MANAGEMENT OF POST MANAGEMENT OF POST PARTUM HAEMORRHAGEPARTUM HAEMORRHAGE

Dr. Rabinarayan SatapathyDr. Rabinarayan Satapathy

Asst. ProfessorAsst. ProfessorDept. of Obst.& GynaeDept. of Obst.& GynaeS.C.B. Medical College,CuttackS.C.B. Medical College,Cuttack

INTRODUCTION The World famous monument “Taj Mahal” was

built in memory of a woman who died of postpartum haemorrhage during her fourteenth child birth.

Postpartum haemorrhage (PPH) is an obstetric emergency and it is the most challenging situation to Obstetricians.

At the end of the last century , 25% of maternal death was estimated to be due to PPH according to WHO.

In developing countries, risk of dying from PPH is 1 in 1000 deliveries.

The incidence of PPH varies from 4-6% of all deliveries.

DIAGNOSIS PPH is a description of an event and not a

diagnosis. Most of the primary PPH occurs within 4 hours

after delivery. In majority of cases, profuse bleeding at the time of caesarean section and after vaginal delivery, makes diagnosis obvious. But rarely bleeding is concealed as broad ligament haematoma or uterine rupture where signs and symptoms of hypovolaemic shock helps in diagnosis of PPH.

Traumatic haemorrhage – the uterus is well contracted.

Atonic haemorrhage – uterus is flabby and becomes hard on massaging.

PREVENTION OF PPH Antenatal Care : Prophylactic iron and folic acid supplementation. Detection of anaemia and its treatment Identification of high risk cases who are prone to

develop PPH (Placenta previa, Twin pregnancy, PIH, Obesity, Large baby, prolonged labour) and their special management.

Intrapartum Care: Active management of third stage of labor, a) Administration of prophylactic oxytocic drugs before

delivery of the placenta.b) Controlled cord traction decreases the risk of PPH by

40%. Oral misoprostol (600mg) is quite effective in

preventing PPH when given after delivery of the baby (WHO, 1998).

Routine uterine palpation , massaging and inspection of both placenta and lower genital tract.

Adequate antibiotics after operative and manipulative delivery.

PRELIMINARY STEPS IN MANAGEMENT OF PPH

Helps of a senior person is always sought. Two IV lines with large bore cannula should be

set up Assessment: (a) amount of blood loss (b) General

condition (c) Degree of hypovolaemia Oxygen to be administered by O2 mask

Blood sent for: Grouping , cross matching, Complete haemogram, coagulation profile, Antibody screening

Fluid replacement : Crystalloid , Colloid, Blood Indwelling urethral catheter. Monitoring of vital parameter: Levels of

consciousness, pulse , Blood pressure, Urine output.

MANAGEMENT OF ATONIC PPH Uterine atonicity is responsible for 75-90% cases

of PPH. In the treatment of atonic PPH, medical methods

are instituted first in a step wise manner before resorting to surgical methods , one should pass onto the next step without losing time because here a minute counts.

MANAGEMENT OF THIRD STAGE BLEEDING Massage the uterus if not contracted , oxytocin

should be added to I.V. drip (10 units in 540ml of fluid).

If signs of placental separation appear , then delivered by controlled cord traction.

If spontaneous separation does not occur and bleeding continues MROP should done under anaesthesia.

MANAGEMENT OF ATONIC PPH AFTER DELIVERY OF PLACENTA

Uterine massage Oxytocin in I/V Drip Methyl ergometrine ( Methergin)0.2 mg I/V Prostaglandin derivatives:

15 methyl PGF2α - 0.25mg I/M or intramyometrial repeated every 15-90minutes and maximum dose of 2 mg or 8 doses.

PGE2: 20 mg given P/V or P/R route. PGE1 (Misoprostol) : 1000 µg used per rectally. ‘O’ Brien and Colleagues (1998) reported that

misoprostol 1000 mg given rectally, was effective in 14 women unresponsive to usual oxytocic.

Bleeding unresponsive to oxytocic Obtain help, Reassess the diagnosis, Begin blood

transfusion, Employ bimanual uterine compression

Bimanual uterine compression

OTHER TRANSVAGINAL OPTION Uterine exploration Balloon tamponade :

• Foleys catheter or stomach balloon of a senga staken- Blackemore tube is inserted within the uterine cavity and inflated.

• It is left for 24 hours• A condom introduced inside uterine cavity and

inflated with fluid. Uterine Packing

• Done under analgesia or anesthesia • Pack completely and uniformly• Prophylactic antibiotics, oxytocic• Vital signs every 15 minutes• Removal at 24-36 hours Contd…

It helpful in :

1. Selcted cases of placental site bleeding

2. When surgical treatment is non available

3. When patient is unsuitable for surgery

4. For transfer of a patient to referral center.

Disadvantage:

• Its mode of action is non-physiological as it

prevents uterine muscle contraction.

