pph moscow1
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GC DI RENZO, MD, PHD, FRCOG, FACOGPERUGIA, ITALY
MANAGEMENT OF POST-PARTUM HEMORRHAGE
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Why focus on preventing
post-partum hemorrhage?
Haemorrhage is the largest direct cause of maternal death
PPH is mostly unpredictable Most PPH is caused by uterine atony Evidence-based, feasible, low-cost
interventions exist Active management at the third stage
of labour can prevent 60% of PPH
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Difficulties associated with comparing
post-partum hemorrhage studies
Method to determine blood loss – Visual underestimation 70–80%
Conduct during third stage of labour Confounding factors in
epidemiological studies 58% of trials do not report their
definition of PPH
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Maternal Health:some ( underestimated) statistics
180–200 millions pregnancies per year 75 millions unwanted pregnancies 50 millions induced abortions 20 millions unsafe abortions 358,000 maternal deaths (1000 per day) 1 death every 1,5 min 20 maternal morbidities per minute 10-15 millions disabilities each year
WHO, 2010
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Every Minute...
Maternal Death Clock 380 women become pregnant 190 women face unplanned or
unwanted pregnancy 110 women experience a
pregnancy related complication 40 women have an unsafe
abortion 1 woman dies from a pregnancy-
related complication 20 women suffer of a disabilty
related to childbirth
WHO, 2010
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About two thirds of maternal deaths are About two thirds of maternal deaths are due todue to
Anemia-HemorrhageObstructed deliveryEclampsiaSepsisUnsafe abortion
They can be treated by a
health professional
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Causes of maternal mortality
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Maternal mortality from post-partum hemorrhage in
the UK
88% received substandard careHall M. 2004; Why mothers die (2000–2002) CEMACH.
0
1
2
3
4
5
6
85–87 88–90 91–93 94–96 97–99 00–02
Mat
erna
l mor
talit
y ra
te/m
illio
n
Year
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Sub-standard care Organisational problems
– Inappropriate booking– Inadequate blood transfusion– Intensive care facilities
Poor quality of resuscitation– Inadequate transfusion– Blood products
Equipment failure– Malfunctioning of specimen transport system
Failure to recognise or treat antenatal medical conditions– Inherited bleeding disorders
Failure of senior staff to attend Concerns about the quality of surgical treatment given
Hall M. 2004; Why mothers die (2000–2002) CEMACH.
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As with many problems, there seems
to be two different kinds of emergencies...
...depending on whether the patient is in a
developed or undeveloped country
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Developed countriesSequence: Diagnosis PPH
Protocol-management
Treatment
Success (>98%)
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Undeveloped countries• Sequence: • Diagnosis PPH (?)
• Emergency (?)
• Transfer (?)
• Centre (?)
• Treatment (?)
• Success (<60%)
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Post-partum hemorrhage
Equal opportunityoccurrence
2/3 no risk factors
Not equalopportunity
killer
Poor Malnourished Unhealthy
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What is post-partum hemorrhage?
Excess blood loss after the birth of a baby
PPH >500 ml (3.5–30%)
Severe PPH >1000 ml (1.5–5.0%)
Immediate PPH: – Onset within 24 h of birth
PPH late: – Onset after 24 h of birth
These definitions are not accepted by all!!
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One of the main One of the main problem……problem……
UNDERESTIMATION OF BLOOD UNDERESTIMATION OF BLOOD LOSSLOSS
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Methods used to diagnose post-partum hemorrhage
Clinical methods– Physiological response to blood loss
Quantitative methods– Visual assessment– Direct collection of blood into bedpan or plastic
bags– Gravimetric method– Changes in hematocrit and haemoglobin– Others
Plasma volume Tagged erythrocytes
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Estimated blood loss
Prasertcharoensuk et al. IJGO 2000
0
5
10
15
20
25
30
>500 ml >1,000 ml
Visual
Measured
Est
imat
ed b
lood
loss
(%
)
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Calibrated bagCalibrated bag(Brass-V)(Brass-V)
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Risk factors
1. placenta previa with or without previous uterine surgery.
2. previous myomectomy.3. previous cesarean delivery. 4. Asherman's syndrome. (treated
surgically)5. submucous leiomyomata. 6. maternal age of 36 years and
older.
