Dr. Doddy Gultom, SpOG.MkesRSUD Tarakan

MANAGEMENT OF POST-PARTUM HEMORRHAGE

Why focus on preventing post-partum hemorrhage?Haemorrhage is the largest direct cause of maternal deathPPH is mostly unpredictableMost PPH is caused by uterine atonyEvidence-based, feasible, low-cost interventions existActive management at the third stage of labour can prevent 60% of PPH

Difficulties associated with comparing post-partum hemorrhage studiesMethod to determine blood loss Visual underestimation 7080%Conduct during third stage of labourConfounding factors in epidemiological studies58% of trials do not report their definition of PPH

Maternal Health:some ( underestimated) statistics180200 millions pregnancies per year75 millions unwanted pregnancies50 millions induced abortions20 millions unsafe abortions358,000 maternal deaths (1000 per day)1 death every 1,5 min20 maternal morbidities per minute10-15 millions disabilities each year

WHO, 2010

Every Minute...Maternal Death Clock380 women become pregnant190 women face unplanned or unwanted pregnancy110 women experience a pregnancy related complication40 women have an unsafe abortion1 woman dies from a pregnancy-related complication20 women suffer of a disabilty related to childbirthWHO, 2010

About two thirds of maternal deaths are due to

Anemia-HemorrhageObstructed deliveryEclampsiaSepsisUnsafe abortion

They can be treated by a health professional

Causes of maternal mortality

Maternal mortality from post-partum hemorrhage in the UK 88% received substandard careHall M. 2004; Why mothers die (20002002) CEMACH.0123456858788909193949697990002Maternal mortality rate/millionYear

Sub-standard careOrganisational problemsInappropriate bookingInadequate blood transfusionIntensive care facilitiesPoor quality of resuscitationInadequate transfusionBlood productsEquipment failureMalfunctioning of specimen transport systemFailure to recognise or treat antenatal medical conditionsInherited bleeding disordersFailure of senior staff to attendConcerns about the quality of surgical treatment givenHall M. 2004; Why mothers die (20002002) CEMACH.

As with many problems, there seems to be two different kinds of emergencies......depending on whether the patient is in a developed or undeveloped country

Developed countriesSequence:Diagnosis PPHProtocol-managementTreatmentSuccess (>98%)

Undeveloped countriesSequence:Diagnosis PPH (?)Emergency (?)Transfer (?)Centre (?)Treatment (?)Success (

Post-partum hemorrhageEqual opportunityoccurrence

2/3 no risk factorsNot equal opportunity killer

PoorMalnourishedUnhealthy

What is post-partum hemorrhage?Excess blood loss after the birth of a baby PPH >500 ml (3.530%)Severe PPH >1000 ml (1.55.0%)

Immediate PPH: Onset within 24 h of birthPPH late: Onset after 24 h of birth These definitions are not accepted by all!!

One of the main problemUNDERESTIMATION OF BLOOD LOSS

Methods used to diagnose post-partum hemorrhageClinical methodsPhysiological response to blood lossQuantitative methodsVisual assessmentDirect collection of blood into bedpan or plastic bagsGravimetric methodChanges in hematocrit and haemoglobinOthers Plasma volumeTagged erythrocytes

Estimated blood lossPrasertcharoensuk et al. IJGO 2000

Calibrated bag(Brass-V)

Risk factors

placenta previa with or without previous uterine surgery.previous myomectomy.previous cesarean delivery. Asherman's syndrome. (treated surgically)submucous leiomyomata. maternal age of 36 years and older.

Risk factors (multivariable analysis)Retained placenta, OR=3.5Failure to progress to second stage, OR=3.4 Placenta accreta, OR=3.3Lacerations, OR=2.4Instrumental delivery, OR=2.3Newborn large for gestational age, OR=1.9Hypertensive disorders, OR=1.7Induction of labour, OR=1.4Augmentation of labour with oxytocin, OR=1.4 Sheiner E, et al. J Matern Fetal Neonatal Med 2005.

