Step wise pelvic devascularisation
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This document outlines the issues surrounding postpartum hemorrhage (PPH), its types, causes, and management strategies, stressing its significance as a leading cause of maternal mortality. It details the step-wise pelvic devascularization technique and other surgical interventions as effective methods for controlling PPH, while highlighting the importance of adequate training for healthcare providers. The document concludes that underestimating blood loss can lead to serious complications, and emphasizes the need for systematic pelvic devascularization as a vital skill in maternity care.
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Step wise pelvic devascularisation
- 2. Dr. Niranjan Chavan MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H Chairperson, FOGSI Oncology and TT Committee (2012-2014) Treasurer, MOGS (2017- 2018) Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016) Chief Editor, AFG Times (2015-2017) Editorial Board, European Journal of Gynecologic Oncology Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters Member, Managing Committee, IAGE (2013-2017) Member , Oncology Committee, AOFOG (2013 -2015) Recipient of 6 National & International Awards Author of 15 Research Papers and 19 Scientific Chapters Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH
- 3. INTRODUCTION • Postpartum hemorrhage (PPH) • World’s leading cause of maternal mortality • 1/3rd of all maternal deaths worldwide PPH • 60% of all maternal deaths in developing countries Countdown to 2015: Maternal, Newborn and Child Survival, WHO, 2012
- 4. INTRODUCTION • Majority of these deaths occur within 4 hours of delivery. • A Practice Bulletin from the ACOG 2011, places the estimate at 140,000 maternal deaths per year or 1 woman every 4 minutes due to postpartum haemorrhage.
- 5. POST PARTUM HEMORRHAGE • Blood loss • Vaginal deliveries > 500mL (3-5%) • Caesarean section deliveries >1000mL (5- 7%) • For clinical purposes, any blood loss that has the potential to produce hemodynamic compromise should be considered a PPH.
- 6. TYPES OF PPH • Primary (immediate) postpartum haemorrhage • Excessive bleeding that occurs within the first 24 hours after delivery • 70% due to uterine atony (failure of the uterus to contract adequately after the child is born)
- 7. TYPES OF PPH • Secondary (late) postpartum haemorrhage • Excessive bleeding occurring between 24 hours after delivery of the baby and 6 weeks postpartum • Due to retained products of conception, or infection, or both combined.
- 9. SHOCK : SYMPTOMS Mild (<20% Blood Volume Moderate (20–40% Blood Severe (>40% Blood Volume) Cool extremities Same, plus: Same, plus: Increased capillary refill time Tachycardia Hemodynamic instability Diaphoresis Tachypnea Marked tachycardia Collapsed veins Oliguria Hypotension Anxiety Postural changes Mental status deterioration (coma)
- 11. ETIOLOGICAL CAUSE CLINICAL RISK FACTORS ABNORMALITY OF UTERINE CONTRACTION (70%) Over distended uterus Polydramnios Multiple gestation Macrosomia Uterine muscle exhaustion Prolonged labor Precipitate labour High parity Intra-amniotic infection Fever Prolonged rupture of membranes Functional or anatomic distortion of the uterus Fibroid uterus Placenta previa or abruptio Uterine anomalies Distended bladder may prevent contraction of the uterus Uterine-relaxing medications Halogenated anaesthetics, nitroglycerin, magnesium sulphate
- 12. ETIOLOGICAL CAUSE CLINICAL RISK FACTORS RETAINED PRODUCTS OF CONCEPTION (20%) •Retained products •Abnormal placentation •Retained cotyledon or succenturiate lobe •Incomplete placenta at delivery •Previous uterine surgery •High parity •Abnormal placenta on ultrasound •Retained blood clots •Atonic uterus
- 13. ETIOLOGICAL CAUSE CLINICAL RISK FACTORS GENITAL TRACT TRAUMA (10%) •Tears (lacerations) of the cervix, vagina, or perineum •Ruptured vulval varicosities •Precipitous delivery •Operative delivery •Mistimed or inappropriate use of episiotomy •Extensions, lacerations at caesarean section •Malposition •Deep engagement •Uterine rupture •Previous uterine surgery •Uterine inversion •High parity •Fundal placenta
- 14. ETIOLOGICAL CAUSE CLINICAL RISK FACTORS ABNORMALITIES OF COAGULATION (<1%) Pre-existing states - haemophilia A -von Willebrand‘s disease1 History of hereditary coagulopathies • History of liver disease Acquired in pregnancy - Idiopathic thrombocytopenic purpura2 - Thrombocytopenia with preeclampsia - Disseminated intravascular coagulation - Preeclampsia - Dead foetus in utero - Severe infection/sepsis - Placental abruption - Amniotic fluid embolus •Bruising •Elevated BP •Elevated BP •Foetal demise •Fever •Elevated white blood cells •Antepartum hemorrhage •Sudden collapse Therapeutic anticoagulation History of thrombotic disease
- 17. IMMEDIATE RESUSCITATION • The primary treatment of PPH is to control the source of bleeding as soon as possible and to replace fluid. • Maintain airway, breathing and circulation • Large bore IV Line: Fluid replacement • O2 Inhalation • Crystalloid is the first fluid of choice for resuscitation. Immediately administer 2 L of isotonic sodium chloride solution or lactated Ringer’s solution in response to shock from blood loss • Blood transfusion Crystalloids restore volume in a 3:1 ratio Colloids restore volume in a 1:1 ratio
- 19. MANAGEMENT OF PPH • External and internal bi-manual uterine massage • Aortic compression • Umbilical vein injection (injection of uterotonic into the umbilical cord attached to the undelivered placenta) • Manual exploration of the uterus and manual removal of the placenta • Repair of perineal trauma including repair of episiotomy • Repair of cervical and high vaginal tears
- 20. TEMPORIZING MEASURES • Temporizing measures recommended for intractable atonic and non-atonic PPH include: 1. External aortic compression 2. Bimanual uterine compression 3. Non-pneumatic anti-shock garment (NASG)
- 21. SURGICAL MANAGEMENT OF PPH • Uterine compression sutures • Systematic pelvic devascularization • Uterine artery embolization • Total or sub-total hysterectomy
- 22. SYSTEMATIC PELVIC DEVASCULARIZATION • Uterine and utero-ovarian artery ligation followed by internal iliac artery ligation. • One of several uterus-conserving techniques. • Relatively simple and effective procedure should be taught during Obstetric and Gynaecologic training.
