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ALTERNATIVE METHODS FOR MANAGEMENT OF ATONIC POSTPARTUM HAEMORRHAGE

ALTERNATIVE METHODS FOR MANAGEMENT OF ATONIC POSTPARTUM HAEMORRHAGE. DR. MURWAN IBRAHIM OMER DGO, MOG, ABOG, FRCOG, FICS Consultant Obstetrician and Gynaecologist. Can we change our practice to improve outcome of PPH?.

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ALTERNATIVE METHODS FOR MANAGEMENT OF ATONIC POSTPARTUM HAEMORRHAGE

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  1. ALTERNATIVE METHODS FOR MANAGEMENT OF ATONIC POSTPARTUM HAEMORRHAGE DR. MURWAN IBRAHIM OMER DGO, MOG, ABOG, FRCOG, FICS Consultant Obstetrician and Gynaecologist

  2. Can we change our practice to improve outcome of PPH? When conventional methods fail to control atonic PPH, there are interventions which are being ignored that should be considered before opting for major surgical procedures.

  3. Postpartum Haemorrhage Is a leading cause of maternal mortality and morbidity. Too Little (IV fluids, oxytocics, BLOOD, Clotting factors) Too Late (resuscitation - blood replacement, misopristol decision for surgery + to get senior surgeon & anaesthetist involved)

  4. PPH • Anticipate - high risk cases (e.g. twins, polyhydramnios, prolonged labour, fibroids, APH, infection, past H/O PPH, retained tissue etc.) • Prevent - Prophylactic Oxytocics(e.g. Syntometrine, syntocinon, ergometrine, misoprostol) • Manage - Promptly - 90% uterine atony - 8% trauma and 2% coagulation disorders FIGO/ ICM STATEMENT ON AMTSL + WHO+ COCHRANE

  5. Guidelines by the Scottish Executive Committee of the RCOG COMMUNICATE. RESUSCITATE. MONITOR / INVESTIGATE STOP THE BLEEDING

  6. STOPTHEBLEEDING Uterine compression IV syntocinon 10 units IV ergometrine 500 mg Syntocinon infusion (30 units in 500 ml) Surgery / Hysterectomy Misoprostol/ Intrauterine pack / Intrauterine balloon / Compression Sutures

  7. Synthetic analog of prostaglandin E1 • Shelf life of several years if kept in their packets • Low cost • Can be administered orally, rectally, vaginally and by sublingual route • Being selective for the PGE1 receptors: Hence fewer systemic side-effects Misoprostol could play an important role in saving lives of thousands of women, particularly in low-resource settings

  8. A study in Pakistan on the outcome of Utero-vaginal Packaging in Primary Postpartum Hemorrhage on 34 patients Pelvic infection was seen in 5 cases i.e., 14.7% (but pre- existing risk factors for infection such as prolonged rupture of membranes, obstructed labour and home delivery were present in all these cases)

  9. TAMPONADE TEST Therapeutic & Prognostic For severe PPH Oesophageal balloon Stomach balloon

  10. The “Tamponade Test” Condous G, Arulkumaran S et.al. Obstetrics & Gynecology. 2003

  11. St George’s Series • 27 consecutive cases of Sengstaken – Blakemore Esophageal catheter tamponade • Bleeding arrested in 22 cases • Tamponade failed in 5 cases. Of them: • 4 underwent a subtotal hysterectomy • 1 was managed with Haemabate and Misoprostol (concomitant use) Doumouchtsis S, Papageorghiou A, Arulkumaran S. Acta Scand 2008

  12. The Sengstaken-Blakemore oesophageal catheter The main disadvantage is that it is not purpose-designed for PPH. Therefore, it may not easily adapt to the shape of the uterine cavity.

  13. “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” Mahmoud Fathalla,MD, PhD, 1997

  14. Uterine balloon tamponade

  15. COMPRESSION SUTURESQuick, safe and effective • B-Lynch • Modified B-Lynch sutures • Combination of sutures

  16. Comparison between Original method & its modification

  17. B-Lynch or Compression sutures

  18. Conservative Treatment for PPH Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007

  19. “It is not the strongest of the species that survives, nor the most intelligent, but the one most responding to change.” Charles Darwin

  20. No of Deliveries

  21. Maternal Mortality Rate

  22. Conclusion When conservative measures fail to control bleeding in post partum haemorrhage, uterovaginal packing, internal uterine tamponade and B-lynch sutures can be used before resorting to hysterectomy. These uterine preserving methods have been used in various countries and have proven to be effective, with minimal maternal morbidity. They are feasible in this country and should be considered by Obstetricians when managing PPH. However, they require training and experience.

  23. Emergency Trolley Emergency protocols Endotracheal tube Laryngoscope GENERAL MANAGEMENT Essential drugs Crystalloids, giving sets, haemacel

  24. Thank You

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