Post Partum Haemorrhage 1- Load

8/14/2019 Post Partum Haemorrhage 1- Load

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Severe bleeding is the single most significantcause of maternal death world wide

More than half of maternal death occur within

24hrs of delivery due to Excessive bleeding. World wide 140000 women die of PPH each

year 1 women per every 4 mts.

In 2004-26 million births occurred in India &Maternal death due to PPH were 24,000

POST PARTUM HAEMORRHAGE


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PREDICTION OF PPH

To Predict and prevent PPH, we must be awareof the causes.

Although many risk factors have beenassociated with PPH it Often occurs withoutwarning

It is impossible to consistently identify womenbecause a normal pregnant women can become

high risk at delivery without any risk factors. Therefore all obstetric units and practitioners

must have facilities, personnel and equipment inplace to manage this PPH properly.


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IF TIMELY INTERVENTION & MANAGEMENT

NOT DONE WE MAY LOOSE THE PATIENT

WITH FOLLOWING COMPLICATIONS

1. Haemorrhagic Shock.

2. Consumptive Coagulopathy.

3. Multiple organ failure ( Renal failure).4. Death.

5. Need for internal iliac ligation and its complications.

6. Need for hystrectomy and loss of child bearing potential.

7. Complications of Blood transfusion.8. Need for other emergency surgical interventions.


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DEFINITION There is no single satisfactory definition of PPH

An estimated blood loss of 500ml following delivery( either Vg or C.section )

Decline in hematocrit level of 10% from admission to post partumperiod or nee for erythrocyte transfusion.

But Blood loss estimates at delivery are always notoriouslyinaccurate with significant underreporting.

Asian women with poor socio economic status and Poor nutrition andlower Haemoglobin, small built and lesser blood volume. Collapseeven with less than 500 ml of Blood loss.

Therefore patients vital parameters and general condition are taken asthe guidelines for the management rather than amount of blood loss.


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PHYSIOLOGICAL CHANGE THAT

OCCURS IN ANTICIPATION OF BLOOD

LOSS AT DELIVERY

Increase Plasma volume by 40% and

RBC Increase by 25%

Increase Coagulation and Hyperviscosity.


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INCIDENCE

3.9% with vaginal delivery

6.4% with Caesarean Section more

common in HISPANICS and

ASIANS


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ANATOMY & PHYSICS OF PPH

Primary haemostasis from placental bed isdue to Compression of uterine vessel as

they pass through the myometrium

( LIVING LIGATURES ) (PINAUDS)


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PHYSICSDegree of Compression of uterine vessel depends on

the force acting on these Vessels which obeys YoungLaplace relationship

F= 2T/r

F: Compressive Force

T: Wall tension created by Uterine Contraction

r: Radius of the uterus

Scientific Basis for management of PPH is

a) Wall tension T - Oxytocics b) Radius r - Emptying ut of Clots and

Placenta


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Grand Multi

PIH / Ante partum Haemorrhage Over distended - Uterus

- Hydramnios- TWINS- Macrosomia

Prolonged labor Augmented labor Rapid Labor (PPT Labor) H/o PPH Asian and Hispanic Ethnicty Chorioamniontis

Operative delivery Episotomy Abnormal Coagulation Drugs Inversion Mismanagement of III Stage

RISK FACTORS FOR PPH


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CAUSES OF PPH. Tone - Atonicity

Tissue - Abnormal ut content Trauma - Accidental injury

Thrombosis - Abnormal Coagulation

4Ts

4As


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TONEAtonicity or 70% of PPH Abnormal Contraction

1. Sepsis - Chorioamnionitis

2. Overdistension - TWINS

Polyhydramnius

Macrosomia

Hydrocepahalous

3. Muscle Exhaustion - Mulliparity

Precipitate Labour

Prolonged Labour

4. Uterine anamolies - Fibroid uterus

Congenital malformations

Induced labour associated with more blood loss thannon induced labour


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TISSUEAbnormal Uterine Content

Retained blood clots- Atonic uterus

Retained placenta or Products

a. Abnormal Placentationb. Multiparity

c. Placental anomalies

d. Previous Uterus surgery

Accreta

IncretaPercreta


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Prevention of PPH

Active Management

of III Stage of

Labour

Universal

Identification of

Woman at risk for

PPH

Active manag-

ement of Labor


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ACTIVE MANAGEMENT OF III STAGE

1. CCT0 Controlled Counter traction andcontrolled Cord Traction

2. 10 u Syntocinun IM at the time of

delivery of Anterior or shoulder inSingleton Pregnancy, after birth of IIbaby in twin pregnancy


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IDENTIFICATION OF WOMAN AT RISK FOR PPH

1. Atonicity - Tone

2. Abnormal uterine - Tissue Content

3. Accidental - TRAUMA Injury

4. Abnormal - Thrombus

Coagulation


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RiskProcess

Aetiology Process Clinical factors

Accidenta

l injury

Uterine inversion

Extensions atcaesarean

Extension at

vaginal delivery

Mismanaged third stage, short cord,fundal placenta.

