postpartum hemorrhage workshop part 2 by dr mohamed elsherbiny

2. Dr. Mohamed El Sherbiny
MD Ob.& Gyn
Postpartum
Hemorrhage (PPH)
Guidelines for Immediate
Action “Part II ”
Damietta Specialized Hospital Workshop 2-11-2013

3. Sources of Evidence
PubMed
Cochrane library
SOGC Clinical Practice Guideline No. 189,2007
Committee, Society for Maternal-Fetal
Medicine(SMFM), November 2010
RCOG Guideline 2005 & 2011( Placenta previa, &
previa accreta)
NICE Clinical Guideline, November 2011 (CS)
Placenta Previa Accreta ACOG Committee 7-2012
Damietta Governorate experience (FIGO 10- 2012 )
UpToDate, Reaink , Augest 2013

4. What Is The Next Step if
Balloon Tamponade Fails ?
The following may be attempted, depending on
clinical circumstances and available expertise:
Haemostatic brace suturing (B-Lynch or
modified compression sutures)
Bilateral ligation of uterine arteries
Bilateral ligation of internal iliac (hypogastric)
arteries
Selective arterial embolisation
RCOG Guideline PPH No.52 May 2009 Grade C
4

5. Compression sutures, may be
attempted as a first intervention, and if
these fail, then uterine, utero-ovarian
and hypogastric vessel ligation may be
tried.
If Balloon Tamponade Fails

6. Stepwise uterine artery ligation (SUAL)
is the first-line surgical approach .
If bleeding is not controlled by SUAL or
no available expert to perform it, shift
to use of uterine compression (Brace)
suture technique is the second step.
Jacob , UpToDate Aug. 2013 Grade C
If Balloon Tamponade Fails

7. Intractable Atonic PPH Algorithm
Vaginal delivery
Failed
Expertise
Stepwise Uterine
Arteries Ligation
(SUAL)
Balloon Tamponade
Laparotomy
± Non-pneumatic
anti-shock garment
if available
Failed : ±Internal iliac ligation
-Hysterectomy
Low experience or Failed SUAL :
B-Lynch/Hayman ± sandwich

8. Uterine Compression
(Brace) Sutures
B-Lynch suture 1997
Hayman suture 2002
Sandwich 2007
(combined with Balloon
tamponade)

9. Test For Uterine Compression Sutures
 An assistant stands between the patient’s legs
to determine and extent of the bleeding.
 The uterus is then exteriorized and bimanual
compression performed.
• The Test is positive if the bleeding stops and
the compression suture will work and stop the
bleeding.

10. B-Lynch Suture

11. Anterior
Posterior
B-Lynch Suture

12. B-Lynch Suture
Monocryl No.1 mounted on 90-cm curved blunt
needle or other rapidly absorbable sutures
B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd
Ed.2012

13. It is recommended that
a laminated diagram of
the brace technique be
kept in theatre.
RCOG Guideline PPH No.52 May 2009 Grade C

14. B-Lynch Technique

16. Simple, effective (91-99%) and cost-saving
Fertility preserved and proven
Mortality avoided
World-wide application(1300 cases) and
successful (only 19 failures reports.
The B-Lynch surgical technique
B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd
Ed.2012

17. Hayman Compression
Suture
Hayman et al Obst. Gynec. 2002,99;3;502-6
A number 2 Vicryl or Dexon suture on a straight,
blunt needle is used to transfix the uterus from
front to back, just above the reflection of the
bladder and is then tied at the fundus of the
uterus.
This can be done as one suture on each
side of the uterus, or more than one suture if
the uterus is particularly broad,

19. Hayman Uterine Compression Suture
Advantage
 Uterine cavity not opened
 Probably quicker and easier to apply
Disadvantage
 Uterine cavity not explored under direct vision
 No feed-back data on fertility outcome
 Morbidity feed-back data limited
 Unequal tension leads may to segmented
 Ischemia secondary to slippage of suture –
‘shouldering’ with venous obstruction
B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd
Ed.2012

