Transcript Uterine rupture

Petr Krepelka, 2013
Hemorrhage is the underlying
causative factor in at least
25% of maternal deaths
in deveveloped and developing
countries
CR
22,4%
PPH
23%
Others
31%
Infections
4%
Preeclampsia
6%
Cardiopathy
16%
DVT-PE
20%
SRB,B.,VELEBIL,P. Analysis of maternal mortality in Czech republic
2000. Česká gynekologie, 2002, 9, p.268-74.
Maternal physiology is well
prepared for hemorrhage
• Increase in blood volume
• Plasma
• RBC
• Hypercoagulable state
• Increase in plasmatic concentration of coagulating
factors
• The “tourniquet” effect of uterine contractions
Blood supply to the pelvis
• Internal iliac (hypogastric) arteries
• Ovarian arteries
are the main vascular supply to the pelvis
connected in a continuous arcade on the
lateral borders of the vagina, uterus, and
adnexa.
Blood supply to the pelvis
The ovarian arteries :
•
direct branches of the aorta beneath the renal
arteries. They traverse bilaterally and
retroperitoneally to enter the
infundibulopelvic ligaments.
Blood supply to the pelvis
The internal iliac arteries:
•
retroperitoneally posterior to the ureter
it divides into an anterior and posterior
divisions.
The internal iliac arteries
Anterior division
5 visceral branches
• Uterine
• Superior vesical
• Middle rectal
• Inferior rectal
• Vaginal
3 parietal branches
• Obturator
• Inferior gluteal
• Internal pudendal
The internal iliac arteries
Posterior division
 Important collateral to the pelvis.
• Iliolumbar
• Lateral sacral
• Superior gluteal
Definition of PPH
• Blood loss 24 hours after birth
– >500 ml- vaginal delievery
– >1000 ml - S.C.
– Bleeding
• continues
• repeats
• destabilizes blood circulation or haemocoagulation
Etiology of PPH
The causes of postpartum hemorrhage can be
thought of as the four Ts:
Tone
Tissue
Trauma
Thrombin
Etiology of PPH
Uterine atony
Multiple gestation
High parity
Prolonged labor
Chorioamnionitis
Augmented labor
 Tocolytic agents
Etiology of PPH
Retained uterine
contents
Products of conception
Blood clots
Etiology of PPH
Placental abnormalities
Congenital
Location
Bicornuate
uterus
Placenta previa
Attachment
Accreta
Increta
Percreta
Acquired
structural
Leiomyoma
Previous
surgery
Peripartum
Uterine inversion
Uterine rupture
Placental abruption
Etiology of PPH
Lacerations and trauma
Planned
•Cesarean section
•Episiotomy
Unplanned
•Vaginal/cervical tear
•Surgical trauma
Etiology of PPH
Coagulation disorders
Congenital
Acquired
DIC
Von Willebrand's disease
Dilutional coagulopathy
Heparin
Women in whom these factors have been
identified should be advised to deliver in a
specialist obstetric unit
Risk Factor
odds ratio
for PPH
•Proven abruptio placentae
13
•Known placenta praevia
12
•Multiple pregnancy
5
•Pre-eclampsia/gestational hypertension
4
The following factors, becoming apparent labour
are associated with an increased risk of PPH.
Risk factor
•Delivery by emergency Caesarean section
•Delivery by elective Caesarean section
•Retained placenta
•Mediolateral episiotomy
•Operative vaginal delivery
•Prolonged labour (>12 hours)
•Big baby (>4 kg)
odds ratio for
PPH
9
4
5
5
2
2
2
Prophylactic oxytocics
should be offered routinely in
the management of the third
stage of labour as they
reduce the risk of PPH by
about 60%.
Antenatal assessment
history
The existence of some of the obstetric
risk factors may be known early in
pregnancy from and examination.
Antenatal assessment
anemia
Detection of more than physiologic
anemia of pregnancy is important,
because anemia at delivery increases
the likelihood of a woman requiring
blood transfusion.
Antenatal assessment
Coagulation studies
May be required in the
presence of congenital or
acquired coagulation defects
Antenatal assessment
Imaging investigations
… are useful in the detection of
placental abnormalities, with
placenta previa and placenta accreta
the most important identifiable risk
factors for massive hemorrhage
Antenatal assessment
Imaging investigations
Conventional gray-scale assessment has a
sensitivity of 93%, a specificity of 79%,
and a positive predictive value of 78% in
the diagnosis of placenta accreta when
previa and previous cesarean scar are
present.