• It may mask trauma and ongoing haemorrhage

• May cause infection

SELECTIVE ARTERIAL EMBOLISATION In 1979 , Brown first reported the method of

angiographically guided arterial embolisation for the treatment of PPH.

Usually uterine artery or internal iliac artery embolisation is done

Advantages:• Success rate is high• Complication rate is low• Very useful when surgery is difficult like

retroperitoneal haematoma• Fertility is preserved• Surgical risk is reduced• If it fails surgical options remains open.

Disadvantages:• Needs interventional radiological set up

which may not be available in emergency.

• Haematoma formation at the site of catheterisation.

• Infection resulting in low grade fever and pelvic abscess.

• Ischaemic phenomenon due to vascular injury.

• Radiation exposure

• Sciatic nerve injury

UTERINE VESSEL LIGATION Uterine artery is ligated first

unilaterally and then bilaterally at a level of upper part of lower uterine segment in LSCS, artery is ligated 2-3cm below the level of uterine incision.

First bladder is pushed down to avoid injury to ureter.

A large atraumatic needle with absorbable suture is used.

SURGICAL METHOD If the patient continues to bleed inspite of

conservative measures Any coagulopathy should be excluded prior to

laparotomy

Needle is passed from anterior to posterior , 2-3 cm & medial to the vessels including full thickness of myometrium and then brought back from posterior to anterior through an avascular area of broad ligament and the knot is tied.

The step is repeated on the otherside

A second pair of stiches can be placed in the same way bilaterally 3-5 cm below the upper ligatures after mobilising the bladder down wards. These ligatures obliterate most of the supply of uterine artery to lower uterine segment and to its cervical branch.

Advantage: Simple to perform and can be done quickly. Lower complication rate. As it is a more distal ligation of artery than

internal iliac there is less chance of further bleeding because of collaterals as compared to internal iliac.

No long term vascular effect has been documented.

Subsequent pregnancy has been documented. Limitation of uterine vessels ligation:

It is not useful in : • Myometrial pathology like myoma• Intramural cervical laceration• Retained placental fragments.

LIGATION OF UTEROOVARIAN ANASTOMOSIS

It involves identifying an avascular area of mesovarium near the uteroovarian ligament and ligating the utero-ovarian vessels by few interrupted stitches.

Pioneered by Howard Kelly Mechanism: By reducing

arterial pulse pressure (85% reduction in bilateral ligation) by converting the pelvic arterial circulation into a venous system.

Procedure: Internal iliac artery is identified and with the help of aneurysm needle , two silk sutures are placed around the artery ½ cm apart and 2 cm below its origin (to exclude the posterior division of internal iliac artery) and tied.

INTERNAL ILIAC ARTERY LIGATION:

Complication: Injury to internal iliac vein and external iliac artery.

Usefulness: It is successful in controlling haemorrhage in

42%. It should be done in relatively haemodynamically

stable patient who desire future pregnancy. Internal iliac ligation is particularly useful in cases

of traumatic PPH (like rupture uterus), where hysterectomy has been done but bleeding is still continuing.

Disadvantages: It is more technically challenging than uterine artery

ligation requiring sufficient skill and experience. It cannot be done in haemodynamically unstable

patient as it is time consuming.

HAEMOSTATIC SUTUREB-Lynch Procedure: Crystopher B Lynch (1997) introduced this

technique of surgical management of PPH where uterus is conserved.

Mechanism of action: The sutures acts by over sewing the uterus to

apply on-going compression. Bimanual compression is performed to test the

potential efficacy of the suture. If compression controls bleeding , brace suture

can be placed.Indication: It is useful in placental accreta, increta, percreta,

placenta previa bleeding and atonic PPH where medical treatment fails.

B-LYNCH PROCEDURE

Technique:

Placing an absorbable suture vertically from 3 cm below the uterine incision to 3 cm above the uterine incision on the right side of the uterus. The stitch is then taken vertically over the fundus and placed horizontally in the posterior uterus at the same level as the anterior suture.

The suture is threaded over the left side of the uterus to place another stitch on the left from 3 cm above the uterine incision to 3 cm below the uterine incision.

The long suture is tied compressing the fundus.

Advantages:: It is easy to apply, can be done quicker than

hysterectomy and internal iliac ligation. Fertility can be conserved.

Disadvantages: Hysterotomy is a prerequisite to perform this

procedure.

Modified B-Lynch Procedure: No 2 chromic catgut is passed through

anterior and posterior walls of the uterus 3 cm above the uterine incision, 4 cm medial to lateral border and passed over fundus to anterior surface and tied.

It is repeated on other side.

ISTHMIC CERVICAL APPOSITION SUTURE: It is particularly helpful in bleeding from lower

uterine segment in cases of placenta previa and morbid adhesion of placenta.

No-2 chromic catgut on a straight needle is passed through anterior wall and posterior wall of the lower segment , 2 cm medial to the lateral boarder and 3 cm below the cut margin.

