Surgical management of pph at tertiary center

SURGICAL MANAGEMENT OF PPH
AT TERTIARY CENTER

PROF. (Dr ) M.C. Bansal
MBBS, MS , FICOG , MICOG .

Pregnancy
the most dangerous journey of mankind…

Definition
WHO defines PPH as blood loss of more than 500
ml following vaginal delivery or more than 1000 ml
after caesarean section. In Asian women even loss
of 300 ml can have sinister effect due to smaller
built, lesser blood volume, lower Hb & poor
nutrition. However, various authors suggest that
PPH should be diagnosed with any amount of
blood loss that threatens the hemodynamic
stability of the woman.

Causes of Maternal Death

Haemorrhage
24.8%

Infection
14.9%
Haemorrhage
Indirect
is the biggest
causes
and fastest
19.8%
killer
Eclampsia
12.9%
Other direct
causes Obstructed labour
Unsafe
7.9% 6.9%
abortion
12.9%

Postpartum Hemorrhage

 PPH is a serious, Life-threatening obstetric problem.

 One of the leading causes of maternal morbidity and
mortality.

 In developing countries mainly due to three delays: -
1. Delay in seeking care.
2. Delay in reaching care.
3. Delay in receiving care.

Maternal Mortality following PPH

WHO estimated
5,29,000 maternal death / year in world
1,36,000 maternal death/ year in India i.e.
30%
29.6% maternal deaths due of PPH.
In India, about 15.15% - 25.8% mothers die
due to PPH.

Additional burden of PPH

• > 50% of births in India take place at
home without the help of trained/
qualified Birth attendant .

• 83% of rural deliveries occur at home

• 80% of women are anaemic

Incidence of PPH
• 11% women with live birth i.e. 14 million
women / year
• 3.9% in vaginal deliveries

• 6.4% in Cesarean section .

• Higher with high risk factor

• 10% overall.

• Mismanagement of III stage results in
higher incidence of PPH

The Four Ts Mnemonic – Causes of PPH

Four Ts Causes Incidence (%)

1st Tone Atonic uterus 70

2nd Lacerations, hematomas, 20
Trauma inversion, rupture

3rd Tissue Retained tissue, 10
Invasive placenta

4th Coagulopathies 1
Thrombin
Am Fam Physician 2007;75:875-82.

MMR & MORBIDITY DUE TO OBSTETRICAL
HAEMORRHAGE

‘Prevention is
easier and better
than cure’

Prevention of PPH ???
It can be achieved
by
Active management
of
3 rd stage of labour

Active Management – Why?

30

20
Percent

10

0
Transfusion Prolonged 3rd Therapeutic Low Retained
Stage Uterotonic Hemoglobin Placenta

Active Management Physiological Management McMormick, Sanghvi,
Kinzie, McIntosh,
IJGO2003

1. Reduces length of time of 3rd stage
2. Reduces amount of blood loss
3. Reduces need for blood transfusions

Prevention
 Universalization of Spancer’s
Modification of Brand- Andrew’s
technique of placental delivery e.g.
prophylactic injection of uterotonics at
the time of delivery of anterior shoulder
followed by traction and counter
traction maneuver for placental
delivery.
 Prompt recognition and aggressive
management according to the cause of
PPH.

Prevention (contd)

 Shout for help 

 1. Blood bank , relative, donors, blood and
blood components.
 2. Anesthetist
 3. Prepare Operation Theater.
 4. Immediate Communication with nearest/
dependent Tertiary center,
 5. Quick transportation to Tertiary Centre
(summon obstetrical flying squad /108
Ambulance)

Recognition Referral Responsiveness

“No matter where a woman delivers, giving birth
should be a moment of joy, not a sentence to
death”

“While managing PPH
Time lapsed should not
be counted in a minute-
--one has not lost one
minute ,but 60 seconds”
Ian Donald

“No amount of Blood from any
blood bank is safer and better
than Her own blood.”