20. Hayman Uterine Compression Suture
El Sherbiny

21. Combination of External
Compression & Internal Tamponade
“ Uterine Sandwich”
 Indicated for patients with persistent
bleeding from uterine atony refractory to
medical therapy and has negative or
unsatisfactory compression suture test .
 The balloon is inflated with median volume of
(range 60 to 250 mL) to avoid "undue blanching
at the compression suture sites," which might
lead to uterine laceration or necrosis
Bakri ,UpToDate,Mar.,2013

22. Intrauterine balloon (Bakri) in combination
with a B-Lynch uterine compression suture
Nelson &O'Brien , Am J Obstet Gynecol. 2007;196(5):
Diemert et al.Am J Obstet Gynecol. 2012;206(1):65.e1
Uterine Sandwich
Bakri balloon tamponade combining with
Hayman external compression suture .
Yoong et al. Acta Obstetricia et Gynecologica Scandinavica ,
91 (2012) 147–1512011

23. Uterine Sandwich
Nelson &O'Brien , Am J Obstet Gynecol. 2007;196(5):

24. Hayman
Uterine
Sandwich
Yoong et al. Acta Obstetricia et Gynecologica Scandinavica ,
91 (2012) 147–1512011

25. Stepwise
Devascularization

27. Stepwise Uterine Devascularization
This technique entails five successive
steps, so if bleeding is not controlled by
one step the next step is taken until
bleeding stops. The steps are
(1)unilateral uterine vessel ligation,
(2) bilateral uterine vessel ligation
(3) low uterine vessel ligation
(4) unilateral ovarian vessel ligation
(5) bilateral ovarian vessel ligation.
AbdRabbo ,Am J Obstet Gynecol. 1994 Sep;171(3):694-

28. Advantages over internal iliac ligation:
Easier dissection.
Lower complication rates.
More distal occlusion of arterial
supply with less potential for
rebleeding because of collaterals
High reported rates of success in
controlling haemorrhaging.
(SOGC ) Clinical Practice Guidelines 2000
Stepwise Uterine Devascularization

30. 12
45
3
Stepwise Uterine Devascularization

31. 1
3
2
Stepwise Uterine Devascularization

32. Each suture: Starts in a vascular
area just lateral to the outer margin
of the uterus, then encompasses
2cm of uterine walls medially
encircling the blood vessels within it.

35. PPH After
CS 35

36. PPH After CS : Causes
1- uterine atony
2-Placent previa &placenta accreta/
increta/percreta
3- Trauma: bleeding from the uterine
incision or extensions of this incision or
bleeding from vaginal or cervical tears
or uterine rupture
4- Retained placenta
36

37. PPH After CS : Management
Uterine atony: Fundal massage and
uterotonic drugs (including intrauterine
injection )
Truma:Inspection for and repair of
lacerations and incisional bleeding.
The angles of a transverse incision should
be clearly visualized and any retracted
vesselsare ligated.
The ipsilateral ureter should be identified
before bleeding is controlled. 37

38. Intractable Atonic PPH Algorithm
Cesarean Section
Expertise
Stepwise Uterine
Arteries
Ligation(SUAL)
Low experience or Failed
SUAL: B-Lynch/Hayman
± sandwich
Failed : ± Internal iliac ligation
Hysterectomy
Excluding the other 3 Ts ( Extension , C. tears ,PP accreta
Upper S Atony

39. Intractable Atonic PPH Algorithm
Cesarean Section
Expertise Stepwise Uterine
Arteries LIG. (± Prophylactic)
Total Hysterectomy
Excluding the other 3 Ts ( U .S.atony , Trauma or thrombin
Lower S Atony
Major P. Previa or Focal PP accreta
Low Experience
Balloon
Tapenade Dissectible Bladder
Longitudinal
Lateral .Uterine
Sutures
Non
-Dissectible
Bladder

40. Management of
Placenta Previa
Accreta
“The New Nightmare”

41. Morbid Adherent
Placenta :
Accreta 79%
Increta 14%
Percreta 7%
79%
14% 7%
Attach to the
myomet.
penetrate to serosa
invade into the
myometrium
UpToDate , Resink , Aug 2013

42. 1-Placenta previa : 9.3% Vs 1/22,154 without PP
2-Uterine scare: 29% with placenta over the scar
Versus 6.5% not over the scar
3-Raised Maternal Age
The most important and the commonest
risk factor is placenta previa after a prior
CS.
Silver et al.. Obstet Gynecol 2006; 107:1226–1232.
Stafford I, et alContemp Obstet Gynecol 2008;82-53:76
Risk Factors For placenta Accreta
Ferrazzani et al,. Fetal Diagnosis and Therapy; 2009. 25:400–403.