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Risk factors (multivariable analysis)
Retained placenta, OR=3.5 Failure to progress to second stage, OR=3.4 Placenta accreta, OR=3.3 Lacerations, OR=2.4 Instrumental delivery, OR=2.3 Newborn large for gestational age, OR=1.9 Hypertensive disorders, OR=1.7 Induction of labour, OR=1.4 Augmentation of labour with oxytocin, OR=1.4
Sheiner E, et al. J Matern Fetal Neonatal Med 2005.
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The risk of placenta previa was 0.26% with an unscarred uterus and increased almost linearly with the number of prior cesarean sections to 10% in patients with four or more.With a placenta previa and one previous cesarean section, the risk of placenta accreta was 24%; this risk continued to increase to 67% (two of three) with a placenta previa and four or more cesarean sections.
Obstetrics & Gynecology 1985;66:89-92 Placenta Previa/Accreta and Prior Cesarean SectionSTEVEN L. CLARK Et al
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Ch. B- Lynch
1° ed 2006
2° ed 2012
MANAGEMENT
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( FIGO 2009 – Cape Town)
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COMPREHENSIVECOMPREHENSIVE
MedicalMedical
Surgical
Mechanical
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Joint statement management of the third stage
of labour to prevent post-partum hemorrhage
Active management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atony– Consists of interventions designed to facilitate the delivery of
the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony. The usual components include: Administration of uterotonic agents Controlled cord traction Uterine massage after delivery of the placenta, as
appropriate Every attendant at birth needs to have the knowledge, skills
and critical judgment needed to carry out active management of the third stage of labour and access to needed supplies and equipment
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Maternal outcomes of active management
trials
McCormick et al, IJGO 2002
0
10
20
30
Transfusion Prolonged third stage
Therapeuticuterotonic
drugs
Lowhaemoglobin
Retainedplacenta
Pat
ien
ts (
%)
Active managementPhysiological management
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POSTPARTUM HEMORRHAGE
need of “ action” in the “golden hour”in order to increase the probability of patient survival:
The mnemonic The mnemonic HAEMOSTASISHAEMOSTASIS can assist in remembering can assist in remembering the sequence of events to confrontthe sequence of events to confront
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HHAEMOSTASISAEMOSTASIS
H: Get HELP
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HHAAEMOSTASISEMOSTASISA: evaluate the vital parameters of the patient and the amount of blood loss
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HAHAEEMOSTASISMOSTASISE: identify the cause (ethiology) and the appropriate treatment (4T)
ToneTissue
Trauma Trombin
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Causes of post-partum hemorrhage (4T)
Anderson et al. Am Fam Physician 2007.
CAUSE
(70%)
(19%) (10%)
(1%)
TONE
TISSUE
THROMBIN
TRAUMA
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RISK FACTORSEtiology Process Clinical Risk Factors
Tone Overdistended Uterus Polyhydramnios, Multiple GestationMacrosomia
Uterine Muscle Fatigue Rapid Labor, Prolonged LaborHigh Parity
Intra Amniotic Infection Fever, Prolonged ROM
Functional/Anatomic Distortion of the Uterus
Fibroid UterusPlacenta PreviaUterine Anomalies
Tissue Retained ProductsAbnormal Placenta
Incomplete Placenta at DeliveryPrevious Uterine ScarHigh Parity
Retained Blood Clots Atonic Uterus
Trauma Lacerations Precipitous or Operative Delivery
Extensions at C/S Malposition, Deep Engagement
Uterine Rupture Previous Uterine Surgery
Uterine Inversion High Parity, Fundal Placenta
Thrombin Pre-existing Coagulopaties, Liver Disease
Acquired in Pregnancy ITP, DIC
Therapeutic Anti-coag History of DVT or PE
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HAEMHAEMOOSTASISSTASISO: proceed with oxytocin infusion, prostaglandins ( via rectal, intramuscolar, IV, intramyometrial)
(off label)
First line
Second line
Third line
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Drugs to prevent and treat uterine atony
•Prophylactic syntometrine versus oxytocin•Prophylactic use of oxytocin•Carbetocin•Injectable prostaglandins•Misoprostol
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• Dioscorides: cyclamen, 100 AD
• Ergot (Claviceps purpurea), 1582 AD
Ancient Oxytocics
40
• Egyptian Papyrus Ebers, 1500 BC
contract uterus: speed birth, stem haemorrhage
hemp in honey
celery in milk
juniper berries
fly excrement (in many ancient pharmacopoeias)
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• Nobel prize in chemistry 1955
sulphur compounds of high importance
first synthesis of a polypeptide hormone