Malposition, deep engagementInstrumental delivery, medianepisiotomy, big baby, precipitate labour

Uterine rupture Previous uterine surgery , uterine

anomalies, instrumental delivery ,misuse of oxytocics, external injury,malpresentation, multiparity, precipitatelabour, external and Internal version ,MRP, morbidly adherent placenta,breech extraction



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RiskProcess

Aetiology Process Clinical factors

AbnormalCoagulati-on

Pre-existing Haemophilla A, Von Willebrandsdisease, ITP, H/O liver diseases.

Acquired inpregnancy

ITP, HELLP syndrome, abruptioplacenta, retained dead foetus

syndrome, amniotic fluid embolism, overwhelming maternal sepsis, therapeuticanticoagulant overdose.


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ACTIVE MANAGEMENT OF LABOUR

IN WOMEN AT RISK OF PPH

1. Additional Syntocinon 10-20 units in 500

ml RL, 150ml/hour

2. 250 g of Carboprost tromethamine , IM,

if no contraindication exists ( Asthma x

Cardiac disease.


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TREATMENT OF PRIMARY PPHLEVELIANDLEVELIICARE

TISSUE TONE TRAUMA THROMBIN

Retainedplacenta

Clots

Uterine Atony Genital Truma Abnormal Coagulation

Profile

Adequateanalgesia

Bimanual compression Ask for CervixExploration Set

Liaise with critical careexperts, hematalogist

Manualremoval

IM Carboprost tromethamine 0.25mg IMrepeat after 15 min after I dose

Compress Wound Blood Products

IV Methyl Ergometrine 0.2 mg, IV ( IIIUterotonic drug )

Analgesia

Aortic Compression Repair

Uterine packing Uterine tamponadesengstaken tude / foleys catheter /Condom

TRANSFER TO A TERTIARY CARE CENTER


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TONE

Uterine Atony

Bimanual compression

IM Carboprost tromethamine 0.25mg IM repeatafter 15 min after I dose

IV Methyl Ergometrine 0.2 mg, IV\ ( III Uterotonicdrug )

Aortic Compression

Uterine packing Uterine tamponade sengstaken

tude / foleys catheter / Condom


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UTERINE ATONY


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BIMANUAL COMPRESSION

Squeeze the

uterus firmlybetween the

hands. Continue

compression untilbleeding stops


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UTERINE PACKING

Packing the uterus is

ineffective and wastes

precious time.

This can be used beforewoman is shifted from

prerophery to hospital

failure to respond to

oxytocics ( under proper

antibiotic cover )

Insert image page no 226 b


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UTERINE TAMPONADETechnique Comments

Foley catheter - 4 inch gauze; can soakwith 5,000 units ofthrombin in 5mL of sterilesaline

Sengstaten- Blakemoretube

SOS Bakri tamponade

balloon

-Insert balloon: instill 300-500 mL.

Condom

Particularly useful as a temporizing measure, but if prompt response in not seen,

preparation should be made for exploratory laparotomy


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CLASSES OF HAEMORRHAGE

Class I

( compensated )

Class II

(mild)

Class III(moderate )

Class IV

(severe)

