Pph drill
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Transcript of Pph drill
Dr. Monika Madaan
Specialist
Dept. Of Obstetrics & Gynaecology
ESI HospitalManesar
PPHSingle most important cause of maternal
mortality worldwide.Accounts for 34% of maternal deaths in
developing countries.
DefinitionAny blood loss than has potential to
produce or produces hemodynamic instability
DefinitionBlood loss > 500 ml after deliveryPrimary : Loss within 1st 24 hours after deliverySecondary : 24 hours till 12 weeks postnatally
Minor : 500-1000 mlModerate : 1000-2000 mlSevere : > 2000 ml
PREDICTION AND PREVENTION
Identify pt. at risk
- Pl previa/accreta
- Anticoagulation Rx
- Coagulopathy
- Overdistended uterus
- Grand multiparity
- Abn labor pattern
- Chorioamnionitis
- Large myomas
- Previous history of PPH
PREDICTION AND PREVENTIONActive Management Of Third Stage Of Labor
(AMTSL): Should be offered routinely and includes:
1.Administration of uterotonics soon after birth.
2.Delayed cord clamping.
3.Delivery of placenta by controlled cord traction followed by uterine massage.
PPH DrillClear and logical sequence of steps
essential in the management of PPH.
CALL FOR HELP
Team Effort
•Skilled Obstetric Team•Trained Anaesthesiologist•Clinical hematologist •Supporting staff
ResuscitationAssessA : AirwayB : Breathing C : Circulation Secure 2 wide bore i.v. lines:- 14-16 gauge Draw blood for grouping & cross matching,
CBC, LFT/KFT, SE & Coagulogram.
Position flatKeep the patient warmAdminister oxygen by mask ( @ 10-15 litres/
min)Catheterize the patient for emptying bladder &
monitoring output
Fluid Replacement
RAPID WARMED infusion of fluidsCrystalloids : Fluids of choice until
compatible blood is arranged1 ml of blood loss= 3 ml of crystalloidsTotal volume of 3.5 litres of clear fluids
(upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood.
If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given
FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal
(ie 12-15 ml/kg or total of 1 litres.)Platelet Concentrate: if Platelet count< 50,000/
microlitre.Cryoprecipitate: if fibrinogen < 1 g/ l.
Continuous vital monitoring.Monitor adequacy of replacement with urine
output (0.5 ml/kg/hr) and CVP (4-8 cm water)Main therapeutic goals are to maintain:Haemoglobin > 8gm/dlPlatelet count > 75 × 109 / lProthrombin < 1.5 × mean controlAPTT < 1.5 × mean controlFibrinogen > 1 gm/ l
Establish Etiology Simultaneously4 T’s
Tone (abnormalities of uterine contraction) :70 – 80%
Trauma (of the genital tract) : 20 %Tissue (retained products of conception) : 10
%Thrombin (abnormalities of coagulation) : 1 %
Contd…
Bimanual Compression
If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions
Administer Uterotonic DrugsFIRST LINE
Oxytocin:
Start with 5 units slow iv or im.
Infusion of 20 units in 1 L@ 60 dr/min.
Continue same dose @ 40 dr/min until bleeding stops.
Maximum upto 3 L.SECOND LINE
Ergometrine/ methyl ergometrine:
Dose: 0.2 mg im or slow iv
Repeat 0.2 mg after 15 min.
Maximum 5 doses (1 mg)
Syntometrine im
THIRD LINE PGF 2α: Dose: 0.25 mg im. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. Misoprostol: 200-800 µg sublingually. Do not exceed 800 µg
WHO GUIDELINES FOR MANAGEMENT OF PPH 2009
Uterine Tamponade• Bakri balloon• Sengstaken Blakemore oesophageal catheter• Condom catheter• Urological Rusch balloon
Success depends upon Positive Tamponade test
Procedure of condom Balloon insertion
Initial Assembly Condoms-2
Foley’s catheter-no.16 Saline with iv set Speculum Sponge holding
forceps
ProcedureLithotomy positionIndwelling Foley’s
catheter.Explore uterus, cervix and
vagina.Inflate balloon with 100-
300 ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test).
Compression sutures
B Lynch Suture•Fundal compression suture•Apposes anterior & posterior wall
Contd…Parallel Vertical compression sutures for placenta praevia
Stepwise Uterine Devascularization
•Uterine arteries
•Tubal branch of ovarian artery
•Internal iliac artery
Uterine Artery EmbolizationPossible only if internal artery ligation has not been done and facility for interventional radiology available
HysterectomyResort to hysterectomy “SOONER RATHER
THAN LATER”High maternal morbidityTiming and adequate replacement is of
utmost importance
Documentation and DebriefingImportant to record:Sequence of eventsTime and sequence of admn of
pharmacological agents, fluids, blood productsThe time of surgical interventionThe condition of mother throughout .
Newer DevelopmentsTranexamic acid : 1 gm i.v slow. Can be
repeated after 30 min if bleeding continues./Recombinant activated factor VII
(Novoseven): 90 µg/ kg . May be repeated within 15-30 minutes. No clear consensus on efficacy.
Carbetocin (oxytocin agonist) : 100 µg i.v or i.m. Produces tetanic uterine contractions.
HAEMOSTASIS ALGORITHMH – Ask for helpA – Assess and resuscitateE – Establish etiologyM – Massage the uterusO – Oxytocic administrationS – Shift to OTT – Tissue n trauma to be excluded and
proceed to tamponadeA – Apply compression suturesS – Systematic pelvic devascularisationI – Interventional radiologyS – Subtotal or total hysterectomy
To Conclude, Management of PPH Has Evolved From:PanicPanicHysterectomy
PitocinProstaglandinsHappiness
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