43. Women with placenta accreta/percreta are
at very high risk of major PPH.
If placenta accreta or percreta is diagnosed
antenatally, there should be consultant-led
multidisciplinary planning for delivery.
RCOG Guideline PPH No.52 May 2009 (Grade C)

44. Complication of 109 Cases Of Placenta
Percreta
Bl.transfusion of > 10 units 40%
Maternal death 7%
Infection 29%
Perinatal death 9%
ureteral ligation 5%
Fistula formation 5%
Uterine rupture 3%.
O'Brien,. Am J Obstet Gynecol 1996; 175:1632.22.

45. Progressive increase
1950 : 1/30,000
1980s : 1 /2500
2002 : 1 / 535
2006 : 1/210
An increase of 142 Fold !! mainly due to
the marked ↑ in CS rate worldwide .
The incidence of Morbid Adherent Placenta
Stafford & Belfort, Contemp Ob/Gyn April:77, 2008
UpToDate , Resink , Aug 2013

46. Frequency of Placenta Accreta According
To Number of CS Deliveries And Presence
of Placenta Previa
Cesarean
delivery
Placenta
previa
No
Placenta previa
First (primary) 3.3 0.03
Second 11 0.2
Third 40 0.1
Fourth 61 0.8
Fifth 67 0.8
≥ Sixth 67 4.7
SMFM. Placenta accreta. Am J Obstet Gynecol 2010. UpToDate , Resink , Aug 2013

47. Prenatal detection of placenta
previa accreta is associated with
decreased in:
Feto-maternal morbidity &
Feto-maternal mortality
Warshak., et al Obstet Gynecol 2010;115:65–9
CHOU et al Ultrasound Obstet Gynecol 2002; 15: 28–35.

48. Diagnosis of placenta accreta before
delivery allows multidisciplinary
planning in an attempt to
minimize potential maternal or
neonatal morbidity and mortality.
ACOG Committee 7-2012

49. Diagnosis of Placenta
Previa Accreta (PPA)

50. Clinical Manifestations of
Placenta Accreta
AP Hemorrhage :In focal accreta
Interapartum hemorrhage : Profuse,
life-threatening at the time of manual
placental separation
The usual first manifestation of diffuse
accreta .
Hematuria :During pregnancy :With
bladder invasion.

51. RCOG Guideline PP PPA No. 27 October 2005
SOGC Clinical Practice Guideline No. 189,2007
RCOG Guideline PPH No.52 ,2009
RCOG Guideline PP PPA No. 27 , 2011
ACOG Committee 7-2012
Recommendations For Prenatal
Diagnosis of PP Accreta
Early counseling
Proper Decision :1-Conservative Vs hysterectomy
2-Elective rather than
emergency

52. PP. With previous CS are at high risk of
having a morbidly adherent placenta and
should have been imaged antenatally.
Colour flow Doppler U/S should be
performed .
PP. With previous CS
RCOG Guideline No. 27 October 2005 Grade C

53. Women with a placenta previa and a prior CS
are at high risk for placenta accreta.
If there is imaging evidence of pathological
adherence of the placenta, delivery should be
planned in an appropriate setting with
adequate resources.
PP. With Previous CS
SOGC CLINICAL PRACTICE GUIDELINE 2007(II-2B)

54. All women who have had a previous CS
must have their placental site
determined by U/S.
RCOG Guideline PPH No.52 May 2009 (Grade C)
Placenta previa With Previous CS
Antenatal sonographic imaging can
be complemented by MRI in
equivocal cases
RCOG Green-top Guideline PP PPA No. 27 2011

55. Diagnosis Of A Morbidly
Adherent Placenta
Woman and her family can be
counseled early
Ghourab et al .Ann Saudi Med 2000;20:382–5.
Dashe et al. Obstet Gynecol 2002;99:692–7.
Evidence
level III
U/S at 20-24 weeks: Why?
Placental migration is less likely if
There has been a previous CS.