Hence be prompt in
saving each second and every
drop of blood of bleeding woman
in her 3rd stage of labour,

Treatment Protocol Of Primary Atonic PPH
(1st T)

Management Management of
of Shock Uterine atonicity

Replacement of blood * Conservative medical or its
component management

* Surgical management
- Conservative surgery
- Radical surgery

Stepwise Management of Atonic PPH
Step I - Bleeding continues
- 15 methyl PGF2 250g every 15-30 mint.
Step II - a) Bimanual compression
b) Aortic compression
Step III - Transvaginal options
- Uterine packing
- Tamponade
Step IV - Compression sutures
B.Lynch, Hayman, Cho Square
Step V -Other surgical measures
- stepwise uterine devascularisation

Step VI - Hysterectomy

Conservative Surgical Management

Mode of Actions:

 Controls PPH
 Preserves reproductive functions

 Avoids hysterectomy and related
complications and consequences

Bimanual Compression of Relaxed Uterus

Conservative Surgical Management
Options In Atonic PPH
 Manual removal of placenta
 Exploration of uterus
 Uterine Packing by Roller gauze, Condom,
Foley Catheter, Sengstaken Blackmore tube,
Surgical Glove distention,Balloon
tamponade
 Step-wise devascularization of uterus
 B-Lynch suture, Hayman suture, Gun Sheela,
Cho multiple square suture
 Internal iliac (hypogastric) artery ligation
 Postpartum Arterial embolisation

UTERINE PACCKING PLASTC BAG INFUSED WITH
SALINE

Balloon Tamponade
 Two-way catheter - temporary
control of PPH
 Feasible in a scenario of atonic
PPH following a vaginal delivery,
unresponsive to medical
management & before
interventional radiological
procedures or surgical
interventions
 Simple, cheap, easy to use &
effective measure

Procedure

 Balloon portion is placed directly into uterus [entire balloon
(500ml capacity) has to be inserted past the cervical canal &
internal os].
 Gentle traction on balloon shaft ensures proper contact
between balloon & tissue surface & enhances tamponade
effect
 Success is judged by a declining loss of blood from cervix &
that seen through drainage port
 Mean time for leaving the tamponade balloon - 8 to 48 hours
 Gradual deflation of the balloon is advised to reduce the
potential risk of further bleeding

Step-Wise Devascularisation Of The Uterus

 1st reported from Egypt
 Effective in controlling PPH in 80% of cases
 Unilateral uterine artery ligation
 Bilateral uterine artery ligation at the upper part of the
lower uterine segment
 Low uterine vessels ligation after mobilization of the
bladder
 Unilateral ovarian vessel ligation
 Bilateral ovarian vessel ligation

Ovarian Artery Ligation

 Ovarian artery directly arises from the aorta

 Anastomosis with the uterine artery in the region of
the uterine aspect of the utero-ovarian ligament

Uterine Artery Ligation

 90% blood supply of uterus in pregnancy
is from uterine vessels

 Ligation of uterine arteries result into
significant reduction in blood flow to the
uterus

Uterine
Artery
Ligation

ABDOMINAL
ROUTE

Vaginal Route for
Uterine Artery Ligation

 Indicated in

atonic PPH
following
vaginal
delivery

B-Lynch Suture
 Exerts continuous vertical compression on uterine
vascular system
 Before proceeding to place the suture into uterus,
potential efficacy of B-Lynch suture should be tested for
by performing open bimanual compression to see if
bleeding stops
 The assistant performs compression & maintains it with
2 hands during the placement of the suture by the
surgeon
 Monocryl suture or Vicryl number 2 should be used

Cho Multiple Square
Compression Sutures
 Multiple square sutures
are used to cover the
whole body of uterus using
a straight 10-cm needle
 May be useful in placenta
previa

Sketch of pelvic blood vessels

Internal Iliac Artery
(Anatomy-Surgical dissection)

INTERNAL ILLIAC ARTERY (ANATOMY) SURGICAL DISSECTION

Internal Iliac Artery Ligation

Conditions indicating ligation –
 Atonic uterus refractory to
other measures
 Abruptio placentae with uterine
atony
 Abdominal pregnancy with
pelvic implantation of the
placenta & placenta accreta

Internal Iliac Artery Ligation

T Therapeutic indications
 Before or after hysterectomy for PPH

 Continuous bleeding from the broad ligament base;
profuse bleeding from pelvic side-wall or vaginal angle
 Diffuse bleeding without , clearly identifiable vascular

bed
 Ruptured uterus in which uterine artery may be torn at

its origin from internal iliac artery
 Where extensive lacerations of cervix have occurred
following difficult instrumental delivery

INTERNAL ILLIAC ARTERY
LIGATION

Uterine Artery Embolization

 Highly feasible, safe & beneficial procedure,
possibly precluding further laparotomy &
hysterectomy
 If successful, not only saves the patient’s life,
but also preserves the functions of uterus
,tubes and ovaries.
 Should be the procedure of choice for PPH
prior to surgical intervention

