Dr. Rakhi GajbhiyeMBBS,MD (MGIMS Sevagram)

Director Mauli Women’s Hospital,Nagpur

Published 9 papers in various journals

Contributed a chapter in the Hands on hysterscopy book published in 2016

Delivered talks in various conferences

Member of IMA,FOGSI,NOGS,IMS,AMF,ISAR,MSR

Surgical management of PPH3.11.17

3.11.17

SURGICAL MANAGEMENT OF PPH

Surgical Interventions

A wide range of Surgical interventions have been reported to control PPH that is unresponsive to medical or mechanical interventions

• Compression sutures

B Lynch suture

Hayman suture

CHO sutures and U sutures

• Ligation of uterine,ovarian,ant.div. int. iliac vessel

• hysterectomy

B Lynch suture

• Christopher B Lynch developed it in 1997

• Objective-To compress the uterus without occluding the UA or the uterine cavity.

• Ind: Atonic PPH,PPH with coagulopathy

• Suture: absorbable-Polyglactin ,Chromic .

• Procedure: A compression test is done and if the uterus responds this suture is attempted.

B-Lynch suture

Procedure:Take a suture 3cm below the incision line and come out 3cm above the line.

Take the suture over the fundus and come posteriorly.

Now take a horizontal suture in the lower segment of uterus posteriorly.

Take this suture over the fundus and come anteriorly.

Insert a suture again 3cm above the incision ,then come out 3cm below the incision .

Tell the assistant to compress the uterus while u tie the knot.

Hayman Compression suture

Ind: Atonic PPH,PPH with coagulopathy.

Easy to perform.

Does not require an incision on the uterus.

Pair of vertical compression sutures passed anteriorly to posterior uterine wall and tied over the fundus.

• Procedure:A delayed absorbable suture like polyglactin on a straight and blunt needle is used to transfix the uterus from anterior uterine wall to the posterior uterine wall half an inch medial to the angle just above the reflection of the bladder.

• The assistant compresses the uterus while you tie a knot at the fundus . The walls get compressed and help to achieve homeostasis by effectively producing tamponade.

Hayman suture

CHO sutures

Indications:Atonic PPH,placental bed bleeding

Procedure: Square stitches are taken by introducing the needle through anterior uterine wall at or opposite to the site of bleeding sinuses and brought out through post wall,reinserted postero-anteriorly and tied,approximating the two uterine walls thereby closing large sinuses.

Complications of

compression sutures

Even though there are no large published data , there are several small observational studies and case reports of the complications .

Complications of

compression sutures

Short term consequences:

• Haemorhage due to cut through of sutures

• Haematometra,Pyometra

• Partial or complete uterine wall necrosis due to ischaemia.

Long term consequences:

• Bowel herniation and Int. obstr. due to dog ear loop of suture

• Asherman’s syndrome- quoted risk-1 in 4

Ligation of vessels

Uterine artery ligation

Ligation of anastomosis of Ovarian and uterine artery.

ligation of ant. div.of internal iliac artery

Uterine artery

ligation(O’Leary stitch)

Procedure:Bladder is pushed down to avoid injury to ureter.

index finger is introduced behind broad ligament to identify avascular space

Take a bite through the avascular space 2-3cm below the level of uterine incision ,then a bite through the myometrium and tie it.

In case of normal del in lat ut border at the junction of upper and lower ut segment.

10-15% of bleeding will stop with U/L UA ligation

70-90% with B/L UA ligation ,as during pregnancy uterine artery supplies 90% of blood to uterus.

Additional lower stitch about 2cm below the first ligature(cervicovaginal br & ascending br) can also be taken

O’Leary stitch

Ligation of utero-ovarian

anastomosis

Procedure:Hold the FT with babcocks

Take a bite below the ovarian ligament and come out from avascular area below the FT and tie

ligation of utero-ovarian

vessels

Internal iliac artery ligation

(ant branch)

Internal Iliac Artery

Ligation

• Ind: Before or after hysterectomy for PPH

• Continuous bleeding from the broad ligament base; profuse bleeding from pelvic side-wall or vaginal angle

• Diffuse bleeding without clearly identifiable vascular bed

• Ruptured uterus in which uterine artery may be torn at its origin from internal iliac artery

• Where extensive lacerations of cervix have occurred following difficult instrumental delivery

Internal iliac artery ligation

(ant branch)

Procedure:Give incision from the lateral end of round ligament to the base of infundibulo-pelvic lig.Open broad ligament to approach retroperitoneal space. Search for the ext iliac vein.Ureter is seen hugging medial peritoneal fold.Internal iliac artery is identified and doubly ligated at least 2cm from its origin.

IIAL

Hysterectomy

• Best immediate option

• When uterine atony is unresponsive to medical and surgical measures — Where facilities for embolization are not available — Obstetrician not well versed with technical aspects of conservative surgical procedures or iliac artery ligation

• Indications :

1. Uterine rupture secondary to obstructed labor , Previous caesarean section

2. If rupture is extensive & haemorrhage cannot be stopped by suture of ruptured area

MM of traumatic causes

Exploration and suturing of vaginal tears, paraurethral tears,Cx tears

Vulval and Broad ligament haematomas

Summary

With so many women dying each year globally, we should work hard at all levels to save every mother and reduce the MMR.

In situations where medical management has failed to control the bleeding, a prompt decision should be taken for mechanical interventions and if need be surgical interventions to save life.

Save the life of the one who gives birth to a new life