- 23. UTERINE ARTERY LIGATION • Expose the lower part of the broad ligament. • Feel for pulsations of the uterine artery near the junction of the uterus and cervix. • Pass a needle loaded with Catgut No 1-0 around the artery and through 2–3 cm of myometrium (uterine muscle) at the level where a transverse lower uterine segment incision would be made. Tie the suture securely. • Place the sutures as close to the uterus as possible because the ureter is generally only 1 cm lateral to the uterine artery. • Repeat on the other side.
- 24. UTERINE ARTERY LIGATION • 1ST Step in systematic pelvic devascularisation. • uterine arteries which provide approximately 90% of uterine blood flow. • Ligation of uterine arteries alone has success rate of 80% in controlling PPH
- 25. SITES FOR LIGATING UTERINE ARTERY
- 26. UTERO OVARIAN ANASTOMOSIS • If the artery has been torn, clamp and tie the bleeding ends. • Ligate the utero-ovarian artery just below the point where the ovarian suspensory ligament joins the uterus. • Repeat on the other side. • Observe for continued bleeding or formation of hematoma. • Close the abdomen in layers.
- 27. INTERNAL ILIAC ARTERY LIGATION • Experiments in the 1960’s by Burchell, ascertained that ligating the hypogastric artery turned the pelvic circulation like a venous system, thereby aiding clotting and controlling PPH. • It is effective in Uterine atony, midline perforation, large broad ligament or lateral pelvic wall haematoma, multiple cervical tears and lower segment bleeding.
- 28. INTERNAL ILIAC ARTERY LIGATION • Bilateral ligation results in 85% reduction in pulse pressure and 50% reduction in blood flow in the arteries distal to the ligation. • Internal iliac artery ligation also helps the vaginal bleeding as the vagina is supplied by the vaginal branch of internal iliac. • The reported success rate of bilateral internal iliac artery ligation varies widely from 42% to 93%.
- 29. INTERNAL ILIAC ARTERY LIGATION
- 30. POST-OPERATIVE CARE • Antibiotics • Analgesics • Assess hemoglobin and labs for DIC • Transfusion
- 31. AUTHORS YEAR METHOD NO. OF WOMEN SUCCESS RATES Evans et al 1985 Internal iliac artery ligation 14 6/14 (42.8%) Clark et al 1985 Bilateral hypogastric artery ligation 19 8/19 (42.1%) Fahmy 1987 Uterine artery ligation 25 20/25 (80%) Fernandez et al 1988 Internal iliac artery ligation 8 8/8 (100%) Chattopadhyay et al 1990 Bilateral hypogastric aretry ligation 29 19/29 (65%) AbdRabbo 1994 Step-wise uterine devascularisation 103 103/103 (100%) Ledde et al 2001 Bilateral hypogastric artery ligation 48 43/48 (89.5%) Hebisch et al 2002 Vaginal & uterine artery ligation 13 12/13 (92.3%) Pennet et al 2004 Bilateral uterine artery ligation 5 2/5 (40%) TOTAL 264 83.7%
- 32. CONCLUSION • Blood loss is consistently underestimated. • Underestimation may result in inadequate treatment resulting in complications or death. • Ongoing trickling can lead to significant blood loss. • Anaemia and other underlying health conditions may profoundly affect a woman‘s ability to tolerate any amount of blood loss.
- 33. CONCLUSION • Systematic pelvic devascularisation is an effective and uterus conserving surgical method to control PPH. • All health care providers providing maternity care require to learn this life-saving skill to enable them to make a significant contribution to reducing maternal deaths and to promote safe motherhood.
- 34. REFERENCES • Countdown to 2015: Maternal, Newborn and Child Survival, WHO, 2012 • Lu M C, Fridman M, Korst L M. et al. Variations in the incidence of postpartum hemorrhage across hospitals in California. Matern Child Health J. 2005;9:297–306. • Sivan E, Spira M, Achiron R, Rimon U, Golan G, Mazaki-Tovi S, et al. Prophylactic pelvic artery catheterization and embolization in women with placenta accreta: can it prevent cesarean hysterectomy? Am J Perinatol 2010;27:455–61 • Harrisons Principle of Internal Medicine, 19th edition • Global causes of maternal death: a WHO systematic analysis Lale et al.The Lancet Global Health June 2014 , Volume 2 , Issue 6 , e323 - e333 • Iwata A, Murayama Y, Itakura A, Baba K, Seki H, Takeda S. Limitations of internal iliac artery ligation for the reduction of intraoperative hemorrhage during cesarean hysterectomy in cases of placenta previa accreta. J Obstet Gynaecol Res. 2010 Apr;36(2):254-9.