DesabanduDr. Kapila. GunawardanaM.B.B.S.,M.S.(Obs & Gyn), F.R.C.O.G.,F.C.O.C.(S.L )Consultant Obstetrician and GynaecologistTeaching Hospital,Peradeniya.

Preamble

Three case ReportsPlace: T.H.

Anuradhpura

Period: 1991- 1996

Case report 01 Case report 02 Case report 03

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IntroductionIntroduction Place of Conservative Measures in the

Management of PPH. In the 19 century, when the medical management of

the PPH failed, only option was to proceed with either hysterectomy or the ligation of internal iliac arteries.

Preservation of the uterus in patients with severe PPH was a “nightmare”.

With the advent of conservative surgical management in the 20th century now it has become a reality.

These techniques have the advantages of; Preservation of Fertility Similar success rates to radical surgery Can avoid complex and risky surgical procedures Low morbidity

Conservative surgical

methods for management

of PPH

A)Tamponade method

B)Compression method

C)Selectivedevascularisati

on

A) Tamponade Method

1. Uterine packing 2. Balloon tamponade -Sengstaken-Blakemore balloon -Bakri Tamponade Balloon -Condom catheters -Others

How Does Tamponade Method Work ?

Idea of this test is to keep intrauterine pressure above the level of uterine capillary pressure by using a sterilized balloon (Pressure in the capillary system is 21-48 mm Hg)

1. a. Reduction of active uterine bleeding

b. Facilitate coagulation system to

function

2. Foreign body effect

1. Gauze Uterine Packing

This was the standard tamponade technique until recently.

Now this technique is not used commonly, since

-Availability of more effective balloon

tamponade method -Improved medical management of PPH -Increased incidence of infection

2. Balloon Tamponade

Better uterine temponade effect can be achieved with a balloon.

A balloon is inserted to the uterus through the cervix & it is inflated with water (400 -500ml) to get the tamponade effect.

Available types Sengstaken-Blakemore balloon (originally

designed to treat oesophageal varices) Bakri Tamponade Balloon (commercially

available type) Condom catheters (can be assemble locally) Others

Bakri Tamponade Balloon

Designed specifically for obstetrical hemorrhage.

Maximum capacity 800cc of balloon (recommended 250cc to 500cc)

Condom Balloons

Can be assembled by using a condom, urinary catheter and IV drip set

Similar effectiveness to the Bakri Balloon.

Low cost.

Other Options of Balloon Tamponade Method

Selection of Patients for Tamponade Method

PPH due to uterine inertia can be treated effectively by this method with combination of medical treatments.

Varying degree of success in other conditions. e.g.- sub mucosal fibroids, placenta previa

Possibility of retain products, genital tract lacerations and coaugulopathy need to be excluded.

How Do We Do It ?

After initial assessment of the patient, balloon is inserted into the uterine cavity through the cervix with a sponge forceps.

Balloon is filled with 300 – 500ml of saline until it become visible at the cervical canal.

If no or minimal bleeding is observed both via central lumen and through the cervix, the “Tamponade test” is considered successful.

Then upper vagina is packed with roller gauze to prevent expulsion of the balloon.

Bladder should be catheterized to prevent bladder distention.

To maintain uterine contraction over the balloon a slow oxytocin infusion ( 20- 40 units) should be continued over the next 12- 24 hrs.

Broad spectrum antibiotics – to minimize the risk of infection.

The patient should be monitored closely ( pulse, BP, temperature, bleeding, input / output, fundal height)

After 24hrs, balloon is deflated and leave in situ and observed for 30min. for active bleeding.

If there is no bleeding, oxytocin drip can be stopped and balloon can be removed in another 30 min time.

Main Advantages and Disadvantages of Tamponade

TechniqueAdvantages Simple procedure – can be performed even with

minimal facilities and skills. Therapeutic as well as diagnostic in

management of PPH. Bleeding can be controlled until the patient is

transferred to a major hospital.

Disadvantages Risk of infection Prolonged intensive monitoring is needed.

B) Compression Method (Sutures)

Compression sutures worked by direct application of pressure on the placental bed bleeding and also by reducing blood flow to the uterus.

B-Lynch Modified B-Lynch Multiple square sutures

B-Lynch Brace Sutures

This involves a pair of vertical brace sutures around the uterus to appose the anterior and posterior walls and to apply continuing compression.

Compression Sutures

Cornu

Fallopian tube

Ovary

Modified B-Lynch

There are different types of modification in B-Lynch.

Without making a lower segment incision, two brace sutures are applied from lower segment of the uterus to the fundus, to compress anterior and posterior wall.

Multiple Square Sutures

Multiples square box sutures are applied in the body of the uterus to approximate and compress anterior and posterior wall of the uterus.

Main Advantages and Disadvantages of the Compression SuturesAdvantages Effective treatment option in uterine inertia

when medical treatment failed. Can be used as a prophylactic measure

following caesarian section when there is a risk of PPH. e.g.-Placenta previa, uterine inertia

Disadvantages Need surgical intervention - laparotomy Need facilities and surgical skills Risk of uterine adhesion - fertility can be

affected.

C) Selective Devascularisation

By reducing blood supply to the uterus facilitate the haemostasis of the uterus.

Uterine artery ligation Utero – ovarian vessel ligation Internal iliac artery ligation Uterine artery and internal iliac

artery embolisation

Uterine Artery Ligation

Uterus received 90% of blood supply from the uterine arteries.

Ligation of these vessels facilitate haemostasis.

This is technically easier and safer than internal iliac artery ligation.

Ligation of Utero-ovarian Vessels

This involves ligation of utero - ovarian anastomosis rather than ligation of ovarian arteries .

Internal Iliac Artery Ligation

Bilateral internal iliac artery ligation results in 85% reduction in pulse pressure in the arteries distal to the ligation.

Reduces blood flow by 50% in distal vessels.

Converts arterial pressure system in to a one with pressures approaching those in the venous system.

Facilitate haemostasis via clot formation.

Uterine Artery and Internal Iliac Artery Embolisation

Feeder arteries of the uterus catheterized and embolised with polyvinyl alcohol particles(150-300 mic in size)

Blood flow of vessels will be arrested and gives Similar effect of ligation of vessels.

This polyvinyl alcohol particles are usually reabsorbed in 10 days time and re-cannulation of the vessels are possible.

Available only at few tertiary care centers where trained interventional radiologists are presented.

Problems Associate with Selective Surgical Devascularisation

Need surgical skills and training. Risk of damage and accidental ligation of

ureter and other vessels. Not much effective when there is a

coaugulopathy. Fertility can be affected ?

Conclusion

With the advent of conservative measures in PPH, number of obstetric hysterectomies have been dramatically reduced.

However, the success of conservative management will depend on, Correct clinical assessment Timely intervention(Not too early, not too late) Application of the ideal procedure Continues monitoring of the condition Direct supervision by the specialist(Team work)

Even though the most procedures of conservative management are simple, it requires good clinical sense to detect correct patient at right time.