In t he name of GOD

1. In the name of GOD

2. Management of postpartum hemorrhage at cesarean delivery ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts

3. INITIAL MANAGEMENT ●Ongoing bleeding may not be recognized when : retroperitoneal (including vaginal and vulvar hematomas) hidden under surgical drapes or thick dressing confined to the uterine cavity after closure of the hysterotomy these sites should be actively evaluated when compensated shock is present (normal blood pressure with increasing heart rate). Retroperitoneal enlargement or bulging of the broad ligament can be signs of retroperitoneal hemorrhage; the abdomen should not be closed until the possibility of ongoing retroperitoneal bleeding has been excluded.

4. On recognition of ongoing bleeding the anesthesia team should be alerted immediately vital signs, hemodynamic and respiratory parameters, and hematologic and biochemical indices should be closely monitored Thromboelastography and thromboelastometry, where available, may be useful for guiding plasma and coagulation product therapy Fluid and blood products, as appropriate, are administered for resuscitation and correction of coagulation and electrolyte abnormalities.

5. When hemorrhage is suspected as the cause of hemodynamic instability, initial (and expedited) management with blood and blood products is advised (as opposed to large volume crystalloid infusion), and early activation of a massive transfusion protocol should be considered. ●Acidosis is corrected using bicarbonate, if necessary. ●Body temperature should be maintained and hypothermia prevented. ●The source of bleeding should be addressed: •If atony is present or suspected, fundal massage and uterotonic drugs are used to contract the uterus.

6. Serious hemorrhage from the uterine incision is generally caused by lateral extension of the incision. Bleeding from a hysterotomy incision can generally be controlled by suture ligation. The angles of a transverse incision should be clearly visualized to ensure that they, and any retracted vessels, are completely ligated. This generally requires exteriorization of the uterus with gentle traction and adequate lateral retraction. Given the proximity of the ureter to the vaginal angle and bladder reflection, the placement of hemostatic sutures laterally to control bleeding from an extension of a hysterotomy laceration should be carried out with extreme caution. If possible, the ipsilateral ureter should be identified before the bleeding is controlled and, once the hemorrhage has been controlled, the integrity of the ureter should be ensured •

7. Baseline electrolyte analysis is important to check ionized calcium and potassium levels since, in the event of multiple units of blood transfusion, these electrolytes can reach critical thresholds very quickly .Aggressive management of electrolyte levels is crucial in modern massive transfusion protocols, and the institution of standardized management protocols is recommended. ●Use of specific clotting factor therapies can be useful and have some advantages in cases of intractable hemorrhage and coagulopathy.

8. CONSERVATIVE SURGICAL INTERVENTIONS

9. Local techniques for managing focal bleeding from the placental site  Local techniques for the management of focal bleeding from the placental implantation site include the placement of figure 8 sutures or other hemostatic sutures directly into the placental bed, and the use of fibrin glues and patches to cover areas of oozing and promote clotting. Focal areas of bleeding can also be excised if they are small and easily accessible, particularly in cases of placenta accreta with persistent bleeding. Application of ferric subsulfate (Monsel's solution) to oozing areas may be helpful and is not harmful.

10. Uterine artery and utero-ovarian artery ligation  Bilateral ligation of the uterine vessels (O’Leary stitch) to control PPH has become a first-line procedure for controlling uterine bleeding at laparotomy . It is preferable to internal iliac artery ligation because the uterine arteries are more readily accessible, the procedure is technically easier, and there is less risk to major adjacent vessels and the ureters. Uterine artery ligation is primarily indicated when bleeding is due to laceration of the uterine or utero-ovarian artery branches, but can also temporarily decrease bleeding from other etiologies by reducing perfusion pressure in the uterine tissue. Although it will not control bleeding from uterine atonyor placenta accreta, it may decrease blood loss while other interventions are being attempted.

11. After identification of the ureter, a large curved needle with a #0 polyglycolic acid suture is passed through the lateral aspect of the lower uterine segment as close to the cervix as possible and then back through the broad ligament just lateral to the uterine vessels. If this does not control bleeding, the vessels of the utero-ovarian arcade are similarly ligated just distal to the cornua by passing a suture ligature through the myometrium just medial to the vessels, then back through the broad ligament just lateral to the vessels, and then tying to compress the vessels (figure 4). Bilateral ligation of the arteries and veins (uterine and utero-ovarian) is successful in controlling hemorrhage in over 90 percent of patients .

13. Uterine compression sutures Uterine compression sutures are an effective method for reducing uterine blood loss related to atony. Procedure-related complications, such as uterine necrosis, erosion, and pyometra, have been reported but are rare . Uterine synechiae have been reported on postpartum hysteroscopy or hysterosalpingogram, although some of these women may have had curettage as well . Limited follow-up of women who have had a uterine compression suture suggests that there are no adverse effects on fertility or future pregnancy outcome. The B-Lynch suture is the most common technique for uterine compression

14. B-Lynch suture   The B-Lynch suture envelops and compresses the uterus, similar to the result achieved with manual uterine compression. The technique is relatively simple to learn, appears safe, preserves future reproductive potential. It should only be used in cases of uterine atony; it will not control hemorrhage from placenta accreta. It will not prevent postpartum hemorrhage in future pregnancies . A large Mayo needle with #1 or #2 chromic catgut is used to enter and exit the uterine cavity laterally in the lower uterine segment (figure 5). A large suture is used to prevent breaking and a rapid absorption is important to prevent a herniation of bowel through a suture loop after the uterus has involuted. The technique has been used alone and in combination with balloon tamponade. This combination has been called the "uterine sandwich."

