SURGICAL MANAGEMENT OF PPH

B.Hemanath

SURGICAL ANATOMY OF UTERUS

It is the final method when all the other methods fail to

control post partum haemorrhage

It includes two steps,

Devascularisation procedure

• a. Ligation of uterine arteries

• b. Ligation of ovarian and ut. artery anastomosis

• c. Ligation of ant. div. of int. iliac artery

• d. B- Lynch compression suture and multiple square sutures

• e. Angiographic arterial embolisation

Hysterectomy

1. Devascularisation procedure :

A. Ligation of ut. arteries;

Ascending branch of uterine artery ligated b/n upper and lower uterine segment.

No.1. chromic catgut is used.

If bleeding continues.

B. Ligation of ovarian & uterine artery anastamosis:

Done just below the ovarian ligament.

Some times, temporary occlusion of ovarian vessels at infundibulopelvic ligament is done by rubber sleeved clamps.

Ligation of uterine artery and utero-ovarian artery

C. Ligation of anterior division of internal iliac artery.

Done unilaterally or bilaterally.

Bilateral ligation avoids hysterectomy in 50% of

the cases.

D. B-Lynch compression sutures &

multiple square sutures

Developed by Christopher B-Lynch.

Used to mechanically compress an atonic uterus in the face of severe PPH.

Success rate is about 80% and can avoid hysterectomy.

B-LYNCH SUTURE

E. Angiographic arterial embolisation.

Done to bleeding vessel under fluoroscopy.

Gel foam is used as embolus.

Success rate >90% & it avoids hysterectomy.

Continuous observation of patient in ICU/ high

dependency unit.

After this procedure, if bleeding is controlled,

2.Hysterectomy – Final most step.

Rarely indicated.

Only if uterus fails to contract & bleeding

continues.

If mother is parous, decision is taken earlier.

It may be total or subtotal depending on the case.

Examination per speculum, is

done under good light.

Identify trauma to perineum,

vagina, cervix.

Hemostasis achieved by appropriate

catgut sutures.

For traumatic PPH