Uterine Compression Sutures for Postpartum Bleeding With Uterine Atony (WITH FLASH)
Etiology and management of uterine atony
description
Transcript of Etiology and management of uterine atony
![Page 1: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/1.jpg)
Etiology and management of uterine atony
Dr. Vedran Stefanovic, docentSpecialist in OB/GYN, Maternal and Fetal MedicineHelsinki University Central [email protected]
![Page 2: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/2.jpg)
Every minute of every day a women dies from complication of pregnancyand childbirth
Global maternal mortality ratio is402/ 100 000 births , 99% in developingcountries (Finland 1.6/100 000 )
Haemorrhage accounts for 30% of cases and is a leading cause of maternal death
Should we be concerned?
YES !!!!
In UK annually 17 maternal deaths due to maternal haemorrhage and the number is increasing !
Cca 75% of ”near misses” cases in Scotland due to haemorrhage ( 5/1000), 50% substandard care !
![Page 3: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/3.jpg)
Uterine atony
• Uterine atony – failure of the uterus to contract adequately following delivery
• The most common cause of postpartum haemorrhage (PPH)
• A critical step in the prevention of PPH is the simultaneous contraction of myometrial fibers during and after the third stage of labour
![Page 4: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/4.jpg)
Uterine contractility
Our knowledge still insufficient !
Uterine contractility regulated by:
-Ca++ (nifedipine as first line medication for treatment of premature contractions -progesterone ( im injections weekly in cases of previous premature birth)-oxytocin (induction of labor, prophylactic administration immediately after second stage of labor completed, treatment of atony, -prostaglandines (misoprostol, sulprostone)
From: Aguilar et al. Physiological pathways and molecular mechanisms regulating uterine contractility.Human Reproduction Update,2010
![Page 5: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/5.jpg)
Uterine atony – risk factors
![Page 6: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/6.jpg)
Uterine atony – management options
![Page 7: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/7.jpg)
from: Ahonen J, Stefanovic V, Lassila R : Management of post-partum haemorrhage, Acta Anaesthesiologica Scandinavica, 2010
![Page 8: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/8.jpg)
Uterine atony management
• Identifying ris factors and prevention• Surgical management of lacerations• Medical• Surgical ( pelvic arterial ligation,
uterine brace suture)• Other (balloon tamponade,
embolization)
![Page 9: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/9.jpg)
Uterine atony
• Identifying risk factors
• Prophylactic oxytocin immediately after delivery of infant (10 IU bolus im or iv),early clamping of umbilical cord and controlled cord traction RR 0.5
• Oxytocin or ergometrine? No statistical difference. Cave ergot alcaloids in patient with hypertension and HIV !
![Page 10: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/10.jpg)
![Page 11: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/11.jpg)
Uterine atony
• Placental retention– incidence cca 2.5%– associated with atonic bleeding– only definite treatment is MANUAL
REMOVAL– usually D&C necessary late sequelae– nitroglycerine, misoprostol, sulprostone
( 1 report with success rate of 44%)
![Page 12: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/12.jpg)
success rate 39.4%
Stefanovic, Paavonen, Tikkanen,Ahonen et al , Intravenous sulprostone reduces need for manual removal of placenta, submitted BJOG
![Page 13: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/13.jpg)
Uterine brace sutures (Lynch)
![Page 14: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/14.jpg)
![Page 15: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/15.jpg)
![Page 16: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/16.jpg)
![Page 17: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/17.jpg)
Grönvall, Stefanovic, Tikkanen, Paavonen Bakri balloon tamponade for intractable massive PPH, submitted
93% final succes rate !!
![Page 18: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/18.jpg)
Depertment of AngioradiologyHelsinki University Central Hospital
– Over 1100 interventions/year– Four angiologists– 24 hrs/day availability
![Page 19: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/19.jpg)
Embolization history
– Nussbaum 1965, selective mesenterial angiography
– Rösch 1972, superselective angiography and embolization with autologic patch
– Brown 1979, the first postpartum embolization with gelatine
![Page 20: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/20.jpg)
Materials
GELFOAM
MICROCOILS
![Page 21: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/21.jpg)
Our study
• April 2004 – June 2007• 39 patients• Data colection from the hospital register• 2 patients with gynaecological
haemorrhage (cervical ectopic pregnancy and postoperative bleeding in the patient with ovarian cancer)
• 37 obstetric patients
![Page 22: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/22.jpg)
37 embolizations or baloon occlusions due to the obstetric haemorrhage
a) 19 emergency embolizations
- uterine atony (n=11) - cervical/vaginal rupture (n=5) - paravaginal haematoma (n=2) -placenta accreta as intrapartum finding (n=1)
b) 12 prophylactic arterial baloon occlusions in the cases of suspected placenta accreta
c) 4 elective occlusions and prophylactic embolisations in
the cases of anticipated placenta accreta/percreta
![Page 23: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/23.jpg)
Case report
• 28- primipara– Vaginal birth, placental partial retention– 3 D&C– Atonic bleeding, 7000 ml (Bakri balloon
not still in use in our hospital)
![Page 24: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/24.jpg)
![Page 25: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/25.jpg)
![Page 26: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/26.jpg)
![Page 27: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/27.jpg)
After gelatine
![Page 28: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/28.jpg)
![Page 29: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/29.jpg)
The best treatment ?
![Page 30: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/30.jpg)
Method Advantages Disadvantages
Uterine brace sutures (Lynch)
1.fast2.suitable for atony treatment with simultaneous use of Bakri balloon
1.requires laparatomy2.haematometra/uterine necrosis/bowel incarceration possible
Bakri Balloon tamponade
1.easy application2.suitable for both uterine and birth canal tamponade3.suitable during patient´s transport4.does not require laparatomy
1.price (350 € )
Pelvic arterial ligation 1.fast 1.requires long surgical experience2.requires laparatomy3.embolisation often not possible afterwards
Embolization 1.identifies small vessels not visible (not accessible) by surgery
1.requires facilities (often far away from the place of labor)2.not available 24/7 in many places
![Page 31: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/31.jpg)
Uterine atony
•Prevention•Recognition•Optimal treatment
![Page 32: Etiology and management of uterine atony](https://reader035.fdocuments.us/reader035/viewer/2022062322/5681517b550346895dbfb436/html5/thumbnails/32.jpg)
Tänan väga!Thank U! Kiitos!