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DR. MURWAN IBRAHIM OMERDGO, MOG, ABOG, FRCOG, FICS
Consultant Obstetrician and Gynaecologist
ALTERNATIVE METHODS FOR
MANAGEMENT OF ATONIC POSTPARTUM
HAEMORRHAGE
Can we change our practice Can we change our practice to improve outcome of to improve outcome of
PPH?PPH?
When conventional methods fail When conventional methods fail to control atonic PPH, there are to control atonic PPH, there are interventions which are being interventions which are being ignored that should be ignored that should be considered before opting for considered before opting for major surgical procedures.major surgical procedures.
Postpartum Postpartum HaemorrhageHaemorrhage
Is a leading cause of maternal Is a leading cause of maternal mortality and morbidity. mortality and morbidity.
Too LittleToo Little (IV fluids, oxytocics, BLOOD, (IV fluids, oxytocics, BLOOD, Clotting factors)Clotting factors)
Too LateToo Late (resuscitation - blood (resuscitation - blood replacement, misopristol decision for replacement, misopristol decision for surgery + to get senior surgeon & surgery + to get senior surgeon & anaesthetist involved)anaesthetist involved)
PPHPPH
AnticipateAnticipate - high risk cases - high risk cases (e.g. twins, (e.g. twins, polyhydramnios, prolonged labour, fibroids, APH, polyhydramnios, prolonged labour, fibroids, APH, infection, past H/O PPH, retained tissue etc.)infection, past H/O PPH, retained tissue etc.)
PreventPrevent - Prophylactic Oxytocics - Prophylactic Oxytocics (e.g. (e.g. Syntometrine, syntocinon, ergometrine, misoprostol)Syntometrine, syntocinon, ergometrine, misoprostol)
ManageManage - Promptly - 90% uterine - Promptly - 90% uterine atony - 8% trauma and 2% coagulation atony - 8% trauma and 2% coagulation disordersdisorders
FIGO/ ICM STATEMENT ON AMTSL + WHO+ COCHRANE
Guidelines Guidelines by the Scottish Executive by the Scottish Executive Committee of the RCOGCommittee of the RCOG
COMMUNICATE. COMMUNICATE. RESUSCITATE.RESUSCITATE. MONITOR / INVESTIGATE MONITOR / INVESTIGATE STOP THE BLEEDINGSTOP THE BLEEDING
STOPSTOP THETHE BLEEDINGBLEEDING
Uterine compression Uterine compression IV syntocinon 10 units IV syntocinon 10 units IV ergometrine 500 IV ergometrine 500 g g Syntocinon infusion (30 units in 500 Syntocinon infusion (30 units in 500
ml)ml) Surgery / HysterectomySurgery / Hysterectomy
Misoprostol/ Intrauterine pack / Misoprostol/ Intrauterine pack / Intrauterine balloon / Compression Intrauterine balloon / Compression SuturesSutures
MisoprostolMisoprostol
Synthetic analog of prostaglandin E1Synthetic analog of prostaglandin E1
• Shelf life of several years if kept in their packets• Low cost• Can be administered orally, rectally, vaginally and by sublingual route• Being selective for the PGE1 receptors: Hence fewer systemic side-effects
Misoprostol could play an important role in saving lives of thousands of women, particularly in low-resource
settings
A study in Pakistan on the outcome of Utero-vaginal A study in Pakistan on the outcome of Utero-vaginal Packaging in Primary Postpartum Hemorrhage Packaging in Primary Postpartum Hemorrhage
on 34 patientson 34 patients
Pelvic infection was seen in 5 cases i.e., 14.7% (but pre- existing risk factors for infection such as prolonged rupture of membranes, obstructed labour and home delivery were present in all these cases)
The “Tamponade Test”The “Tamponade Test”
Condous G, Arulkumaran S et.al. Obstetrics & Gynecology. 2003
St George’s SeriesSt George’s Series
27 consecutive cases of Sengstaken – Blakemore 27 consecutive cases of Sengstaken – Blakemore Esophageal catheter tamponadeEsophageal catheter tamponade
Bleeding arrested in 22 cases Bleeding arrested in 22 cases Tamponade failed in 5 cases. Of them:Tamponade failed in 5 cases. Of them:
4 underwent a subtotal hysterectomy4 underwent a subtotal hysterectomy1 was managed with Haemabate and Misoprostol 1 was managed with Haemabate and Misoprostol
(concomitant use)(concomitant use) Doumouchtsis S, Papageorghiou A, Arulkumaran S. Acta Scand 2008
The Sengstaken-Blakemore The Sengstaken-Blakemore oesophageal catheteroesophageal catheter
The The mainmain disadvantage is that it disadvantage is that it is not purpose-designed for PPH.is not purpose-designed for PPH.
Therefore, it may not easily adapt Therefore, it may not easily adapt to the shape of the uterine cavity.to the shape of the uterine cavity.
“Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.”
