postpartum haemorrhage - the surgical aspects

Postpartum haemorrhage

- the surgical aspectsSvensk förening för Obstetrik och Gynekologi, Tallberg14th April 2015P J Steer

Emeritus Professor of Obstetrics

Academic Department of Obstetrics and Gynaecology

Chelsea and Westminster Hospital

Imperial CollegeLondon

WITH

THANKS TO

PROFESSOR

MICHAEL

BELFORT

Baylor Medical College

Texas Children’s Hospital,

Houston,

USA

UTERINE ATONY -

SURGICAL APPROACH• Correction of uterine inversion

• Uterine compression and massage

• Packing / Balloon

• Uterine compression suture

• Uterine artery ligation

• Internal iliac ligation

• Hysterectomy

• Logethotopolous pack

• Arterial embolisation

CORRECTION OF UTERINE

INVERSION

• Vaginal approach

REPLACING AN INVERTED UTERUS

Acute uterine inversion: a new technique of hydrostatic replacement.

O. Ogueh and G. Ayida. Br J Obstet Gynaecol 104 (8):951-952, 1997.

VENTOUSE

CORRECTION OF UTERINE

INVERSION

• Abdominal approach

LAPAROTOMY - Another use for the

ventouse!

E. Antonelli, O. Irion, P. Tolck, and M. Morales. Subacute uterine inversion: description of a novel replacement technique using the obstetric ventouse.

BJOG. 113 (7):846-847, 2006.

LAPAROSCOPY - Use of counterpressure

R. Vijayaraghavan and Y. Sujatha. Acute postpartum uterine inversion with haemorrhagic shock: laparoscopic reduction

BJOG. 113 (9):1100-1102, 2006.

THE ATONIC UTERUS

• Anti-shock garment

• Bimanual compression

• Packing

• Balloons

• Compression sutures

Non-pneumatic anti-shock garment reduces average blood loss by 50%

S. Miller, S.et al. First aid for obstetric haemorrhage:

the pilot study of the non-pneumatic anti-shock garment in Egypt.

BJOG. 113 (4):424-429, 2006.

BIMANUAL COMPRESSION

PACKING

THE

UTERUS

S. Hsu, B. Rodgers, A. Lele, and J. Yeh.

Use of packing in obstetric hemorrhage of uterine origin.

J.Reprod.Med. 48 (2):69-71, 2003.

INTRAUTERINE BALLOON

Management of massive

postpartum haemorrhage:

use of a hydrostatic balloon

catheter to avoid laparotomy

R. Johanson, M. Kumar,

M. Obhrai, and P. Young.

BJOG 108 (4):420-422, 2001.

500 cc warm saline

in-situ for 24 hours

INTRAUTERINE BALLOON

Y. N. Bakri, A. Amri, and Jabbar F. Abdul.

Tamponade-balloon for obstetrical bleeding.

Int.J Gynaecol Obstet. 74 (2):139-142, 2001.

INTRAUTERINE BALLOON

Effectiveness of balloons

• 23 patients unresponsive to medical therapy

• 2 required hysterectomy

Dabelea V, Schultze PM, McDuffie RS Jr. Am J Perinatol. 2007 Jun;24(6):359-64.

Effectiveness of balloons

• Used in 27 cases at St George’s Hospital, London

• Sengstaken-Blakemore tube used

• Haemostasis achieved in 22 (81%)

• Four hysterectomies

• Removal at 24 hours – no further bleeding

S. K. Doumouchtsis, et al. Acta Obstet Gynecol Scand. 87 (8):849-855, 2008.

INTRAVAGINAL BALLOON

M. Tattersall and W. Braithwaite.

Balloon tamponade for vaginal lacerations causing

severe postpartum haemorrhage.

BJOG 2007; 114:647-8.

Belfort-Dildy device

Photograph courtesy of Gary Dildy, M.D.

Belfort MA, Dildy GA, Garrido J, White GL. Intraluminal pressure in a uterine tamponade balloon is curvilinearly related to the volume of fluid infused. Am J Perinatol 2011;28(8):659-66

Uterine Balloon Tamponade� Compression and decreased flow within the uterine

arteries can be demonstrated on ultrasound

� Flow rapidly returns to normal after removal

Flow within uterine artery during tamponade

Before Placement Balloon in place After Removal

Uterine Balloon Tamponade

• Post-marketing surveillance study

– 57 enrolled, 55 had PPH, 51 placed

• Study population:

– C/S 45% & Twins 24%

– EBL 2,000 (855 - 8,700) mL

• Delivery-to-Placement was 2.2 (0.3 – 210) hours

– Bleeding decreased or stopped 98% of cases

– Hysterectomy avoided in 92% of cases

• Uterine balloon volume >500 mL in 45% of cases

Dildy GA, Belfort MA, Adair CD et al. Initial experience with a dual-

balloon catheter for the management of postpartum hemorrhage.