56. Diagnostic Modalities of The
Morbidly Adherent Placenta
Ultrasound
Gray scale U/S
Colour flow Doppler
 3D power Doppler
MRI
Ultrasound is the most useful modalities
for evaluating placental position and
implantation
Resnilk ,UpToDate , Aug 2013ACOG Committee 7-2012

57. A Non Adherent
Placenta Previa
1-Normal subplacental Hypoechoic Zone(myometrial vasculature
2-Normal posterior bladder wall
3-Normal placental vascular pattern
Gray scale U/S

58. 1-Normal subplacental Hypoechoic Zone (myometrial
vasculature )
2-Normal posterior bladder wall
A Non
Adherent
Placenta
Previa

59. Greyscale :
Loss of the retroplacental sonolucent zone
Irregular retroplacental sonolucent zone
Thinning or disruption of the hyperechoic
serosa–bladder interface.
Abnormal placental lacunae.
Presence of focal exophytic masses
invading the urinary bladder
RCOG Green-top Guideline No. 27 2011
What Are The U/S Criteria for
Diagnosis of P Accreta?

60. A Morbidly Adherent Placenta Previa
1-Loss or Irregularity of the retroplacental sonolucent zone
2- Thinning or disruption of the hyperechoic serosa–bladder
interface

61. 3-Vascular lacunae"swiss chess appearance”+ve Pred.v :95%
A Morbidly Adherent Placenta

62. Abnormal placental lacunae. "swiss cheese appearance”
Positive perdictive value +ve Pred.v :95%
A Morbidly Adherent Placenta
Turbulence

63. Diffuse or focal lacunar flow
Vascular lakes with turbulent flow (peak
systolic velocity over 15 cm/s)
Hypervascularity of serosa–bladder
interface
Markedly dilated vessels over peripheral
subplacental zone.
RCOG Green-top Guideline No. 27 2011
What Are The Colour Doppler
Criteria for Diagnosis of PPA ?

64. Diffuse or focal lacunar flow

65. Hypervascularity of serosa–bladder interface

66. Markedly dilated vessels over peripheral
subplacental zone

67. Multiple large vessels extending through the
bladder wall of PP. percreta.

68. At least one diagnostic criterion was present.
Multiple diagnostic criteria : Higher prediction
Diagnostic Performance of U/S
Modalities
RCOG Green-top Guideline No. 27 January 2011
Shih et al . Ultrasound Obstet Gynecol,203-33:193 ;2009.

69. Overall, grayscale U/S is sufficient to diagnose
PPA , with a sensitivity of 77–87%, specificity of
96–98%, a positive predictive value of 65–93%).
The use of power Doppler, color Doppler, or 3D
imaging does not significantly improve the
diagnostic sensitivity compared with that
achieved by grayscale U/S alone
ACOG Committee 7-2012
Positive Doppler data confirm the diagnosis

70. It is still debated.
Sensitivity & specificity are comparable
with U/S
MRI was better at detecting the depth of
infiltration or when U/S findings are
inconclusive
The main MRI features of placenta accreta :
● Uterine bulging
● Heterogeneous signal intensity within the
placenta
● Dark intraplacental bands on t2-weighted
imaging.
The Role Of MRI In Diagnosing PPA
RCOG Green-top Guideline No. 27 January 2011

71. Sagittal T2WI MR of a placenta percreta
:placental invasion into the bladder

72. Prenatal Care
Correction of iron deficiency anemia, if present
Antenatal corticosteroids between 23 and 34
weeks of gestation for pregnancies at increased
risk of delivery within seven days (eg,
antepartum bleeding)
Anti-D immune globulin if vaginal bleeding
occurs and the patient is Rh(D)-negative
Serial U/S assessment of the placenta is
generally not useful after the diagnosis of
accreta, increta, or percreta has been made
Resnilk ,UpToDate , Aug 2013

