Post Partum Haemorrhage 1- Load

POST PARTUM HAEMORRHAGE • Severe bleeding is the single most significant cause 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

PREDICTION OF PPH • To Predict and prevent PPH, we must be aware of the causes. • Although many risk factors have been associated with PPH it Often occurs without warning • It is impossible to consistently identify women because 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 in place to manage this PPH properly.

IF TIMELY INTERVENTION & MANAGEMENT NOT DONE WE MAY LOOSE THE PATIENT WITH FOLLOWING COMPLICATIONS 1. 2. 3. 4. 5. 6. 7. 8.

Haemorrhagic Shock. Consumptive Coagulopathy. Multiple organ failure ( Renal failure). Death. Need for internal iliac ligation and its complications. Need for hystrectomy and loss of child bearing potential. Complications of Blood transfusion. Need for other emergency surgical interventions.

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 partum period or nee for erythrocyte transfusion. • But Blood loss estimates at delivery are always notoriously inaccurate with significant underreporting. • Asian women with poor socio economic status and Poor nutrition and lower Haemoglobin, small built and lesser blood volume. Collapse even with less than 500 ml of Blood loss. • Therefore patients vital parameters and general condition are taken as the guidelines for the management rather than amount of blood loss.

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.

INCIDENCE • 3.9% with vaginal delivery • 6.4% with Caesarean Section more common in HISPANICS and ASIANS

TYPES

Primary or Early

Secondary or Late

Within 24 hours of delivery

After 24 hours and within 6-12 Weeks Post partum

ANATOMY & PHYSICS OF PPH • Primary haemostasis from placental bed is due to Compression of uterine vessel as they pass through the myometrium ( LIVING LIGATURES ) (PINAUDS)

PHYSICS Degree of Compression of uterine vessel depends on the force acting on these Vessels which obeys Young Laplace 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

RISK FACTORS FOR PPH • • •

• • • • • • • • • • • •

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

CAUSES OF PPH. • • • •

Tone Tissue Trauma Thrombosis

-

4T’s 4A’s

Atonicity Abnormal ut content Accidental injury Abnormal Coagulation

TONE Atonicity or 70% of PPH Abnormal Contraction 1. 2.

3.

4.

Sepsis Overdistension

-

Chorioamnionitis TWINS Polyhydramnius Macrosomia Hydrocepahalous Muscle Exhaustion Mulliparity Precipitate Labour Prolonged Labour Uterine anamolies Fibroid uterus Congenital malformations Induced labour associated with more blood loss than non induced labour

TONE Atonicity or 70% of PPH Abnormal Contraction 5. Drugs

6. 7.

Halogenated anesthetic agents Nitrates NSAID’S MgSo4 B Sympathomimetics ( Tocolysis) Nifidipine Antepartum Haemorrahage Couvelaire uterus Exhastion of Muscle Mismanagement of III Stage a. No attempts to deliver the placenta until it is separated and the fundus is firmly retracted. b. Squeezing of the uterus should be avoid. c. A III stage > 18 mins. risk of PPH 6 times

TISSUE Abnormal Uterine Content Retained blood clots- Atonic uterus Retained placenta or Products a. b. c. d.

Abnormal Placentation Multiparity Placental anomalies Previous Uterus surgery

Accreta Increta Percreta

Prevention of PPH

•Active Management of III Stage of Labour •Universal

• Identification

of Woman at risk for PPH

• Active

management of Labor

ACTIVE MANAGEMENT OF III STAGE 1. CCT0 Controlled Counter traction and controlled Cord Traction 2. 10 u Syntocinun IM at the time of delivery of Anterior or shoulder in Singleton Pregnancy, after birth of II baby in twin pregnancy

IDENTIFICATION OF WOMAN AT RISK FOR PPH

1. Atonicity

2. Abnormal uterine 3. Accidental 4. Abnormal Coagulation

Tone Tissue Content TRAUMA Injury Thrombus

IDENTIFICATION OF WOMAN AT RISK FOR PPH Risk Process

Aetiology Process

Atonicity or •Sepsis abnoraml •Over-distension Contraction of uterus •Muscle exhaustion Uterine anomalies

Clinical factors

•Chorioamnionits •Twins •Polyhydramnios •Big baby •Dm Multiparity •Prolonged/precipitate labour Fibroid uterus •congenital malformation

