Why we

must consider ??

concerne about PPH?

Every minute of everyday, a woman dies in

pregnancy or childbirth. -> 500.000 / year,
99% in underdeveloped country

Its equal to 3 jumbojet carrying 500 term gravid

women crashed everyday in a whole year
 MASSIVE PPH:
A blood loss >2500 ml (or >30% blood volume)
Or
transfusion of 5 units of blood
Or
Treatment for coagulopathy.
(The Scottish Confidential Audit of Severe Maternal
Morbidity /SCASMM)

Causes of maternal mortality

58% OF THIS DEATH MAY

HAVE BEEN PREVENTABLE
BECAUSE TOO LITTLE BEING
DONE & TOO LATE CONTINUES
TO CONTRIBUTE TO MMR
GIVING BIRTH SAFELY IS LARGELY A PRIVILEGE OF
THE RICH
MILLENIUM DEVELOPMENT GOALS (MDGs) REPORT 2009

The change is posibble: UK history:

100ys ago uk MMR 1:290 1: 19000
Massive haemorrhage
Is an obstetrics emergency that require a
systemic, multidisciplinary approach to:

RESTORE THE VOLUME

CLOTTING SYSTEM
AND THE OXYGEN CARRYING CAPACITY OF BLOOD, WHILE
STEPS ARE TAKEN TO ARREST THE BLEEDING, A. S . A . P

MULTIDISCIPLINARY INCLUDE:
SKILLED MIDWIFE
SENIOR OBSTETRICIAN(s)
SURGEON/GYNECOLOGIST ONCOLOGIST SKILLED ON
PELVIC SURGERY
SENIOR ANESTHETIST,
EXPERIENCED MIDWIFE
CONSULTAN HAEMATOLOGIST
PHYSIOLOGY OF
PARTURITION
re

Comparison of emergency hysterectomy

associated with parity and previous Csc

Para 0

Previous
cs

RR 18,32 (10,26-
32,71)
P<0,001
Placenta accreta
Morbidly adherent placenta
Risk Factors:

Placenta previa expecially with Previous C

Section
submucous myoma,
Previous curettage,
Ashermans syndrome,
advanced maternal age,
grandmultiparity,
smoking,
chronic hypertension [14].
Placenta accreta
DIAGNOSTIC ULTRASOUND
Gambaran lacunar/swiss chesse
appearance lebih patognomonik
 Placenta accreta
pascahisterektomi
Management options:

Elective c section >35 weeks of gestasion

Diagnostic cystoscopy in placenta
percreta invading or compressing the
bladder was suspected.
Ureteral stents were placed in proven
cases with placenta percretta invading
the bladder.
A multidisciplinary team
Internal iliac artery catheters were placed
preoperatively
 If placenta removal failed, the uterine
incision was closed and cesarean
histerectomy was performed.BEST
CHOICE
If histerectomy considered unsafe ,e.g.
placenta has already invaded the bladder,
placenta was left in situ
Selective uterine artery embolization
Metothrexate 1 mg/kg administered
Delayed histerectomy
Uterine Atonia
MANAGEMENT
by the Scottish Executive
Committee of the RCOG
MULTIDISCIPLINARY

TEAM
 STOP THE BLEEDING
Exclude causes of bleeding other than uterine atony
Ensure bladder empty
Uterine compression
IV syntocinon 10 units (Grade A: 60% risk)
IV ergometrine 500 mg
Syntocinon infusion (30 units in 500 ml)
IM Carboprost (500 mg)

Surgery earlier rather than late

Hysterectomy early rather than late
co
MANAGEMENT OF MASSIVE
HAEMORRHAGE
 If conservative measures fail to
control haemorrhage, initiate
surgical haemostasis SOONER
RATHER THAN LATER
B-Lynch suture
Bilateral ligation of uterine arteries
Bilateral ligation of internal iliac
(hypogastric arteries)
Hysterectomy
(GRADE C)
The overall rate of failure histerectomy :
25%
Woman> 35 yo
Multiparous women
Unemployee/manual occupational group
Had vaginal delivery
delay of between 2-6 hours from delivery
Compression suture

CONCLUSION:
THE NEED OF A CONTROL OF BLOOD LOST
AFTER DELIVERY TO AVOID UNRECOGNIZED
BLEEDING (evicence level III)
 1 post cesarean hysterectomy & 3
cases post debulking
undergone ligation of bilateral
uterine or hypogastric arteri but no
avail
Blood lost 2500-6000cc
can control haemorrhage and
provide crucial time to correct
physiologic and metabolic changes
resulting from uncontrollable
haemorhage
The drain was removed 48 hours
after surgery at bedside, in 1 case
96hours with laparoscopy surgery.
All the patient survived.
CONCLUSION

IN MAJORITY CASES MASSIVE BLEEDING POST C

SECTION AND HISTERECTOMY USUALLY PREVENTABLE
IF CLINICIAN MAKE GOOD PREPARATION IN EVERY
CASES , EARLY DIAGNOSIS AND PROMPT TREATMENT.
IF MASSIVE ONGOING BLEEDING HAPPENS, CLINICIANS
MUST ASK FOR HELP AND WORK TOGETHER IN A TEAM.
PREECLAMPTIC PATIENTS NEED EXTRA CARE BECAUSE
HEMOCONCENTRATION CAN CAUSE SERIOUS
PROBLEMS EVEN IN BLEEDING 250CC
Thank you
Stepwise devascularization,
including ligature of descending
uterine and vaginal artery