Case presentation on surgical mgt OF PPH BY DR.ANWAR H(1).pdf

Surgical managment of PPH

1. Case Presentation on Surgical Mgt. of
PPH
Presenter: Dr.Anwar H.(Yr-4 OBGYN Resident)




May 2023









may
1

2. Out line
1.Objective
2.Case summary
3.Discussion of surgical Mgt. of PPH
4.Comments
5.References

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3. Objective
1. To use the case as an entry point to discuss on the
Surgical mgt. of PPH & to improve Mgt. of our
patients care in the future carrier.
3

4. CASA SUMMARY
•IDENTIFICATION
•Name: FMU
•Sex: Female
•Age:26yrs
•MRN:347842
•Region: Oromia
•Wareda: Kombolcha
•Religion: Muslim
•Ethnicity: Oromo
•Admission date: 30/08/2015
4

5. CASE SUMMARY….
•HISTORY
Resident evaluation
Date 30/8/2015 @ 9:00pm
•C/C: Gush of fluid per vagina/1day
•HPP:
•She is G-VIII, p-VII(5 alive, 2END, 2SB, all by V/D.)
•She does not remembers her LNMP but claim to be amenorrhic
for the past 9 months.
•She has no ANC follow up.


5

6. Case summary…..
•She comes with referral from kombolcha HC. With diagnosis
of prolonged PROM + NRFHRB
•After she presented there with gush of clear non foul smelling
fluid per vagina of 1 day duration.
•But she has no history of pushing down pain or decreased fetal
movement.
•Other wise she has no other danger sign and symptom of
pregnancy.
•She has no hx of diagnosed DM, HTN, Cardiac & renal
disease.
6

7. Cont…
•Physical Examination
•G/A: Healthy looking
•V/S: Bp = 110/70mmHg , PR= 90 ,RR=22
•HEENT: Pink conjunctiva and NIS
•Chest : Clear and resonant
•CVS: S1 & S2 well heard, No murmur or gallop
•Abdomen:
–Term sized gravid uterus
– long lie & Cephalic presentation
– FHB +ve (138Bpm)
– Uterine contraction-2/10’/20-30”
7

8. cont….
•GUS:
–No vaginal bleeding
–Cervix: 2cm dilated & 60% effaced
–Membrane- ruptured, clear liquor
– Station- high(-2)
•MSSK/IGS: NAD
•CNS: COTPP
8

9. Cont…..
•INVESTIGATION DONE
• CBC(Hgb= 8.2gm/dl MCV=63fl plt=259 x10*9/L)
•BG & Rh= B(+ve)

•Obstetric U/S
 SIUP
 FHB +ve
 placenta fundal
 Cephalic presentation
 AGA= 37Wks + 4d
BPD=9.4CM= 38Wks + 2d
FL=6.3cm=33Wks + 4d
 EFW=2846gm
 SDP=1.5cm
INDEX: 3
rd
TMPx + ? R/O Skeletal dysplasia


9

10. cont….
•Asst.: 3
rd
TMPx + Unknown date + Grand MG + PROM + R/O
False labor + ? Skeletal dysplasia
•PLAN:
–Admit to labor ward
–Tracing with CTG
–follow with PROM Chart
–Ampicillin 2gm IV QID till delivery
–To ripen with 25mcg of misoprostol Q4hr if no spontaneous
onset of labor ensue.
10

11. PROM CHART
Date Time BP PR R
R
Tem
p
FH
B
Foul
smelling
discharge
V.bleeding WBC
30/8/15 8:00pm 117/63 83 20 36.1 129 No No
8:30pm 130 No “
9:30pm 120 No “
10:00pm 110/60 78 20 36.4 139 No „
11:00pm 100/65 74 20 36.1 144 No “
1/9/15 12:00am 138 No “
1:00am 146 No “
2:00am 105/65 73 22 181 “ “
4:00am 106/60 70 20 142 “ “
6:00am 101/50 68 20 123 “ “
7:00am 136
11

