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20 October 2006
BACKGROUND
PPH
Major cause of maternal mortality Soetomo Hospital
1st : PE-E (39.7%)
Time related
BACKGROUND
PPH
Access etiology : explore 4T Laboratory test : CBC, Coagulation, Cross match Get help : Obstetrician,Anesthesiologist, Lab, ICU Local control : Man.comp. Ut. Pack, Embolization BP & Coagulation : Cristaloid, Blood product Tone Tissue : massage, compression, drugs : manual removal, curretage : Correct inversion, repair laceration, Ident. rupture
Direct th/
Intractable
Trauma
Surgery
Ligate
Hysterectomy
Abdominal packing Embolization
Oxitocyn
Medical
Prostaglandin
Methergin Bimanual Compression
Mechanical
Tamponade
Gauze Balloon
Embolization
Ut (+) : Ligation B-Lynch
Surgical
BACKGROUND
Ideal treatment / device?
Efective Widely available Cheap Easy
No Concealed Bleeding Better Coverage Atraumatic insertion Fast Simple to place and remove Removal does not cause bleeding Less Infection No spec. skill Ideal ?
PPH
PPH : Vag > 500 cc ; Op > 1000cc
Late >24 h
Early <24 h
CLASS
1 2
Ammount (cc)
900 1200-1500
Loss (%)
15 20-25
Respons
Asimptomatik
3 4
1800-2100 >2400
Tachicardia,tachipneu, weak pulse, ortostatic hipotension 30-35 Tachicardia,tachipneu, hipotension, cold extr. 40 Shock, oligo-uria/anuria
Estimated blood loss is commonly only about half the actual loss ! (Cuningham,2005)
When in shock, the brain, heart, and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs.
Unpredictable Event
Even in a mother without a single predisposing factor
Tone Tissue Trauma Thrombin
PPH
Access etiology : explore 4T Laboratory test : CBC, Coagulation, Cross match Get help : Obstetrician,Anesthesiologist, Lab, ICU Local control : Man.comp. Ut. Pack, Embolization BP & Coagulation : Cristaloid, Blood product Tone Tissue : massage, compression, drugs : manual removal, curretage : Correct inversion, repair laceration, Ident. rupture
Direct th/
Intractable
Trauma
Surgery
Ligate
Hysterectomy
Abdominal packing Embolization
Balloon Tamponade
Used in urology for stretching the bladder and for stemming mucosal hemorrhage
2 Successful case report Placentae acreta
Oxytocin Drip Kept for 6 - 24/48 hrs Deflate gradually Antibiotics coverage A/G/M : 7 days
Atonic PPH occurs due to failure of living ligatures of uterine muscles to compress the vessels.
Directly compressing the bleeding vessels by hydrostatic pressure Improving the efficiency of failed live ligature by uterine muscle contractions
Mechanism of Action
By allowing sufficient time for resuscitation of the patient, which enables the severely anoxic uterine muscle to recover from tissue anoxia and contract.
The pressure in the capillary system is 21-48 mm of Hg or 28.5-65.5 cm of water. Pressure in intervillous space is 25mm of Hg or 33.9cm of water. Hence the pack stops most of the bleeding except for arteriolar spurters wherein the pack may fail or be less effective
Disadvantage
Pressure Not Fully controled
Indications
Atonic PPH Coagulation failure Inversion Traumatic PPH
Contraindications
Suspected or diagnosed uterine rupture.
Tamponade Test
SengstakenBlakemore Tube Insert into uterine cavity Filled 70 -300cc NS (+) Bleeding stop and No surgery (-) Bleeding Continue, Surgery needed
Average : 3 gallons
Only < 1000 cc needed
Case I
Mrs. Y / 37 th GIIIP2-2, Aterm, PROM ANC : Suwandi Hospital Dilation 2cm, Contraction (-) Termination : Misoprostol 2 x 50 mcg 2nd Misoprostol : Contraction start 4 hrs : Delivered Rapid Labor
/3900/51/6-8
PPH of Atonic Oxytocin and Misoprostol >1500 cc loss Intractable PPH Reffered to Soetomo Hospital Hb : 2,6 g/dL, Thrombocyte : 8000, Shock Medical bleeding Intubated, Explored at the Op. Theater Laceration of labia major and cervix
7 Wb 10 TC, Hb : 8,8 g/dL, Thrombo : 105.000 Kept for 48 hrs No sign of infection Discharge at day 5 No menstrual complain
Case II
Mrs. R / 24 th GIP0-0, 36/37 wks, Eisenmenger Syndrome ANC : Soetomo Hospital Congenital Heart Disease : VSD Termination : Elective CS + Tubectomy Hb :13 + 300 cc during operation, Misoprostol 4 tab
/2300/45/7-8
4 hrs post CS : PPH of Atonic Oxytocin and Misoprostol 800 cc loss and continued, Hb : 12,1 Under Ketamin + Dormicum Perform Sayebas technique
NS 350 cc Cefotaxim 3 x1 g Gentamycin 2 x 80 mg Oxytocin Drip Misoprostol
Case III
Mrs. S / 39 th GIIP1-1 , Aterm, Gemelli ANC : Midwive Preeclampsia, Lung Oedem I : FE /2400/4-9/8-9 II : Version Extraction /2600/47/6-8 Hb: 11,6 g/dL
2 hrs post partum : PPH of Atonic Oxytocin and Misoprostol > 500 cc loss and continued, Hb : 9,8g/dL Perform Sayebas technique
NS 300 cc Cefotaxim 3 x1 g Oxytocin Drip Misoprostol
CASE
Predisposing Case Rapid I Labor Misoprostol Case Eisenmenger II Syndrome Case -Gemeli III -PIH -SM
A TIMING M
CAUSE
Other
Hb
Trans fusion
Soon
? - 2,6
7 WB 10 TC -
+ +
2 hr Post CS
800 500
CASE
MOD Time NS Duration Antibiotics (mnt) (cc) (hrs) 45 350 48 Cefotaxim Infection Anestesi
20 30
350 300
24 48
Summary
PPH : Great Mother killer Use of Condom as tamponade is highly effective and avoid the surgical need 3 Cases reported with successful result in Dr. Soetomo Hospital 2005 Hopefully contribute to reduce Maternal morbidity and mortality