Postpartum haemorrhage by Dr Ravikanth G.O. Dept of OBG KVG Medical

Postpartum haemorrhage : 

Postpartum haemorrhage

Definition : 

Definition the mean blood loss with vaginaldelivery and caesarean section are 500 and 1000 ml respectively clinical definition of “need for blood transfusion clinical assessment that includes any amount of blood loss that threatens the woman’s hemodynamic stability. WHO PPH is generally defined as blood loss greater than or equal to 500 ml within 24 hours after birth, severe PPH is blood loss greater than or equal to 1000 ml within 24 hours

Epidemiology : 

Epidemiology Leading cause of MMR 25% of MMR in India One of the Millennium Development Goals set by the United Nations in 2000 is to reduce maternal mortality by three-quarters by 2015.

classification : 

classification Primary PPH(early)occur in the first 24 hours following delivery Third stage bleeding True PPH secondary PPH (late) occurring between 24 hours and 12 weeks postnatal

Etiology : 

Etiology Abnormalities of uterine contraction - over distended uterus – polyhydramnios multiple gestation - macrosomia uterine muscle exhaustion - precipitate labour - prolonged labour - high parity intra amniotic infection - fever - prolonged ROM functional/anatomic distortion of the uterus – fibroid uterus - placenta previa - uterine anomalies

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Retained Products of conception - retained cotyledon or succinturiate lobe - high parity retained blood clots

Genital Tract Trauma : 

Genital Tract Trauma lacerations of the cervix, - precipitous delivery Trauma to vagina or perineum - operative delivery extensions of incison - malposition deep engagement - uterine rupture - previous uterine surgery - uterine inversion - high parity - fundal placenta

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uterine inversion - high parity - fundal placenta

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Abnormalities of Coagulation - pre-existing states - hx of hereditary coagulopathies hemophilia A hx of liver disease - von Willebrand’s Disease - ITP - bruising - thrombocytopenia with pre-eclampsia - elevated BP - DIC - fetal demise - dead fetus in utero - antepartum hemorrhage - severe infection - sudden collapse - abruption - amniotic fluid embolus - therapeutic anti-coagulation - hx of blood clot

Pathophysiology : 

Pathophysiology Placental circulation at term 600ml/min 120 spiral artery&vein Haemostasis myometrial contraction & thrombosis Blood loss can be steady/fast Clinical symptoms ∞prepregnant state Normal HT preeclamptic normotensive

Pathophysiology : 

Pathophysiology Early –decrease in MAP stroke volume central venous pressure -increase in A-V Po2 sympathetic discharge ( (venocostriction) Late- >25%volume deficit increase in maldistribution of blood vasoconstriction-iscehamia&DIC vascular permiability

CLINICAL FINDINGS IN PPH : 

CLINICAL FINDINGS IN PPH Degree of Shock Compensation Blood loss 500-1000 ml 10-15% no symptoms/signs Blood Pressure normal

Mild : 

Mild ml 1000-1500 ml 15-25% palpitation slight fall (80-100mmHg) Pulse 100-120/min Urine output > 30ml

Moderate blood loss : 

Moderate blood loss 30-40%blood loss 1500-2000ml Confused Pulse 120-140 BP-70-80mmHg RR-30-40/min Urine out put 5-15ml/hr

Severe blood loss : 

Severe blood loss >40%blood loss >2000ml Lethargic Pulse >140/min or not recordable BP <70mmHg or not recordable Urine output <5ml/hr

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Routine prophylaxis of PPH

High Risk Factor(Approximate odds ratio) for PPH : 

High Risk Factor(Approximate odds ratio) for PPH Risk factor before onset of labour • Proven abruptio placentae 13 • Known placenta praevia 12 • Multiple pregnancy 5 • Pre-eclampsia/gestational hypertension 4

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Nulliparity 3 • Previous PPH 3 • Asian ethnicity 2 • Obesity 2

Treatment with Anticoagulant Drugs : 

Treatment with Anticoagulant Drugs Unfractionated Heparin (UH) Low Molecular Weight Heparin (LMWH) as enoxaparin (Clexane) or dalteparin (Fragmin) of increased risk of thromboembolism may be receiving aspirin (75 mg daily) antenatally warfarin

Risk Factors Becoming Apparent During Labour/Delivery : 

