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Post Partum
Haemorrhage
Francoise Iossifidis
Darent Valley Hospital
� Background
� Definitions
� Risk Factors/Etiology
� PPH Management
� Communication, Resuscitation, Monitoring & Ix, Arresting the bleeding,
drugs used
� Patients who refuse blood
� How to survive your first PPH
PREVENTION AND MANAGEMENT
OF POSTPARTUM HAEMORRHAGE
Background
� Major cause of maternal death and morbidity despite a fall in
number in this triennium
� In the UK major obstetric haemorrhage is 3.7/1000
� 50% of the 500 000 maternal death globally is due to
haemorrhage
� All units should have protocols in place for its identification and
management.
� CMACE 2006-08 9 deaths 0.39/100 000
� Majority of these considered preventable
� Obstetric haemorrhage encompasses antepartum and
postpartum
� APH often associated with subsequent PPH
� 1 -Sepsis (26)
� 2 -Pre-eclampsia and eclampsia (19)
� 3 -Thromboembolism (18)
� 4- Amniotic fluid embolism (13)
� 5- Early pregnancy deaths (13)
� 6 -Haemorrhage (9)
Volume 118, Supplement 1, March 2011 BJOG An International
Journal of
Obstetrics and Gynaecology
Saving Mothers’ Lives
Reviewing maternal deaths to make
motherhood safer: 2006–2008March 2011
The Eighth Report of the Confidential
Enquiries into Maternal
Deaths in the United Kingdom
Definitions
� Primary PPH
� Loss of >500 ml blood from genital tract within 24h of birth of baby
� Minor (500-1000ml)
� Major (>1000ml)
� Moderate 1000-2000ml
� Severe >2000ml
� Secondary PPH
� Abnormal/excessive bleeding from birth canal between 24h and 12/52
postnatally
All PPH are audited and reported on a monthly basis
Issues
International definition of PPH not unified:
� Traditional WHO definition of primary PPH encompasses all
blood losses > 500ml
� Est loss >1000ml appropriate cut off for major PPH and
initiation of emergency protocol measures other 1500ml
� Estimations of blood volume based on weight (weight kg/12)
� Allowing for physiological increase in pregnancy blood vol at
term = 100ml/kg
Issues
� Blood loss of >40% (approx 2800ml) total bld vol : ‘life-
threatening’
� Consideration of antenatal Hb (<11g/dl Ix and Rx pre delivery)
� Evidence that iron-def anaemia assoc with atony secondary to
depleted uterine myoglobin levels (needed for muscle action)
� Visual blood loss estimates often underestimate true loss
Risk Factors for PPH
Most cases of PPH have no identifiable risk factors however the following increase the risk of PPH:
� Increased BMI� Fibroids� Polyhydramnios� Twin pregnancy� Previous LSCS� Pre-eclampsia….
Four T’s (Society of Obs and Gynae of Canada)
� Tone 80% Uterine atony
� Trauma 10% Lacerations, uterine rupture
� Tissue 9% Retained products
� Thrombin 1% Coagulation disorders
PPH Management
� Team management/communication
� Protocol
� Regular skill drills
� Resuscitation
� Monitoring & Investigation
� Arresting the bleeding
Team management� Basic measures for minor PPH (500-1000ml)
� Alert midwife-in-charge
� Alert first-line obstetric and anesthetic staff
� Full protocol for major PPH
� Call experienced midwife (in addition to midwife in charge)
� Declare “code blue”
� Call obstetric middle grade and alert consultant
� Call anaesthetic middle grade and alert consultant
� Call ODP
� Alert consultant clinical haematologist on call
If no code blue in place
� Alert blood transfusion laboratory
� Call porters for delivery of specimens/blood
One member of the team designated to record events, fluids, drugs and vital signs
Resuscitation
� Assess A, B, C
� O2 10-15l/min
� IV access (14G x2)
� Position flat
� Patient warming blanket
� Transfuse PRC ASAP
� Until available infuse up to 3.5l: of warmed crystalloid: Hartmann’s solution 2l +/- colloid 1-2l as rapidly as required
� Use best device available to achieve RAPID WARMED infusion of fluids (eg level 1 rapid infusor)
� Special blood filters should NOT be used acutely - slow infusions
� Recombinant factor VIIa therapy should be based on the results of coagulation (Protocol)
QuickTime™ and a decompressor
are needed to see this picture.