The risk of placenta previa was 0.26% with an unscarred uterus and increased almost linearly with the number of prior cesarean sections to 10% in patients with four or more.With a placenta previa and one previous cesarean section, the risk of placenta accreta was 24%; this risk continued to increase to 67% (two of three) with a placenta previa and four or more cesarean sections.Obstetrics & Gynecology 1985;66:89-92 Placenta Previa/Accreta and Prior Cesarean SectionSTEVEN L. CLARK Et al

Ch. B- Lynch 1 ed 2006 2 ed 2012MANAGEMENT

( FIGO 2009 Cape Town)

COMPREHENSIVE

MedicalSurgical Mechanical

Joint statement management of the third stage of labour to prevent post-partum hemorrhageActive management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atonyConsists of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony. The usual components include:Administration of uterotonic agentsControlled cord tractionUterine massage after delivery of the placenta, as appropriateEvery attendant at birth needs to have the knowledge, skills and critical judgment needed to carry out active management of the third stage of labour and access to needed supplies and equipment

Maternal outcomes of active management trialsMcCormick et al, IJGO 20020102030TransfusionProlonged third stageTherapeuticuterotonicdrugsLow haemoglobinRetained placentaPatients (%)Active managementPhysiological management

POSTPARTUM HEMORRHAGEneed of action in the golden hourin order to increase the probability of patient survival: The mnemonic HAEMOSTASIS can assist in remembering the sequence of events to confront

HAEMOSTASISH: Get HELP

HAEMOSTASISA: evaluate the vital parameters of the patient and the amount of blood loss

HAEMOSTASISE: identify the cause (ethiology) and the appropriate treatment (4T) ToneTissueTrauma Trombin

Causes of post-partum hemorrhage (4T)Anderson et al. Am Fam Physician 2007.CAUSE(70%)(19%)(10%)(1%)TONETISSUETHROMBINTRAUMA

RISK FACTORS

Etiology ProcessClinical Risk FactorsToneOverdistended UterusPolyhydramnios, Multiple GestationMacrosomiaUterine Muscle Fatigue Rapid Labor, Prolonged LaborHigh ParityIntra Amniotic InfectionFever, Prolonged ROMFunctional/Anatomic Distortion of the UterusFibroid UterusPlacenta PreviaUterine AnomaliesTissueRetained ProductsAbnormal PlacentaIncomplete Placenta at DeliveryPrevious Uterine ScarHigh ParityRetained Blood ClotsAtonic UterusTraumaLacerationsPrecipitous or Operative DeliveryExtensions at C/SMalposition, Deep EngagementUterine RupturePrevious Uterine SurgeryUterine InversionHigh Parity, Fundal Placenta

ThrombinPre-existingCoagulopaties, Liver DiseaseAcquired in PregnancyITP, DICTherapeutic Anti-coagHistory of DVT or PE

HAEMOSTASISO: proceed with oxytocin infusion, prostaglandins ( via rectal, intramuscolar, IV, intramyometrial)(off label) First line Second line Third line

Drugs to prevent and treat uterine atony

Prophylactic syntometrine versus oxytocinProphylactic use of oxytocinCarbetocinInjectable prostaglandinsMisoprostol

Dioscorides: cyclamen, 100 AD

Ergot (Claviceps purpurea), 1582 ADAncient Oxytocics*Egyptian Papyrus Ebers, 1500 BCcontract uterus: speed birth, stem haemorrhagehemp in honeycelery in milkjuniper berriesfly excrement (in many ancient pharmacopoeias)

Nobel prize in chemistry 1955sulphur compounds of high importancefirst synthesis of a polypeptide hormone

T Reinheimer, 20091953: Synthesis of OxytocinVincent du VigneaudAmerican biochemistdiscovery, isolation, and synthesis together with ADH/vasopressin *The Nobel Foundation 1955http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/oxytocin.gif

T Reinheimer, 2009Oxytocin Todayoxytocin (sometimes combined with ergometrin)*Martindale 2008http://www.appdrugs.com/ProdJPGs/OxytocinLg.jpgLabour induction/augmentationProphylaxis and Treatment of Postpartum haemorrhageretained placenta: umbilical vein injectionmilk ejection/lactation: oxytocin nasal spray

T Reinheimer, 2009Oxytocin AgonistsCarbetocin (DURATOCIN, PABAL)long-acting synthetic analogueindication: prevention of uterine atonyveterinary medicine*Pritt et al. 2004, Manning et al. 2008http://www.bcnpeptides.com/images/products/carbetocina.jpgWO/2003/000692, US/20070117794 Non-peptide agonistspatented for erectile dysfunctionWAY-262464: patented for anxiety, schizophrenia