73. Decision Making
U/S Guided

74. Counseling & Consent
Any woman with suspected placenta praevia
accreta should be counseled clearly in a
consent form.
This should include:
 The anticipated skin and uterine incisions
 Whether conservative management or
proceeding straight to hysterectomy if
accreta is confirmed at surgery
RCOG Green top Guideline No. 27 January 2011

75. 1- Consultant obstetrician planned and
directly supervising delivery
2- Consultant anaesthetist planned and
directly supervising anaesthetic at delivery
3-Blood and blood products available
4- Multidisciplinary involvement in pre-op
planning
What Preparations Should Be Made Before
Surgery?
RCOG Green-top Guideline No. 27 January 2011

76.  At least two large bore intravenous catheters
should be placed.
 A 3-way Foley catheter and ureteral stents
should be available in case they are needed to
assess integrity of the urinary tract.
 Balloon catheterization of the internal iliac
arteries may resulted in significantly less blood
loss, lower blood transfusion requirements, and
shorter duration of surgery. Others investigator
have not documented significant benefits
What Preparations Should Be Made
Before Surgery?
Resnilk ,UpToDate , Aug 2013

77. 5-Discussion and consent includes possible
interventions (Such as hysterectomy,
leaving the placenta in place, Cell salvage
and intervention radiology)
6-Local availability of a level 2 critical care bed.
What Preparations Should Be Made Before
Surgery?
RCOG Green-top Guideline No. 27 January 2011

78. At what gestation should elective
delivery occur?
Elective CS delivery in asymptomatic women is
not recommended before 36–37 weeks GA for
suspected placenta accreta.
RCOG Green top Guideline No. 27 January 2011
A course of corticosteroid at 34 ws
gestation and deliver after 48 hours. This
is supported by reported outcomes, as
well as a decision analysis
UpTODate ,Resink, Aug 2013ACOG Committee 7- 2012

79. Opening the uterus at a site distant from
the placenta, and delivering the baby
without disturbing the placenta.
Going straight through the placenta to
achieve delivery is associated with more
bleeding and a high chance of
hysterectomy and should be avoided.
RCOG Green-top Guideline No. 27 2011
What Surgical Approach Should Be
Used For Suspected PPA ?
Grade C/D

80. Guided U/S
Opening the uterus at a site distant
from the placenta
UpTODate ,Resink, Aug 2013

81. Preoperative or intraoperative
sonographic localization of the
placental edge is helpful for
determining the best position for the
hysterotomy incision
UpTODate ,Resink, Aug 2013

82. Strong evidence of of
diffuse PP accreta
Focal or No strong
evidence of of
PPevia accreta
No incision at the
placental site (USCS)
Don’t separate the
placenta even if the
uterus is conserved
Separation of the
placenta may be
allowed if the uterus
is to be conserved

83. Focal PP
Accreta

84. Focal accreta :
TAH is
recommended
If future fertility is
strongly desired :
Conservatism
Separation of the
placenta may be
allowed if the uterus is
to be conserved

85. Transient Packing &Stepwise
Uterine A ligation 1&2
Stepwise
Longitudinal
lateral sutures
Total
Hysterectomy
No Strong fertility
need
Fertility need
Focal or Unexpected PP Accreta
Faild
Non Dissectible
Bladder
If still bleeding (50%)
Separation of the Placenta
Dissectible
Bladder
Balloon inverted
Glove Tamponade
??Opening
the bladder

86. Mohamed El Sherbiny MD Ob.& Gyn.
Damietta Egypt
Conservative Management of
Placenta Previa-Accreta by
Prophylactic Uterine Arteries
Ligation and Stepwise Vertical
Compression Sutures.
XX FIGO World Congress
October 2012

87. Materials
This protocol was followed in 13 women
undergoing CS for placenta previa with
focal accreta suspected or diagnosed by
ultrasound, color and power Doppler
studies.
All patients were recruited from
ultrasound scanned women with previous
CS

88. Materials
The exclusion criteria were:
1-Posterior placenta previa
2-Placental implantation away from the
scar
3- Diffuse PP accreta that either :
a-Wide area of accreta or
B-Deep penetration to the bladder

89. Setting
Damietta General Hospital
Damietta Specialized Hospital and
Dr. El.Sherbiny Hospital
Between April 2004 and December 2011.