T Reinheimer, 2009
1953: Synthesis of Oxytocin
Vincent du Vigneaud
– American biochemist
– discovery, isolation, and synthesis
together with ADH/vasopressin
41
The Nobel Foundation 1955http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/oxytocin.gif
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T Reinheimer, 2009
Oxytocin Today
– oxytocin (sometimes combined with ergometrin)
42
Martindale 2008http://www.appdrugs.com/ProdJPGs/OxytocinLg.jpg
• Labour induction/augmentation
• Prophylaxis and Treatment of Postpartum haemorrhage
retained placenta: umbilical vein injection
milk ejection/lactation: oxytocin nasal spray
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T Reinheimer, 2009
Oxytocin Agonists
Carbetocin (DURATOCIN, PABAL)
– long-acting synthetic analogue
– indication: prevention of uterine atony
– veterinary medicine
43
Pritt et al. 2004, Manning et al. 2008http://www.bcnpeptides.com/images/products/carbetocina.jpg
WO/2003/000692, US/20070117794
• Non-peptide agonists
patented for erectile dysfunction
WAY-262464: patented for anxiety, schizophrenia
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• 30 women with elective caesarean section
• 5 u of oxytocin either as a bolus injection or an infusion over 5 min
• Heart rate and intra-arterial blood pressure recorded every 5 s
Mean arterial pressure (MAP) changes with oxytocin
Mea
n ch
ange
of M
AP
(m
mH
g)
Study period (s)
Thomas JS, et al. Br J Anaesth 2007
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Carbetocin – Pharmacodynamics
Oxytocin Carbetocin
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N=240Study design: Prospective double-blind randomized controlled studyDrugs: Carbetocin 100 µg i.m. vs. syntometrine (5 IU of oxytocin and0.5 mg of ergometrine) i.m.Primary outcome: postpartum hemorrhage requiring additional uterotonic therapySecondary outcome: incidences of postpartum hemorrhage (>500 ml) and severe postpartum hemorrhage (>1,000 ml) as well as adverse effects profile
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Authors Conclusion:
A single dose of intramuscular carbetocin
100µg may be more effective as compared to a single intramuscular dose of syntometrine (5 IU of oxytocin and 0.5 mg of ergometrine) in reducing postpartum blood loss
Lower incidence of adverse effects.
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N=377Study design: double-blind randomised single centre studyDrugs: carbetocin 100 µg or oxytocin 5 IU, both i.v.Primary outcome: Need of additional pharmacological oxytocic interventions.Secondary outcomes: Estimated blood loss, difference in preoperative and postoperative haemoglobin, incidence of blood transfusion and adverse effects
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Authors conclusion:
Carbetocin reduces the use of additional oxytocics following caesarean section when compared with the licensed dose of oxytocin (5 IU)
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StudyCarbetocin
n/NOxytocin
n/NRR (Fixed)
95% CIWeight
(%)RR (Fixed)
95% CI
01 Caesarean delivery
Boucher 1998 0/29 3/28 100 0.14 (0.01, 2.56)
Dansereau 1999 15/317 32/318 900 0.47 (0.26, 0.85)
Subtotal (95% CI)
346 346 100.0 0.44 (0.25, 0.78)
Total events: 15 (carbetocin), 35 (oxytocin)Test for heterogeneity chi-square=0.66; df=1; p=0.42; I2=0.0% Test for overall effect z=2.81; p=0.005
02 Vaginal delivery
Boucher 2004 12/83 12/77 100.0 0.93 (0.44, 1.94)
Subtotal (95% CI)
83 77 100.0 0.93 (0.44, 1.94)
Total events: 12 (carbetocin), 12 (oxytocin)Test for heterogeneity not applicableTest for overall effect z=0.20; p=0.8
Carbetocin versus oxytocin
0.001
• REVIEW: Oxytocin agonists for preventing PPH• COMPARISON: 01 Carbetocin versus oxytocin• OUTCOME: 02 Use of additional uterotonic therapy
0.1 1 10 100 1000Favours carbetocin Favours oxytocin
Su LL, et al. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005457
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Conclusions
Prevention of PPHVaginal birth: active management, Oxytocin (3-5 IU), no prostaglandins, no ergometrinCaesarean section: Carbetocin (Pabal®), Oxytocin 5IU 2-3min – no bolus, no PGs, no ergometrin
Therapy of PPHOT (10-40 IU/liter), ergometrin (0.2mg every 2-3 hours)PGE2/PGF2alpha (0.25 mg i.m. every 15-90 min)Misoprostol 800-1000mcg rectally (off label)Carbetocin (off label)
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HAEMOHAEMOSSTASISTASIS
S: transfer the patient to the operating room( exclude trauma or retained products, proceed with bimanual compression)
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HAEMOSHAEMOSTTASISASIST: “Balloon Tamponade”;
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HAEMOSHAEMOSTTASISASIST: “Balloon Tamponade”;
Uterine packing
(2009)
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Traditional method
Bakri balloon Bakri balloon
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TAMPONADE WITH BAKRI BALLOON