Mahmoud Fathalla,MD, PhD, 1997
Uterine balloon tamponadeUterine balloon tamponadeAuthorsAuthors YearYear Type of Type of
studystudyMethodMethod No of No of
womenwomenSuccess Success RatesRates
GoldrathGoldrath 19831983 Case seriesCase series Foley catheterFoley catheter 2020 19/20 19/20 (95%)(95%)
Bakri et alBakri et al 20012001 Case seriesCase series Silicone BalloonSilicone Balloon 55 3*/5 (60%)3*/5 (60%)
Condous et Condous et alal
20032003 Case seriesCase series Sengstaken -Sengstaken -BlakemoreBlakemore
1616 14/16 14/16 87.50%87.50%
Akhter et Akhter et alal
20032003 Case seriesCase series CondomCondom 2323 23/23 23/23 (100%)(100%)
Penney et Penney et al (Scottish al (Scottish Audit)Audit)********
20032003 AuditAudit BalloonBalloon 66 5/6 (83.3%)5/6 (83.3%)
Penney Penney et et al al (Scottish (Scottish Audit)Audit)********
20042004 AuditAudit BalloonBalloon 2121 15/21 15/21 (71.4%)(71.4%)
Seror et alSeror et al 20052005 Case seriesCase series Sengstaken -Sengstaken -BlakemoreBlakemore
1717 12/17 12/17 (70.6%)(70.6%)
St George’s St George’s current current seriesseries
20062006 Case seriesCase series Sengstaken -Sengstaken -BlakemoreBlakemore
2727 22/27 22/27 (81.5%)(81.5%)
TotalTotal 135135 83.7%83.7%
COMPRESSION SUTURESCOMPRESSION SUTURESQuick, safe and effectiveQuick, safe and effective
B-LynchB-LynchModified B-Lynch suturesModified B-Lynch suturesCombination of suturesCombination of sutures
Comparison between Original method & its modification
B- Lynch brace B- Lynch brace suture.suture.
Modified B-Lynch brace Modified B-Lynch brace suture.suture.
1. Requires 1. Requires expertise.expertise.
1. Easy to perform.1. Easy to perform.
2. Transverse LUS 2. Transverse LUS incision required.incision required.
2. LUS incision not 2. LUS incision not required.required.
3. Time consuming.3. Time consuming. 3. Less time consuming 3. Less time consuming (can be completed in 2-3 (can be completed in 2-3 min).min).
4. Cervical stenosis. 4. Cervical stenosis. 4. No cervical stenosis4. No cervical stenosis
5. Haematometra 5. Haematometra formation.formation.
5. No Haematometra 5. No Haematometra formation.formation.
6. Bleeding from LUS 6. Bleeding from LUS due to multiple bites. due to multiple bites.
6. No bleeding from 6. No bleeding from LUS.LUS.
B-Lynch or Compression suturesB-Lynch or Compression suturesAuthorsAuthors YearYear TyTyppe of e of
studystudyMethodMethod No of No of
womenwomenSuccess RatesSuccess Rates
B-Lynch et al B-Lynch et al 19971997 Case seriesCase series B-LynchB-Lynch 55 5/5 (100%)5/5 (100%)
Cho et alCho et al 20002000 Case series Case series Square suturesSquare sutures 2323 23/23 (100%)23/23 (100%)
Pal et alPal et al 20032003 Case seriesCase series B-LynchB-Lynch 66 6/6 (100%)6/6 (100%)
Smith et alSmith et al 20032003 Case seriesCase series B-LynchB-Lynch 77 6/7 (85.7%)6/7 (85.7%)
Penney et aPenney et al (Scottish l (Scottish Audit)Audit)
20032003 AuditAudit****** B-LynchB-Lynch 1010 9/10 (90%)9/10 (90%)
Penney at alPenney at al (Scottish (Scottish Audit)Audit)
20042004 AuditAudit****** B-LynchB-Lynch 1919 13/19 (68.4%)13/19 (68.4%)
Wohlmuth et alWohlmuth et al 20052005 Case seriesCase series B-LynchB-Lynch 1212 11/12 (91.6%)11/12 (91.6%)
Pereira et al Pereira et al 20052005 Case seriesCase series Compressive Compressive suturessutures
77 7/7 (100%)7/7 (100%)
Nelson Nelson et alet al 20020066 Case seriesCase series Modified B-Modified B-Lynch Lynch suturessutures
55 5/5 (100%)5/5 (100%)
TotalTotal 9494 85/94 85/94 ((90.490.4 %) %)
Conservative Treatment for PPHConservative Treatment for PPHMethodMethod No of CasesNo of Cases Success ratesSuccess rates
B-Lynch + other B-Lynch + other Compression Compression suturessutures
9494 90.4%90.4%
Arterial Arterial embolizationembolization
218218 91%91%
Arterial ligationArterial ligation 264264 83.7%83.7%
Uterine balloon Uterine balloon tamponadetamponade
135135 83.7%83.7%
Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007
““It is not the strongest of It is not the strongest of the species that survives, the species that survives, nor the most intelligent, nor the most intelligent, but the one most but the one most responding to change.”responding to change.”
Charles DarwinCharles Darwin
No of Deliveries
0
5000
10000
15000
20000
25000
30000
35000
19751977
19791981
19831985
19871989
19911993
19951997
19992001
20032005
20072009
Maternal Mortality Rate
0
100
200
300
400
500
600
700
800
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
ConclusionConclusion When conservative measures fail to When conservative measures fail to
control bleeding in post partum control bleeding in post partum haemorrhage, uterovaginal packing, haemorrhage, uterovaginal packing, internal uterine tamponade and B-lynch internal uterine tamponade and B-lynch sutures can be used before resorting to sutures can be used before resorting to hysterectomy. These uterine preserving hysterectomy. These uterine preserving methods have been used in various methods have been used in various countries and have proven to be countries and have proven to be effective, with minimal maternal effective, with minimal maternal morbidity.morbidity.
They are feasible in this country and They are feasible in this country and should be considered by Obstetricians should be considered by Obstetricians when managing PPH. However, they when managing PPH. However, they require training and experience.require training and experience.
Emergency Trolley
Endotracheal tube Laryngoscope
Essential drugs
Crystalloids, giving sets, haemacel
Emergency protocols
GENERAL MANAGEMENT