90. Methods
After delivery of the fetus, the uterine
cavity was temporarily packed by
gauze
till prophylactic bilateral double
ligation of the uterine arteries is
performed, then the placenta was

91. Uterine cavity is
temporarily packed by
gauze

92. 1
2
Stepwise Uterine Devascularization
Prophylactic bilateral
double ligation of the
uterine arteries

93. Prophylactic bilateral
double ligation of the
uterine arteries

94. Stepwise Longitudinal Lateral Sutures
Anatomy: Branches of the uterine arteries pass transversely to
anastomose with the opposite side

95. Tow lines of longitudinal number 1 chromic
catgut sutures are taken through anterior and
posterior uterine wall perpendicular to the
vessels and 2 cm medial to the outer borders of
the lower uterine segment .
Stepwise Longitudinal Lateral Uterine
Sutures: First Step

96. Stepwise Longitudinal Lateral Uterine Sutures:
First Step
1
1

97. Stepwise Longitudinal Lateral Uterine
Sutures: Second Step
If still there is bleeding, other 2 medial similar
lines of number 1 catgut sutures are taken
leaving free central area.

98. 1
1
2 2
Stepwise Longitudinal Lateral Uterine Sutures:
First Step

103. Longitudinal lateral sutures
at the site of bleeding
suturing both uterine walls

105. R
E
S
U
L
T
S
E S U L T S

106. Suspected Focal PPA (n:13)
10 cases
evidence of
focal accreta
Double UAs Ligation
and removal of the Placenta
2 cases
No evidence of
accreta
1 cases
evidence of
Diffuse accreta
Treated
outside this
protocol by
leaving the
placenta in
situ &closing
the uterus
Compression
sutures protocol
All successful
1 cases
Bleeding
stopped
One cases
Need
Compress
-ion
sutures
protocol

107. Results
All 10 women with focal
accreta later resumed
normal menstrual flow.

108. Results
All of them underwent diagnostic
office hysteroscopy 2 months after the
surgery, nine of them showed normal
uterine cavity .
Only one had mild synechia and was
corrected in the same hysteroscopic
setting

109. Results
The mean surgical time was
50 minutes and
The mean transfused blood
volume was 750 mL.

111. Conclusion
Placental site bleeding due to adherent
focal placenta accreta can be safely
controlled by prophylactic double
bilateral uterine artery ligation
followed by stepwise vertical
compression sutures in women who
desire preservation of fertility.

112. Balloon Tamponade After CS
Balloon catheters have been used with
variable success to control bleeding
after CS delivery with :
 Placenta Previa Or
 Adherent Placenta
Frenzel et al ,Br J Obstet Gynaecol 2005;112: 7-676
Bakri et al . Int J Gynaecol Obstet 2001;74:139–42
Vitthala et al. Aust N Z J Obstet Gynaecol. 2009;49(2):191.
(Success R.: 56%)
Ishii et al , J. Obstet. Gynaecol. Res. January 2012 ,Vol. 38, No. 1: 102–107,

113. Inverted finger knotted glove

115. Inserting the end of the 2 catheters through the open
uterine incision to the cervix and then into the vagina

117. After closure, assistants infate the balloon with
sterile saline while inspecting the uterus from above

118. Diffuse
PP Accreta

119. Strong evidence of diffuse PP accreta
1 -T AH is recommended
2- ± Conservatism
(Placenta left "in situ")
Only if
 Hemodynamic stability
Normal coagulation
Strong desire for fertility
Accept the risks involved
No incision at the placental site (USCS)
No separate the placenta even if the uterus
is planned to be conserved ACOG Committee 7- 2012

