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PPH – Global and The UK Perspectives
S ArulkumaranProfessor & Head
Obstetrics and GynaecologySt George’s University of London
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*Other direct causes include: ectopic pregnancy, embolism, anesthesia-related ** Indirect Causes include: anemia, malaria, heart disease
75% Of MM & third of NN mortality takes place 75% Of MM & third of NN mortality takes place during labor/ birth or within 24 Hrs.during labor/ birth or within 24 Hrs.
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PPH Global Perspectives• 30-50% of maternal deaths due to PPH• Inadequate Health facilities• Inadequate skilled attendance• Inadequate medication or surgical facilities• Long delay in reaching facilities/ providing treatment Solutions• Better communication and transport• Health facilities (affordable/ self respect & dignity• Health personal (no need for controlled traction)• Medications; PG/ Misprostol, Tranexamic acid, R
Factor VII a, 1;1 PCV to Plasma transfusion• Simpler techniques – Balloon Tamponade/
Compression sutures/ Anti-shock Garment
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Strategies to Prevent Maternal MortalityBasic Emergency Obstetric Functions (6)
THREE INJECTIONS
•Post partum Hemorrhage – Oxytocics (IV/ IM/ Oral) & active management of the third stage of labor
•Hypertensive Disease > Eclampsia – Antihypertensive & Anticonvulsants – Mg SO4 –IV/ IM
•Sepsis – post abortion or labor & delivery – Antibiotics IV/IM
THREE MANUAL FUNCTION
•Manual removal of placenta
•Evacuation of the uterus of retained placental tissue
•Vacuum Assisted Delivery in cases of second stage delay
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Strategies to Prevent Maternal MortalityComprehensive Em Obstetric Functions (6 + 2)
• Basic Emergency Obstetric Functions+
• Caesarean Section• Blood Transfusion
• Four more to be added – Misoprostol, Anti Shock Garment, Tamponade balloon & Compression suture for post partum hemorrhage + latest – no need for controlled cord traction with syntocinon; need cord traction with misoprosotol??
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Anti Shock Garment
• Effective Easy to use, Re-usable
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TAMPONADE TESTTherapeutic & PrognosticFor severe PPH
Stomach balloon
Esophagealballoon
Condous G, Arulkumaran S et.al. Obstetrics & Gynecology. 2003
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Glove catheterNo need for condom Or suture material – S Africa
Condom Catheter –Bangaladesh, Sri Lanka, India - 85% success rate
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COMPRESSION SUTURESCOMPRESSION SUTURESQuick, safe and effectiveQuick, safe and effective
B-LynchB-LynchHorizontal full thickness Horizontal full thickness
sutures sutures Vertical full thickness suturesVertical full thickness suturesSquare suturesSquare suturesCombination of suturesCombination of sutures
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B- LYNCH COMPRESSION SUTURES
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SIMPLE VERTICAL COMPRESSION SUTURES
Cornu
Fallopian tube
Ovary
Hayman R, Arulkumaran S, Steer PObstetrics & Gynecology. 2002
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Conservative Surgical Treatment for Conservative Surgical Treatment for PPHPPH
MethodMethod No of CasesNo of Cases Success ratesSuccess rates
B-Lynch + other B-Lynch + other Compression Compression suturessutures
9494 90.4%90.4%
Arterial embolizationArterial embolization 218218 91%91%
Arterial ligationArterial ligation 264264 83.7%83.7%
Uterine balloon Uterine balloon tamponadetamponade
135135 83.7%83.7%
Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007
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UK – Direct deaths due to PPHYears Pl Abr Pl Pr PPH GT tr Total Rate/10 5
‘85-’87 4 0 6 6 16 0.71‘88-’90 6 5 11 3 25 1.06‘91-’93 3 4 8 4 19 0.82‘94-’96 4 3 5 5 17 0.77‘97-’99 3 3 1 2 9 0.42‘’00-’02 3 4 10 1 18 0.90‘03-’05 2 3 9 3 17 0.80‘06-’08 2 2 5 0 9 0.39
Karoshi et.al. 2012
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Karoshi et.al. 2012
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TOP TEN RECOMMENDATIONS
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PPH in the UK (UKOSS)• Major obstetric haemorrhage 3.7/1000 maternities
(370/ 100,000)• Uterine atony was major cause of haemorrhage• Feb 2005 - Feb 2006 – Postpartum Hysterectomy to
control haemorrhage -40.6 for 100,000 maternities (CI – 36.3 – 45.4)
• Severe PPH – specific 24.4/100,000 – uterine compression suture, pelvic vessel ligation, embolisation. Factor VII a (CI - 21.7-27.3)
• The effect of balloon tamponade was not evaluated?