Risk Factors Becoming Apparent During Labour/Delivery Delivery by emergency Caesarean section 9 • Delivery by elective Caesarean section 4 • Retained placenta 5 • Operative vaginal delivery 2 • Prolonged labour (>12 hours) 2 • Big baby (>4 kg) 2 • Pyrexia in labour 2

Special condition : 

Special condition factor VIII deficiency (haemophilia A carrier) factor IX deficiency (haemophilia B carrier) and Von Willebrand’s disease

Routine prevention : 

Routine prevention Correction of anemia during ANC Institutional delivery Prevention of prolonged labour Prevention of infection Adequate hydration during delivery Active management of labour

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Once PPH has been identified, ◊ Communication ◊ Resuscitation ◊ Monitoring and Investigation ◊ Arresting the Bleeding

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- Uterine massage  I.V. fluids Empty bladder Oxytoxic Agents Methergine 0.2mg Carboprost 250μg Cytotec 800-1000μg Significant PPH  Hemostasis vaginal tear /cervical tear /pelvic hematoma  Hemostasis Surgery/Embolization

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Drug doses for management of PPH Oxytocin Dose and route IV: Infuse 20 units in 1 l IV fluids at 60 drops per Minute Continuing dose IV: Infuse 20 units in 1 l IV fluids at 40 drops/min Maximum dose Not more than 3 l of IV fluids containing

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Ergometrine IM or IV (slowly): 0.2 mg IM: 0.25 mg Repeat 0.2 mg IM after 15 minutes If required, give 0.2 mg IM or IV (slowly every 4 hours Max 5 dose

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15-Methyl prostaglandin F2a 0.25 mg i.m. every15 minutes Max of 8 doses

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Do not give oxytocin as an IV Bolus Do not give prostaglandin in Pre-eclampsia, hypertension, heartdisease Asthma Prostaglandin F2a should not be given intravenously. It may be fatal.

Birth Trauma: Hematomas : 

Birth Trauma: Hematomas Hematomas less than 3cm in diameter can be observed expectantly. If larger, incision and evacuation of clot is necessary. Irrigate and ligate bleeding vessels. With diffuse oozing, perform layered closure to eliminate dead space. Consider prophylactic antibiotics.

Cervical Laceration : 

Cervical Laceration Begin repair at apex

Repair of cervical laceration : 

Repair of cervical laceration

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◊ If bleeding is unrelenting and results of coagulation studies are still unavailable: ∗ Give 1 litre Fresh Frozen Plasma ∗ Give 10 units cryoprecipitate empirically ◊ Use the best equipment available to achieve RAPID WARMED infusion of fluids ◊ Do not use special blood filters: they slow infusions ◊ Dextrans are hazardous and should not be used in obstetric practice.

major PPH, blood loss >1000 mls OR clinical shock) : 

major PPH, blood loss >1000 mls OR clinical shock) ◊ IV access (14 G cannula x 2) ◊ head down tilt ◊ oxygen by mask at 8 litres / min ◊ Transfuse blood ASAP Until blood available, infuse in turn (as rapidly, as required): ∗ crystalloid (eg Hartmann’s) maximum 2 litres ∗ colloid (eg Gelofusine, Haemaccel, human albumin 4.5%) maximum 1.5 litres ◊ If X-matched blood still unavailable once 3.5 litres of crystalloid/colloid infused: ∗ GIVE ‘O’ NEG BLOOD OR ∗ GIVE Un X-matched, own group blood as available

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Gentle uterine curette Local matress sutures Hemostatic baloons U.A.E. Conserv Rx of Pl accreta  TAH Uterine packing Uterina a. ligation Stepwize devascularization Internal iliac artery ligation B-Lynch brace procedure Uterine repair U.A.E.  TAH Significant PPH Ut Atony/Tears/rupture of uterus/hematoma Pl previa/accreta/retaned prouducts of conception Failed Medical Rx

Pelvic Hematoma : 

Pelvic Hematoma

Vulvar hematoma : 

Vulvar hematoma

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Cesarean hysterectomy

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Post hysterectomy

Removal of retained Placenta : 

Removal of retained Placenta Oxytocin 10U in 20cc of NS placed in clamped umbilical vein. If this fails, get OB assistance. Check Hct, type & cross 2-4 u. Two large bore IVs. Anesthesia support.