120. 1-No further Treatment (Expectant)
2- Uterine artery embolization
3-Methotrexate therapy
4-Hemostatic sutures
5-Arterial ligation
6- Balloon tamponade
Placenta Left "in Situ “
What is the Further Treatment ?
UpTODate ,Resink, Aug 2013

121. Risks of Uterine Conservation With
the Placenta Left in Situ
UpTODate ,Resink, Aug 2013
 Severe vaginal bleeding: 53 %
 Sepsis: 6 %
 Secondary hysterectomy: 20% percent (range 6
to 31 %)
 Death: 0.3 % (range 0 to 4 %)
 Subsequent pregnancy: 67 % (range 15 to 73 %)

122. Cunningham et al, Williams Obstetrics, 23rd
edit. 2010
Elective Versus Emergency
Peripartum Hysterectomy
Complications Elective
(n=345)
Emergency
(n=644)
Transfusion 28% 83%
Urinary T.
injuries
1.8% 6.5%
Surgical
infection
21% 25%
Death 0% 1.4%
Briery (2007), Castaneda (2000), Glaze (2008), Kastner (2002), Kwee (2006),
Sakse (2008

123. Conservative management of
placenta accreta when the woman is
already bleeding is unlikely to be
successful and risks wasting
valuable time..
RCOG Green-top Guideline No. 27 2011
What Surgical Approach Should Be
Used For PPA Already in Bleeding?
GPP

124. Peripartum
Hysterectomy
Key Points

125. Peripartum Hysterectomy
Abnormal placentation is
the main indication for
peripartum
hysterectomy.
Glaze et al Obstet Gynecol. 2008 Mar; 111(3):732-8 ( 87 case 8 years Canadian)
LEVEL OF EVIDENCE: III.

126.  A vertical skin incision is optimal, Pfannenstiel
incision is not sufficient.
 Classical CS-Hysterectomy
 After delivery of the infant, the cord is cut,
the uterine incision is oversewn
circumferentially to decrease blood loss,
and hysterectomy is performed.
Hysterectomy: The Technique

127. Peripartum Hysterectomy
 The hysterectomy Should be Total
 It should be simple , rapid, with minimal dead
space and raw surfaces (fear of coagulopathy).
 Tow to three drainages

128. Inadequate exposure or traction may
lead to vascular or ureteral injury
Balfour abdominal retractor
Hysterectomy: The Technique

129. Hysterectomy: The Technique
 If the bladder does not dissected easily, it
should be opened at the dome. Palpation
and inspection of the posterior bladder
from the interior makes it easier to find
the dissection plane
 Consultation with a gynecologic oncologist
or urologist is warranted if the surgeon is
not familiar with bladder surgery.

130. Post Hysterectomy Bleeding
• Diffuse post hysterectomy bleeding may be controlled
by abdominal packing to allow time for normalization
of the woman’s haemodynamic and coagulation status.
(II-3)
• The pack composed of gauze in a sterile plastic bag
brought out through the vagina and placed under
tension. This pack is also known as a parachute,
mushroom, or umbrella pack.
S O G C C L I N I C A L P R AC T I C E G U I D E L I N E S 2000 II

131. Assembly of a pelvic pressure pack
to control hemorrhage. A sterile x-
ray cassette cover drape (plastic
bag) is filled with gauze rolls tied
end-to-end. The length of gauze is
then folded into a ball (A) and placed
within the cassette bag in such a
way that the gauze can be unwound
eventually with traction on the tail
(D). Intravenous tubing (E) is tied to
the exiting part of the neck (C) and
connected to a 1-liter bag (G). Once
in place, the gauze pack (A) fills the
pelvis to tamponade vessels and the
narrow upper neck (B) passes to exit
the vagina (C). The IV bag is
suspended off the foot of the bed to
sustain pressure of the gauze pack
on bleeding sites.

132. pelvic pressure pack, as constructed from an X-ray cassette drape, sterile
gauze rolls, and an intravenous infusion set-up

133. the pelvic pressure pack in situ

135. Thank You