postpartum haemorrhage - the surgical aspects
TRANSCRIPT
![Page 1: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/1.jpg)
Postpartum haemorrhage
- the surgical aspectsSvensk förening för Obstetrik och Gynekologi, Tallberg14th April 2015P J Steer
Emeritus Professor of Obstetrics
Academic Department of Obstetrics and Gynaecology
Chelsea and Westminster Hospital
Imperial CollegeLondon
![Page 2: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/2.jpg)
WITH
THANKS TO
PROFESSOR
MICHAEL
BELFORT
Baylor Medical College
Texas Children’s Hospital,
Houston,
USA
![Page 3: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/3.jpg)
UTERINE ATONY -
SURGICAL APPROACH• Correction of uterine inversion
• Uterine compression and massage
• Packing / Balloon
• Uterine compression suture
• Uterine artery ligation
• Internal iliac ligation
• Hysterectomy
• Logethotopolous pack
• Arterial embolisation
![Page 4: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/4.jpg)
CORRECTION OF UTERINE
INVERSION
• Vaginal approach
![Page 5: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/5.jpg)
REPLACING AN INVERTED UTERUS
![Page 6: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/6.jpg)
Acute uterine inversion: a new technique of hydrostatic replacement.
O. Ogueh and G. Ayida. Br J Obstet Gynaecol 104 (8):951-952, 1997.
VENTOUSE
![Page 7: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/7.jpg)
CORRECTION OF UTERINE
INVERSION
• Abdominal approach
![Page 8: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/8.jpg)
LAPAROTOMY - Another use for the
ventouse!
E. Antonelli, O. Irion, P. Tolck, and M. Morales. Subacute uterine inversion: description of a novel replacement technique using the obstetric ventouse.
BJOG. 113 (7):846-847, 2006.
![Page 9: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/9.jpg)
LAPAROSCOPY - Use of counterpressure
R. Vijayaraghavan and Y. Sujatha. Acute postpartum uterine inversion with haemorrhagic shock: laparoscopic reduction
BJOG. 113 (9):1100-1102, 2006.
![Page 10: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/10.jpg)
THE ATONIC UTERUS
• Anti-shock garment
• Bimanual compression
• Packing
• Balloons
• Compression sutures
![Page 11: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/11.jpg)
Non-pneumatic anti-shock garment reduces average blood loss by 50%
S. Miller, S.et al. First aid for obstetric haemorrhage:
the pilot study of the non-pneumatic anti-shock garment in Egypt.
BJOG. 113 (4):424-429, 2006.
![Page 12: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/12.jpg)
BIMANUAL COMPRESSION
![Page 13: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/13.jpg)
PACKING
THE
UTERUS
S. Hsu, B. Rodgers, A. Lele, and J. Yeh.
Use of packing in obstetric hemorrhage of uterine origin.
J.Reprod.Med. 48 (2):69-71, 2003.
![Page 14: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/14.jpg)
INTRAUTERINE BALLOON
Management of massive
postpartum haemorrhage:
use of a hydrostatic balloon
catheter to avoid laparotomy
R. Johanson, M. Kumar,
M. Obhrai, and P. Young.
BJOG 108 (4):420-422, 2001.
500 cc warm saline
in-situ for 24 hours
![Page 15: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/15.jpg)
INTRAUTERINE BALLOON
Y. N. Bakri, A. Amri, and Jabbar F. Abdul.
Tamponade-balloon for obstetrical bleeding.
Int.J Gynaecol Obstet. 74 (2):139-142, 2001.
![Page 16: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/16.jpg)
INTRAUTERINE BALLOON
![Page 17: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/17.jpg)
Effectiveness of balloons
• 23 patients unresponsive to medical therapy
• 2 required hysterectomy
Dabelea V, Schultze PM, McDuffie RS Jr. Am J Perinatol. 2007 Jun;24(6):359-64.
![Page 18: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/18.jpg)
Effectiveness of balloons
• Used in 27 cases at St George’s Hospital, London
• Sengstaken-Blakemore tube used
• Haemostasis achieved in 22 (81%)
• Four hysterectomies
• Removal at 24 hours – no further bleeding
S. K. Doumouchtsis, et al. Acta Obstet Gynecol Scand. 87 (8):849-855, 2008.
![Page 19: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/19.jpg)
INTRAVAGINAL BALLOON
M. Tattersall and W. Braithwaite.
Balloon tamponade for vaginal lacerations causing
severe postpartum haemorrhage.
