O&G Update

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Primary Horizontal version

Techniques in the management of

postpartum haemorrhage

• •

– balloon tamponade and the brace suture

There is no clear evidence how long the balloon tamponade should be left in place. In most cases, 4 – 6 hours of tamponade should be adequate to achieve haemostasis and ideally, it should be removed during day time hours, in the presence of appropriate senior staff, should further intervention be required.

Background

Dr Jason Lim Registrar Dept of Obstetrics & Gynaecology

Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage which remains as one of the major causes of maternal death in both developed and developing countries. In the 2003 – 2005 report of the UK Confidential Enquiries into Maternal Deaths, haemorrhage was the third highest direct cause of maternal death (6.6 deaths/million maternities). These reports review all the maternal deaths in the UK over a three-year period or triennium. They are a useful resource for obstetricians in Singapore as the level of obstetric care in the UK is very similar to that of Singapore. In the 2003-2005 report, the majority of maternal deaths due to haemorrhage were considered preventable, with 10 out of 17 (58%) cases in the 2003 – 2005 triennium judged to have received ‘major substandard care’. Haemorrhage also emerges as the major cause of severe maternal morbidity in almost all ‘near miss’ audits in both developed and developing countries. Because of its importance as a leading cause of maternal mortality and moridity, effective management of obstetric haemorrhage especially postpartum haemorrhage must be considered a priority in the training of all obstetricians.

Management of Postpartum Haemorrhage The caveat to the management of PPH lies in both resuscitation and a well-rehearsed systematic approach. Several initial measures that can be adopted include the use of oxytocics, syntometrine, misoprostol, ergometrine, carboprost and bimanual uterine compression. If pharmacological measures fail to control the haemorrhage, one can initiate surgical haemostasis sooner rather than later. Intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage. If this fails to stop the bleeding, the following conservative surgical interventions may be attempted, depending on clinical circumstances and available: • • • • •

Below-mentioned is a suggested step-wise process of applying the 16 Fr Rusch Balloon catheter (Figure 1):

Vertical Version

Different Variations

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of balloon tamponade as a ‘test’, serves to affirm its place as first-line ‘surgical’ management.

• •

Over the past decade, various types of haemostatic compression sutures have been featured in different published case series. The best known type, described in 1997, requires hysterotomy for its insertion and is thus suitable when the uterus has already been opened at caesarean section. The procedure is named after Christopher B-Lynch, a UK obstetrician who devised this method. Observational data suggest that haemostatic suture techniques are effective in controlling severe PPH and in reducing the need for hysterectomy. The B-Lynch suture is technically easy to perform. The procedure can be completed in minutes. We often tell trainees that the procedure is akin to “applying a haversack or backpack to the body of the uterus” because this is what the uterus look like at the end of the procedure. It is our practice to iniially compress the uterus between the two hands of the surgeon to see if bleeding from the atonic uterus. This step, if successful, often predicts that the B-Lynch suture will work. The suture can then be applied with a good chance of success. Both the balloon tamponade with the Rusch balloon and B-Lynch suture have been used to good effect at SGH. They are replacing the traditional and more technically challenging procedures for atonic PPH such as internal iliac artery ligation and can be life-saving when faced with a case of massive PPH.

Pantone PMS 355C

The balloon tamponade intervention is sometimes described as the ‘tamponade test’. A ‘positive test’ (control of PPH following inflation of the balloon) indicates that laparotomy is not required, whereas a ‘negative test’ (continued PPH following inflation of the balloon) is an indication to proceed to laparotomy. The concept

• • •

A Quarterly CME Apr - Jun 2011

Figure 2. Illustration of the B-Lynch technique

In recent years, tamponade using various types of hydrostatic balloon catheter has superseded uterine packing for control of atonic PPH. Case series have used a Foley catheter, Bakri balloon, Sengstaken-Blakemore oesophageal catheter and a condom catheter. The urological Rusch balloon has been described as preferable by virtue of larger capacity, ease of use and low costs.

Ensure all equipment ready. Ensure good adequate lighting available. Position patient in lithotomy. Prepare approximately 1 L of warmed saline or water. An assistant uses lateral retractors to expose and identify cervical os. Apply sponge artery forceps to anterior lip of cervix. Use a pair of forceps to guide the 16 Fr Rusch Balloon catheter into the uterine cavity almost reaching the uterine fundus. Insufflate approximately 500mls to 750mls of warmed saline or water into the Rusch Balloon catheter to inflate the balloon within the uterine cavity. Do NOT pump any water into the catheter’s inner small balloon. Upon inflating the balloon with approximately 500mls to 750mls water, apply 2 cord clamps at the distal end of the Rusch Balloon catheter away from the introitus to secure the water within the balloon.

MICA (P) 116/05/2011

Haemostatic Compression Sutures (B-Lynch Sutures)

Haemostatic brace suturing (such as B-Lynch compression sutures) Bilateral ligation of uterine arteries Bilateral ligation of internal iliac arteries Selective arterial embolisation by an interventional radiologist Early recourse to hysterectomy

Balloon Tamponade

Observe for any further PPH. Insert an indwelling urinary catheter and vaginal pack to retain the Rusch balloon within the uterine cavity.

Head A/Prof Tan Hak Koon Senior Consultant Prof Charles Ng Prof Ho Tew Hong Dr Yu Su Ling A/Prof Tay Sun Kuie Dr Yong Tze Tein Dr Chua Hong Liang Dr Tan Lay Kok Dr Devendra K (Chief Editor, OGN) Dr Tan Poh Kok Consultant Dr Tan Wei Ching Dr Fong Kah Leng Dr Hemashree Rajesh Associate Consultant Dr Tan Eng Loy Dr Cindy Pang Dr Elisa Koh Registrar Dr Jason Lim Dr Renuka Devi Dr Ravichandran N

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Neonatal and Developmental Medicine Head

A/Prof Yeo Cheo Lian

Figure 1. Illustration of a Rusch Balloon Catheter

Senior Consultant Prof Ho Lai Yun A/Prof Daisy Chan (Advisor, OGN) Dr Lian Wee Bin Dr Selina Ho

Consultant Dr Varsha Atul Shah Dr Poon Woei Bing Registrar Dr Masitah Binte Ibrahim Dr Sridhar Arunachalam Staff Registrar Dr Imelda L. Ereno

Enuresis in children

CME Activities

Ovarian stimulation in ART Techniques in the management of

postpartum haemorrhage

• 4th Gynaecological & Early Pregnancy Ultrasound Workshop 24 Sept 2011 SGH PGMI.

– balloon tamponade and the brace suture

Services Antenatal Counselling for High Risk Pregnancy Neonatal Intensive Care Neonatal High-Dependency and Normal Nursery Neonatal Screening Child health Screening Ambulatory Paediiatrics Universal Hearing Screening Developmental Screening

DEPARTMENT OF OBSTETRICS & GYNAECOLOGY Tel: 6321 4667 / 6321 4668 / 6321 4651 & 6321 4675 Fax: 6225 3464 Obstetric Co-ordinator: 6326 5923 Endocrine / Climateric Co-ordinator: 6321 4330 Urogynaecology Co-ordinator: 6326 5929 Oncology Co-ordinator: 6436 8106

Appointment: 6321 4377 Centre for Assisted Reproduction (CARE): 6321 4292 Early Pregnancy Unit (EPU) Hotline: 6321 4516 Prenatal Diagnostic Centre (PDC): 6321 4516 http://www.sgh.com.sg


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