ANGIOGRAPHY – UTERINE ARTERY

BLOCKED
uterine
ARTERY
after
EMBOLIZ
ATION

Hysterectomy
 Best immediate option
 When uterine atony is unresponsive to uterotonics
 Where facilities for embolization are not available
 Obstetrician not well versed with technical aspects of
conservative surgical procedures or iliac artery ligation

 Indications
 Uterine rupture secondary to obstructed labor
 Previous Caesarean section
 If rupture is extensive & hemorrhage cannot be contained by
suture of ruptured area

PPH in CASE of ABRUPTIO PLACENTA ( Covouliare Uterus)

2nd T Surgical Treatment of
Traumatic PPH
Causes 
1.CervicalTear-Lateral, annular, bucket handle type
detachment.
2. Vaginal Tear - Circular / Vertical, colporrhaxis.
3. Extended Episiotomy — upwards towards
posterior fornix, downwards involving anus
and rectum.
4. Vulval Hematoma .
5. Perineal lacerations.
6. Para Urethral tear , clitoral tear.
7. Uterine Rupture – complete / incomplete
8. Broad Ligament hematoma

Cervical Tear Repair
 Recognition - unilateral / bilateral
 Stitching under good light,

Treatment Protocol for Rupture

Treatment protocol of Uterine rupture

3rd T - TISSUE FACTOR
 Retained Placenta
1. With Active Bleeding---MRP
- Partially Separated.-----MRP
- Retained Cotyledons.----Uterine Exploration and E&C
- Retained piece of Membranes.—Uterine Exploration and
E&C
2. With No Bleeding.
- Active Retention ( Hour Glass Contraction)-G.A., Placental
Delivery.
- Placenta Accreta
- Placenta Inccreta
-Placenta Perccreta.
 Acute inversion of Uterus--Protocol

Retention of Placenta
Retention of Retention of
Detached Placenta Adherent Placenta

Uterine Hour glass contraction Simple Adhesion Morbid Adhesion
Inertia ( constriction ring ) Placenta Accreta
Placenta Inccreta
Placenta Perccreta

Morbid Adherent Placenta
 Placenta Accreta Rare occurs in 1: 500 to
1: 700 deliveries. Placenta adhers to uterine
wall because the Decidua and the Nitabuch
layer , the physiological cleavage in decidua is
lacking or incomplete.
 Inccreta placenta penetrates the uterine
myometrium to variable3 depth.
 Perccreta Very rare occurring in1 : 6,000 to
1: 40,000 deliveries. Placenta perforates the
entire thickness of uterine wall and serosa
even., -- entire placenta or part of it maybe
morbidly adherent.

A hysterectomy specimen of placenta Percreta

Placenta Perccreta
( A case of Placenta Previa & rupture Uterus)

Rx of Morbid Adherent Placenta
 Once the diagnosis is made , counseling the woman
and her relatives regarding possible need of Hystere
ctomy will avoid psychological and medicolegal
problems.
 Medical Management Umbilical cord is cut close
to placenta and left in situ. A course of 6 doses of
Methotrexate is given orally or parenterly in a dose
of 50 mg Methotrexate and 6mg Folinic acid on
alternate days.
 Follow up with USG and Beta HCG estimation
weekly indicates the need for further courses of the
medicine.
 Woman can have normal Delivery in future.

Inversion Of Uterus
 “Turning inside out of the uterus”
 Acute Inversion is extremely rare ---In India its incidence
is reported ----1: 23,0000 deliveries.
 Management
1. Resuscitation measures must be promptly instituted ,
Blood transfusion , I.V.fluids and sedation given.
2.Immediate manual reposition in labour room under
sedation ( 2- 4.gm MgSo4 in 10ml iv or Terbutalin o.25
in5ml saline iv.)without administration of utero -tonics .
3.O “ Sullivan ‘s technique of intra vaginal hydrostatic
pressure.
4. Surgical Technique---usually required in chronic
case3s.

Faulty Technique of placental delivery leading to
Inversion Uterus(a,b,,c)

Acute complete Inversion of Uterus with Attached Cord

Diagramatic Staging Of Inversion OF Uterus

Abdominal view of Inversion Of Uterus

Manual Reposition Of Inverted Uterus

Treatment Protocol for Inversion Uterus

Saving life of the one giving birth
to a new life…

Surgical management of pph at tertiary center

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