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Post Partum Hemorrhage Medical management
ByDr Nandini Joshi
MD, D.N.B.Assistant Professor
Dept of OBG, KAMS&RC08-07-2015
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OUTLINE INTRODUCTION INCIDENCE DEFINITION PHYSIOLOGY CLASSIFICATION ETIOLOGY RISK FACTORS PREVENTION MEDICAL MANAGEMENT
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Is Postpartum Hemorrhage a legacy of our Evolutionary
Past? PPH : “An Enigma” An unfortunate side effect for natural
selection for Larger brain The complimentary increase in neonatal
brain Extremely Invasive pattern of placenta
Second contributory factor “Bipedalism” resulting into narrow pelvis , more invasiveness of placenta and extreme remodelling of maternal vasculature
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PPH: Historical Aspects
Mughal Emperor Shah Jahan had 14 children with his wife, the Empress Mumtaz. In 1630, she died of postpartum hemorrhage.He ordered the building of the most beautiful tomb on Earth for her.
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The Swedish Approach
A different approach in the same century (17th century) in Sweden
Queen Ulrika Eleonora also lost people close to her in childbirth
She mandated one or two women from each town to come to Stockholm for midwifery training.
Maternal Mortality transformed
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Postpartum Hemorrhage Today: Living in the shadow of Taj Mahal
Most common Cause for MMR “PPH” (25%- 55%) Globally 1,40,000 women die every year due to PPH otherwise 1 mother dies every 4 minutes -ACOG practice Bulletin 2006
MMR in India (2011-2012) – 178/100000 live births
PPH accounts for 30% of MMR in India
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Incidence ~ 4.1% of all deliveries & Atonic PPH – 3.4% - BJOG 2012
One of the Millennium Development Goals(MDG -5 in 2000) was to reduce maternal mortality by 75% by 2015.
But so far only 45% reduction has been achieved
INCIDENCE
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DEFINITIONS An estimated blood loss of >
500 ml after vaginal delivery & > 1000 ml after cesarean section. . (Pritchart etal 1962)
A decline in hematocrit level of 10% (WHO1989)
Any amount of blood loss that threatens woman’s hemodynamic stability.
Massive PPH refers to a blood loss of >2000 ml or >30% of blood volume.
Pitfalls in definition :Arbitrary, subjective,& based on visual estimation (Underestimate actual blood loss)
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CLASSIFICATION OF PPH
PRIMARY PPH SECONDARY PPH
Occurring within 24 hrs of delivery
(4-6% of all deliveries)
Occurring after 24hrs to 6 wks postpartum
1-3 % of all deliveries Cochrane Database Sits Rev2002;(1), ACOG Practice Bulletin 2006
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Physiological Adaptations during
Pregnancy Maternal blood volume expands by 40% to 50%
during pregnancy. Blood flow to the gravid uterus at term is 650ml/min,
and large amounts of blood can be lost rapidly from placental bed in the absence of uterine tone
Living Ligature : Myometrial fibers in middle layer, run in criss-cross
manner and have double curvature Contraction of these fibers occludes large (spiral
arterioles) blood vessels that run between them.
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s
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ETIOLOGY OF PPH 4 ‘T’s TONE : Uterine atony (70%), Full Bladder
TISSUE: Retained tissue ,clots
TRAUMA: Uterine, cervical or vaginal laceration
THROMBIN: Coagulopathy (Pre-existing / Aquired)
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ETIOLOGY OF PPHPRIMARY PPH SECONDARY PPH
Uterine atony (80%) Retained products (placenta,membranes,clots) Vaginal/cervical lacerations or haematoma Rupture uterus Broad ligament hematoma Uterine inversion.Defects in coagulation
Subinvolution of placental siteRetained products of conceptionInfectionInherited coagulation defects
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RISK FACTORS FOR PPH: Antenatal
Past history of hemorrhage( risk in 1st ,2nd & 3rd
pregnancy is 5.8%, 14.8%, 21.7% respectively)
Placental abruption & Placenta praevia
Multiple pregnancy (3.3%), macrosomia(2%)
Hypertension in pregnancy (pre eclamptic
state, eclampsia, HELLP) (2.2%)
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…Antepartum Chorioamnionitis (2.7%)
Polyhydramnios & Multiparity
Fetal death
Anemia
Uterine myoma, or Manual Removal
of placenta
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RISK FACTORS FOR PPH- Intrapartum Operative / Instrumental delivery- cesarean or
assisted vaginal.
