POSTPARTUM

HAEMORRHAGE

Olufemi Aworinde, FWACS

Consultant Obstetrician/Gynaecologist,

Bowen University, Iwo.

Introduction

• PPH is a major cause of both maternal mortality

and morbidity

• Responsible for estimated mortality rate of

140,000 per year or one maternal death every

four minutes

• Occurs in 4-6% of all deliveries

• Majority of the death occur within 24 hours

(especially within 4 hours of delivery) indicating

that it is a consequence of third stage of labour

Definition

Abnormal bleeding (excessive blood loss)

from the genital tract within the first 42 days

after delivery.

•≤ 24 h = primary postpartum hemorrhage

•> 24 h = secondary postpartum hemorrhage

Primary postpartum haemorrhage

• Excessive bleeding of greater than 500 ml within

24hrs after vaginal birth. (lower amount of blood

loss life-threatening for anemic women)

>1000ml during CS

• Loss of 10% of blood volume

• Loss of 1% of booking weight

• Loss sufficient to produce symptoms

Why primary PPH?

•60% of maternal death occur postpartum with 50%

in first 24hrs.

•2/3 (90%) have no identifiable predisposing factors

to PPH

Equal opportunity occurrence not an equal

opportunity killer

Risk of dying from PPH depends on:

• the amount and rate of blood loss

• the health status of the woman (premorbid state).

•Social factors : poverty, lifestyle, malnutrition, and

women’s lack of decision-making power to control

their own reproductive health.

Classification1. Amount of blood loss-

> 1000 ml = severe postpartum hemorrhage

2. Change in haematocrit –

10% drop btw AP and PP PCV

3. Rapidity of blood loss –

• >150ml/min within 20mins

• >50% bld vol

Class of

haemorrhage

Acute blood loss

(ml)

Percentage

lost (%)

Signs and

symptoms

1 900 15 Usually no

symptoms

2 1200-1500 20-25 ^RR,PR,

decrease urine

output, postural

hypotension

3 1800-2100 30-35 Overt

hypotension,

^RR,^PR, CCE,

BP falls

4 2400 40 Profound shock,

PR, BP non

recordable

Causes of primary PPH

Tonus (uterine atony)

Uterine overdistention: multiparity, polyhydramnios, macrosomia

Tocolytics: nifedipine, Mg, beta-mimetics, indomethacin

Prolonged obstructed labor with uterine inertia

Injudicious use of oxytoxics to induce/ augument labor

Halogenated anesthetics e.g. halothane

Fibroid uterus

Placenta praevia

Tissue

Impediment to uterine contraction/retraction: multiple fibroids, retained

placenta

Placental abnormality: placenta accreta, succenturiate lobe

Prior uterine surgery: myomectomy, classical or lower segment

Obstructed labor

Prolonged third stage of labor

Trauma

Vulvovaginal injury

Episiotomy/tears

Uterine rupture

Thrombin (coagulopathy)

•Acquired during pregnancy:

1.Thrombocytopenia of HELLP syndrome

2.DIC - eclampsia, IUFD, septicemia, placenta abruptio,

amniotic fluid embolism.

•Hereditary: Von Willebrand’s disease

•Anticoagulant therapy: valve replacement, patients on

absolute bedrest.

1. ANTENATAL

• Advanced maternal age

• Obesity, BMI> 35

• Grand multi

• Uterine abnormalities- fibroids, congenital

• Maternal blood dyscracias

• Overdistended uterus- MP, polyhydrramnios, big baby

• IUFD

• Prev PPH/ Prev Retained placenta

RISKS FACTORS FOR PPH

2. INTRAPARTUM

•Precipitate/ prolonged labour

•Chorioamnionitis

•Amniotic fluid embolism, DIC

•Uterine inversion

•Genital tract trauma

•Assisted vag delivery

•LSCS, Emergency > Elective

3. POSTPARTUM

• Retained products

• DIC

• Drug induced hypotonia (anesthesia, MgSO4)

• Bladder distention preventing uterine

contraction

SCIENTIFIC EVIDENCES ON PPH

• PPH is unpredictable:90 percent of women with

PPH had no identifiable risk factors.