BJOG 2007; 114:647-8.
![Page 20: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/20.jpg)
Belfort-Dildy device
Photograph courtesy of Gary Dildy, M.D.
![Page 21: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/21.jpg)
Belfort MA, Dildy GA, Garrido J, White GL. Intraluminal pressure in a uterine tamponade balloon is curvilinearly related to the volume of fluid infused. Am J Perinatol 2011;28(8):659-66
Uterine Balloon Tamponade� Compression and decreased flow within the uterine
arteries can be demonstrated on ultrasound
� Flow rapidly returns to normal after removal
Flow within uterine artery during tamponade
Before Placement Balloon in place After Removal
![Page 22: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/22.jpg)
Uterine Balloon Tamponade
• Post-marketing surveillance study
– 57 enrolled, 55 had PPH, 51 placed
• Study population:
– C/S 45% & Twins 24%
– EBL 2,000 (855 - 8,700) mL
• Delivery-to-Placement was 2.2 (0.3 – 210) hours
– Bleeding decreased or stopped 98% of cases
– Hysterectomy avoided in 92% of cases
• Uterine balloon volume >500 mL in 45% of cases
Dildy GA, Belfort MA, Adair CD et al. Initial experience with a dual-
balloon catheter for the management of postpartum hemorrhage.
Am J Obstet Gynecol 2013 Sep 18.
![Page 23: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/23.jpg)
B-LYNCH SUTURE
C. B-Lynch, A. Coker, A. H. Lawal,
J. Abu, and M. J. Cowen.
The B-Lynch surgical technique
for the control of massive
postpartum haemorrhage:
an alternative to hysterectomy?
Five cases reported.
Br J Obstet Gynaecol 104 (3):372-375, 1997.
![Page 24: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/24.jpg)
Square suturing
J. H. Cho, H. S. Jun, and C. N. Lee.
Hemostatic suturing technique for uterine bleeding during cesarean delivery.
Obstet Gynecol. 96 (1):129-131, 2000.
![Page 25: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/25.jpg)
FURTHER MODIFICATIONSR. G. Hayman, S. Arulkumaran, and P. J. Steer.
Uterine compression sutures: surgical management of postpartum hemorrhage.
Obstet Gynecol 99 (3):502-506, 2002.
FRONT VIEW SIDE VIEW
![Page 26: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/26.jpg)
ANTERIOR VIEW
![Page 27: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/27.jpg)
POSTERIOR VIEW
![Page 28: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/28.jpg)
HAYMAN SUTURE
11 cases, 1 hysterectomy –F. Ghezzi, A. Cromi, S. Uccella, L. Raio, P. Bolis, and D. Surbek.
The Hayman technique: a simple method to treat postpartum haemorrhage.
BJOG. 114 (3):362-365, (March) 2007.
![Page 29: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/29.jpg)
Dealing with bleeding from the
lower segment
![Page 30: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/30.jpg)
A
Broad Ligament
Round Ligament
Bladderreflectedcaudally
A. Positioning of closed artery forceps.This maintains a patent cervical canalon tightening lower sutures
Anterior view
Fallopian Tube
Anterior view of Completed sutures
ARULKUMARAN MODIFICATIONR. G. Hayman, S. Arulkumaran, and P. J. Steer.
Uterine compression sutures: surgical management of postpartum hemorrhage.
Obstet Gynecol 99 (3):502-506, 2002.
AA
![Page 31: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/31.jpg)
PARALLEL VERTICAL
COMPRESSION SUTURES
Y. M. Hwu, C. P. Chen, H. S. Chen, and T. H. Su. Parallel vertical compression sutures:
a technique to control bleeding from placenta praevia or accreta during caesarean section.
BJOG. 112 (10):1420-1423, 2005.
![Page 32: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/32.jpg)
PARALLEL VERTICAL
COMPRESSION SUTURES
Y. M. Hwu, C. P. Chen, H. S. Chen, and T. H. Su. Parallel vertical compression sutures:
a technique to control bleeding from placenta praevia or accreta during caesarean section.