Percentageblood loss

500- 1,000 ml or10-15 %

1,000-1,500mlor 15-25 %

1,500-2,000mlor 25-35%

2,000-3,000mlor 35-45%

Signs and

symptoms

Plapitation,

dizziness,tachycardia

Weakness,

sweating,tachycardia

Restlessness,

oliguria, pallor

Collapse, air

hunger, anuria

Pulse Normal 80-100/min 100-120/min 120-140/min

Systolic BP Normal Normal or slightfall 80-100 min

70-80mmhg 60mmHg

Mean arterialBP

80-90mmHg 80_90mmHG 50-70mmHg 50mmHg


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FLUID RESUSCITATION

Crytalloids Colloids

Ringer lactate / Normal saline If Blood loss is more than 20%

Replacement Volume: to maintain systolic BPat 90mm of Hg

If more that 4-5L is required then CVP guided

fluid replacement

6% STARCH OR 3.5% Gelatin

30-40ml per Kg per day

Remove sample for cross matching prior

to infusion

Never use 5% Dextrose or dextrosecontaining fluids

Normal Saline : restrict its use to 2l avoidhypernatremia

Image @ page no 226 c


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Packed Cells FFP Platelets

Indications 2 Units of FFP have tobe given for every 6units of packed cellstransfusion

To maintain platelets>50,000/cumm

If Blood loss is more than40%

Pre delivery Hb is < 7 gms/dl.Critical trigger for packaged

cells transfusion prior to

surgical haemostasis

Repeat Hb is 4-5gm/dlHCT


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TISSUE

Under adequate Analgesia Anaesthsia

Evacuate clots

Manual removal of placenta if notseparated

If placental tissue piecemeal removal

by sponge holder gently & gentlecurettage


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TRAUMA

Explore, identify the trauma ask for cervical

exploring set, repair the tears / Lacerations

Laparotomy for rupture, if Inversion correct

under Anasthesia

Insert Image page of Roger P .smith no 229 A & BMUDALIAR: Page No 283 A and B

Page No 289 40.2 & 40.3


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THROMBIN

Discuss with critical care experts /

hematologists

Blood products

Replace clotting factors

Anti coagulant antidote

OO CO O


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BLOOD COMPONENT THERAPYProduct Volume (mL) Contents Effect (per unit)

Packed red

cells

240 Red blood cells,

white blood cells,plasma

Increase hematocrit 3

percentage point,hemoglobin by 1 g/dl

Platelets 50 Platelets, red bloodcells, white bloodcells, plasma

Increase platelet count5,000-10,000/mm3per unit

Fresh frozenplasma

250 Fibrinogen,antithrombin III,factors V and VIII

Increase fibrinogen by10mg/dl

Cryoprcipit-

Ate

40 Fibrinogen, factors

VIII and XIII, vonWillebrand factor

Increase fibrinogen by 10

mg/dl

Modified from Marti SR, Strong TH Jr Transfusion of blood components and derivatives in the obstetric intensive care

patients ..


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BLOOD COMPONENT THERAPYSurgical Management of PPH

Uterine artery ligation Bilateral; also can ligate uteroovaria vessels

B-Lynch suture

Hypogastric artery ligation Less successful than earlier thought; difficult

technique ; generally reserved for practitionersexperienced in the procedure

Repair of rupture

Hysterectomy


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ATONIC PPH

Bimanual massage

and compression

Elevation

Ulerotonic agents Aortic Compression

Remove slide


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UTEROTONIC AGENTSDrug* Dose/Route Frequency Comment

Oxytocin(Pitocin) IV:10-40 units in 1 liter normalsaline or lactated

Ringers solution

IM: 10 units

Continuos Avoid undiluted rapid IV infusionWhich causes hyotension

Methylergonovine

(Methergine)

IM: 0.2 mg Every 2-4h Avoid if patient is hypertensive

15-methyl PGF2a

( Carboprost )(Hemabate)

IM: 0.25 mg Every 15-90 min, 8doses maximum

Avoid in asthmatic patients;relative contraindication if hepatic,renal, and cardiac disease.Diarrhea, fever, tachycardia canoccur.

Dinoprostoe

( Prostin E2)

Suppository : vaginal or rectal 20mg

Every 2 h Avoid if patient is hypotensiveFever is common. Stores frozen, it

must be thawed to roomtemperature

Misoprostol

( Cytotec, PGE1)

Abbreviation: IV, Intravenously; IM, Intramuscularly; PG, Prostaglandin

* All agent can cause nausea an vomiting


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EVIDENCE BASE RECOMMENDATIONS

Routine active management is superior to

expectant management in terms of blood loss, PPHand other serious third stage complications

Breast stimulation appears beneficial in terms ofreduction in PPH, but safety issues have not be

fully evaluated The used of syntomertrine (oxytocin and

ergomtrine) as part of routine active managementof third stage of labour appears to be associatedwith a statistically significant reduction in risk of PHwhen compared to oxytocin where blood loss is

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Post Partum Haemorrhage 1- Load