12. Case summary…..
•On the same day:
•False labor was diagnosed and misoprostol 25mgm was
started @ 4:00 am
•labor started after 5hr of misoprostol @ 8:00 am(3c/10’/40-
50”).
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13. Progress note(by senior Resident)
•Date 1/9/2015 @ 9:00am
•Subjectively:
•She has pushing down pain
•Objectively:
•G/A: ASL(in labor pain)
•V/S: Bp= 110/ 70 PR = 104 RR= 20 T=36.6C
• Abdomen:
–Term sized gravid uterus
–Long lie and cephalic presentation
–FHB +ve (60-90bpm)
–Uterine Cx: 4/10’/45-50”
13

14. Progress…
•GUS:
–Cervix : fully dilated
–G-III MSAF
–Station 2
–Brow presentation
–Grossly adequate pelvis
•Asst. Same +persistent Brow presentation + severe fetal
bradycardia + BOH

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15. Plan
•To take consent and prepare for Emergency C/S

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16. Operation note
•Under GA, abdomen entered through pfennenstiel skin incision.
•Finding:
–Intact gravid uterus
–Healthy looking ovaries and tubes
–G-III MSAF
–30% Retro placental clot
•What is Done & out come:
•LUSTCS done to effect a delivery of alive male newborn
weighing 3kg with APGAR score of 4,2, 0 on the 1
st
, 5
th
& 10
th

minute respectively
•EBL 500ml, mother leave OR with stable V/S
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17. Post op order

•Date: 1/9/15
•Dx- Immediate post op after LUSTCS done for Severe
bradycardia
•C-Subcritical
•D-NPO
•A- Encourage early ambulation
•I-Post op Hgb.
•NC- Routine
•V/S & Ux massage: Q15’ for 2hr then Q30’ for 4hr
•Mf(DNS,RL,NS)1Bag tid x 24hr
•Diclofenac 75mg im bid & tramadol 50mg iv QID X24hr
•Keep urine catheter for 8hr







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18. Post OP V/S
Date Time BP PR RR T InPut UOP SPO2 VB MEDICA
TION
1/9/15 11:00am 95/65 82 20 36.5 98% No Tramadol
50mg IV

11:15am 90/60 88 20 36.4 87% No
11:30am 85/50 99 22 2 NS

95%
11:45 80/55 105 22 96% No
12:00 90/60 „‟
12:15 102/64 78 22 96% „‟
12:30 105/65 80 20 98% No
12:45 105/63 82 22 98% No
01:00 104/62 80 22 98% No
01:15 78/42 105 22 96% No
01:30 74/38 108 22 94% No
01:45 74/45 110 20 95% No
02:00 78/46 128 22 98% No
02:15 80/48 120 22
02:30 78/50
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19. Post op evaluation
•Date 1/9/15 @ 1:15pm
•P-immediate post op after LUSTCD was done for indication of
severe fetal Bradycardia
•On-Mf. & Oxytoxin drip
•Subj:-no new complaint
•Obj:-GA-ASL
•V/S BP=78/42 PR=96 RR=22 T=
•HEENT: pale conjunctiva & NIS
•Abdomen:
–full and moves with respiration
–clean surgical wound dressing
–shifting dullness +ve


19

20. Progress…
•GUS:
– no active Vx bleeding
– cervix 3cm dilated
–no blood clots in vagina & uterus
•CNS: COTPP
•Ultrasound
– Uterus is empty
There is 4.2 x 3cm posterior cul-de-sac collection
INDEX: Intra abdominal collection
•Asst. = Same + PPH 2⁰ to intra-abdominal collection +
hypovolemic shock 2⁰ ABL


20

21. Progress…
•Plan
•To Prepare x-matched blood
•To Resuscitate with iv crystalloid
•To apply NASG
•Prepare for relaparatomy
•To consult duty senior
21

22. ReLaparotomy
•Findings:
–300ml of blood sucked out
–Lt. side broad ligament hematoma expansion
•Done:
•Abdominal hysterectomy + Rt. salphyngo Oophorectomy
done.
•EBL =900ml
•Patient leave OR table with V/S(BP=118/64, PR=130,
Spo2=94%, UOP=400ml).
22

