Dr. Neda HashemiAssistant professor of OB&GYN

Rasool Akram HospitalIRAN University of Medical Science

Uterine atony Bimanual Uterine compression HELLP! (OB, Anesthesia, Nursing, OR) Empty bladder 2nd Large Bore IV Fluids + Blood Products Uterotonic agent

Anderson JM, AFP 2007

I. Mechanical interventions: Uterine massage by elevation and compression of fundus with 2 hands.

II. Medical interventions: a. Oxytocin IV or IM If no IV: give 10 units oxytocin IM If IV: 20-40 units oxytocin in liter . Do not give oxytocin IV push (hypotensive risk)

b. Methergine (unless hypertension in pregnancy) 0.25 to 0.5 mg IM (not IV) or intramyometrial q2-4hrs

c. Hemabate (carboprost tromethamine) 125-250 mcg IM every 15-90 min,max 8 doses

d. Cytotec (misoprostol) 800-1000mcg rectally. May give 200mcg sublingually (results in serum level in 90 sec) plus 600 to 800mcg rectally.

Prostaglandin E2 (Dinoprostone, Prostin E2) 20mg suppository per rectum q2hrs

Oxytocin : Can cause hypotension/water intoxication

Methylergonovine (Methergine) : Avoid with hypertension

Prostaglandin F2 alpha (Carboprost, Hemabate) : Can cause diarrhea, fever and tachycardia

Avoid with asthma or hypertension or cardiovascular disorder

Prostaglandin E1 (Misoprostol, Cytotec) : Elevated temperature, shivering ,diarhhea

Prostaglandin E2 (Dinoprostone, Prostin E2) : Elevated temperature

Avoid with hypotension

Uterine compression sutures

Uterine tamponade: ballon, Uterine packing

Uterine vessel ligation and uteroovarian artery

ligation

Internal iliac vessel ligation

Hysterectomy

Gauze packing of the uterus Uterine tamponade balloon (300-500cc)

(Bakri) Foley balloon in the uterus (60-80cc) Condom catheter(500cc)

If tamponade is successful, consider proceeding to embolization if available.

If embolization is not available, and patient is stable, maintain inflation for 12-24 hours. Have surgery suite ready and anesthesia and assistant available. Then remove vaginal packing, and slowly aspirate volume from balloon. If bleeding starts up again, re-inflate and proceed to surgery.

Uterine artery ligation

Greater than 95% success rate.

This technique is most useful (and successful) when hemorrhage is of:

A moderate degree and originates from the lower uterine segment

Low placental implantation site

Lower segment extensions or lacerations, as well as for

A uterine artery laceration itself. A vaginal approach to ligation of the uterine arteries has been reported.

Sutures are placed to ligate the ascending uterine artery and the anastomotic branch of the ovarian artery. The procedure should be performed on each side.

Hypogastric Artery LigationThe technique

The ligation should be performed about 2 cm distal to the

bifurcation to avoid disrupting the posterior division of the

hypogastric, which can lead to ischemia and necrosis of the

skin and subcutaneous tissue of the gluteus.

Two nonabsorbable sutures of 2-0 silk should be used for

ligation.

It is important that hypogastric artery ligation be performed

bilaterally to adequately decrease pressure to the uterus.

Aortic compression — Severe bleeding may pose a threat of exsanguination within a few minutes.

In these cases, the surgeon should palpate the aorta a few centimeters superior to the sacral promontory and compress the aorta just proximal to the bifurcation.

This will markedly slow the volume of bleeding and affords a better opportunity for finding and controlling the source of hemorrhage.

Hysterectomy Hysterectomy is the last resort, but should not be delayed in

women who require prompt control of uterine hemorrhage to prevent death.

Because of the lack of experience and skill with the technique of hypogastric artery ligation, many clinicians prefer to do a hysterectomy to control postpartum hemorrhage.

Hysterectomy usually is the safest procedure and also the quickest that can be performed for refractory bleeding.

Patients undergoing hypogastric artery ligation who subsequently required hysterectomy had an increased incidence of cardiac arrest secondary to blood loss.

Best management of PPH is by using the below algorithm of ‘HAEMOSTASIS’:

H – ask for Help A – Assess (vital parameters, blood loss) and resuscitate E – Establish the cause, ensure availability of blood M – Massage uterus O – Oxytocin infusion S – Shift to theatre/anti-shock garment – bimanual

compression T – Tamponade test A – Apply compression sutures S – Systematic pelvic devascularisation I – Interventional radiologist – if appropriate, uterine artery

embolisation S – Subtotal/total abdominal hysterectomy