Surgical Surgical Management Management of Post Partum of Post Partum HaemorrhageHaemorrhage

International Training and Workshop, International Training and Workshop, Wales 2011Wales 2011

Emeritus Professor C B-Emeritus Professor C B-Lynch GORSL 2007Lynch GORSL 2007

Consultant Obstetrician Consultant Obstetrician and Gynaecological and Gynaecological

SurgeonSurgeon

Milton Keynes General Milton Keynes General Hospital Hospital

(NHS Foundation (NHS Foundation Trust)Trust)

(Oxford Deanery, U.K.)(Oxford Deanery, U.K.)

Catastrophic haemorrhage is a persistent Catastrophic haemorrhage is a persistent problem with substandard care as a regular problem with substandard care as a regular event event – CEMACH ‘Why Mothers Die’ UK – 2000 2002– CEMACH ‘Why Mothers Die’ UK – 2000 2002

Approximately 25%! of maternal deaths in Approximately 25%! of maternal deaths in developing countries are attributable to PPHdeveloping countries are attributable to PPH

PPH is a worldwide problem and one of the PPH is a worldwide problem and one of the three messengers of deaththree messengers of death

To Prevent the perils of PPHTo Prevent the perils of PPH

an intrauterine balloon an intrauterine balloon tamponade with or without tamponade with or without the B-Lynch suture the B-Lynch suture technique or modification technique or modification should be tried first. should be tried first. e.g PPH following vaginal e.g PPH following vaginal deliverydelivery

Mention one surgical technique in Mention one surgical technique in obs & gyn that :obs & gyn that :

Saves lifeSaves life Saves fertilitySaves fertility SimpleSimple QuickQuick CheapCheap Tested for success immediately Tested for success immediately

before and after performance before and after performance B-Lynch et B-Lynch et al; BJoG March 1997 v104:pp372-375al; BJoG March 1997 v104:pp372-375

>4000 cases reported (1997 -2010)>4000 cases reported (1997 -2010)Reported postoperative ‘complications’:Reported postoperative ‘complications’:e.g - Partial Ischemic necrosis - e.g - Partial Ischemic necrosis - Joshi et al; BJoG March Joshi et al; BJoG March 20042004

Uterine necrosis – Uterine necrosis – Treloar et all; BJoG January 2006Treloar et all; BJoG January 2006

Successful application in early pregnancy: Successful application in early pregnancy: first trimester [13 weeks] – first trimester [13 weeks] – Hillaby K et all; JoGHillaby K et all; JoG Second Trimester [21 weeks] - Second Trimester [21 weeks] - Price et al; JoGPrice et al; JoG

Known reported failure world wide 31/1827 Known reported failure world wide 31/1827 (0.016%) - (0.016%) - (CBL data collection and personal communications)(CBL data collection and personal communications)

Professor C B-Lynch Professor C B-Lynch GORSL 2007GORSL 2007Consultant Obstetrician and Gynaecological Consultant Obstetrician and Gynaecological

SurgeonSurgeon

Milton Keynes General Hospital (NHS Trust)Milton Keynes General Hospital (NHS Trust)

(Oxford Deanery, U.K.) (Oxford Deanery, U.K.)

27th November 198927th November 1989 Massive PPHMassive PPH Patient refusing hysterectomyPatient refusing hysterectomy

Clinical PointsClinical Points

The B-Lynch Suture Compression The B-Lynch Suture Compression Technique - Technique - Clinical PointsClinical Points

The ten point principle The ten point principle

Lloyd Davis or Frog Legged Position Lloyd Davis or Frog Legged Position EssentialEssential

The Uterus must be exteriorisedThe Uterus must be exteriorised Basic surgical competence requiredBasic surgical competence required Bi-Manual Compression to test for Bi-Manual Compression to test for

potential successpotential success Transverse lower segment incision madeTransverse lower segment incision made Uterine cavity checked, explored & Uterine cavity checked, explored &

evacuated.evacuated.

The B-Lynch Suture Compression The B-Lynch Suture Compression Technique - Technique - Clinical PointsClinical Points

Apply monocryl No. 1 mounted on 90Apply monocryl No. 1 mounted on 90 cm cm curvedethiguard blunt needle curvedethiguard blunt needle (code:W3709) (Ethicon, Somerville, N.J.) (code:W3709) (Ethicon, Somerville, N.J.) suture correctly with even tension (no suture correctly with even tension (no shouldering) shouldering)

Allow free drainage of blood, debris & Allow free drainage of blood, debris & inflammatory material.inflammatory material.

Check bleeding control vaginally, Check bleeding control vaginally, including swabs and instrumentsincluding swabs and instruments

Wave to anaesthetists, offer a prayer and Wave to anaesthetists, offer a prayer and close the abdomenclose the abdomen

Causes of failure:Causes of failure: Placenta percreta (1)Placenta percreta (1) Wrong technique (10) (uterine Wrong technique (10) (uterine

necrosis -2 cases!)necrosis -2 cases!) Uncontrolled DIC (4)Uncontrolled DIC (4) No pre operative test done (6)No pre operative test done (6) Not properly applied (6)Not properly applied (6) Delayed application (4)Delayed application (4)

Even Tension; No Ischemia; no necrosis;

Normal Uterine Normal Uterine characteristicscharacteristics

C Tsitlakidis et al; C Tsitlakidis et al; 10 year follow up of the effects of 10 year follow up of the effects of the b-lynch suture Int/fertill 51 the b-lynch suture Int/fertill 51 (2006)(2006)

Shouldering IschemiaShouldering Ischemia

Anterior Posterior

The uterus as it The uterus as it appears at appears at laparotomy, 24 laparotomy, 24 hours following a hours following a uterine brace suture.uterine brace suture.