Finberg HJ, Williams JW. Placenta accreta: prospective sonographic diagnosis in patients
with placenta previa and prior cesarean section. J Ultrasound Med 1992;11:333-43.
Antenatal assessment
Imaging investigations
Certain characteristics, such as the ”Swiss
cheese appearance” with placenta previa,
are associated with a threefold increase in
mean blood loss during cesarean section.
Guy GP, Peisner DB, Timor-Tritsch IE. Ultrasonographic evaluation of
uteroplacental blood flow patterns of abnormally located and adherent
placenta. Am J Obstet Gynecol 1990;163:723-7.
Antenatal assessment
Imaging investigations
Colour Doppler may increase the specificity to
96%, which gives a positive predictive value in
high-risk patients of 87% and a negative
predictive value of 95% and allows better
assessment of the depth of placental myometrial
or serosal invasion.
Chou MM, Ho ESC, Lee YH. Prenatal diagnosis of placenta previa
accreta by transabdominal color Doppler ultrasound. Ultrasound
Obstet Gynecol 2000;15:28-35.
Antenatal assessment
Imaging investigations
Further imaging by MRI is
recommended to assess bladder
involvement in percreta and assess
high-risk cases.
Thorp Jr. JM, Councell RB, Sandridge DA, et al. Antepartum diagnosis
of placenta previa percreta by magnetic resonance imaging. Obstet
Gynecol 1992;80:506-8.
• loss of the hypoechogenic retroplacental zone
• irregular uterine serosa
• high vascularisation between myometrium and placenta
• intraplacental lacunae
• thinning of uterine wall
Guidelines
by the Scottish Executive
Committee of the RCOG
COMMUNICATE.
RESUSCITATE.
 MONITOR / INVESTIGATE.
STOP THE BLEEDING.
COMMUNICATE
call 6
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Call experienced midwife
Call experienced obstetrician
Call experienced anaesthesiologist
Alert haematologist
Alert Blood Transfusion Service
Call porters for delivery of specimens / blood
RESUSCITATE
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IV access with 14 G cannula
Head down tilt
Oxygen by mask, 8 litres / min
Transfuse
•Crystalloid (eg Hartmann’s)
•Colloid (eg Hemacel)
•once 3.5 litres infused, GIVE ‘O NEG’ If no crossmatched blood available OR give uncross-matched
own-group blood, as available
•Give up to 1 liter Fresh Frozen Plasma and 10 units
cryoprecipitate if clinically indicated
MONITOR / INVESTIGATE
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Cross-match 6 units
Full blood count
Clotting screen
Continuous pulse / BP /
ECG
Foley catheter: urine output
CVP monitoring
Discuss transfer to ICU
STOP THE BLEEDING
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Exclude causes of bleeding other than uterine atony
Ensure bladder empty
Uterine compression
IV syntocinon 10 units
IV ergometrine 500 mg
Syntocinon infusion (30 units in 500 ml)
IM Carboprost (500 mg)
Surgery earlier rather than late
Hysterctomy early rather than later
If conservative measures fail to control
haemorrhage, initiate surgical haemostasis
SOONER RATHER THAN LATER
I. Acute laparotomy, direct
intramyometrial injection of
Carboprost (Haemabate) 0.5mg
II. Bilateral ligation of uterine arteries
III. Bilateral ligation of internal iliac
(hypogastric) arteries
IV. Hysterectomy
Resort to hysterectomy
SOONER RATHER
THAN LATER
(especially in cases of placenta accreta or
uterine rupture)
HYSTERECTOMY
RATHER
SOONER THAN LATER
Uterine rupture
Placenta accreta
Whole blood frequently is used for rapid
correction of volume loss because of its
ready availability, but component
therapy is ideal. A general practice has
been to transfuse 1 unit of fresh-frozen
plasma for every 3 to 4 units of red cells
given to patients who are bleeding
profusely
Genital tract lacerations
Genital trauma always
must be eliminated first
if the uterus is firm.
Management of uterine atony
• Explore the uterine cavity.
• Inspect vagina and cervix for lacerations.
• If the cavity is empty, massage and give
methylergometrine 0.2 mg, the dose can be
repeated every 2 to 4 hours.
• Rectal 800mcg. Misoprostol is beneficial
(unfortunately is not accesible)
Management of uterine atony
During the administration of uterotonic agents,
bimanual compression may control hemorrhage.
The physician places his or her fist in the vagina
and presses on the anterior surface of the uterus
while an abdominal hand placed above the fundus
presses on the posterior wall. This while the
Blood for transfusion made available.