– Simple and efficient (87-95 % success rate)
– Applicable after cesarean and vaginal births
– Used as method of prevention in “cesareans at high hemorrhagic risk” (placental pathologies, uterine over-distension, preeclampsia, precedent hysterotomy, coagulopathy, etc) and in the case of contraindications for prostaglandins (asthma, glaucoma, important hepatic and renal dysfunction)
– Easy to insert and remove
– Continuous monitoring of blood loss
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BAKRI BALLOON The Bakri is a balloon in silicon, latex-free, which is
filled with physiological solution (500 cc max) and is able to create a real intrinsic compression on the myometrial walls: the filling volume can be varied in relation to the dimension of the uterus and the contractile response
Additionally to the ease of insertion it has the possibility to monitor the amount of blood loss thanks to the drainage holes located in the distal part of the catheter, which is attached to a sac in order to collect the fluids. This access is used also to perform washings of the uterine cavity.
Associate adequate antibiotic coverage Removal of the balloon within 24 hrs administering
uterotonics/uterokinetics before deflating
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Bakri balloon Bakri balloon
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Bladder
Bakri balloon
Bakri balloon
The intrauterine balloon Ultrasound
myoma
BAKRI BALLOON
Catetere vescicale
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HAEMOSTHAEMOSTAASISSISA: apply “sutures”
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HAEMOSTHAEMOSTAASISSISA: apply “ compression sutures”
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B-Lynch suture
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Hayman uterine compressive sutures Does not necessitate to open
the uterine cavity
Cho multiple quadrate sutures
HAEMOSTHAEMOSTAASISSISA: apply “compressive sutures”
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Suture of Hayman
HAEMOSTHAEMOSTAASISSISA: perform “ sutures”
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HAEMOSTAHAEMOSTASSISISS: Systematic pelvic devascularization
Rescue Surgery: Ligation uterine artery and ovarian artery
Triple ligation of Tsiruinikov :
ligation of the uterine arteries, round ligament and the uterine-ovarian.
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Vascular ligation
– Uterine
– Ovarian
– Int iliac
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Vascular ligation
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Ligation hypogastric artery
Underneath the superior gluteal artery
Rescue Surgery HAEMOSTAHAEMOSTASSISIS
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Hansch E, etal. AJOG 1999
Hypogastric artery ligationsuccess 84%
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(Limiting factors: hemodinamically stable cases - presence of angiographist - transport to radiology)
Fragments of gelfoam are injected (gelatin sponge resorbable in 10-30 days)
HAEMOSTASHAEMOSTASIISS
I: Interventional radiologist –”Uterine Artery Embolization”
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HAEMOSTASHAEMOSTASIISSI: Interventional radiologist –”Uterine Artery Embolisation”
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Rescue Surgery :
total hysterectomy / subtotal
1.55 % births
0.24% and 0.90% of all cesarean sections
between 1480 and 1800 hysterectomies/year associated with cesarean section
ISTAT 2006
HAEMOSTASIHAEMOSTASISSS : Subtotal or total abdominal hysterectomy
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The ideal treatment should be:
intuitive and easy to apply
secure and effective in the “prevention” and the arrest of
hemorrhages
has an immediate result
avoids hysterectomy
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Our Philosophy…
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EFFICACY & EFFICIENCY
Team work
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•TEAM- Obstetricians, Anesthetists, Blood bank, Interventional
Radiologists
Max therapeutic Max therapeutic efforts within 2-3 hrsefforts within 2-3 hrs
Contemporary Contemporary involvement of all involvement of all professional figuresprofessional figures
Liberal use of all Liberal use of all therapeutic agentstherapeutic agents
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Follow in a stepwise way the guidelines
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BASICS
1. INTERVENTIONAL RADIOLOGISTS IN THE THEATRE
2. CLAMPING UTERINE VESSELS BEFORE PLACENTAL DELIVERY
3. ASSOCIATION OF COMPRESSIVE SUTURES AND BAKRI BALLOON
INFORMED CONSENT
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B-Lynch + Bakri Balloon
“ SANDWICH EFFECT“
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B-Lynch + Bakri Balloon
IT LOOKS LIKE THE LUGGAGES OF IMMIGRANTS…..