•Uterine atony accounts for 70-90% of PPH cases.

• Active Management of the Third Stage of Labor

(AMTSL) can prevent 60% of uterine atony.

•Prevention of PPH will significantly reduce

maternal mortality and morbidity.

CHALLENGES WITH DIAGNOSIS

OF HAEMORRHAGE

• Clinical estimation of blood loss is

notoriously inaccurate.

• Many studies demonstrate that visual

estimates range from 30 to 50% of actual

losses.

• Inaccuracy increases with increasing

blood loss (This was particularly true

above 1000 ml).

ASSESSMENT OF THE

PATIENT

PREVENTION OF PPH

1. Active Management of the Third Stage of

Labour (AMTSL) – By Skilled Birth Attendants

(SBA)

2. Misoprostol and the Prevention of Post-Partum

Haemorrhage – if Oxytocin unavailable or

limited SBAs

3. (Expectant) Management of the Third Stage of

Labour in the Absence of Uterotonic Drugs

4. Routine inspection of placenta & membranes

Joint Statement

International Confederation of Midwives (ICM)

International Federation of Gynaecology and Obstetrics (FIGO) 2006

Active Management of the Third Stage of

Labour (AMTSL) – By Skilled Birth

Attendants

• Administration of oxytocin or another

uterotonic drug within one minute after

the birth of the baby

• Controlled cord traction

• Uterine massage after delivery of the

placenta as appropriate.

(Expectant) Management of the Third

Stage of Labour in the Absence of

Uterotonic Drugs

• Await signs of placental separation

• Encourage maternal effort to bear down with contractions

• Controlled cord traction is not recommended in absence of Uterotonic drugs, or prior to signs of separation of the placenta

• Uterine massage after delivery of the placenta as appropriate.

• No longer practised

Misoprostol reduces PPH with or without controlled cord traction or uterine

massage

TREATMENT PROTOCOL

1. Resuscitation

2. Assessment for cause of PPH

3. Pharmacological therapy

4. Balloon Tamponade

5. Uterine Artery Embolization

6. Surgical treatment

1. RESUSCITATION

• A – Airway patency

• B – Breathing sustenance

• C – Circulation support

The NASG is recommended for:

• Class II hypovolemicshock: > 750 ml blood loss, pulse > 100 and blood pressure normal or slightly decreased.

• Not recommended for use with :– a viable fetus,

– patients with mitral stenosis, congestive heart failure, pulmonary hypertension,

– bleeding sites above the level of the diaphragm.

Non-pneumatic Anti-Shock

Garment (NASG):

• used immediate first-aid

treatment for reversing

hypovolemic shock & decreasing

blood loss secondary to obstetric

hemorrhage, by application of

lower body counter pressure.

•Keeps women alive during long

transports for referral

NON-PNEUMATIC ANTI-

SHOCK GARMENT (NASG)

Patient wearing the non-pneumatic anti-shock garment in hospital

2. DETERMINATION OF CAUSE

OF PPH1. Assessment for uterine tone

• Mechanical massage

• Pharmacological therapy

• Bimanual uterine Compression

2. Evaluation for genital tract trauma• Speculum examination

• EUA

• Laparotomy

3. Placental tissue retention• Routine confirmation of placenta at delivery

4. If bleeding

persists,

perfom

Bimanual

compression

3. PHARMACOLOGIC

THERAPY I. Oxytocin (Pitocin):

– First choice

– Intravenous infusion

or intramuscular

– Usable in hypertension

2. Syntometrine/Ergome

trine:

– Effective

– Dose can be repeated

– Contraindicated in

hypertensive states

3. Misoprostol:

– Given sublingual,

orally or rectally

(vaginally)