Prolonged labour (7.6%)
Precipitate labour (rapid labour),
Induction or augmentation
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…Intrapartum
Chorioamnionitis
Shoulder dystocia
Internal podalic version & extraction of 2nd
twin
Acquired coagulopathy(e.g. HELLP, DIC)
General anaesthesia with inhaled agents
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RISK FACTORS FOR PPH – Postpartum
Lacerations or episiotomy (4.7%) Retained placenta (7.8%) Placental abnormalities Uterine rupture Uterine inversion Acquired coagulopathy (e.g. DIC)
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But Remember Always that PPH
is a Very unpredictable
condition and Every parturient
women is at risk of having PPH
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CLINICAL CLASSIFICATION ADOPTED FROM BENEDETTI 2002
Hemorrhage class
Acute blood loss (ml)
Blood loss %
Clinical signs & symptoms
Management
1 500-1000 15 % Mild tachycardia , Tachypnea, Diaphoresis
Marks Action line, Observation +/- ReplacementTherapy
2 1200-1500 20-25 %
Postural Hypotension, Tachycardia, Tachypnea, Decrease urine output
Fluid Replacement with oxytocics
3 1800-2100
30-35 %
Overt hypotension, Tachycardia,Tachypnea, Oliguria, Cold clammy extrimities
Urgent active management
4 2400 40% Profound shock Critical active management
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“It is extremely difficult to make complex things simple whereas it is easy to make simple things complex” -Steve JobsThe Passage of time is likely to increase the complexity
of any given case because continuous bleeding, not
appropriately and adequately controlled on a timely basis,
invariably leads to coagulopathy
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The Golden hour ‘ Time by which resuscitation must be initiated to ensure better
survival’. Because,if medical therapy using 3 or 4 uterotonics has not
worked within one hour, there is no logical reason to think they will work in next hour
“Rule of 30” Patient has probably lost >30% blood volume if, Fall in systolic BP by 30mmHg Heart Rate rises by 30bpm RR rises to >30/min Hb or Hct drops by 30% Urine output < 30ml/hr“She is in Moderate to severe Shock”
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The Lethal Triad – Bloody Vicious Cycle
Hypothermia Acidosis Coagulopathy
Plays a major role in the morbidity & mortality of severely injured or exsanguinating patient
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PPH Armamentarium Uterotonics Delayed cord clamping Controlled cord traction Uterine Massage Bimanual compression Balloon tamponade Compression sutures Uterine artery embolization Systematic devascularization Hysterectomy
Components of AMTSL
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PREVENTION OF PPH Identify Predisposing Factors. Treat anemia & educate patients
regarding PPH. High risk patients to be managed in
tertiary care I/V access ,arrange blood if assessed as
at risk AMTSL (Active management of third
stage)
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ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR (AMTSL)
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MANAGEMENT OF PPH Initial treatment of PPH includes early recognition
followed by prompt attention to the resuscitation & a simultaneous search for the cause of the bleeding.
Once PPH has been identified, management involves four components, all of which must be undertaken SIMULTANEOUSLY:
Communication, Resuscitation, Arresting the bleeding, Monitoring & investigation. - RCOG 2009
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JOINT STATEMENT & ACTION PLANLAUNCHED IN 2004 BY ICM/FIGO
An algorithm has been suggested for the management of PPH H.A.E.M.O.S.T.A.S.I.S.
