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PPH – Global and The UK Perspectives

PPH – Global and The UK Perspectives. S Arulkumaran Professor & Head Obstetrics and Gynaecology St George’s University of London. 75% Of MM & third of NN mortality takes place during labor/ birth or within 24 Hrs.

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PPH – Global and The UK Perspectives

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  1. PPH – Global and The UK Perspectives S Arulkumaran Professor & Head Obstetrics and Gynaecology St George’s University of London

  2. 75% Of MM & third of NN mortality takes place during labor/ birth or within 24 Hrs. *Other direct causes include: ectopic pregnancy, embolism, anesthesia-related ** Indirect Causes include: anemia, malaria, heart disease

  3. 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

  4. 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

  5. Strategies to Prevent Maternal MortalityComprehensive Em Obstetric Functions (6 + 2) • Basic Emergency Obstetric Functions + • Caesarean Section • Blood Transfusion • Fourmore 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??

  6. Anti Shock Garment • Effective Easy to use, Re-usable

  7. TAMPONADE TEST Therapeutic & Prognostic For severe PPH Esophageal balloon Stomach balloon Condous G, Arulkumaran S et.al. Obstetrics & Gynecology. 2003

  8. Glove catheter No need for condom Or suture material – S Africa Condom Catheter –Bangaladesh, Sri Lanka, India - 85% success rate

  9. COMPRESSION SUTURESQuick, safe and effective • B-Lynch • Horizontal full thickness sutures • Vertical full thickness sutures • Square sutures • Combination of sutures

  10. B- LYNCH COMPRESSION SUTURES

  11. SIMPLE VERTICAL COMPRESSION SUTURES Cornu Fallopian tube Ovary Hayman R, Arulkumaran S, Steer P Obstetrics & Gynecology. 2002

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

  13. UK – Direct deaths due to PPH Years 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 Karoshiet.al. 2012

  14. Karoshi et.al. 2012

  15. TOP TEN RECOMMENDATIONS

  16. 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?

  17. CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS TOO LITTLE – TOO LATE Too Little (IV fluids, oxytocics, BLOOD, Clotting factors) Too Late (PG, resuscitation - blood replacement, decision for surgery + to get senior surgeon & anaesthetist involved) Placenta Accreta – special problem

  18. Response of the Professional BodiesRCOG/ NPSA/ RCA/ RCR RCOG Green top guidelines 1. Postpartum haemorrhage; Prevention and Management 2. Blood transfusion in Obstetrics 3. Placenta Praevia, Placenta Praevia accreta, vasa praveia; Diagnosis and management RCOG Good Practise guidelines 1. The role of Interventional radiology in Obstetrics 2. Responsibility of consultant on call 3. The maternity dashboard NPSA – Care bundle for the management of placenta Accreta www.rc.og.org.uk Google – Greentop guidelines

  19. GREEN TOP GUIDELINES ‘THE PREVENTION & MANAGEMENT OF PPH’

  20. Algorithm for management of Atonic PPH ‘HAEMOSTASIS’ • H - Ask for Help • A - Assess vital parameters & blood loss and Resuscitate – (Rule of 30) • E -Establish etiology + Ecbolics (syntometrine, ergometrine, bolus syntocinon) + Ensure availability of blood. • M -Massage Uterus – bimanual compression • O -Oxytocin infusion / prostaglandins - intravenous / per rectal / intramuscular / intra-myometrial/ Tranexamic acid

  21. Algorithm for management of Atonic PPH ‘HAEMOSTASIS’ • S- Shift to OT - Shock Garment (anti) - Aortic compression/ Bimanual compression • T - (4 T’s) Tissue/ Trauma/Tone/Thrombin > Tamponade (before coagulopathy)– Balloon / packing • A - Apply compression sutures – B- Lynch / modified/ +/- Balloon • S - Systematic Pelvic devascularisation – Uterine / Ovarian / Quadruple / internal iliac • I - Interventional Radiology – If appropriate, Uterine artery embolisation • S - Subtotal / Total abdominal hysterectomy

  22. Conservative Surgical Tr. for PPH Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007

  23. Massive PPH - Surgical Techniques Near Miss Enquiries - Scotland • Use of Balloon techniques – 6 in ’03 > 42 in ’06 • Haemostatic compression sutures – 10 in ’03 >24 in ’06. • Over 4 years; 106 balloon techniques - 95% success rate; 76 brace sutures – 83% success rate • Peripartum hysterectomy – 15% in 2003 > 8% in 2006 • Avoidable delay in diagnosis & management –8% • Failure to follow protocol/plan – 6%

  24. From April 2010 – CNST audit requirement - Pilot CQC – building risk profile of Hospitals

  25. 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

  26. Maternity Dashboard Royal 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

  27. 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)

  28. 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

  29. THANK YOU More Medical and Simpler Surgical Techniques should help to reduce morbidity & mortality

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