NO RISK OF ISCHEMIA
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Prevention of Postpartum Hemorrhage ( cases with elevated hemorrhagic risk: i.e., placenta previa post-C.S.)
STEP 1 PRELIMINARY PROPHYLACTIC
CATHETERIZATION OF THE DESCENDING AORTA
STEP 2 EXTRACTION OF THE FETUS BY C.S. AND PLACENTAL DELIVERY
STEP 3MULTIPLE QUADRATE ENDOUTERINE
HEMOSTATIC SUTURES
STEP 4PREPARATION OF B-LYNCH
COMPRESSIVE SUTURES
STEP 5 APPLICATION OF HYDROSTATIC BALLOON (BAKRI-BALLOON)
STEP 6
REPOSITIONING OF UTERUS –UTERINE SUTURES-HYDROSTATIC BALLOON
INFLATION-B-LYNCH LIGATURE
IF THESE MANEUVRES FAILDEVASCOLARIZATING LIGATURE /SELECTIVE EMBOLIZATION
/HYSTERECTOMY
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STEP 1
Angiography
transomeral/transfemoral pre-carefour
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STEP 2 DELIVERY OF THE FETUS
ADMINISTRATION OF CARBETOCIN
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STEP 2 CLAMPING UTERINE VESSELS
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Prevention of postpartum hemorrhage ( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )
Assistance Plan
STEP 2 Squared hemostatic endouterine sutures
Rationale: at the level of the inferior uterine segment reduced muscular component ; incomplete mechanical hemostasis after placental delivery; conspicuous hemorrhage
multiple quadrate sutures in the IUS of 2-3 cm, transdecidual. (Dexon n.1-2,needle with large curvature )
Retraction of the muscular fibers with clamping and occlusion of the vasculature Affro
nti
me
s
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STEP 3 Squared hemostatic endouterine sutures
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Prevention of postpartum hemorrhage ( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )
Assistance Plan
STEP 3 B-Lynch compressive sutures
The ligature of the sutures follows after STEP 4
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STEP 4 PREPARATION OF B-LYNCH SUTURE
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STEP 4
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Prevention of postpartum hemorrhage
STEP 4 Application of hydrostatic balloon (Bakri balloon)
Uterine closure
Hydrostatic balloon inflation
B-Lynch suture ligature
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STEP 5
BAKRI-BALLOON POSITIONING
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MILD INFLATION OF THE BALLOON
STEP 5
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REPOSITIONING THE UTERUS; FULL INFLATION OF BALLOON; B-LINCH SUTURE APPLIED
STEP 6
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( Ex adiuvantibus ) postpartum hemorrhage
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( Ex adiuvantibus )
Separatore cellulare a flusso continuo
Unità di gestione della temperatura corporea
postpartum hemorrhage
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postpartum hemorrhage
ADULT INTENSIVE CARE UNIT POSTPARTUM
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END POINT :
SURGICAL CONSERVATIVE TREATMENT
REACHED 95% ( 78 OUT OF 82 )
• 4 HYSTERECTOMIES
ONGOING
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US SCANDIFFICULT CASES…….
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RMNDIFFICULT CASES….
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US SCAN CHECK AFTER 30 DAYS
DIFFICULT CASES ….
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DIFFICULT CASES... ( 02.09.2011)
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DIFFICULT CASES...... ( 02.09.2011)
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DIFFICULT CASES... ( 02.09.2011)
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DIFFICULT CASES...