30 women with elective caesarean section5 u of oxytocin either as a bolus injection or an infusion over 5 min Heart rate and intra-arterial blood pressure recorded every 5 sMean arterial pressure (MAP) changes with oxytocinMean change of MAP (mmHg)Study period (s)Thomas JS, et al. Br J Anaesth 2007

Carbetocin PharmacodynamicsOxytocinCarbetocin

N=240Study design: Prospective double-blind randomized controlled studyDrugs: Carbetocin 100 g i.m. vs. syntometrine (5 IU of oxytocin and0.5 mg of ergometrine) i.m.Primary outcome: postpartum hemorrhage requiring additional uterotonic therapySecondary outcome: incidences of postpartum hemorrhage (>500 ml) and severe postpartum hemorrhage (>1,000 ml) as well as adverse effects profile

Authors Conclusion:A single dose of intramuscular carbetocin 100g may be more effective as compared to a single intramuscular dose of syntometrine (5 IU of oxytocin and 0.5 mg of ergometrine) in reducing postpartum blood loss

Lower incidence of adverse effects.

N=377Study design: double-blind randomised single centre studyDrugs: carbetocin 100 g or oxytocin 5 IU, both i.v.Primary outcome: Need of additional pharmacological oxytocic interventions.Secondary outcomes: Estimated blood loss, difference in preoperative and postoperative haemoglobin, incidence of blood transfusion and adverse effects

Authors conclusion:Carbetocin reduces the use of additional oxytocics following caesarean section when compared with the licensed dose of oxytocin (5 IU)

Carbetocin versus oxytocin0.001REVIEW: Oxytocin agonists for preventing PPHCOMPARISON: 01 Carbetocin versus oxytocinOUTCOME: 02 Use of additional uterotonic therapy0.11101001000Favours carbetocinFavours oxytocinSu LL, et al. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005457

StudyCarbetocin n/NOxytocin n/NRR (Fixed) 95% CIWeight (%)RR (Fixed) 95% CI01 Caesarean deliveryBoucher 19980/293/281000.14 (0.01, 2.56)Dansereau 199915/31732/3189000.47 (0.26, 0.85)Subtotal (95% CI)346346100.00.44 (0.25, 0.78)Total events: 15 (carbetocin), 35 (oxytocin) Test for heterogeneity chi-square=0.66; df=1; p=0.42; I2=0.0% Test for overall effect z=2.81; p=0.00502 Vaginal delivery Boucher 200412/8312/77100.00.93 (0.44, 1.94)Subtotal (95% CI)8377100.00.93 (0.44, 1.94)Total events: 12 (carbetocin), 12 (oxytocin) Test for heterogeneity not applicable Test for overall effect z=0.20; p=0.8

ConclusionsPrevention of PPHVaginal birth: active management, Oxytocin (3-5 IU), no prostaglandins, no ergometrinCaesarean section: Carbetocin (Pabal), Oxytocin 5IU 2-3min no bolus, no PGs, no ergometrin

Therapy of PPHOT (10-40 IU/liter), ergometrin (0.2mg every 2-3 hours)PGE2/PGF2alpha (0.25 mg i.m. every 15-90 min)Misoprostol 800-1000mcg rectally (off label)Carbetocin (off label)

HAEMOSTASISS: transfer the patient to the operating room( exclude trauma or retained products, proceed with bimanual compression)

HAEMOSTASIST: Balloon Tamponade;

HAEMOSTASIST: Balloon Tamponade;Uterine packing(2009)

Traditional methodBakri balloon

TAMPONADE WITH BAKRI BALLOON Simple and efficient (87-95 % success rate) Applicable after cesarean and vaginal births Used as method of prevention in cesareans at high hemorrhagic risk (placental pathologies, uterine over-distension, preeclampsia, precedent hysterotomy, coagulopathy, etc) and in the case of contraindications for prostaglandins (asthma, glaucoma, important hepatic and renal dysfunction)Easy to insert and removeContinuous monitoring of blood loss