Removal of Abnormal Placenta : 

Removal of Abnormal Placenta Relax uterus with halothane general anesthetic and subcutaneous terbutaline. Bleeding will increase dramatically. With fingertips, identify cleavage plane between placenta and uterus. Keep placenta intact. Remove all of the placenta.

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MROP

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Biochemical markers - Placenta previa - Previous C/S - Adv maternal age  Sonographic markers Clinical Risk Factors  Suspect Placenta accreta Placenta acreata

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Attempt Placental removal  Hemorrhage Cesarean Section -Local sutures Uterine artery ligation Embolization TAH Classic management

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- Significant blood loss - MOF (ARDS, DIC, ARF ) Injury to other organs -Bladder, Urether Need for Hysterectomy Classic management

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- Placenta Accreta - Conservative approach Amnio at 37wks gestation for FLM Day of C/S catheters are placed in the abd. aorta Intraop : - Sono maps the position of the Placenta -Uterine incision just above placental edge (High transverse incision)

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- Placenta Accreta - Selective embolization of the uterine arteries under fluoroscopic guidance (20-25 min) Delivery of infant: - Leave placenta intact - Insure hemostasis of uterine incision Conservative approach

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2 wks P-Partum

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6mo PP

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Intraoperative management 1.-Map exact position of placenta  Make high transverse uterine incision to avoid cutting through placenta 2.- Deliver fetus  Rapid hemostasis of uterine incision (clamps, sutures) TAH Dg uncertain Avoid TAH Definitive Rx UAE Remove pl Leave Pl in situ UAE Do not remove pl -Placenta Accreta -

-Placenta Accreta - : 

-Placenta Accreta - Wants to avoid TAH (religious/cultural) Desires subsequent pregnancies Significant Bladder involvment Tolerates poorly large hemodynamic shifts (IHSS, Eisenmenger syndrome etc) Conservative approach

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Follow-up management 1.- Ultrasound exams  Vascularity 2.- HCG titers (If  consider Mtx) 3. Daily Temps, Other S&S of infection 4.- Bleeding 5.- Coagulation profile -Placenta Accreta -

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UTERINE INVERSION

Uterine Inversion : 

Uterine Inversion Push center of uterus with three fingers into abdominal cavity. Need to replace the uterus before cervical contraction ring develops. Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage. When completed, treat uterine atony.

Uterine Rupture : 

Uterine Rupture Rare: 0.04% of deliveries. Risk factors include: Prior C/S: up to 1.7% of these deliveries. Prior uterine surgery. Hyperstimulation with oxytocin/prostaglandin Trauma. Parity > 4.

Uterine Rupture after delivery : 

Uterine Rupture after delivery Vaginal bleeding. Abdominal tenderness. Maternal tachycardia.. Cessation of uterine contraction Hypotension more than expected with apparent blood loss.

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WHO recommendations for management of PPH

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Should blood loss be routinely quantified during management of the third stage of labour for the purpose of diag nosing PPH? Which uterotonics should be offered in the management of PPH due to uterine atony? Oxytocin carbetocin ergometrine synometrine 15methyl carboprost F2alpha misoprostal sulprostone

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Should misoprostol be offered in the management of PPH due to uterine atony? Should tranexamic acid be offered in the treatment of PPH due to uterine atony? Should recombinant factor VIIa be offered in the treatment of PPH due to uterine atony? Should uterine massage be offered in the treatment of PPH?

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Should bimanual uterine compression be offered in the treatment of PPH? Should uterine packing be offered in the treatment of PPH? Should intrauterine balloon or condom tamponade be offered in the treatment of PPH? Should external aortic compression be offered in the treatment of PPH?

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Should nonpneumatic antishock garments be offered in the treatment of PPH? Should uterine artery embolization be offered in the treatment of PPH? Surgical interventions in the treatment of PPH Should uterotonics be offered as treatment for retained placenta?

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Should intra-umbilical vein injection of oxytocin with or without saline be offered as treatment for retained placenta? Should antibiotics be offered after manual extraction of the placenta as part of the treatment of retained placenta? Should crystalloids be offered for fluid replacement in women with PPH?

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Should health care facilities have a protocol for management of PPH? Should health care facilities have a formal protocol for referral of women diagnosed as having PPH? Should simulation of PPH treatment be part of training programmes for health care providers?