BJOG. 112 (10):1420-1423, 2005.
![Page 33: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/33.jpg)
B Dawlatly, I Wong, K Khan,
& S Agnihotria Department of Obstetrics and
Gynaecology,
Whipps Cross University Hospital,
London.
BJOG: 114; 502 (April 2007)
Using the cervix to stop bleeding in a woman
with placenta accreta: a case report
![Page 34: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/34.jpg)
Multiple U suture
Hackethal A et al (2008)
Hum Reprod. 2008
23:74-79
![Page 35: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/35.jpg)
Compression suture and balloon
Combined B-lynch suture with
intrauterine balloon catheter
triumphs over massive postpartum haemorrhage.
D. Danso and P. Reginald.
BJOG. 109 (8):963, 2002.
![Page 36: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/36.jpg)
Compression suture and balloon
• 5 patients with compression suture and balloon
• 11 hours median use (range 10-24)
• Effective in all cases
• No complications seen
Nelson WL, O'Brien JM.
Am J Obstet Gynecol. 2007 May;196(5):e9-10.
![Page 37: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/37.jpg)
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
Uterine compression suture
without hysterotomy -
why a non-absorbable suture
should be avoided.
– C. Cotzias and J. Girling. J Obstet Gynaecol 25 (2):150-152,
2005.
![Page 38: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/38.jpg)
Removable sutures
Matsubara S, Acta Obstet Gynecol Scand 2014; 93:1069-70
![Page 39: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/39.jpg)
Removable sutures
Zhang ZW et al, BJOG 2014; 122:429-433
![Page 40: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/40.jpg)
Removable sutures
Aboulfalah A et al, Frontiers in Surgery, 2014; 1: article 43
![Page 41: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/41.jpg)
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
• Pyometria after hemostatic square suture
technique
– M. Ochoa, A. D. Allaire, and M. L. Stitely.
– Obstet Gynecol. 99 (3):506-509, 2002.
• Uterine cavity synechiae after hemostatic
square suturing technique.
– H. H. Wu and G. P. Yeh.
– Obstet Gynecol. 105 (5 Pt 2):1176-1178, 2005.
![Page 42: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/42.jpg)
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
• Partial ischemic
necrosis of the
uterus following a
uterine brace
compression
suture.
– V. M. Joshi and M. Shrivastava. BJOG.111 (3):279-280, 2004.
![Page 43: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/43.jpg)
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
E. J. Treloar, R. S. Anderson, H. S. Andrews, and J. L. Bailey. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage.
BJOG. 113 (4):486-488, 2006.
![Page 44: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/44.jpg)
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
• Partial necrosis following Cho sutures– Reyftmann L et al (2009) Gynecol Obstet Fertil 37:579-582
• Partial necrosis following local compression suture– Gottlieb AG et al (2008) Obstet Gynecol 112:429-431
• Partial necrosis following B-Lynch plus Cho suture– Akoury H, Sherman C. (2008) J Obstet Gynaecol Can.
30:421-4
![Page 45: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/45.jpg)
COMPLICATIONS OF UTERINE
COMPRESSION SUTURES
• 8 cases of uterine necrosis
• 3 cases of uterine rupture in subsequent pregnancy
• Two cases of pyometra
• One case of haematometra
• Two cases of Asherman’s syndrome
• Synechiae
Amorim-Costa et al, Acta Obstet Gynecol Scand. 2011 Jul;90(7):701-6
![Page 46: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/46.jpg)
Synechiae
• Study 1 (Hackethal technique):
– Uterine compression sutures successful in
26/33
– 15 later had hysteroscopy and/ or HSG
– 4 had synechiae (27%)
• Study 2 (B-Lynch’s or Cho’s technique):
– 13/37 subsequent hysteroscopy
– 3 had Asherman’s, 7 had synechiae
Poujade O, BJOG 2011;118:433-439
Rathat G, Fertil Steril 2011; 95:405-9
![Page 47: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/47.jpg)
49 pregnancies after uterine
compression suturing• Outcome similar to controls:
– 34 (81%) term delivery
– 2 (4.7%) preterm
– 4 (9.5%) miscarriage
• One perinatal loss
– Twins , placenta praevia, ruptured uterus
(previous classical)
• 34% had pelvic adhesions compared with 17.5%
controls
Hyeong G, et al Obstet Gynecol 2013; 122: 565-570
![Page 48: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/48.jpg)
Matsubara S, et al
Acta Obstet Gynecol Scand. 2013 Apr;92(4):378-85.