BAKRI BALLOON The Bakri is a balloon in silicon, latex-free, which is filled with physiological solution (500 cc max) and is able to create a real intrinsic compression on the myometrial walls: the filling volume can be varied in relation to the dimension of the uterus and the contractile responseAdditionally to the ease of insertion it has the possibility to monitor the amount of blood loss thanks to the drainage holes located in the distal part of the catheter, which is attached to a sac in order to collect the fluids. This access is used also to perform washings of the uterine cavity. Associate adequate antibiotic coverageRemoval of the balloon within 24 hrs administering uterotonics/uterokinetics before deflating

Bakri balloon

BladderBakri balloonBakri balloonThe intrauterine balloon Ultrasound

HAEMOSTASISA: apply sutures

HAEMOSTASISA: apply compression sutures

B-Lynch suture

Hayman uterine compressive sutures Does not necessitate to openthe uterine cavityCho multiple quadrate suturesHAEMOSTASISA: apply compressive sutures

Suture of Hayman HAEMOSTASISA: perform sutures

HAEMOSTASISS: Systematic pelvic devascularizationRescue Surgery:Ligation uterine artery and ovarian arteryTriple ligation of Tsiruinikov : ligation of the uterine arteries, round ligament and the uterine-ovarian.

Vascular ligationUterineOvarianInt iliac

Vascular ligation

Ligation hypogastric arteryUnderneath the superior gluteal arteryRescue Surgery HAEMOSTASIS

Hansch E, etal. AJOG 1999

Hypogastric artery ligationsuccess 84%

(Limiting factors: hemodinamically stable cases - presence of angiographist - transport to radiology)Fragments of gelfoam are injected (gelatin sponge resorbable in 10-30 days)HAEMOSTASISI: Interventional radiologist Uterine Artery Embolization

HAEMOSTASISI: Interventional radiologist Uterine Artery Embolisation

Rescue Surgery :total hysterectomy / subtotal1.55 % births0.24% and 0.90% of all cesarean sectionsbetween 1480 and 1800 hysterectomies/year associated with cesarean sectionISTAT 2006HAEMOSTASISS : Subtotal or total abdominal hysterectomy

The ideal treatment should be:

intuitive and easy to apply secure and effective in the prevention and the arrest of hemorrhageshas an immediate resultavoids hysterectomy

Our Philosophy

EFFICACY & EFFICIENCYTeam work

TEAM- Obstetricians, Anesthetists, Blood bank, Interventional Radiologists Max therapeutic efforts within 2-3 hrs

Contemporary involvement of all professional figures

Liberal use of all therapeutic agents

Follow in a stepwise way the guidelines

BASICSINTERVENTIONAL RADIOLOGISTS IN THE THEATRECLAMPING UTERINE VESSELS BEFORE PLACENTAL DELIVERY

ASSOCIATION OF COMPRESSIVE SUTURES AND BAKRI BALLOONINFORMED CONSENT

B-Lynch + Bakri Balloon SANDWICH EFFECT

B-Lynch + Bakri BalloonIT LOOKS LIKE THE LUGGAGES OF IMMIGRANTS..NO RISK OF ISCHEMIA

Prevention of Postpartum Hemorrhage ( cases with elevated hemorrhagic risk: i.e., placenta previa post-C.S.)

STEP 1

PRELIMINARY PROPHYLACTIC CATHETERIZATION OF THE DESCENDING AORTA

STEP 2

EXTRACTION OF THE FETUS BY C.S. AND PLACENTAL DELIVERY

STEP 3

MULTIPLE QUADRATE ENDOUTERINE HEMOSTATIC SUTURES

STEP 4

PREPARATION OF B-LYNCH COMPRESSIVE SUTURES

STEP 5

APPLICATION OF HYDROSTATIC BALLOON (BAKRI-BALLOON)

STEP 6

REPOSITIONING OF UTERUS UTERINE SUTURES-HYDROSTATIC BALLOON INFLATION-B-LYNCH LIGATURE

IF THESE MANEUVRES FAILDEVASCOLARIZATING LIGATURE /SELECTIVE EMBOLIZATION /HYSTERECTOMY

STEP 1

Angiographytransomeral/transfemoral pre-carefour

STEP 2DELIVERY OF THE FETUS ADMINISTRATION OF CARBETOCIN

STEP 2

CLAMPING UTERINE VESSELS

Prevention of postpartum hemorrhage ( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )Assistance PlanSTEP 2 Squared hemostatic endouterine suturesRationale: at the level of the inferior uterine segment reduced muscular component ; incomplete mechanical hemostasis after placental delivery; conspicuous hemorrhagemultiple quadrate sutures in the IUS of 2-3 cm, transdecidual. (Dexon n.1-2,needle with large curvature )Retraction of the muscular fibers with clamping and occlusion of the vasculature