An example of poor An example of poor techniquetechnique

Without exploration Without exploration and drainage of the and drainage of the uterine cavityuterine cavity

University of Seoul University of Seoul (Korea)(Korea)

23 cases23 cases Didn’t mention Didn’t mention

extent of bleedingextent of bleeding Pierce uterus 32 Pierce uterus 32

timestimes Does not close all Does not close all

transverse branchestransverse branches ? Cavity Patency? Cavity Patency Leading to Leading to

pyometriapyometriaOchoa et al; ObGy 99:506-509Ochoa et al; ObGy 99:506-509

Obstet Gynecol 2000 Obstet Gynecol 2000 Jul;96(1):129-131Jul;96(1):129-131

Prophylactic Application:Prophylactic Application:

>70 cases >70 cases All No PPH (but high All No PPH (but high risk)risk)

Complications (none reported)Complications (none reported)

Preventing the perils of PPHPreventing the perils of PPH

Stepwise devascularisation or internal iliac vessel Stepwise devascularisation or internal iliac vessel ligation should be done by a surgeon with appropriate ligation should be done by a surgeon with appropriate experience & expertise.experience & expertise.

Arterial embolisation has established potential, but Arterial embolisation has established potential, but the logistics of arrangements with the radiology the logistics of arrangements with the radiology department has to follow strict obstetric & radiological department has to follow strict obstetric & radiological protocol.protocol.

Sub-total or total hysterectomy, may continue to rise Sub-total or total hysterectomy, may continue to rise with mortality & morbidity if the rise in caesarean with mortality & morbidity if the rise in caesarean section rate is not controlled.section rate is not controlled.

Trainees should have regular workshop & fire drill Trainees should have regular workshop & fire drill training of the application of the Brace suture training of the application of the Brace suture compression & other conservative tamponade compression & other conservative tamponade techniques.techniques.

Obstetric Trauma - PPHObstetric Trauma - PPH

Post Partum Haemorrhage Following Post Partum Haemorrhage Following Acute Uterine InversionAcute Uterine Inversion

Bleeding from lower genital tractBleeding from lower genital tract

Acute inversion reported in 1:2,000 Acute inversion reported in 1:2,000 deliveriesdeliveries

May go unrecognised or May go unrecognised or misdiagnosed as uterine fibroidmisdiagnosed as uterine fibroid

Acute Uterine InversionAcute Uterine Inversion

In difficult cases, replacement may In difficult cases, replacement may have to be by laparotomy followed have to be by laparotomy followed

by another B-Lynch technique by another B-Lynch technique ‘stepwise atraumatic digital ‘stepwise atraumatic digital

replacement’ replacement’

(ref: TEXTBOOK OF POSTPARTUM HEMORRHAGE(ref: TEXTBOOK OF POSTPARTUM HEMORRHAGE sapiens publishing 2006) sapiens publishing 2006)

Acute uterine inversion.Acute uterine inversion.

Acute uterine inversion. Finger tips placed below Acute uterine inversion. Finger tips placed below fundus of uterus to facilitate reduction.fundus of uterus to facilitate reduction.

Acute uterine inversion.Acute uterine inversion.Progressive reduction with some ischaemia.Progressive reduction with some ischaemia.

Acute uterine inversion.Acute uterine inversion.Return of vascularity.Return of vascularity.

Acute uterine inversion. Complete reduction and Acute uterine inversion. Complete reduction and revascularization with normal clinical features.revascularization with normal clinical features.

Post Partum Haemorrhage Post Partum Haemorrhage Following Genital Tract Following Genital Tract

TraumaTrauma

Below the Level of the Pelvic FloorBelow the Level of the Pelvic Floor

Lithotomy positionLithotomy position Adequately anaesthetisedAdequately anaesthetised Passive drainage should be encouragedPassive drainage should be encouraged Local bleeding identified, transfixed and Local bleeding identified, transfixed and

haemostasedhaemostased Exploration of pudendal vesselsExploration of pudendal vessels Transfixion haemostasisTransfixion haemostasis Vaginal packVaginal pack Antibiotic coverAntibiotic cover

Above the Level of the Pelvic FloorAbove the Level of the Pelvic Floor

Enlarge & extend proximally between the 2 Enlarge & extend proximally between the 2 layers of the broad ligamentlayers of the broad ligament

May enable conservative managementMay enable conservative management Laparotomy & drainage may become Laparotomy & drainage may become

necessary via subperitoneal approachnecessary via subperitoneal approach Time of presentation is variableTime of presentation is variable Clinical features may not fitClinical features may not fit Low abdominal pain, tachycardia & pallorLow abdominal pain, tachycardia & pallor Conservative management failed – laparotomy, Conservative management failed – laparotomy,

evacuation & retro-peritoneal drainageevacuation & retro-peritoneal drainage Watchful of secondary haemorrhageWatchful of secondary haemorrhage Consider embolisation Consider embolisation

Stepwise DevascularisationStepwise Devascularisation Internal Iliac (hypogastric) artery Internal Iliac (hypogastric) artery

ligationligation Complex pelvic surgeryComplex pelvic surgery Peripartum abdominal hysterectomyPeripartum abdominal hysterectomy

Subtotal/TotalSubtotal/Total TF Baskett, Chapter 34 – A TEXTBOOK OF POSTPARTUM HEMORRHAGE TF Baskett, Chapter 34 – A TEXTBOOK OF POSTPARTUM HEMORRHAGE

Secondary PPH Secondary PPH KM Groom, TZ Jacobson ,Chapter 35 - A KM Groom, TZ Jacobson ,Chapter 35 - A TEXTBOOK OF POSTPARTUM HEMORRHAGE TEXTBOOK OF POSTPARTUM HEMORRHAGE