2.management of postpartum haemorrhage.pptx

Management of PPH

1. MANAGEMENT OF PPH Dr Iqra Osman

2. Multidisciplinary team consisting of obstetrician , a n aesthetis t , h a emotolo g is t , theat r e s t aff a nd n ursi n g s t aff is ideal. The patients general condition is evaluated and if he/she i s i n shock immedi a te r esuscitati v e measu r es a r e instituted. A h a nd on uterus wi l l co n firm ato n ic i ty a n d en a b l e uteri n e ma s sage w h i ch s ho u l d be do n e conti n uo u s l y .

3. PRINCIPL E S OF MANAGEM E NT GENERAL MEASURES Resuscitati v e mea s u r es Investigations Monitoring C o nf i rm the ca u se of PPH MEDICAL METHODS MECHANICAL METHODS SURGICAL METHODS R A DIOLOGIC A L A R TERIA L EM B O L IS A TION

4. GENERAL MEASURES RESUSCITATIVE MEASURES FLUID REPLACEMENT T w o i n tr a v e n o u s i n fusi o n s w i th l a r g e 14 g a u ge c a n n u l a e a r e s t a r ted A i m i s to r e p l a ce 2 - 3 times the estimated b l o o d l o se Crystalloids (normal saline or Ringer lactate) infused at the r a te of 1 L i n 1 5 - 2 min Colloids can be given until blood is available (1-2L) C r os s match b l o od sho u l d b e g i v en as r a p i d l y as p os s i b le A central venous pressure line can be introduced

5. BLOO D COM P ONEN T THEO R Y Correction of RBC deficit is guided by the rule that each unit of packed cells will restore Hb concentration by 1gm/dl If there is evidence of coagulation defects fresh frozen plasma, platelet concentrates, and cryoprecipitate are made a va i l a b l e

6. F or e v e r y 6 u n it s of r ed cel l s , 4 un i ts of f r e s h f r ozen p l asma can be g i v en E a ch ad u l t dose of c r y op r eci p itat e wi l l ra i se f i b ri n ogen l e v el b y 1 0mg/ d l Each adult dose of platelet concentrates will raise the p l atel e t co u nt b y 2 0/L

7. OTHER MEASURES O x ygen can be g i v en b y a m ask or nasal ca n n u l a at rate of 1 - 1 5 L/min Patients leg may be elevated in order to increase venous return If unconscious patient should be turned to one side to minimise aspiration in case of vomiting Important to keep patient warm as hypothermia will ex a cerb a te p o or per i p h eral ci r cu l ati o n

8. INVESTIGATIONS LABOR A T O R Y TESTS H b , h a ematocri t , b l oo d g r o u p i ng a n d c r os s match i ng m ust be do n e P l atel e t count, fi b ri n ogen as s a y , p a r tial th r ombo p l a s t in tim e , p r oth r o m b i n time sho u l d be measu r ed . Electrolytes, urea and creatinine needed in severe hemorrhage Bedside tes t s l i k e clot obse r vati o n te s t or clotti n g time can be d o ne

9. MONITORING P u ls e and Blo o d p r es s u r e Hea r t r a te b y ECG mon i tor Oxy g en sa t urat i on b y p u ls e o x i me t r y Central venous pressure line- to assess adequacy of fluid replacement Hour l y ur i ne o u tp u t F l u i ds and dr u gs g i v en

10. CONFIRMATION OF DIAGNOSIS Genital tract injuries are looked for and if present, sutured If p l acenta i s n ot y et ex p el l ed signs of s e perat i on a r e looked for If the r e a r e r etai n ed p l ace n tal fragme n ts , th e y a r e removed Succenturiate lobe should not be missed Co a g u l o pat h y i s c h ec k ed

11. MEDICAL METHODS Oxytocin 20 - 40 u n it s i n 5 0ml of normal sal i ne Ergometrine Er g ometri n e . 2 5 mg or metherg i n . 2mg g i v en P r os t aglandi n d e ri v ati v es 15 methyl analogue of prostodin- 250microgram given.

12. MECHANICAL METHODS BIMANUAL COMPRESSION A b dom i n a l h a nd mas s a g es the p o s t eri o r aspect of u terus and the vaginal hand made into a fist presses the anterior uterine aspect through anterior fornix. Should be done continuously to promote uterine contraction Aortic compression against sacral promontory to reduce bleeding.

13. 🞂 Oth e r mecha n ic a l method s i n cl u d e uter i n e p a cki n g a n d b a l l oon tampo n a d e BIMANUAL COMPRESSION

14. SURGICAL METHODS UNDER SEWING CHO’s MULTIPLE BLOCK SUTURES B LYNCH OR BRACE SUTURE MODIFIED B LYNCH (HAYMAN) SYSTEMIC PELVIC DEVASCULARISATION - HYSTERECTOMY

15. UNDERSEWING U n ders e wi n g the p l ace n tal bed wit h fig u r e of e i g ht or purse string sutures Done at caesarean section for placenta praevia MULTIPLE BLOCK SUTURES Involve approximation of anterior and posterior uterine walls with multiple squares until no space is left in uterine cavity

16. MULTIPLE BLOCK SUTURES

17. BRACE SUTURE I n v o l v es use of v e r tical br a ce sutu r es V e r y e a sy t o per f orm Commonly performed at caesarean section but can also be do n e after vag i n a l de l i v e r y . MODIFIED B LYNCH(HAYMAN) Involves use of two vertical compression sutures placed on eit h er side of fu n d u s Qu i c k er than brace sutu r e . Does not require a low transverse incision . Hence it is useful following a vaginal delivery

18. BRACE SUTURE

19. SYSTEMIC PELVIC DEVASCULARISATION Involve laparotomy and progressive stepwise devascularisation Uterine , ovarian and finally the internal iliac arteries are ligated A b sorba b l e sutu r es sho u l d be u sed a l w a ys The ascending branch of uterine artery or the anterior division of internal iliac artery are usually ligated.

20. UTERINE ARTERY LIGATION

21. HYSTERECTOMY Co n side r ed as a las t r e s o r t Indications include severe atonic hemorrhage, placenta accreta , placenta praevia and uterine rupture Subttotal h ys t e r ecto m y m a y be easier a n d q u ic k er b u t is i n a d eq u ate i n cases whe r e b l eed i ng i s i n the l o w er segment as in placenta praevia and adherent placenta Ov a ries sho u l d be r etai n ed

22. RADIOLOGICAL ARTERIAL EMBOLISATION The p atie n t sho u d be hemo d yn a mica l l y s t a b le Un d er a n g i ogr a p h i c g u i d a n ce a n d pe r cutane o us transcatheter technique , femoral artery catheterisation is done Blee d i n g v es s els a r e ide n tified Embolisation carried out with gel foam or microspheres

23. Management of secondary PPH High vag i n a l s wa b s h o u l d be ta k en f or cu l tu r e Broad spectrum antibiotics should be started If the ultrasound scan reveals retained products , uterus sho u l d be e vac u ated The tissues obtained should be sent for culture and h i s t o p ath o l o g i c al s t u d ies If the r e i s e vi d ence of se p sis , e vac u ati o n sho u l d be de l a y ed b y 1 2 - 24 h o urs to r ed u ce risk of septicem i a If bleeding is severe uterine artery ligation or h y s te r ecto m y i s d one

24. THAN K Y OU