STEP 3 Squared hemostatic endouterine sutures

Prevention of postpartum hemorrhage ( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )Assistance PlanSTEP 3 B-Lynch compressive suturesThe ligature of the sutures follows after STEP 4

STEP 4 PREPARATION OF B-LYNCH SUTURE

STEP 4

Prevention of postpartum hemorrhageSTEP 4 Application of hydrostatic balloon (Bakri balloon)Uterine closure Hydrostatic balloon inflationB-Lynch suture ligature

STEP 5 BAKRI-BALLOON POSITIONING

MILD INFLATION OF THE BALLOON

STEP 5

REPOSITIONING THE UTERUS; FULL INFLATION OF BALLOON; B-LINCH SUTURE APPLIED

STEP 6

( Ex adiuvantibus ) postpartum hemorrhage

( Ex adiuvantibus )Separatore cellulare a flusso continuoUnit di gestione della temperatura corporeapostpartum hemorrhage

postpartum hemorrhageADULT INTENSIVE CARE UNIT POSTPARTUM

END POINT : SURGICAL CONSERVATIVE TREATMENT REACHED 95% ( 78 OUT OF 82 ) 4 HYSTERECTOMIESONGOING

US SCANDIFFICULT CASES.

RMNDIFFICULT CASES.

US SCAN CHECK AFTER 30 DAYSDIFFICULT CASES .

DIFFICULT CASES...( 02.09.2011)

DIFFICULT CASES......( 02.09.2011)

DIFFICULT CASES...( 02.09.2011)

DIFFICULT CASES...

CESAREAN HYSTERECTOMY

CESAREAN HYSTERECTOMY

CESAREAN HYSTERECTOMY

CESAREAN HYSTERECTOMY

ConsiderationsAll pregnancies are at risk of hemorrage in the post partum even if at the moment of birth there were no risk factors.Because our goal is to improve maternal health and prevent the possibility of death during the pregnancy or birth it is fundamental to possess, other than asolid preparation, a trustworthy and well trained team and the necessary instruments.

( Bakri balloon;Cell sorter with continuous flow; FloSeal)

New conservative approach in the management of PPHG. Clerici, G. Epicoco, E. Bottaccioli, S. Arena, I. Giardina, G. C. Di Renzo, G. AffontiUniversity Hospital of Perugia, Perugia, ItalyINTRODUCTIONPostpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Most deaths occur within the first 4 hours after delivery, often as a consequence of placental delivery. Treatment option for PPH include conservative management (uteritonic drugs, selective devascularization by ligation or embolization of the uterine artery, external compression with uterine sutures and intrauterine packing). Failure of these options necessitates hysterectomy.The objective of the study is to report our experience with a conservative management protocol to treat PPH in high risk patients diagnosed with placenta previa/accreta.METHODSA retrospective study of 49 patients (since October 2007) with placenta previa/accreta who underwent a conservative management protocol (see table).RESULTSConservative management of PPH was successfully achieved in 48 patients (98%). In only one case it was necessary to perform post-partum hysterectomy for massive bleeding due to severe placental accretism. In another case it was necessary selective embolization of the right uterine artery due to the presence of hematoma in the right part of the lower uterine segment and in the right paracolpus. The mean estimated blood loss was 1620 ml (range 1100-2340 ml). The mean hospital stay was 5.5 days (range 4-10 days). 22 patients (45%) underwent intraoperative and postoperative blood transfusions and the mean transfused volume was 700 ml. 18 patients (37%) were admitted for 24-48 h to intensive care unit for intensive monitoring. 30% of patients experienced moderate fever in the first 24-48 h and they were treated with antibiotics.CONCLUSIONSAll pregnancies are at risk of PPH. Its management is dictated by several considerations including hemodynamic status and desire to preserve fertility. Conservative interventions should represent mandatory step for treatment of PPH in high risk patients with placenta previa/accreta. The results of this conservative protocol are encouraging .