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CONFIDENTIAL ENQUIRY CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHSINTO MATERNAL DEATHS TOO LITTLE – TOO LATETOO LITTLE – TOO LATE
Too Little (IV fluids, oxytocics, Too Little (IV fluids, oxytocics, BLOOD, Clotting factors)BLOOD, Clotting factors)
Too Late (PG, resuscitation - blood Too Late (PG, resuscitation - blood replacement, decision for surgery + replacement, decision for surgery + to get senior surgeon & to get senior surgeon & anaesthetist involvedanaesthetist involved) )
Placenta Accreta – special problemPlacenta Accreta – special problem
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Response of the Professional BodiesRCOG/ NPSA/ RCA/ RCR
RCOG Green top guidelines 1. Postpartum haemorrhage; Prevention and Management2. Blood transfusion in Obstetrics3. Placenta Praevia, Placenta Praevia accreta, vasa praveia; Diagnosis and management
RCOG Good Practise guidelines1. The role of Interventional radiology in Obstetrics2. Responsibility of consultant on call3. The maternity dashboard
NPSA – Care bundle for the management of placenta Accreta
www.rc.og.org.uk Google – Greentop guidelines
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GREEN TOP GUIDELINES‘THE PREVENTION & MANAGEMENT OF PPH’
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Algorithm for management of Atonic PPH Algorithm for management of Atonic PPH ‘HAEMOSTASIS ‘HAEMOSTASIS’’
HH - - Ask for HelpAsk for Help
AA - Assess vital parameters & blood loss - Assess vital parameters & blood loss and Resuscitate – (Rule of 30)and Resuscitate – (Rule of 30)
EE -Establish etiology + Ecbolics -Establish etiology + Ecbolics (syntometrine, ergometrine, bolus syntocinon) (syntometrine, ergometrine, bolus syntocinon) + Ensure availability of blood. + Ensure availability of blood.
MM -Massage Uterus – bimanual compression -Massage Uterus – bimanual compression
OO -Oxytocin infusion -Oxytocin infusion / prostaglandins / prostaglandins - - intravenous / per rectal / intramuscular / intra-intravenous / per rectal / intramuscular / intra-myometrial/ myometrial/ Tranexamic acidTranexamic acid
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Algorithm for management of Atonic PPH Algorithm for management of Atonic PPH ‘ ‘HAEMOSTASISHAEMOSTASIS’’
SS - Shift to OT - Shock Garment (anti) - Aortic - Shift to OT - Shock Garment (anti) - Aortic compression/ Bimanual compressioncompression/ Bimanual compression
TT - (4 T’s) Tissue/ Trauma/Tone/Thrombin > - (4 T’s) Tissue/ Trauma/Tone/Thrombin > Tamponade (before coagulopathy)– Balloon / packingTamponade (before coagulopathy)– Balloon / packing
AA - Apply compression sutures – B- Lynch / - Apply compression sutures – B- Lynch / modified/ +/- Balloonmodified/ +/- Balloon
SS - Systematic Pelvic devascularisation – Uterine / - Systematic Pelvic devascularisation – Uterine / Ovarian / Quadruple / internal iliac Ovarian / Quadruple / internal iliac
II - Interventional Radiology – If appropriate, - Interventional Radiology – If appropriate, Uterine artery embolisationUterine artery embolisation
SS - Subtotal / Total abdominal hysterectomy- Subtotal / Total abdominal hysterectomy
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Conservative Surgical Tr. for PPHConservative Surgical Tr. for PPHMethodMethod No of CasesNo of Cases Success ratesSuccess rates
B-Lynch + other B-Lynch + other Compression suturesCompression sutures
9494 90.4%90.4%
Arterial embolizationArterial embolization 218218 91%91%
Arterial ligationArterial ligation 264264 83.7%83.7%
Uterine balloon Uterine balloon tamponadetamponade
135135 83.7%83.7%
Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007
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Massive PPH - Surgical TechniquesMassive PPH - Surgical TechniquesNear Miss Enquiries - ScotlandNear Miss Enquiries - Scotland
Use of Balloon techniques – 6 in Use of Balloon techniques – 6 in ’’03 > 42 in 03 > 42 in ’’0606Haemostatic compression sutures – 10 in Haemostatic compression sutures – 10 in ’’03 03
>24 in >24 in ’’06.06.Over 4 years; 106 balloon techniques - 95% Over 4 years; 106 balloon techniques - 95%
success rate; 76 brace sutures – 83% success success rate; 76 brace sutures – 83% success raterate
Peripartum hysterectomy – 15% in 2003 > 8% in Peripartum hysterectomy – 15% in 2003 > 8% in 20062006
Avoidable delay in diagnosis & management –8%Avoidable delay in diagnosis & management –8%Failure to follow protocol/plan – 6%Failure to follow protocol/plan – 6%
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From April 2010 – CNST audit requirement - PilotCQC – building risk profile of Hospitals
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Responsibility of Consultant on Call (RCOG advice – 2009)
• Labour ward duties (safer childbirth)• Must attend
– Major Post Partum Haemorrhage– Eclamptic fit– Collapsed patient– Major placenta praevia– Return to theatre -Laparotomy– When trainee asks for it
• Be present (depending upon trainee’s experience)– Trial of instrumental delivery– Twins/preterm labour C/S / vaginal Breech delivery– C/S at full dilatation/ for Transverse lie/ BMI >40
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Maternity DashboardRoyal College of Obstetricians and Gynaecologists
The Maternity Dashboard – Tool to monitor implementation of principles of clinical governance ‘on the ground’.
A powerful, visible way of continually monitoring and assessing how a unit is doing.
Enables teams to respond in a timely and appropriate manner to ensure a safe and responsive high-quality service.
Helps to develop an ethos of total quality improvement.
www.rcog.org.uk/womens-health/clinical-guidance/maternity-dashboard-clinical-performance-and-governance-score-card
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Performance & Governance Score Card ‘Maternity
Dashboard’
• Designed by Prof. Arulkumaran & Team –Northwick Park
• Recommended by CMO’s Report
• Looks at Activity, Staffing, Clinical Risk indicators, User feedback (e.g. complaints)
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Maternity Dashboard - Ensures high quality safe care.- Tool for Commissioners, Providers,
Consumers and Regulators
Massive PPH, blood transfusion, hysterectomies, admission to ICU
KNOWLEDGE TRANSFER N MEOWS CHART
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More Medical and Simpler Surgical Techniques shouldhelp to reduce morbidity & mortality
THANK YOU