Then it is brought back through posterior and anterior walls 1 cm medial to first entry and tied anteriorly. The same procedure is repeated on other side.

A pair of closed artery forceps are passed between both stutres through the cervical canal to ensure drainage of uterine collection.

HYSTERECTOMY Indication:

• Placenta accreta or percreta• Uterine atony• Association of placenta previa and prior

LSCS• Rupture uterus• Extension of LSCS incision• Broad ligament haematoma after forceps ,

lacerated cervix/vagina after ventouse• Severe chorioamniotitis

The principle is to clamp, cut and drop the pedicles to below the level of uterine arteries. Contd…

Whether subtotal or total hysterectomy:• Subtotal hysterectomy is often the choice of

operation to reduce the operation time and blood loss in cases of atonic PPH.

• If bleeding site is in lower uterine segment or cervix as in cervical laceration or central placenta previa bleeding will not be controlled by subtotal hysterectomy and total hysterectomy is needed.

Advantage of hysterectomy:• It is the definitive treatment and stops

bleeding in atonic and traumatic PPH• Familiarity of the obstetricians with the

procedure of hysterectomy. Disadvantage: Future child bearing capacity is

sacrificed.

PLACENTA ACCRETA-INCRETA-PERCRETA AND POST PARTUM HAEMORRHAGE

Management depends on the site of implantation, depth of penetration and extent of the placental involvement.

In case of focal placenta accreta- the cotyledon is either pulled off the myometrium.

In more extensive involvement as placental removal is attempted, profuse bleeding occurs demanding immediate blood transfusion.

Prompt hysterectomy is the definitive treatment When there is total placenta accreta-leaving the

placenta in situ, administration of methotrexate and regular follow up with serial β-HCG estimation and USG are suggested by some authorities. Other conservative approach is manual removal of placenta as much as possible and then packing of uterus.

However , leaving the placenta is not universally acceptable because of the risks of haemorrhage and infection.Hence the safest t/t is prompt hysterectomy.

Suspected when bleeding continuing with a firmly retracted uterus (may also be associated with atonic PPH).

Laceration of cervix and vagina.

Repair needs : good light source, exposure, optimal instrument , infiltration of vasopressure at the cut margins.

Suturing should start above the apex

Interrupted sutures preferred.

TRAUMATIC PPH

PELVIC HAEMATOMA Pain, Symptom of pressure, HypovolaemiaSmall haematoma (<5cm): Conservative treatment.Larger haematoma: Should be explored under general anaesthesia. Bleeder ligated If not found - dead space obliterated by mattress suture Vaginal pack Prophylactic antibiotic Blood transfusion usually required.

UTERINE RUPTURE Simple repair if patient wants to preserve her child

bearing capacity. Otherwise hysterectomy is performed.

UTERINE INVERSION Complete uterine inversion – Iatrogenic Management: Resuscitation Assistance including one anaesthesiologist. Immediate replacement If placenta is still attached , MROP should be done

after the uterus is reposed. If manual replacement fails , repeat under

ananesthesia & tocolytic. Hydrostatic (O’ Sullivan’s) replacement If fails

then , reposition may be done by abdominal Haultains operation

After replacement uterus should be kept contracted with oxytocic.

Observe for reinversion.

COAGULATION DISORDER Consumptive coagulopathy usually acquired can

be reversed by treatment of underlying pathological process.

No intervention improves maternal prognosis in amniotic fluid embolism.

Heparin and E-aminocapraic acid are dangerous. Judicious and rational management with fresh

frozen plasma or even fresh blood may arrest bleeding and improve patients general condition.

Aim is to keep clotting factors at safe levels: i.e., Fibronogen ≥ 100mg/dl Platelets ≥ 40,000/mm3

FDP < 1 mg/dl

SECONDARY POST PARTUM HAEMORRHAGE:

Secondary PPH most commonly occurs within 5-15 days postpartum.

Common causes are :Retained and infected products of conception.Placental polypSubmucous fibromaChoriocarcinoma

Diagnosis : Other than vaginal bleeding , there may be

evidence of sepsis (pyrexia, lower abdominal pain, offensive discharge per vagina, subinvolution of uterus and uterine tenderness).

Pelvic ultrasound helps in diagnosis

Management:Antibiotics

Intravenous fluid

Oxytocic

Blood transfusion

In presence of product of conception – evacuation is done

In case of placental bleeding – packing may be helpful to arrest bleeding

In exceptional cases uterine artery ligation or hysterectomy is needed.

CONCLUSION Postpartum haemorrhage is still a leading

cause of maternal mortality.Availability of prostaglandins has greatly

reduced the incidence of severe PPH of atonic origin.

To deal with PPH , a prompt and effective action is necessary within a very short period of time.

When conservative measures fail , early resort to hysterectomy is life saving.

The best is to save the life and uterus. But, losing a life in an attempt to preserve the uterus is the greatest tragedy in an obstetricians life!