CONSERVATIVE MANAGEMENT PROTOCOL

STEP 1 Preliminary prophylactic catheterization of the descending aorta

STEP 2 Extraction of the fetus by C.S. and placental delivery

STEP 3 Multiple quadrate endouterine haemostatic sutures

STEP 4-Preparation of B-Lynch compressive sutures

STEP 5 Application of hydrostatic balloon (Bakri balloon)

STEP 6 Repositioning of uterus - uterine sutures - hydrostatic balloon inflation B-Lynch ligature

If the maneuvers fail the next step is devascolarizating ligature/selective embolization of the uterine arteries.If all procedures fail, proceed with hysterectomy.

Monitoring of maternal hematologic parameters 24 hrs before C.S. and 2 h after the procedure, than every 2-4 h for the following 24 hrs in relation to clinical conditions. Blood transfusion if the hemoglobin level decreases more than 7 g/dl and the hematocrit value is less than 21% ; The Bakri balloon is removed 24 h after delivery.

CONCLUSIONS

FACTS:All pregnancies are at risk of PPH even if no predisposing factors are presentLuis G. Keith 2007

BOTTOM LINEAverting maternal death is based on having a prepared mind, a prepared team and a full range of possible therapiesLuis G. Keith, 2007

Postpartum HemorrhageRecommendations:Every department needs to have a protocol for management of O.E., with periodic re-evaluation (Life Support training)Cases at risk of E.O. need to give birth in a II-III level structureUncontrollable hemorrhages may necessitate hysterectomy: an expert surgeon needs to be avaliable quickly 24 hrs a dayActivate the multidisciplinary team early in the management of a case at risk Institutional guidelines for the treatment of hemorrhages with periodic simulation training (skills and drills)

THANK YOU

**For each woman who dies during pregnancy, 30 women suffer complications.Initiatives should include:Family planningManagement of complications of abortionManagement of complications of pregnancy and childbirth**************From Evolution to ancient oxytocics3.5 thousand years ago, Egyptians were fully aware of the current problem:If you could promote uterine contraction, you would speed labourand stem haemorrhage.

Papyrus Ebers recommends various recipes, likeFly excrement is even mentioned in various ancient pharmacopoeias.

100 AD Discorides a Greek physician lived at Neros time recommends cyclamen, a flower.1600 anno domini, Gerad a British herbalist advices chervil, a pot herb.

This all has nothing to do with an OT agonist, I do not know, if it works, but it concerns exactly the same life threading indication!

Finally ergot came up, extracts and alkaloids from a fungus on rye.Longer used than OT, it causes strong uterine contraction, abortions,but is more toxic: nausea, vomiting, and hypertension*About 60 years ago, OXT was synthesised by Vincent du Vigneaud, an American biochemist.Driven by his interest in sulphur containing amino acidshe managed to isolate OXT and ADH from crude pituitary preparations.

He identified the structure of the nona-peptide.Here a chromatogram shows separated amino acids of the hydrolysateand an identical chromatogram from a mixture of artificial amino acids.

He succeeded with the synthesis of the first polypeptide hormone,put the amino acids together in the right sequence, closed the ring andfinally proved chemical properties and physiological activity.The most thrilling experience: The synthetic polypeptide and the natural product were identical.At that time, it wasnt taken for granted that synthetic and natural products behave chemically and pharmacologically identical.*Today, OT alone or in combination with ergometrin is globally available.However there are regional differences regarding the recommended use.The slide is not complete and does not mean OT is always the treatment of choice.It is described in monographs of several pharmacopoeias such asMost known brands are Syntocinon from Novartis, Pitocin from Pfizer etc.However some of the products have been withdrawn form the markets.

