Management of Atonic PPH

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MANAGEMENT OF ATONIC PPH By- Mohammad Sadiq Final yr. MBBS MMCRI

In the Name of God, Most Gracious, Most Merciful : 

In the Name of God, Most Gracious, Most Merciful

ATONIC PPH : 

ATONIC PPH Prophylaxis Diagnosis Investigations Treatment - Medical - Manipulations - Surgical

ATONIC PPH : 

ATONIC PPH PROPHYLAXIS Routine prophylactic use of an oxytocic drug following delivery. Controlled cord traction. Close monitoring of patient immediately postpartum.

CLINICAL SCENARIO : 

CLINICAL SCENARIO A 25 yr. old lady arrives in the obstetric casualty with bleeding postpartum. O/E she is found to be dyspnoeic, with a pulse of 120bpm, feeble in character. Her extremities are cold and clammy and the B.P. is recorded as 90/?. WHAT DO YOU DO??????

POSTPARTUM HAEMORRHAGE : 

POSTPARTUM HAEMORRHAGE DIAGNOSIS PLACE A HAND OVER THE ABDOMEN Uterus firmly contracted Uterus large & flabby TRAUMATIC PPH ATONIC PPH ATONIC PPH

ATONIC PPH : 

ATONIC PPH Resuscitation Investigations Obstetric Management MANAGEMENT

INITIAL RESUSCITATION : 

INITIAL RESUSCITATION Nasal oxygen via face mask. Pack the vagina to stem the bleeding. DO NOT do a P/V till blood is at hand. Draw, send blood for Grouping & cross matching

INITIAL RESUSCITATION : 

INITIAL RESUSCITATION Assess: Pulse B.P. R.R. Peripheries Secure the lines: - 2 large bore i.v. cannulas (14-16 gauge) Crystalloid – NS, RL, 5% D Colloid

INITIAL RESUSCITATION : 

INITIAL RESUSCITATION Aim: Replace all fluid losses in 1st hr. Followed by maintainence fluids to replace continuing losses and maintain vitals. How much to infuse? If coagulopathy develops: - FFP, Cryoprecipitate, platelets.

INITIAL RESUSCITATION : 

INITIAL RESUSCITATION Continuous oximetry Pulse & Blood Pressure every 15 mins Indwelling urinary catheter Urine output – hourly (1ml/min –adqt) CVP Arterial line – if indicated. MONITORING

INVESTIGATIONS : 

INVESTIGATIONS Complete Haemogram Blood grouping & cross matching Coagulation screen Fibrin degradation products Electrolytes, Urea, Creatinine PRIMARY CYCLE

INVESTIGATIONS : 

INVESTIGATIONS CxR – if CVC is inserted ABG – if SpO2 ? PRIMARY CYCLE Repeat Primary cycle 6th hrly Subsequent care in ICU

OBSTETRIC MANAGEMENT : 

OBSTETRIC MANAGEMENT AIMS : Replace the blood loss Stop the bleeding

OBSTETRIC MANAGEMENT : 

OBSTETRIC MANAGEMENT MEDICAL MANIPULATIVE SURGICAL Oxytocics: Oxytocin Ergometrin Syntometrin PGF 2? Misoprostol Bimanual compression Tamponade test Intrauterine packing Brace sutures Arterial ligation Embolisation Hysterectomy

MEDICAL MANAGEMENT : 

MEDICAL MANAGEMENT IN SITU EXPELLED With blood at hand, do a P/V Gentle pressure – passage of clots Gentle uterine massage

MEDICAL MANAGEMENT : 

MEDICAL MANAGEMENT Fundal massage – contraction + Methergine 0.20mg i.v. Placenta examined - Missing cotyledons/lobes - Explore under anaesthesia AFTER PLACENTAL EXPULSION: AFTER PLACENTAL EXPULSION: BRANDT ANDREWS’ TECHNIQUE RULE OUT: Soft tissue trauma Retained Placenta Coagulopathy

MEDICAL MANAGEMENT : 

MEDICAL MANAGEMENT Methergine 0.2mg i.v. 20 U oxytocin in 500ml 5% D – At what Rate ? 2nd dose of Methergine Carboprost (15-methyl PGF 2?) 250 mg every 15 mins. (8 doses max.) Misoprostol rectally 800?g NOT CONTROLLED NOT CONTROLLED NOT CONTROLLED

MANUPILATIVE : 

MANUPILATIVE BIMANUAL COMPRESSION TAMPONADE TEST INTRAUTERINE PACKING

MANUPILATIVE : 

MANUPILATIVE BIMANUAL COMPRESSION

MANUPILATIVE : 

MANUPILATIVE “TAMPONADE” TEST After R/O coagulopathy Select patients for surgery Sengstaken Blakemore tube Rusch catheter Filled with 100-150ml warm NS Warmth speeds up clotting cascade Good result – avoid laprotomy

SURGICAL MANAGEMENT : 

SURGICAL MANAGEMENT UNDERSUTURING PLACENTAL BED BRACE / B-LYNCH SUTURES ARTERIAL LIGATION HYSTERECTOMY EMBOLISATION

SURGICAL MANAGEMENT : 

UNDERSUTURING PLACENTAL BED SURGICAL MANAGEMENT When PPH follows: - Placenta Previa - Low lying placenta Large sinuses responsible for the bleeding must be oversewn.

SURGICAL MANAGEMENT : 

BRACE / B – LYNCH SUTURES SURGICAL MANAGEMENT 1 2 3

SURGICAL MANAGEMENT : 

ARTERIAL LIGATION SURGICAL MANAGEMENT Uterine artery Internal Iliac artery Utero-ovarian artery anastomosis

SURGICAL MANAGEMENT : 

HYSTERECTOMY SURGICAL MANAGEMENT Only DEFINITIVE treatment Last resort Severely shocked with danger to life SUBTOTAL TOTAL ? Risk of Ca Cx

SURGICAL MANAGEMENT : 

ARTERIAL EMBOLISATION SURGICAL MANAGEMENT Trained interventional radiologist needed Absorbed in 10 days

CONCLUSION : 

CONCLUSION Resuscitation IS central to management A hand over the abdomen reveals a lot DO NOT do a P/V until blood is at hand Reserve atleast 6 units of cross matched blood Rule out complications & trt accordingly Oxytocics play a key role Do NOT attempt to forcefully remove a placenta If all else fails, a timely hysterectomy can be life saving.

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