Am J Obstet Gynecol 2013 Sep 18.

B-LYNCH SUTURE

C. B-Lynch, A. Coker, A. H. Lawal,

J. Abu, and M. J. Cowen.

The B-Lynch surgical technique

for the control of massive

postpartum haemorrhage:

an alternative to hysterectomy?

Five cases reported.

Br J Obstet Gynaecol 104 (3):372-375, 1997.

Square suturing

J. H. Cho, H. S. Jun, and C. N. Lee.

Hemostatic suturing technique for uterine bleeding during cesarean delivery.

Obstet Gynecol. 96 (1):129-131, 2000.

FURTHER MODIFICATIONSR. G. Hayman, S. Arulkumaran, and P. J. Steer.

Uterine compression sutures: surgical management of postpartum hemorrhage.

Obstet Gynecol 99 (3):502-506, 2002.

FRONT VIEW SIDE VIEW

ANTERIOR VIEW

POSTERIOR VIEW

HAYMAN SUTURE

11 cases, 1 hysterectomy –F. Ghezzi, A. Cromi, S. Uccella, L. Raio, P. Bolis, and D. Surbek.

The Hayman technique: a simple method to treat postpartum haemorrhage.

BJOG. 114 (3):362-365, (March) 2007.

Dealing with bleeding from the

lower segment

A

Broad Ligament

Round Ligament

Bladderreflectedcaudally

A. Positioning of closed artery forceps.This maintains a patent cervical canalon tightening lower sutures

Anterior view

Fallopian Tube

Anterior view of Completed sutures

ARULKUMARAN MODIFICATIONR. G. Hayman, S. Arulkumaran, and P. J. Steer.

Uterine compression sutures: surgical management of postpartum hemorrhage.

Obstet Gynecol 99 (3):502-506, 2002.

AA

PARALLEL VERTICAL

COMPRESSION SUTURES

Y. M. Hwu, C. P. Chen, H. S. Chen, and T. H. Su. Parallel vertical compression sutures:

a technique to control bleeding from placenta praevia or accreta during caesarean section.

BJOG. 112 (10):1420-1423, 2005.

PARALLEL VERTICAL

COMPRESSION SUTURES

Y. M. Hwu, C. P. Chen, H. S. Chen, and T. H. Su. Parallel vertical compression sutures:

a technique to control bleeding from placenta praevia or accreta during caesarean section.

BJOG. 112 (10):1420-1423, 2005.

B Dawlatly, I Wong, K Khan,

& S Agnihotria Department of Obstetrics and

Gynaecology,

Whipps Cross University Hospital,

London.

BJOG: 114; 502 (April 2007)

Using the cervix to stop bleeding in a woman

with placenta accreta: a case report

Multiple U suture

Hackethal A et al (2008)

Hum Reprod. 2008

23:74-79

Compression suture and balloon

Combined B-lynch suture with

intrauterine balloon catheter

triumphs over massive postpartum haemorrhage.

D. Danso and P. Reginald.

BJOG. 109 (8):963, 2002.

Compression suture and balloon

• 5 patients with compression suture and balloon

• 11 hours median use (range 10-24)

• Effective in all cases

• No complications seen

Nelson WL, O'Brien JM.

Am J Obstet Gynecol. 2007 May;196(5):e9-10.

COMPLICATIONS OF UTERINE

COMPRESSION SUTURES

Uterine compression suture

without hysterotomy -

why a non-absorbable suture

should be avoided.

– C. Cotzias and J. Girling. J Obstet Gynaecol 25 (2):150-152,

2005.

Removable sutures

Matsubara S, Acta Obstet Gynecol Scand 2014; 93:1069-70

Removable sutures

Zhang ZW et al, BJOG 2014; 122:429-433

Removable sutures

Aboulfalah A et al, Frontiers in Surgery, 2014; 1: article 43

COMPLICATIONS OF UTERINE

COMPRESSION SUTURES

• Pyometria after hemostatic square suture

technique

– M. Ochoa, A. D. Allaire, and M. L. Stitely.

– Obstet Gynecol. 99 (3):506-509, 2002.

• Uterine cavity synechiae after hemostatic

square suturing technique.

– H. H. Wu and G. P. Yeh.

– Obstet Gynecol. 105 (5 Pt 2):1176-1178, 2005.

COMPLICATIONS OF UTERINE

COMPRESSION SUTURES

• Partial ischemic

necrosis of the

uterus following a

uterine brace

compression

suture.

– V. M. Joshi and M. Shrivastava. BJOG.111 (3):279-280, 2004.