General medicalH: Ask for helpA: Assess (vitals, blood loss) & resuscitateE: Establish etiology & check Ecbolics (syntometrine, ergometrine, bolus syntocinon) & Ensure availability of bloodM: Massage uterusO: Oxytocin infusion, prostaglandins (i/v,rectal,i/m, intra-myometrial)Specific surgicalS: Shift to operating room, exclude retained products & trauma, bimanual compression, antishock Garment if transfer requiredT: Tissue & Trauma to be excluded , proceed for Tamponade balloon, uterine packingA: Apply compression suturesS: Systematic pelvic devascularization (uterine, ovarian, quadruple, internal iliac)I: Intervention radiologist, uterine artery embolization if appropriateS: Subtotal or total abdominal hysterectomy
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H – Ask for Help Multidisciplinary ApproachAlert – Senior obstetrician Anaesthetists Midwives/ Nursing Staff Theatre staff Haematologists Blood Bank Hospital Porters Intensive care units
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A – Assess & Resuscitate
Assess Vital signs & Estimate Blood Loss
Adequate venous access : 2 large bore I/V
cannulas(16-18G)
Draw Blood sample (~20ml) for CBP, Group,
Cross Match, Coagulation screen, RFT & LFT
Foley’s catheter : Monitoring adequate renal
perfusion.
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ESTIMATION OF BLOOD LOSS Visual Estimation: underestimates
blood loss by 30-50%.
Clinical Symptoms : changes in clinical
status may lag behind blood loss.
PPH bags
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A conical calibrated drape BRASSS V DRAPE: For objective assessment of blood loss (decreases error by 15-33%)
BRASSS V DRAPE is being used in low resource setting
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Volume replacement
Fluid of Choice – Crystalloid over colloids
Crystalloid of choice – Ringer Lactate
Crystalloid, 3- 5ml / ml of blood loss to maintain
urine output at > 30 ml /hr
Loss of 1l of blood requires replacement with 4-
5l of crystalloids (NS or RL) or colloids until
Cross – matched blood is available
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In class III – class IV haemorrhage : CAB of
basic life support should be provided
C Circulation – circulatory blood volume must
be restored & maintained. Infuse 1 litre
crystalloid solution with in 15-20 min, at least 2-3
litres of fluid in first hour to be given.
A Ensure Airway is patent
B Breathing- If respiration is not adequate,
involve anaesthesiologist and intesivist
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Shock Index : Heart rate/ Systolic BP
Normal value – 0.5-0.7
In significant Haemorrhage – 0.9- 1.1
Change in SI – A better correlate in
identifying acute blood loss
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E – establish etiology, ecbolics, ensure availability of blood
Rule out 4 ‘T’s and act - Tone – Start Massage & uterotonics Trauma – EUA & Repair or Pressure
pack Tissue – manual removal under
anaesthesia Thrombin (coagulopathy) : correction
with FFP, cryoprecipitate
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M – Massage the uterus Manually Bimanually
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BIMANUAL COMPRESSIONForm a fist. Place the fist in anterior fonix & apply pressure against the anterior wall of uterusWith the other hand press deeply into the abdomen behind the uterus, applying pressure against the posterior wall of uterusMaintain pressure until bleeding is controlled & uterus contracts while continuing resuscitate measures
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O – Oxytocin infusion, And Other ecbolics
For management of PPH, oxytocin should be preferred over other uterotonics.
If oxytocin is not available or alone is not effective, ergometrine or oxytocin-ergometrine fixed-dose combination should be offered as 2nd line treatment.
If the above 2nd line treatments are not available or not effective, a prostaglandin should be offered as the 3rd line of treatment.