IDENTIFICATION OF WOMAN AT RISK FOR PPH Risk Process

Aetiology Process

Clinical factors

Abnormal Retained blood Atonic uterus. uterine clots Retained Abnormal placentation content placenta or (accreta, increta, percreta), products multiparity, placental anomalies, previous uterine surgery

IDENTIFICATION OF WOMAN AT RISK FOR PPH Risk Process

Aetiology Process

Accidenta •Uterine inversion • Extensions at l injury caesarean

•Extension at vaginal delivery Uterine rupture

Clinical factors

Mismanaged third stage, short cord, fundal placenta. Malposition, deep engagement Instrumental delivery, median episiotomy, big baby, precipitate labour Previous uterine surgery , uterine anomalies, instrumental delivery , misuse of oxytocics, external injury, malpresentation, multiparity, precipitate labour, external and Internal version , MRP, morbidly adherent placenta, breech extraction

IDENTIFICATION OF WOMAN AT RISK FOR PPH Risk Process

Aetiology Process

Abnormal Pre-existing Coagulation Acquired in pregnancy

Clinical factors

Haemophilla A, Von Willebrand’s disease, ITP, H/O liver diseases. ITP, HELLP syndrome, abruptio placenta, retained dead foetus syndrome, amniotic fluid embolism, over whelming maternal sepsis, therapeutic anticoagulant overdose.

ACTIVE MANAGEMENT OF LABOUR IN WOMEN AT RISK OF PPH 1. Additional Syntocinon 10-20 units in 500 ml RL, 150ml/hour 2. 250 µg of Carboprost tromethamine , IM, if no contraindication exists ( Asthma x Cardiac disease.

TREATMENT OF PRIMARY PPH LEVEL I AND LEVEL II CARE

TISSUE

TONE

TRAUMA

THROMBIN

Retained placenta Clots

Uterine Atony

Genital Truma

Abnormal Coagulation Profile

Ask for Cervix Exploration Set

Liaise with critical care experts, hematalogist

Adequate Bimanual compression analgesia

Manual removal

IM Carboprost tromethamine 0.25mg IMCompress Wound repeat after 15 min after I dose IV Methyl Ergometrine 0.2 mg, IV ( III Uterotonic drug )

Analgesia

Aortic Compression

Repair

Uterine packing Uterine tamponade sengstaken tude / foley’s catheter / Condom

TRANSFER TO A TERTIARY CARE CENTER

Blood Products

? TISSUE Retained placenta Clots

Adequate analgesia

Manual removal

Insert image page no 281 A Fig 39.3 Manual removal of placenta

TONE •Uterine Atony •Bimanual compression •IM Carboprost tromethamine 0.25mg IM repeat after 15 min after I dose •IV Methyl Ergometrine 0.2 mg, IV\ ( III Uterotonic drug ) •Aortic Compression •Uterine packing Uterine tamponade sengstaken tude / foley’s catheter / Condom

UTERINE ATONY

BIMANUAL COMPRESSION Squeeze the uterus firmly between the hands. Continue compression until bleeding stops

AORTIC CMPRESSIO Apply pressure above umbilicus, compressing the aorta to stop uterine bleeding until femoral pulse is not felt. Continue pressure till further help.

UTERINE PACKING • Packing the uterus is ineffective and wastes precious time. • This can be used before woman is shifted from prerophery to hospital failure to respond to oxytocics ( under proper antibiotic cover )

Insert image page no 226 b

UTERINE TAMPONADE Technique Foley catheter

Comments - 4 inch gauze; can soak with 5,000 units of thrombin in 5mL of sterile saline

Sengstaten- Blakemore tube SOS Bakri tamponade balloon

-Insert balloon: instill 300500 mL.

Condom Particularly useful as a temporizing measure, but if prompt response in not seen, preparation should be made for exploratory laparotomy

CLASSES OF HAEMORRHAGE Class I ( compensated )

Class II (mild)

Class III (moderate )

Class IV (severe)

Percentage blood loss

500- 1,000 ml or 10-15 %

1,000-1,500ml or 15-25 %

1,500-2,000ml or 25-35%

2,000-3,000ml or 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 slight fall 80-100 min

70-80mmhg

60mmHg

80-90mmHg

80_90mmHG

50-70mmHg

50mmHg

Mean arterial BP

FLUID RESUSCITATION Crytalloids

Colloids

Ringer lactate / Normal saline

If Blood loss is more than 20%

Replacement Volume: to maintain systolic BP at 90mm of Hg If more that 4-5L is required then CVP guided •6% STARCH OR 3.5% Gelatin fluid replacement •30-40ml per Kg per day Never use 5% Dextrose or dextrose containing fluids