23. Post op order
•Date: 1/9/15
•Dx- Immediate post op after laparotomy was done for intra-
abdominal collection
•V/S : Q15’ for 2hr then Q30’ for 4hr
•Mf(DNS,RL,NS)1Bag TID x 24hr
•Ceftriaxone 1gm iv BID
•Metronidazole 500mg iv TID
•Diclofenac 75mg IM BID & Tramadol 50mg iv QID X24hr
•Keep urine catheter for 12hr
•Transfuse with at least 3 unit of blood

23

24. Post operatively
•Transfused with 1 unit of (o+ve) blood
•Post op Hgb:
– Date 2/09/15=7gm/dl
–Date 5/9/15=5.8gm/dl
–Date 9/9/2015= 5.9gm/dl
24

25. Post op follow up
Date Time BP PR RR T⁰ INPU
T
UOP SPO2 VB MED.
1/9/15 4:30pm 115/70 104 22 36.3 92% no tramadol
4:45 ” 113/65 98 22 36.4 94%
5:00 ” 100/65 86 22 36.4 95%

9:00 ” 100/70 90 20 36.2 94%

9:30 ” 105/65 91 22 36.1 93%

10:00 ” 100/70 92 20 36.2 92%

10:30 100/65 94 20 36.1 95%

11:00 100/70 90 22 36.2 96%

11:30 105/65 89 26 36.1 95%

2/9/15 12:00am 100/60 90 24 36.2 96%
12:30 “ 104/59 90 24 97%
25

26. Date Time BP PR RR T⁰ INPU
T
UOP SP
O2
VB MED.
2/9/15 1:00 am 105/62 86 24 98%
1:30 “ 108/60 80 24
2:00 “ 110/62 78 22
2:30 “ 114/66 90 22
3:00 115/65 100 20
3:30 120/60 100 20 96%
4:30 120/60 100 20 97%
5:30 115/70 98 20 98%
6:30 125/70 92 20 99%
7:00 115/66 101 20 98
8:00 123/69 94 20 96%
9:00 115/66 104 20 97%
10:00 115/70 102 20 96%
11:00 110/66 94 20 97%
12:00 112/68 100 20
2:30pm 117/65 100 20 36.2 91%
2:45 109/56 116 21 1000ml/8hr

3:00 113/61 107 20
3:15 110/53 109 21
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27. Date Time BP PR RR T⁰ INPU
T
UOP SPO2 VB MED
2/9/15 3:30pm 125/58 111 21 97%
4:00 118/67 98 20 96%
5:00 121/58 96 20 96%
6:00 117/72 90 20 97%
7:00 115/60 100 20 96%
3/9/15 6:00am 110/70 100 20 95%
7:00 112/70 90 22 95%
8:00 110/72 98 20 97%
9:30 112/68 90 20 98%
10:30 104/58 86 20 97%
11:30 102/60 78 22 96%
12:00 108/58 72 20 96%
1:00 100/60 70 20 36.5 95%
2:00 110/60 72 20
4/9/15 9:00am 125/70 90 21
11:00am 115/70 88 21
2:00pm 120/70 105 20
5/9/15 12:00pm 100/60 61 20
8:00 95/60 96 20
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28. Cont…
•Date 8/9/15
•Patient transferred to maternity ward with stable vital sign
for further transfusion
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29. DISCUSSION
29

30. Introduction
•Postpartum hemorrhage (PPH) is an obstetric emergency
•It is the 1
st
-leading cause of maternal morbidity and mortality
worldwide.
•PPH- Defined as cumulative blood loss ≥ 1000ml or
•Blood loss accompanied by sign and symptoms of hypovolemia
within 24 hours after birth process regardless of route of
delivery.
•Clinically also defined as a decrease in Hct. of 10% from the
base line.
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31. Classification & Etiology

• Primary or early PPH: in the first 24 hours
after delivery
•etiologies: Uterine atony, Retained placenta,
Genital tract lacerations, Uterine rupture, Uterine inversion,
Coagulopathy