There are two major indications:OT infusions are useful to induce and augment labour.For PPH it is used alone or in combination with ergometrin.And there are additional indications such as:OT injected in umbilical cord vein to assist removal of a retained placenta.In the past, as nasal spray with good BA was used, it can induce lactation.OT challenge test to detect placental insufficiency and still birth risk:OT is infused in third trimester and the baby is monitored for heart rate anomalies.Finally in abortion it plays probably more a theoretical than practical role.*The next slide is dedicated to OT agonists.Carbetocin it is a long-acting synthetic analogue of OT.It contains a thioether instead a disulfide bridge, it lacks an amino acid - cysteine 1, and a phenol alcohol is blocked by a methyl ether.It is used for treatment of uterine atony following Caesarean sectionand in veterinary medicine.To my knowledge this is the only therapeutically or commercially relevant oxytocin agonist.An incredible number of OT derivatives have been synthesized, from different companies, from universities, from professors Manning +others some are published/patented, but I am not aware that any of them reached great relevance so far.However, there are some experimental peptides published like hydroxy threonine OT

And more recently there is again activity in non-peptide, central agonists such as the following:There is a series of compounds patented for erectile dysfunctionand from Wyeth-Ayerst a series for treatment of anxiety and schizophrenia-related diseases.Another series including compound 39 from ex-Ferring UK. molto bassa-debole .E sottolinea i potenziali effetti dannosi*****Nellimmagine in 3D si evidenzia la perfetta aderenza tra bakri e parete uterina***Efecto: transfomra la circulacin plvica en un sistema venosoCriterio de seleccinHemodinmicamente establesPreservar fertilidadExperiencia del cirujanoxito en el 42% de los casos (Clark, 1985)

**Ribaltare il problema: non pi la donna in radiologia,bens il radiologo in sala operatoria,se adeguata programmazione sanitaria (sale operatorie schermate,lettino operatorio radiotrasparente,angiografo portatile.Non necessariamente Maometto che va alla montagna,ma anche possibile che la montagna vada da Mometto*****Quando la muscolatura uterina perde la capacit contrattile va in atonia e pertanto il tamponamento uterino pu non essere sufficiente ad evitare la miopatia dilatativa.Con le bretelle della B-Lynch contropressione e quindi compressione sia estrinseca che intrinseca***Indispensabili sala schermata;angiografo portatile;lettino operatorio radiotrasparente.Preferibile lapproccio transomerale in quanto permette ,in caso di bisogno, alle due equipe di lavorare contemporaneamente;Il team di sala indossa grembiule piombato**Con angiostati ,pinze di Satinski o pinze ad anelli.Abbiamo aggiunto questo step da febbraio (placenta percreta).Da allora uso sistematico in quanto riduce in maniera significatica lentit della marea montante.Abbiamo iniziato con gli angiostati che per sono pinze estremamente delicate che sono ottimali per clampaggio diretto dei vasi,meno efficaci quando devono comprendere tessuto interposto.Attualmente Satinski**A destra suture quadrate poste sulla parete posteriore; a sinistra sulla parete aanteriore (bisogna preventivamente scollare la vescica ed evitare di trapassare allesterno.*60mm ;1/2 circonferenza****Nelle immagini ,a scopo didattico,tutte le operazioni sono eseguite ad utero esteriorizzato:Se non vi sufficiente spazio riposizionare lutero nella pelvi e poi procedere con isterorrafia,gonfiaggio,legatura della B-Lynch. Molta attenzione nel non bucare accidentalmete il pallone durante listerorrafia o durante lapposizione di punti emostatici aggiuntivi**Nei piccoli sanguinamenti a nappo,specie in precarie condizioni coagulative.In passato molto impiegato il FloSeal,oggi ritenuto pi maneggevole il Quixil (possibilit anche di erogazione con nebulizzatore.Costo inferiore)**Estremamente importante il separatore cellulare che ci permette di processare parte del sangue perso e recuperarlo;fondamentale nellimmediato postoperatorio recuperare e mantenere una adeguata temperatura corporea. ***Potremmo essere accusati di over treatment,e di eccessivo utilizzo di risorse.Almeno in interventi di elezione,in casi gi noti ad alto rischio emorragico bisogna predisporre la massima messa in sicurezza possibile,per ridurre al minimo il rischio materno.**Placenta previa centrale:notevoli lacune Vascolari che infiltrano il miometrio.Non ben evidenziabile il tessuto miometrale da quello placentare.deformazione dellimpronta vescicale.riscontro al color doppler e in basso alla elaborazione 3D dei vasi**Dallalto scansione sagittale 17 e scansione sagittale 13 con soppressione grasso (Fat Suppression)In basso scansioni coronali 9 e 11**A nostro avviso risultato impensabile senza limpiego delle risorse utilizzate.Quanti avrebbero salvato lutero? ****