3Den%26sa%3DG

Database: pts data from 320 Acute-Care Hospitals

2,209 PPH* (mortality 1.2%) med age 33 years (14–50)

2002 - 2007

*TAH 2 days after CS


Wright JW et al Obstet Gynecol 2010;115:1194-1200

Gentle explanation, listening and sympathy for her and her partner

with appropriate follow up are essential


The woman is psychologically traumatized by a sequence of events that started with an expectation

of normal labour and delivery to spiral out of control with

blood transfusion, general anesthesia, intensive care and loss of uterus and fertility

Bose P et al BJOG 2006;113:919-24


PPH on bed only (1000 ml)

PPH spilling to floor (2000 ml)

Azienda Ospedaliera Universitaria Integrata di Verona Ginecologia e Ostetricia - Policlinico G Rossi

2001-2 OSATS

(assessing surg competence) 115 Residens

5 Residency Programs

Residents who had received additional training outside the operating room

using various simulator had better performance than residents who are not

AJOG 2005;192:1331-40

http://images.google.ca/imgres?imgurl=http://ec.europa.eu/education/img/flags/usa.gif&imgrefurl=http://ec.europa.eu/education/programmes/eu-usa/index_en.html&h=329&w=492&sz=6&hl=en&start=1&tbnid=Rk5l56U0QzbEqM:&tbnh=87&tbnw=130&prev=/images?q%3DUSA%2BFLAGS%26gbv%3D2%26svnum%3D10%26hl%3Den%26sa%3DG


Making systematic training in real settings unattainable

Increasing fragmentation

Production pressure

Unprecedented constraints on training

Ziv A et al. Acad Med 2003;78:783–8


http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjfxYrP5afPAhWEExoKHe2-AG8QjRwIBw&url=http://www.pictaram.com/user/gigi_zanovello/3279623558&bvm=bv.133700528,d.d2s&psig=AFQjCNG9wXr9lSeW_96AKiGpcbkLiBiB5A&ust=1474799285407623

Disporre per presenza immediata: Personale di sala operatoria al completo

Ch ostetrico esperto e/o ch ginecologo oncologo Anestesista esperto in emergenze ostetriche

Urologo nella placentazione anomala

Valutazione Clinica/SNLG «Save the mother /Save the uterus»

Applicare procedura Istituzionale Allertare radiologia interventistica

Disporre per Recupero Sangue


Conclusioni

Formazione/Isterectomia di preferenza totale


Pz in posizione litotomica colorante vaginale e in vescica Laparotomia (longitudinale/trasversale)

Applicazione di Tourniquet, forcipressura leg ut ovarici e tube

Applicare Istruzione Operativa PPH

Fallimento/non indicazione interventi conservativi

azienda ospedaliera universitaria integrata di verona ... · before closing the abdomen total...

Documents