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32. Classification & Etiology of PPH
• 2⁰ or delayed(late) PPH:
•occurs from 24 hours to 12 weeks after delivery
•Etiology -Endometritis, Placental site sub involution, Retained
placental fragments, Coagulopathy, Gestational choriocarcinoma

•Our patients it is 1⁰ PPH 2⁰ to lateral extension of hysterotomy
incision
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33. Management of PPH
•The management depends on the etiology of PPH and
hemodynamic status of the pt.
•In addition to fluid administration and transfusion of blood
products;
•Temporizing maneuvers should be attempted prior to
performing any surgical procedures in hemodynamically
unstable pts.
•so every effort should be made to reverse contributing factors
such as hypothermia, acidosis and coagulopathy;
•Cessation of hemorrhage depends on reversal of any
coagulopathy acidosis


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34. Mgt…
•Quick assessment of the etiology & the source of bleeder is
important 1
st
steps b/c the mgt. vary(4T’s).
•Generally, in treatment of PPH, less invasive method should be
used initially if possible.
•The initial mgt. Depends on the etiology
– medical mgt.
–Radiological mgt.
–Surgical mgt.
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35. Laparotomy
•Laparotomy is best performed through a vertical midline
incision to provide exposure of both the pelvis and
abdomen
•In patients at or post cesarean delivery, the existing
incision is used.

•In our pts the existing Pfenninstiel incision
is used for relap.
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36. Laparotomy….
•The abdominal cavity is irrigated to remove blood and clots and
inspected for the source of bleeding.
•These sites should be actively evaluated in patients with
compensated shock (normal blood pressure with increasing heart
rate).
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37. TEMPORARY MEASURES FOR STABILIZING HEMODYNAMICALLY
UNSTABLE PATIENTS

•Patients at imminent risk of exsanguination

- Manual aortic compression
- Resuscitative endovascular balloon
occlusion of the aorta
- Intermittent intraaortic balloon occlusion

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38. Temporizing maneuver…….
38

39. Myometrial laceration
•Serious hemorrhage is caused by lateral extension of the incision.
•Generally, Bleeding from a hysterotomy incision is controlled by
suture ligation.
•The angle of transverse incision should be clearly visualized for
retracted vessels.
•. Deterioration of maternal vital sign without obvious bleeding
should alert intraperitoneal or retro-peritoneal bleeding


39

40. Laceration…..
•An Enlarging hematoma beyond the end of the incision (or
swelling beneath the surface of broad ligament) suggest
retracted blood vessel with ongoing bleeding.
•On lateral lacerations, placement of hemostatic sutures should
be made with caution to avoid injury to the ureters.

40

41. Laceration of uterine artery or utero-
ovarian artery branches
•Bilateral ligation of uterine vessels (O’ Leary stitch) is the
preferred approach for controlling PPH from Uterine artery or
branches of utero-Ovarian artery.
•Bleeding adjacent to the uterus without clear bleeding points
can be managed by ligation of uterine vessels

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42. Hysterectomy
•It is Definitive treatment of uterine bleeding
•If the fertility preserving procedures do not reduce the
bleeding to the manageable level.


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43. Post laparotomy inspection
•The need for ≥2 units of blood(packed RBC) per hour for
3hour is a sign of significant ongoing bleeding & a need to
return to OR or
•Arterial embolization by an interventional vascular
specialist.
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44. Comment
•Poor follow up of labor progress(incomplete
partograph)
•Referral diagnosis of NRFHRP was undermined
•Lack of blood is a challenging in rescesitation.
•Clear observation of the two lateral age for active
bleeding or for placement of suture before closure of
the abdomen should be made in lateral extension;


44

45. REFERRANCE
1.ACOG PRACTICE BULLETIN VOL.130 NO
183 October 2017 (P1-19)
2.Gabbe Obstetrics, 7
th
edition, Chapter 18 p406
PPH
3.Williams Obstetrics, 25
th
edition, PPH p758
4. Up to date -2018 topic on PPH,

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