Resuscitation
� Fluid therapy
crystalloid: up to 2L Hartmann’s or Plasmalyte
colloids: up to 1-2L of colloid until the blood products
arrive
� Cell salvage if possible
� Blood products
In an organised way, “Code Blue”
� Drugs:
to contract the uterus
to help the coagulation
Resuscitation
� 2006 guideline from British Committee for Standards in
Haematology - main therapeutic goals of management of
massive blood loss is to maintain:
� Hb > 8g/dl
� PLT count > 75 x 10 9/l
� PT <1.5 x mean control
� APTT < 1.5 x mean control
� Fibrinogen > 1.0 g/l
Monitoring & Investigation� Blood
� X match if not already done(4 u min), FBC, Coagulation (incl Fib), U&Es, LFTs
� Monitor temperature every 15 min
� Continuous pulse, BP recording and RR (oximeter, ECG, NIBP)
� Foley catheter for UO monitoring
� 2 x 14/16G cannulae
� Consider IABP
� Consider transfer to ICU once bleeding controlled/ monitoring on obstetric HDU if appropriate
� TRALI
� Record parameters on HDU or equivalent chart
� Documentation of fluid balance, blood, blood products and procedures
� ABGs
How to stop the bleeding
� Causes for PPH may be considered to relate to one of the 4 Ts
� Tone, tissue, trauma, thrombin
� Most common cause of primary PPH is uterine atony
� Clinical examination necessary to exclude other causes:
� Retained products (placenta, membranes, clots)
� Vaginal/cervical lacerations or haematoma
� Ruptured uterus
� Broad ligament haematoma
� Extragenital bleeding (for example, subscapular liver
rupture)
� Uterine inversion
Uterine Atony: a team effort
� Bimanual uterine compression (rubbing up the fundus) to
stimulate contractions
� Ensure bladder is empty (Foley catheter)
� Syntocinon 5 u by slow IV injection (may have repeat dose)
� Ergometrine 0.5mg by slow IV/IM injection (C/I in HTN)
� Syntocinon infusion (40u in 500ml @ 125ml/hr) or in 50mls if
PET
� Carboprost 0.25mg IM injection repeated at intervals of not less
than 15min to max of 8 doses (C/I in asthma)
� Direct intramyometrial injection of carboprost 0.5mg (C/I in
asthma - responsibility with administering clinician as not
recommended for intramyometrial use)
� Misoprostol 1000mcg PR
Surgical Haemostasis
� Intrauterine balloon tamponade
� Haemostatic brace suturing (B Lynch suture) delayed suture
(>2h) increases the rate of hysterectomy
� Bilateral ligation of uterine arteries
� Bilateral ligation of internal iliac arteries
� Selective arterial embolisation
� Resort to hysterectomy SOONER RATHER THAN LATER (esp
if placenta accreta or uterine rupture)
� UKOSS 40.6/100 000 hysterectomies to control haemorrhage
with<1% death
� 39% morbidly adherent placenta, main cause previous LSCS
Drugs to help the coagulation
� Tranexamic acid
� Beriplex
� Recombinant Factor VIIa
� Vit K
� Management of major PPH
Prevention
� All women who have had a previous LSCS must have their
placental site determined.
� Identify women “at risk” and be prepared.
� Women delivered by LSCS must have regular obs recorded on
the MEOWS chart for the first 24hrs.
� RCOG recommend that women with major placenta praevia
who have previously bled should be admitted and managed as
in patients from 34/40
� All clinicians should be aware of the guidelines for management
of women who refuse blood.
Jehovah’s Witness
� Optimise Hb during pregnancy, oral iron, IV iron, folic acid, recombinant
human erythropoietin.
� Advance directives from hospital and JW Hospital Committee
� Anaesthetic clinic
� Plan delivery as much as possible
� Management:
� Same management as any PPH but without being able to give blood.
� Inform the consultant anaesthetist
� Alert the consultant haematologist early.
� Recombinant factor VIIa
� Tranexamic acid
� Prothrombin complex concentrate Beriplex
� Cell salvage
� Increase the dose of syntocinon, ensure good uterine contraction.
How to survive your first PPH
� Do not panic, think ABC
� Do not join in the mass hysteria
� Call for help i.e. consultant and senior ODP
� If in doubt always declare a code blue
� Beware of hidden blood loss
� Be ahead of the game
� Be assertive and ensure adequate communication.
Thank you