16. Balloons The exact mechanism of action of these devices is unclear, but is likely related to areduction in uterine artery perfusion pressure . Whether this is the result of direct compression of the uterine artery in the lower segment or due to wall conformational changes has not been determined . Continued excessive bleeding indicates that tamponade is not effective and surgery or embolization should be performed.

17. TYPES OF BALLOON CATHETERS Bakritamponade balloon catheter The Bakritamponade balloon catheter consists of a silicone balloon maximum recommendedfill volume 500 mL The collapsed balloon is inserted into the uterus . when filled with fluid, the balloon adapts to the configuration of the uterine cavity to tamponade endometrial bleeding. The central lumen of the catheter allows drainage and is designed to monitor ongoing bleeding above the level of the balloon . The device is intended for one-time use.

23. Indications Intrauterine balloon tamponade is indicated when uterotonic drugs and bimanual compression of the uterus fail to control bleeding. Intrauterine balloon catheters have also been used with variable success to control or reduce bleeding after cesarean deliverywith placenta previa, low lying placenta, or a focally invasive or adherent placenta. A small number of cases of delayed (secondary) postpartum hemorrhage have been successfully managed with balloon catheters . Intrauterine balloon catheters have also been successful in management of acute, recurrent uterine inversion and prophylactically or as an adjuvant therapy to control bleeding in women with cesarean scar pregnancy or cervical pregnancy.

24. Contraindications Intrauterine balloon tamponade is contraindicated in postpartum patients allergic to any component of the device. Clinical settings where tamponade is unlikely to be effective (eg, bleeding from pelvic vessels or cervical or vaginal trauma; uterine abnormalities that prevent effective balloon tamponade; suspected uterine rupture; cervical cancer; and purulent infection of the vagina, cervix or uterus). These devices should not be used when a large amount of placenta is adherent to the uterus and immediate hysterectomy may be life-saving.

25. Internal iliac artery ligation  Bilateral ligation of the internal iliac arteries (hypogastric arteries) has been used to control uterine hemorrhage by reducing the pulse pressure of blood flowing to the uterus. The utility of internal iliac artery ligation may be compromised when there are extensive collateral vessels (such as in placenta percreta). The technique is challenging even for an experienced pelvic surgeon, especially when there is a large uterus, a transverse lower abdominal incision, ongoing pelvic hemorrhage, or the patient has a high body mass index. Successful and safe bilateral hypogastric ligation becomes even more difficult when attempted by a surgeon who rarely operates deep in the pelvic retroperitoneal space . For these reasons, uterine compression sutures and, less commonly, uterine artery ligation, have largely replaced this procedure as first-line surgical options. The internal iliac ligation procedure is described separately.

26. HYSTERECTOMY Hysterectomy is generally the last resort for treatment of atony, but should not be delayed in women who require prompt control of uterine hemorrhage to prevent death. By comparison, in women with placenta accreta/increta/percreta or uterine rupture, early resort to hysterectomy is one of the best approaches for controlling hemorrhage. With improving prenatal diagnosis of placental attachment disorders, hysterectomy can often be anticipated and discussed with the patient before cesarean delivery.

27. POST-LAPAROTOMY INSPECTION  At the completion of the laparotomy and before closing the abdomen, the operative field should be inspected carefully for hemostasis. Microvascular bleeding usually can be controlled using topic hemostatic agents.

28. PELVIC PRESSURE PACK FOR PERSISTENT BLEEDING AFTER HYSTERECTOMY  Patients with continued severe hemorrhage after hysterectomy can enter a lethal downward spiral characterized by hypothermia, coagulopathy, and metabolic acidosis . Criteria proposed for this "in extremis" state include pH <7.30, temperature <35 degrees Celsius, combined resuscitation and procedural time >90 minutes, nonmechanical bleeding, and transfusion requirement >10 units packed red blood cells (RBCs) .

29. MANAGEMENT OF HEMORRHAGE FIRST RECOGNIZED AFTER THE PATIENT HAS LEFT THE OPERATING ROOM  If excessive vaginal bleeding is present, the cervix and vagina should be inspected and lacerations repaired under adequate anesthesia. If the uterus is boggy, the diagnosis of uterine atony is made. The initial management of uterine atony after cesarean delivery is similar to that after vaginal delivery and consists of: ●Uterine massage to contract the uterus ●Administration of uterotonic drugs ●Fluid resuscitation and transfusion ●Laboratory tests to evaluate blood loss and coagulopathy and type and cross for multiple units of packed red blood cells ●Balloon tamponade

30. If excessive bleeding persists, uterine artery embolization is an option for stable patients in whom volume status can be maintained until the procedure can be completed (approximately two hours). Many clinicians use both balloon tamponade and uterine artery embolization in this situation. These procedures are discussed in detail separately. Laparotomy is indicated in patients with massive bleeding and those who are unstable since it is unlikely that replacement of blood products will match blood loss in these patients.