-WHO 2009
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UTEROTONICS: Oxytocin
Methyl Ergometrine , Syntometrine
Prostaglandins- 15methyl PGF2α, misoprostol (PGE1)
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able 1. Medical Management of Postpartum HemorrhageDrug* Dose/Route Frequency CommentOxytocin (Pitocin) IV: 10–40 units in 1
liter normal saline or lactated Ringer's solution @125ml/hrIM: 10 units
Continuous Avoid undiluted rapid IV infusion, which causes hypotension.
Methylergonovine(Methergine)
IM/IV: 0.2 mg Every 2–4 h upto 5 doses in 24hrs
Avoid if patient is hypertensive.
15-methyl PGF2α
(Carboprost)(Hemabate)
IM: 0.25 mg Every 15min, 8 doses maximum
Avoid in asthmatic patients; relative contraindication if hepatic, renal, and cardiac disease. Diarrhea, fever, tachycardia can occur.
Misoprostol(Cytotec, PGE1)
800–1,000 mcg rectally or sublingually
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METHYL ERGOMETRINE
Require very specific storage conditions, as they
deteriorate rapidly with exposure to light, heat, humidity.
Side effects: Nausea, vomiting, paresthesias ,chest pain,
tinitus, headache, increased BP Contraindicated in:
Sepsis, migraineHypertension, heart disease,Peripheral vascular disease, Raynaud’s phenomenon Liver & kidney disease,
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SYNTOMETRINE Combination of oxytocin 5U & Ergometrine 0.5mg Given I/M
No important clinical differences in the effectiveness of syntometrine & oxytocin for the prevention of PPH , (Choy et al , BJOG 2002; 109,173-177)
Associated with a higher risk of hypertension, vomiting
In severe PPH, syntometrine did not demonstrate a benefit rather cause increased side effects such as hypertension & vomiting due to the ergot component . (Cochrane Database of Systematic Reviews. 2004;1)
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PGF2α
It is administered in doses of 0.25 mg IM. Contraindication is asthma due to broncho-
constrictive properties of the F class of prostoglandins.
Produce nausea, vomiting, diarrhea & pyrexia, case report of severe intrapulmonary shunting & hypotension seen. Cardiac , pulmonary ,renal & hepatic disease are contraindications
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MISOPROSTOL Synthetic PGE1 analogue Oral/ Vaginal/ Rectal/Sublingual Oral,sublingual route(faster onset of action).
Rectal & Vaginal routes(greater bioavailability+longer duration of action).
Inexpensive, temprature stability Plasma concentration peaks in 30 min(oral),
1-2 hrs (vaginal)
Adverse factors(dose dependent); nausea, vomiting, diarrhea, chills, shivering, fever.
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TRANEXAMIC ACID IN PPH WHO 2009
Tranexamic Acid may be offered in treatment for PPH if: (i) Uterotonics has failed to stop the bleeding(ii) If bleeding may be partly due to trauma.
(Strength of Recommendation – Strong - WHO 2012)
There is a consensus view that fibrinolytic inhibitors (such as tranexamic acid) seldom, have a place in the management of obstetric haemorrhage. RCOG 2009
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BLOOD COMPONENT THERAPY
MTP – Massive Transfusion Protocol
Involves transfusion of >10PRBCs in 24 hours
Ideal ratio of RBC:FFP is 1:1 Can be combined with PRPs if
thrombocytopenia in 1:1:1 ratio
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Use of Activated Recombinant Factor VII (Novoseven) in Obstetrics(COG 2010)
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S – Shift to OT or higher center If initial medical therapy fails within
Golden Hour, shift to a center where multidisciplinary approach available – “PPH precedes Death by 2 hours”
Two important life savior methods to transfer include
Aortic compression by Skilled Birth Attendant
Non Pneumatic Anti Shock Garment
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NNASG Maintains
circulations to Vital organs – Brain , Heart & Kidney
No time Limit No side effects
like gangrene as it is Non Pneumatic
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“Women are not dying because of a disease we cannot treat.
They are dying because societies have yet to make the decision that
their lives are worth saving”.
Mohd. Fathalla, President of FIGO- 1997
THANK YOU