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Click to edit Master title style • Click to edit Master text styles – Second level • Third level – Fourth level Replacing Blood and Performing Surgery Replacing Blood and Performing Surgery » Fifth level with the NASG in Place with the NASG in Place Farouk Jega, MD Program Manager, CC ‐ PPH Project Pathfinder International, Nigeria 1/24/2011 1

Introduction Introduction Click to edit Master title style • The Non ‐ Pneumatic Anti ‐ Shock Garment (NASG) is NOT • Click to edit Master text styles definitive treatment for PPH. – Second level • The NASG helps the clinician to stabilize the patient in shock, • Third level while awaiting definitive treatment or transfer. – Fourth level » Fifth level • In most instances, further treatment (intravenous fluid infusions, blood transfusion, uterotonics, surgery) is required. 1/24/2011 2

Blood Transfusion with the NASG Blood Transfusion with the NASG Click to edit Master title style • Immediate priority is to expand blood volume with crystalloids. • Click to edit Master text styles – Second level • Appropriate IV infusions are also not • Third level always available at public health facilities. – Fourth level » Fifth level • Blood transfusion a must in severe PPH; most women die from delay/not receiving blood transfusion at all following PPH. • Unfortunately, availability of safe blood for transfusion still an issue in most intervention health facilities. 1/24/2011 3

Uterotonics for Treatment of Atonic PPH Uterotonics for Treatment of Atonic PPH Click to edit Master title style • Oxytocin, ergometrine, misoprostol • Click to edit Master text styles • All relatively cheap – Second level • Third level • Not always available – Fourth level • Issues with storage (temperature, light), resulting in instability » Fifth level • Some resistance with use of misoprostol as an abortifacient drug • Procurement logistics also an issue 1/24/2011 4

Blood and Blood Products in PPH Blood and Blood Products in PPH Click to edit Master title style • Essential for the management of PPH. • Click to edit Master text styles • Unfortunately not always available even in – Second level so ‐ called Comprehensive Essential Obstetric Care (CEOC) facilities. • Third level – Fourth level • The National Blood Transfusion Service takes the lead in securing safe blood in public health facilities in the country; grossly under ‐ » Fifth level funded. • Problems with power supply for storage, apathy of potential blood donors, and screening. • Most blood banks operate a replacement policy; source usually paid donors and patients’ relatives. 1/24/2011 5

Our Solution: Our Solution: Click to edit Master title style Solar Blood Banks and ‘ ‘Emergency Blood Emergency Blood’ ’ Solar Blood Banks and • Click to edit Master text styles • 5 ‐ 10 pints of blood secured and saved for obstetric emergencies (collaboration between maternity unit and blood – Second level bank) • Third level – Fourth level • Challenges still with replenishing used up blood » Fifth level • Solar blood bank set up with Cloverleaf funding • Community being mobilized to donate blood voluntarily as part of community component of the project 1/24/2011 6

Surgery with the NASG Surgery with the NASG Click to edit Master title style • Different types of surgery possible with the NASG: – Vaginal route • Click to edit Master text styles • Manual removal of placenta – Second level • Evacuation of retained products of conception • Third level • Repair of lacerations – Fourth level » Fifth level – Abdominal • Caesarean section • Laparotomy • Uterine devascularization procedures • Hysterectomy 1/24/2011 7

Uterine Compression Sutures Uterine Compression Sutures Click to edit Master title style • Conservative surgical intervention for atonic PPH • Click to edit Master text styles • Easier than emergency hysterectomy and devascularization – Second level procedures • Third level – Fourth level • Different types described: Hayman; Cho multiple square » Fifth level sutures; B ‐ Lynch sutures • Same principle: the suture aims to exert continuous vertical compression on the uterine vascular system 1/24/2011 8

B ‐ ‐ Lynch Sutures Lynch Sutures B Click to edit Master title style • Also called brace sutures • Click to edit Master text styles – Second level • First applied for a patient with massive hemorrhage who refused consent for hysterectomy (November 1989) • Third level – Fourth level » Fifth level • Slight modification of the other compression sutures with many advantages 1/24/2011 9

Anterior and Posterior Suture Placement Anterior and Posterior Suture Placement Click to edit Master title style • Click to edit Master text styles – Second level • Third level – Fourth level » Fifth level 1/24/2011 10

Anterior and Posterior Suture Placement Anterior and Posterior Suture Placement Click to edit Master title style Repeat the same procedure posteriorly as before with assistant maintaining compression • Click to edit Master text styles – Second level • Third level – Fourth level » Fifth level 1/24/2011 11 More details including video available at www.glowm.com

Postoperative Follow ‐ ‐ up up Postoperative Follow Click to edit Master title style • No major complications nor mortality reported • Click to edit Master text styles – Second level • MRI showed no intraperitoneal or intrauterine sequelae • Third level – Fourth level » Fifth level • Most have had successful future pregnancies and deliveries 1/24/2011 12

B ‐ ‐ Lynch Suture: Clinical Points Lynch Suture: Clinical Points B Click to edit Master title style • Basic surgical competence required • Click to edit Master text styles • Bimanual compression first to test potential efficacy – Second level • Simple and cost ‐ effective • Third level – Fourth level • Future fertility preserved » Fifth level • Potential for prophylactic application at Caesarean section • Relatively new procedure so not all providers comfortable with technique • Hard to get the opportunity to train surgeons 1/24/2011 13

Conclusion Conclusion Click to edit Master title style • The B ‐ Lynch procedure has been recommended by the 2000 ‐ 2002 Triennial Confidential Enquiry into Maternal Deaths and • Click to edit Master text styles the RCOG in the UK and the Cochrane Database of Systematic – Second level Reviews. • Third level • To date, no serious complications have been reported. – Fourth level » Fifth level • Procedure is simple, safe and effective in arresting hemorrhage due to uterine atony. • Particularly useful in our setting where women want to keep their uteri to maintain fertility and menstruation for religious and cultural reasons. 1/24/2011 14

Conclusion, cont’ ’d d Conclusion, cont Click to edit Master title style • Click to edit Master text styles • The NASG is not the definitive treatment for the NASG. We have found that blood replacement and performing surgery – Second level are the most difficult elements of the Clinical and Community • Third level Action Model to put in place. – Fourth level » Fifth level 1/24/2011 15