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CESAREAN HYSTERECTOMY
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CESAREAN HYSTERECTOMY
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CESAREAN HYSTERECTOMY
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CESAREAN HYSTERECTOMY
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ConsiderationsAll pregnancies are at risk of hemorrage in the post partum
even if at the moment of birth there were no risk factors.
Because our goal is to improve maternal health and prevent the possibility of death during the pregnancy or birth it is
fundamental to possess, other than a
solid preparation,
a trustworthy and well trained team and the necessary instruments.
( Bakri balloon;Cell sorter with continuous flow; FloSeal)
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New conservative approach in the management of PPHG. Clerici, G. Epicoco, E. Bottaccioli, S. Arena, I. Giardina, G. C. Di Renzo, G. Affonti
University Hospital of Perugia, Perugia, Italy
INTRODUCTIONPostpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Most deaths occur within the first 4 hours after delivery, often as a consequence of placental delivery. Treatment option for PPH include conservative management (uteritonic drugs, selective devascularization by ligation or embolization of the uterine artery, external compression with uterine sutures and intrauterine packing). Failure of these options necessitates hysterectomy.The objective of the study is to report our experience with a conservative management protocol to treat PPH in high risk patients diagnosed with placenta previa/accreta.
METHODSA retrospective study of 49 patients (since October 2007) with placenta previa/accreta who underwent a conservative management protocol (see table).
RESULTSConservative management of PPH was successfully achieved in 48 patients (98%). In only one case it was necessary to perform post-partum hysterectomy for massive bleeding due to severe placental accretism. In another case it was necessary selective embolization of the right uterine artery due to the presence of hematoma in the right part of the lower uterine segment and in the right paracolpus. The mean estimated blood loss was 1620 ml (range 1100-2340 ml). The mean hospital stay was 5.5 days (range 4-10 days). 22 patients (45%) underwent intraoperative and postoperative blood transfusions and the mean transfused volume was 700 ml. 18 patients (37%) were admitted for 24-48 h to intensive care unit for intensive monitoring. 30% of patients experienced moderate fever in the first 24-48 h and they were treated with antibiotics.
CONCLUSIONSAll pregnancies are at risk of PPH. Its management is dictated by several considerations including hemodynamic status and desire to preserve fertility. Conservative interventions should represent mandatory step for treatment of PPH in high risk patients with placenta previa/accreta. The results of this conservative protocol are encouraging .
CONSERVATIVE MANAGEMENT PROTOCOL
STEP 1 –Preliminary prophylactic catheterization of the descending aorta
STEP 2 –Extraction of the fetus by C.S. and placental delivery
STEP 3 –Multiple quadrate endouterine haemostatic sutures
STEP 4-Preparation of B-Lynch compressive sutures
STEP 5 –Application of hydrostatic balloon (Bakri balloon)
STEP 6 –Repositioning of uterus - uterine sutures - hydrostatic balloon inflation – B-Lynch ligature
If the maneuvers fail the next step is devascolarizating ligature/selective
embolization of the uterine arteries.If all procedures fail, proceed with
hysterectomy.
• Monitoring of maternal hematologic parameters 24 hrs before C.S. and 2 h after the procedure, than every 2-4 h for the following 24 hrs in relation to clinical conditions.• Blood transfusion if the hemoglobin level decreases more than 7 g/dl and the hematocrit value is less than 21% ;• The Bakri balloon is removed 24 h after delivery.
Affronti
EMS
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CONCLUSIONS
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FACTS:FACTS:
All pregnancies are at risk of All pregnancies are at risk of
PPH even if no predisposing PPH even if no predisposing
factors are presentfactors are present
Luis G. Keith 2007
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BOTTOM LINE
Averting maternal death is Averting maternal death is based on having a prepared based on having a prepared mind, a prepared team and mind, a prepared team and a full range of possible a full range of possible therapiestherapies
Luis G. Keith, 2007
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Postpartum HemorrhageRecommendations:
•Every department needs to have a protocol for management of O.E., with periodic re-evaluation (Life Support training)•Cases at risk of E.O. need to give birth in a II-III level structure
•Uncontrollable hemorrhages may necessitate hysterectomy: an expert surgeon needs to be avaliable quickly 24 hrs a day
•Activate the multidisciplinary team early in the management of a case at risk
•Institutional guidelines for the treatment of hemorrhages with periodic simulation training (skills and drills)
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THANK YOU