– Effective, cheap, easy

to administer

– Side –effects of

shivering or pyrexia

– Used where no other

oxytocics or SBAs

– Single dose of

600mcg

3. PHARMACOLOGIC

THERAPY 4. Prostaglandin F2α

(Carboprost):– Used as 3rd line agent,

unresponsive to others

– Controls 86% of non-responders

– Intramuscular dose of 250mcg every 15 minutes to maximum of 2mg

– Be avoided in asthma, hypertension & cardio-pulmonary disease

5. Recombinant Factor VIIa:

– Used as hemostatic to treat coagulopathy tendency

– Useful in HELLP syndrome & DIC

– Intravenous dose of 40-60mcg/Kg

– Used when above oxytocics fail

Tranexamic acid• A randomized double-blind, placebo-controlled trial by the

WOMAN Trial Collaborators reported that TXA (an

antifibrinolytic) significantly reduced death due to bleeding

in women with postpartum hemorrhage.

• WHO strongly recommends use of intravenous TXA (within

3hrs of birth), in addition to standard care for women with

clinically diagnosed post-partum haemorrhage.

• 1g (100mg/mL) intravenously at 1 mL/min (ie, given over

10 min), with a second dose of 1g IV if bleeding continues

after 30 min, or if bleeding restarts within 24hrs of

completing the first dose.

• Delay in treatment reduces benefit, decreasing by 10% for

every 15 min delay, and with no benefit seen after 3hrs

Medications Used for Uterine Atony

DRUG ROUTE OTHERS

Oxytocin (Pitocin) 10-40 IU/L IV 10 IU IM if no IV access

Methylergonovine (ergometrine) 0.2mg IM may be repeated every

2-4hrs up to max 1.5mg

15-methyl PGF2a (Hemabate,

Carboprost)

250 ug IM may be repeated

every 15 minutes,

maximum 8 doses

Misoprostol (Cytotec) 800-1000 ug

rectal

Tranexamic Acid (TXA) , 1 g IV within

3hrs of onset

may be repeated once

if bleeding continues

after 30 minutes

LACERATION REPAIR• Genital tract laceration is very common and can

occur anywhere in the tract

• Genital tract exploration is done once uterine atony

has been ruled out and bleeding persists

• Good light source and systematic inspection are

essential for good repair

• Hand over hand technique is used for the repair of

cervical laceration

Uterine curretage

• If bleeding persists, rule out retained products

of conception

• Examine placenta under running water

• Bedside USS may be useful

• Uterine curettage under USS guidance using

a large, blunt curette may be required

BALLOON TAMPONADE• Involves inflation of

balloon devices with

<500mls using:

– Sengstaken tube,

– Rüsch balloon,

– Bakri balloon

– Condom+Catheter

• Used temporarily

when medications fail

and surgery

contemplated

• For up to 48hours

UTERINE ARTERY

EMBOLIZATION• Percutaneous transcatheter

arterial embolization:

– Gelatin or

– polyvinyl alcohol (PVA)

particles

• Patient rapidly recovers without

undergoing additional surgery.

• Saves life of patient,

• Preserves uterus adnexal organs

& fertility

• Is procedure of 1st choice in

developed countries

• Success range: 75 –100%

SURGICAL TREATMENT:

Other Conservative Methods

• Other Methods:B-Lynch Suture: performed at

Laparatomy, through uterine

incision, using Monocryl or

Vicryl No. 2 No C/S

scar

Cho

method

SURGICAL TREATMENT:

Other Conservative Methods

• Internal Iliac artery

Ligation

• High uterine artery

ligation

SURGICAL TREATMENT:

Permanent MethodHysterectomy:

• Best method to Rx unresponsive uterine

atony if:

– No facilities for Embolization

– No skills for other conservative methods

– Late decision to do hysterectomy is usually

fatal

CONCLUSION

• PPH needs to be drastically reduced

• The scrupulous adherence to the

aforementioned strategies is the only way

to achieve this.

THANK YOU!

THANK

YOU!THANK

YOU!