COMPLICATIONS OF UTERINE

COMPRESSION SUTURES

E. J. Treloar, R. S. Anderson, H. S. Andrews, and J. L. Bailey. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage.

BJOG. 113 (4):486-488, 2006.

COMPLICATIONS OF UTERINE

COMPRESSION SUTURES

• Partial necrosis following Cho sutures– Reyftmann L et al (2009) Gynecol Obstet Fertil 37:579-582

• Partial necrosis following local compression suture– Gottlieb AG et al (2008) Obstet Gynecol 112:429-431

• Partial necrosis following B-Lynch plus Cho suture– Akoury H, Sherman C. (2008) J Obstet Gynaecol Can.

30:421-4

COMPLICATIONS OF UTERINE

COMPRESSION SUTURES

• 8 cases of uterine necrosis

• 3 cases of uterine rupture in subsequent pregnancy

• Two cases of pyometra

• One case of haematometra

• Two cases of Asherman’s syndrome

• Synechiae

Amorim-Costa et al, Acta Obstet Gynecol Scand. 2011 Jul;90(7):701-6

Synechiae

• Study 1 (Hackethal technique):

– Uterine compression sutures successful in

26/33

– 15 later had hysteroscopy and/ or HSG

– 4 had synechiae (27%)

• Study 2 (B-Lynch’s or Cho’s technique):

– 13/37 subsequent hysteroscopy

– 3 had Asherman’s, 7 had synechiae

Poujade O, BJOG 2011;118:433-439

Rathat G, Fertil Steril 2011; 95:405-9

49 pregnancies after uterine

compression suturing• Outcome similar to controls:

– 34 (81%) term delivery

– 2 (4.7%) preterm

– 4 (9.5%) miscarriage

• One perinatal loss

– Twins , placenta praevia, ruptured uterus

(previous classical)

• 34% had pelvic adhesions compared with 17.5%

controls

Hyeong G, et al Obstet Gynecol 2013; 122: 565-570

Matsubara S, et al

Acta Obstet Gynecol Scand. 2013 Apr;92(4):378-85.

UTERINE ARTERY LIGATION

O'Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage.

J Reprod Med 1995;40:189-93.

INTERNAL ILIAC LIGATION

Main danger is damage to the internal iliac vein: Success rates 43-90%

SHOULD ONLY BE DONE BY EXPERIENCED SURGEON

Das BN,.Biswas AK. Ligation of internal iliac arteries in pelvic haemorrhage.

J Obstet Gynaecol Res. 1998;24:251-4.

V. Joshi, S. Otiv, R. Majumder,

Y. Nikam, and M. Shrivastava.

Internal iliac artery ligation for

arresting postpartum haemorrhage.

BJOG. 114 (3):356-361, 2007.

Correct Way

IF THE BLEEDING IS

HEAVY, CONSIDER

AORTIC

COMPRESSION

Caesarean hysterectomy

Caesarean Hysterectomy

• Don’t leave it too late

• Do subtotal first

• Leave the vault open initially as it helps to find the cervix

• Stop once the bleeding is controlled

• Involve vascular surgeons prn

• Consider Logethotopolous pack

Logethotopolous pack

Preparation

of

Logethoto-

polous

pack

USE A SCRIBE

ARTERIAL EMBOLISATION

• First described in 1979

• up to 95% success

• Requires angiography facilities

C. Boulleret, et al.

Hypogastric arterial selective and superselective embolization for

severe postpartum hemorrhage: a retrospective review of 36 cases.

Cardiovasc.Intervent.Radiol. 27 (4):344-348, 2004.

C. Boulleret, et al.

Hypogastric arterial selective and superselective embolization for

severe postpartum hemorrhage: a retrospective review of 36 cases.

Cardiovasc.Intervent.Radiol. 27 (4):344-348, 2004.

ARTERIAL EMBOLISATION

• Gelfoam is material of choice (Vedantham 1997)

• Preoperative placement of catheters - calculate radiation dosage and inform patient of risks to fetus if > 5 Rads

• Potential complications of embolisation:

– Angiography (haematoma, contrast nephrotoxicity)

– Pelvic infection (low-grade fever, pelvic abscess)

– Ischaemic phenomena (necrosis, buttock claudication)

Complications of Embolisation

Al-Thanyan et al. Obstet Gynecol 2012;120:468–70

DON’T PANIC

• If you rush,

you will make

silly mistakes

SPECIAL POINT

https://drive.google.com/file/d/0B2zXNlGDKFDEV0QxSHBnYWF5Mmc/view

Summary

• Balloon tamponade is effective first-line management

• Uterine compression sutures should usually be tried

next

• Compression sutures have significant complications,

associated mainly with uterine ischaemia

• Hysterectomy may still be necessary

• The Logethotopolous pack can be life-saving as a

last resort

• Embolisation can be useful

• Real-time guidance by computer may be valuable