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Surgical Management of Post Partum Haemorrhage

Surgical Management of Post Partum Haemorrhage. Emeritus Professor C B-Lynch GORSL 2007. Consultant Obstetrician and Gynaecological Surgeon Milton Keynes General Hospital (NHS Foundation Trust) (Oxford Deanery, U.K.). PPH - Essential Data (cont.).

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Surgical Management of Post Partum Haemorrhage

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  1. Surgical Management of Post Partum Haemorrhage International Training and Workshop, Wales 2011

  2. Emeritus Professor C B-Lynch GORSL 2007 Consultant Obstetrician and Gynaecological Surgeon Milton Keynes General Hospital (NHS Foundation Trust) (Oxford Deanery, U.K.)

  3. PPH - Essential Data (cont.) Catastrophic haemorrhage is a persistent problem with substandard care as a regular event – CEMACH ‘Why Mothers Die’ UK – 2000 2002 Approximately 25%! of maternal deaths in developing countries are attributable to PPH PPH is a worldwide problem and one of the three messengers of death

  4. To Prevent the perils of PPH an intrauterine balloon tamponade with or without the B-Lynch suture technique or modification should be tried first. e.g PPH following vaginal delivery

  5. IS IT ONE OF THE BEST IDEAS IN O&G? Mention one surgical technique in obs & gyn that : Saves life Saves fertility Simple Quick Cheap Tested for success immediately before and after performance B-Lynch et al; BJoG March 1997 v104:pp372-375

  6. IS IT ONE OF THE BEST IDEAS IN O&G? >4000 cases reported (1997 -2010)Reported postoperative ‘complications’:e.g - Partial Ischemic necrosis - Joshi et al; BJoG March 2004Uterine necrosis – Treloar et all; BJoG January 2006 Successful application in early pregnancy: first trimester [13 weeks] – Hillaby K et all; JoGSecond Trimester [21 weeks] - Price et al; JoG Known reported failure world wide 31/1827 (0.016%) - (CBL data collection and personal communications)

  7. THE INVENTOR Professor C B-Lynch GORSL 2007 Consultant Obstetrician and Gynaecological Surgeon Milton Keynes General Hospital (NHS Trust) (Oxford Deanery, U.K.)

  8. THE IDEA 27th November 1989 Massive PPH Patient refusing hysterectomy

  9. The B-Lynch Suture Surgical Technique Clinical Points

  10. The B-Lynch Suture Compression Technique - Clinical Points The ten point principle • Lloyd Davis or Frog Legged Position Essential • The Uterus must be exteriorised • Basic surgical competence required • Bi-Manual Compression to test for potential success • Transverse lower segment incision made • Uterine cavity checked, explored & evacuated.

  11. The B-Lynch Suture Compression Technique - Clinical Points • Apply monocryl No. 1 mounted on 90cm curvedethiguard blunt needle (code:W3709) (Ethicon, Somerville, N.J.) suture correctly with even tension (no shouldering) • Allow free drainage of blood, debris & inflammatory material. • Check bleeding control vaginally, including swabs and instruments • Wave to anaesthetists, offer a prayer and close the abdomen

  12. UPDATE Causes of failure: Placenta percreta (1) Wrong technique (10) (uterine necrosis -2 cases!) Uncontrolled DIC (4) No pre operative test done (6) Not properly applied (6) Delayed application (4)

  13. B-Lynch Suture TechniqueApplied Correctly Even Tension; No Ischemia; no necrosis;

  14. MRI – B-Lynch Suture 6 Months Later Normal Uterine characteristicsC Tsitlakidis et al; 10 year follow up of the effects of the b-lynch suture Int/fertill 51 (2006)

  15. Cervical-isthmic apposition suture Shouldering Ischemia Anterior Posterior

  16. Partial ischemic necrosis of the uterus followinga uterine brace compression suture The uterus as it appears at laparotomy, 24 hours following a uterine brace suture. An example of poor technique Without exploration and drainage of the uterine cavity

  17. Haemostatic multiple square suture method University of Seoul (Korea) 23 cases Didn’t mention extent of bleeding Pierce uterus 32 times Does not close all transverse branches ? Cavity Patency Leading to pyometriaOchoa et al; ObGy 99:506-509 Obstet Gynecol 2000 Jul;96(1):129-131

  18. UPDATE (cont.) Prophylactic Application: >70 cases  All No PPH (but high risk) Complications (none reported)

  19. Preventing the perils of PPH Stepwise devascularisation or internal iliac vessel ligation should be done by a surgeon with appropriate experience & expertise. Arterial embolisation has established potential, but the logistics of arrangements with the radiology department has to follow strict obstetric & radiological protocol. Sub-total or total hysterectomy, may continue to rise with mortality & morbidity if the rise in caesarean section rate is not controlled. Trainees should have regular workshop & fire drill training of the application of the Brace suture compression & other conservative tamponade techniques.

  20. Obstetric Trauma - PPH Post Partum Haemorrhage Following Acute Uterine Inversion Bleeding from lower genital tract

  21. Acute inversion reported in 1:2,000 deliveries May go unrecognised or misdiagnosed as uterine fibroid Acute Uterine Inversion

  22. In difficult cases, replacement may have to be by laparotomy followed by another B-Lynch technique ‘stepwise atraumatic digital replacement’ (ref: TEXTBOOK OF POSTPARTUM HEMORRHAGE sapiens publishing 2006)

  23. Acute uterine inversion.

  24. Acute uterine inversion. Finger tips placed below fundus of uterus to facilitate reduction.

  25. Acute uterine inversion. Progressive reduction with some ischaemia.

  26. Acute uterine inversion. Return of vascularity.

  27. Acute uterine inversion. Complete reduction and revascularization with normal clinical features.

  28. Post Partum Haemorrhage Following Genital Tract Trauma

  29. Below the Level of the Pelvic Floor Lithotomy position Adequately anaesthetised Passive drainage should be encouraged Local bleeding identified, transfixed and haemostased Exploration of pudendal vessels Transfixion haemostasis Vaginal pack Antibiotic cover

  30. Above the Level of the Pelvic Floor Enlarge & extend proximally between the 2 layers of the broad ligament May enable conservative management Laparotomy & drainage may become necessary via subperitoneal approach Time of presentation is variable Clinical features may not fit Low abdominal pain, tachycardia & pallor Conservative management failed – laparotomy, evacuation & retro-peritoneal drainage Watchful of secondary haemorrhage Consider embolisation

  31. More Complex Surgery for PPH Management Stepwise Devascularisation Internal Iliac (hypogastric) artery ligation Complex pelvic surgery Peripartum abdominal hysterectomySubtotal/TotalTF Baskett, Chapter 34 – A TEXTBOOK OF POSTPARTUM HEMORRHAGE Secondary PPH KM Groom, TZ Jacobson ,Chapter 35 - A TEXTBOOK OF POSTPARTUM HEMORRHAGE

  32. Stepwise Devascularisation

  33. Дякую за увагу Чи є якісь запитання? Бажаючі можуть отримати DVD

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