ALTERNATIVE METHODS
FOR MANAGEMENT OF
ATONIC POSTPARTUM
HAEMORRHAGE
DR. MURWAN IBRAHIM OMER
DGO, MOG, ABOG, FRCOG, FICS
Consultant Obstetrician and Gynaecologist
Can we change our practice to
improve outcome of PPH?

When conventional methods fail to control
atonic PPH, there are interventions which
are being ignored that should be considered
before opting for major surgical procedures.
Postpartum Haemorrhage

Is a leading cause of maternal mortality and
morbidity.
Too Little (IV fluids, oxytocics, BLOOD, Clotting
factors)
Too Late (resuscitation - blood replacement,
misopristol decision for surgery + to get senior
surgeon & anaesthetist involved)
PPH
Anticipate - high risk cases (e.g. twins,
polyhydramnios, prolonged labour, fibroids, APH,
infection, past H/O PPH, retained tissue etc.)
Prevent - Prophylactic Oxytocics (e.g.
Syntometrine, syntocinon, ergometrine, misoprostol)
Manage - Promptly - 90% uterine
atony - 8% trauma and 2% coagulation
disorders
FIGO/ ICM STATEMENT ON AMTSL + WHO+ COCHRANE
Guidelines
by the Scottish Executive
Committee of the RCOG
COMMUNICATE.
 RESUSCITATE.
 MONITOR / INVESTIGATE
 STOP THE BLEEDING

STOP THE BLEEDING





Uterine compression
IV syntocinon 10 units
IV ergometrine 500 mg
Syntocinon infusion (30 units in 500 ml)
Surgery / Hysterectomy
Misoprostol/ Intrauterine pack / Intrauterine
balloon / Compression Sutures
Misoprostol
Synthetic analog of prostaglandin E1
• Shelf life of several years if kept in their packets
• Low cost
• Can be administered orally, rectally, vaginally and by
sublingual route
• Being selective for the PGE1 receptors: Hence fewer
systemic side-effects
Misoprostol could play an important
role in saving lives of thousands of
women, particularly in low-resource
settings
A study in Pakistan on the outcome of Utero-vaginal
Packaging in Primary Postpartum Hemorrhage
on 34 patients
100
80
60
40
20
91.2%
8.8%
0
Success Rate
Failure Rate
Pelvic infection was seen in 5 cases i.e., 14.7% (but pre- existing risk factors
for infection such as prolonged rupture of membranes, obstructed labour and
home delivery were present in all these cases)
TAMPONADE TEST
Therapeutic & Prognostic
For severe PPH
Oesophageal
balloon
Stomach balloon
The “Tamponade Test”
90
80
70
60
50
40
30
20
10
87.5%
12.5%
0
Success Rate
Failure Rate
Condous G, Arulkumaran S et.al.
Obstetrics & Gynecology. 2003
St George’s Series
18.5%
81.5%
Success Rate
Failure Rate
 27 consecutive cases of Sengstaken – Blakemore
Esophageal catheter tamponade
 Bleeding arrested in 22 cases
 Tamponade failed in 5 cases. Of them:
4 underwent a subtotal hysterectomy
1 was managed with Haemabate and Misoprostol
(concomitant use)
Doumouchtsis S, Papageorghiou A, Arulkumaran
S. Acta Scand 2008
 The
Sengstaken-Blakemore
oesophageal catheter
 The
main disadvantage is that it
is not purpose-designed for PPH.
 Therefore,
it may not easily adapt
to the shape of the uterine cavity.

“Women are not dying because of
diseases we cannot treat. They are dying
because societies have yet to make the
decision that their lives are worth
saving.”

Mahmoud Fathalla,MD, PhD, 1997
Uterine balloon tamponade
Authors
Year
Type of study
Method
No of
women
Success Rates
Goldrath
1983
Case series
Foley catheter
20
19/20 (95%)
Bakri et al
2001
Case series
Silicone Balloon
5
3*/5 (60%)
Condous et al
2003
Case series
Sengstaken -Blakemore
16
14/16 87.50%
Akhter et al
2003
Case series
Condom
23
23/23 (100%)
Penney et al
(Scottish
Audit)****
2003
Audit
Balloon
6
5/6 (83.3%)
Penney et al
(Scottish
Audit)****
2004
Audit
Balloon
21
15/21 (71.4%)
Seror et al
2005
Case series
Sengstaken -Blakemore
17
12/17 (70.6%)
St George’s
current series
2006
Case series
Sengstaken -Blakemore
27
22/27 (81.5%)
135
83.7%
Total
COMPRESSION SUTURES
Quick, safe and effective
B-Lynch
Modified B-Lynch sutures
Combination of sutures
Comparison between Original method & its
modification
B- Lynch brace suture.
Modified B-Lynch brace suture.
1. Requires expertise.
1. Easy to perform.
2. Transverse LUS incision
required.
3. Time consuming.
2. LUS incision not required.
4. Cervical stenosis.
3. Less time consuming (can be
completed in 2-3 min).
4. No cervical stenosis
5. Haematometra
5. No Haematometra formation.
formation.
6. Bleeding from LUS due to 6. No bleeding from LUS.
multiple bites.
B-Lynch or Compression sutures
Authors
Year
Type of
study
Method
B-Lynch et al
1997
Case series
B-Lynch
Cho et al
2000
Case series
Square sutures
Pal et al
2003
Case series
Smith et al
2003
Penney et al (Scottish
Audit)
No of
women
Success Rates
5
5/5 (100%)
23
23/23 (100%)
B-Lynch
6
6/6 (100%)
Case series
B-Lynch
7
6/7 (85.7%)
2003
Audit***
B-Lynch
10
9/10 (90%)
Penney at al (Scottish
Audit)
2004
Audit***
B-Lynch
19
13/19 (68.4%)
Wohlmuth et al
2005
Case series
B-Lynch
12
11/12 (91.6%)
Pereira et al
2005
Case series
Compressive
sutures
7
7/7 (100%)
Nelson et al
2006
Case series
Modified BLynch sutures
5
5/5 (100%)
94
85/94 (90.4 %)
Total
Conservative Treatment for PPH
Method
No of Cases
Success rates
B-Lynch + other
Compression sutures
94
90.4%
Arterial embolization
218
91%
Arterial ligation
264
83.7%
Uterine balloon
tamponade
135
83.7%
Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007
“It is not the strongest of the
species that survives, nor the
most intelligent, but the one
most responding to change.”
Charles Darwin
No of Deliveries
35000
30000
25000
20000
15000
10000
5000
0
09
20
07
20
05
20
03
20
01
20
99
19
97
19
95
19
93
19
91
19
89
19
87
19
85
19
83
19
81
19
79
19
77
19
75
19
20
09
20
07
20
05
20
03
20
01
19
99
19
97
19
95
19
93
19
91
19
89
19
87
19
85
19
83
19
81
19
79
19
77
19
75
Maternal Mortality Rate
800
700
600
500
400
300
200
100
0
Conclusion


When conservative measures fail to control
bleeding in post partum haemorrhage,
uterovaginal packing, internal uterine tamponade
and B-lynch sutures can be used before resorting
to hysterectomy. These uterine preserving
methods have been used in various countries
and have proven to be effective, with minimal
maternal morbidity.
They are feasible in this country and should be
considered by Obstetricians when managing
PPH. However, they require training and
experience.
Emergency Trolley
Emergency protocols
GENERAL MANAGEMENT
Endotracheal tube
Laryngoscope
Essential drugs
Crystalloids, giving sets, haemacel