Retained placenta
Retained placental fragments are a leading cause
of early and delayed postpartum hemorrhage.
Treatment is manual removal, General anesthesia
with any volatile agent (1.5–2 minimum alveolar
concentration (MAC)) may be necessary for
uterine relaxation
On rare occasions, a retained placenta is an
undiagnosed placenta accreta, and massive
bleeding may occur during attempted manual
removal.
Placenta accreta
• Placenta accreta is defined as an abnormal
implantation of the placenta in the uterine wall,
of which there are three types:
(1) accreta vera, in which the placenta adheres to the
myometrium without invasion into the muscle.
(2) increta, in which it invades into the myometrium.
(3) percreta, in which it invades the full thickness of the
uterine wall and possibly other pelvic structures, most
frequently the bladder.
Placenta accreta
In a patient with a previous cesarean
section and a placenta previa:
Previous one has 14% risk of placenta accreta
Previous two has 24% risk of placenta accreta
Previous three has 44% risk of placenta accreta
Uterine rupture
Rupture of the uterus is described
as complete or incomplete and
should be differentiated from
dehiscence of a cesarean section
scar.
Uterine rupture
The reported incidence …
For all pregnancies is 0.05%
After one previous lower segment cesarean section 0.8%
After two previous lower segment cesarean section is 5%
All pregnancies following myomectomy may be complicated by
uterine rupture.
Uterine rupture
Complete rupture describes a
full-thickness defect of the
uterine wall and serosa
resulting in direct
communication between the
uterine cavity and the
peritoneal cavity.
Uterine rupture
Incomplete rupture describes a
defect of the uterine wall that is
contained by the visceral
peritoneum or broad ligament
in patients with prior cesarean
section.
Uterine rupture
Dehiscence describes partial
separation of the scar with
minimal bleeding, with the
peritoneum and fetal
membranes remaining intact.
Management of Rupture
Uterus
The identification or suspicion of uterine
rupture must be followed by an immediate
and simultaneous response from the
obstetric team.
Surgery should not be delayed owing to
hypovolemic shock because it may not be
easily reversible until the hemorrhage is
controlled.
Management of Rupture
Uterus
Upon entering the abdomen, aortic compression
can be applied to decrease bleeding.
 Oxytocin should be administered to effect
uterine contraction to assist in vessel
constriction and to decrease bleeding.
Hemostasis can then be achieved by ligation of
the hypogastric artery, uterine artery, or ovarian
arteries.
Management of Rupture
Uterus
 At this point, a decision must be made to perform
hysterectomy or to repair the rupture site. In most cases,
hysterectomy should be performed.
 In selected cases, repair of the rupture can be
attempted. When rupture occurs in the body of the
uterus,
 Bladder rupture must be ruled out by clearly mobilizing
and inspecting the bladder to ensure that it is intact.
This avoids injury on repair of the defect as well.
Management of Rupture
Uterus
A lower segment lateral rupture can cause
transection of the uterine vessels. The vessels
can retract toward the pelvic side wall, and the
site of bleeding must be isolated before placing
clamps to avoid injury to the ureter and iliac
vessels.
Typically, longitudinal tears, especially those in
a lateral position, should be treated by
hysterectomy, whereas low transverse tears may
be repaired.
Step by step devascularisation
Uterine Artery Ligation
Uterine artery ligation involves taking
large purchases through the uterine wall to
ligate the artery at the cervical isthmus
above the bladder flap .
Internal iliac artery ligation
The internal iliac artery is exposed by ligating and
cutting the round ligament and incising the pelvic
sidewall peritoneum cephalad, parallel to the
infundibulopelvic ligament The ureter should be
visualized and left attached to the medial
peritoneal reflection to prevent compromising its
blood supply.
Internal iliac artery ligation
The hypogastric artery should be completely
visualized. A blunt-tipped, right-angle clamp is
gently placed around the hypogastric artery, 2.5
to 3.0 cm distal to the bifurcation of the common
iliac artery. Passing the tips of the clamp from
lateral to medial under the artery is crucial in
preventing injuries to the underlying hypogastric
vein .
B-Lynch suture
Bleeding after hysterectomy
Abdominal pelvic pressure pack
Intraarterial therapeutic embolisation
• The first application - 1979
• Benefits
– Effectiveness 90%
– Identification of the bleeding source
– Distal vascular stop
• Disadvantage
– Time factor
– Technical and personal conditions
Odegaard,E.: Intractable postpartum haemorrhage treated with selective arterial
embolization.
Tidsskr Nor Laegeforen.2003,123,19,s.2715-6.
[email protected]