![Page 49: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/49.jpg)
UTERINE ARTERY LIGATION
O'Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage.
J Reprod Med 1995;40:189-93.
![Page 50: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/50.jpg)
INTERNAL ILIAC LIGATION
Main danger is damage to the internal iliac vein: Success rates 43-90%
SHOULD ONLY BE DONE BY EXPERIENCED SURGEON
Das BN,.Biswas AK. Ligation of internal iliac arteries in pelvic haemorrhage.
J Obstet Gynaecol Res. 1998;24:251-4.
![Page 51: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/51.jpg)
V. Joshi, S. Otiv, R. Majumder,
Y. Nikam, and M. Shrivastava.
Internal iliac artery ligation for
arresting postpartum haemorrhage.
BJOG. 114 (3):356-361, 2007.
![Page 52: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/52.jpg)
Correct Way
![Page 53: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/53.jpg)
IF THE BLEEDING IS
HEAVY, CONSIDER
AORTIC
COMPRESSION
![Page 54: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/54.jpg)
![Page 55: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/55.jpg)
Caesarean hysterectomy
![Page 56: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/56.jpg)
Caesarean Hysterectomy
• Don’t leave it too late
• Do subtotal first
• Leave the vault open initially as it helps to find the cervix
• Stop once the bleeding is controlled
• Involve vascular surgeons prn
• Consider Logethotopolous pack
![Page 57: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/57.jpg)
Logethotopolous pack
![Page 58: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/58.jpg)
![Page 59: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/59.jpg)
Preparation
of
Logethoto-
polous
pack
![Page 60: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/60.jpg)
USE A SCRIBE
![Page 61: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/61.jpg)
ARTERIAL EMBOLISATION
• First described in 1979
• up to 95% success
• Requires angiography facilities
C. Boulleret, et al.
Hypogastric arterial selective and superselective embolization for
severe postpartum hemorrhage: a retrospective review of 36 cases.
Cardiovasc.Intervent.Radiol. 27 (4):344-348, 2004.
![Page 62: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/62.jpg)
C. Boulleret, et al.
Hypogastric arterial selective and superselective embolization for
severe postpartum hemorrhage: a retrospective review of 36 cases.
Cardiovasc.Intervent.Radiol. 27 (4):344-348, 2004.
![Page 63: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/63.jpg)
ARTERIAL EMBOLISATION
• Gelfoam is material of choice (Vedantham 1997)
• Preoperative placement of catheters - calculate radiation dosage and inform patient of risks to fetus if > 5 Rads
• Potential complications of embolisation:
– Angiography (haematoma, contrast nephrotoxicity)
– Pelvic infection (low-grade fever, pelvic abscess)
– Ischaemic phenomena (necrosis, buttock claudication)
![Page 64: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/64.jpg)
Complications of Embolisation
Al-Thanyan et al. Obstet Gynecol 2012;120:468–70
![Page 65: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/65.jpg)
DON’T PANIC
• If you rush,
you will make
silly mistakes
SPECIAL POINT
![Page 66: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/66.jpg)
https://drive.google.com/file/d/0B2zXNlGDKFDEV0QxSHBnYWF5Mmc/view
![Page 67: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/67.jpg)
![Page 68: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/68.jpg)
![Page 69: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/69.jpg)
![Page 70: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/70.jpg)
![Page 71: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/71.jpg)
![Page 72: Postpartum haemorrhage - the surgical aspects](https://reader031.vdocuments.site/reader031/viewer/2022020301/5879efc31a28ab8f608b54b7/html5/thumbnails/72.jpg)
Summary
• Balloon tamponade is effective first-line management
• Uterine compression sutures should usually be tried
next
• Compression sutures have significant complications,
associated mainly with uterine ischaemia
• Hysterectomy may still be necessary
• The Logethotopolous pack can be life-saving as a
last resort
• Embolisation can be useful
• Real-time guidance by computer may be valuable