•Remove sample for cross matching prior to infusion

Normal Saline : restrict its use to 2l avoid hypernatremia

Image @ page no 226 c

Packed Cells Indications •If Blood loss is more than 40% •Pre delivery Hb is < 7 gms/dl. •Critical trigger for packaged cells transfusion prior to surgical haemostasis Repeat Hb is 4-5gm/dl HCT<15% If continuous bleeding

FFP

Platelets

2 Units of FFP have to To maintain platelets be given for every 6 >50,000/cumm units of packed cells transfusion

TISSUE Under adequate Analgesia Anaesthsia

• Evacuate clots • Manual removal of placenta if not separated • If placental tissue piecemeal removal by sponge holder gently & gentle curettage

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 & B MUDALIAR: Page No 283 A and B Page No 289 – 40.2 & 40.3

THROMBIN • Discuss with critical care experts / hematologists • Blood products • Replace clotting factors • Anti coagulant antidote

BLOOD COMPONENT THERAPY Product

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 blood Increase platelet count cells, white blood 5,000-10,000/mm3per unit cells, plasma

Fresh frozen 250 plasma

Fibrinogen, Increase fibrinogen by antithrombin III, 10mg/dl factors V and VIII

CryoprcipitAte

Fibrinogen, factors Increase fibrinogen by 10 VIII and XIII, von mg/dl Willebrand factor

40

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

BLOOD COMPONENT THERAPY Surgical Management of PPH Uterine artery ligation

Bilateral; also can ligate uteroovaria vessels

B-Lynch suture

Hypogastric artery ligation

Repair of rupture Hysterectomy

Less successful than earlier thought; difficult technique ; generally reserved for practitioners experienced in the procedure

ATONIC PPH • Bimanual massage and compression – Elevation • Ulerotonic agents • Aortic Compression Remove slide

UTEROTONIC AGENTS Drug*

Dose/Route

Frequency

Comment

Oxytocin(Pitocin)

IV:10-40 units in 1 liter normal saline or lactated Ringer’s solution IM: 10 units

Continuos

Avoid undiluted rapid IV infusion Which causes hyotension

Methylergonovine (Methergine)

IM: 0.2 mg

Every 2-4h

Avoid if patient is hypertensive

15-methyl PGF2a

IM: 0.25 mg

Every 15-90 min, 8Avoid in asthmatic patients; doses maximum relative contraindication if hepatic, renal, and cardiac disease. Diarrhea, fever, tachycardia can occur.

( Carboprost ) (Hemabate)

Dinoprostoe ( Prostin E2)

Suppository : vaginal or rectal 20Every 2 h mg

Avoid if patient is hypotensive Fever is common. Stores frozen, it must be thawed to room temperature

Misoprostol ( Cytotec, PGE1)

Abbreviation: IV, Intravenously; IM, Intramuscularly; PG, Prostaglandin * All agent can cause nausea an vomiting

EVIDENCE BASE RECOMMENDATIONS • Routine active management is superior to expectant management in terms of blood loss, PPH and other serious third stage complications • Breast stimulation appears beneficial in terms of reduction in PPH, but safety issues have not be fully evaluated • The used of syntomertrine (oxytocin and ergomtrine) as part of routine active management of third stage of labour appears to be associated with a statistically significant reduction in risk of PH when compared to oxytocin where blood loss is < 1000 ml.

EVIDENCE BASE RECOMMENDATIONS • Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injection uterotonics as part of the active management of third stage of labour especially for low risk women. • No information is available from randomised controlled trials to inform management of women with secondary postpartum haemorrhage. • Umbilical vein injection of saline solution plus oxytocin appears to be effective in management of retained placenta. Saline solution alone does not appear to be more effective than expectant management. Further research into umbilical vein injection of oxytocin, prostaglandins or plasma expanders is needed.

Recommendations by WHO I.

2.

3.

4.

Category A: Practices which are demonstrably useful and must be encouraged ►Prophylactic oxytocics in third stage of labour in woman with risk of PPH, or endangered by even a small amount of blood loss. Category B : Practices which are harmful or ineffective and should be eliminated ►Use of oral ergometrine in third stage of labour to present or control haemorrhage. ►Routine use of parenteral ergometrine in third stage of labour. Category C: Practices for which insufficient evidence exists and further research is needed to clarify the issue ►Routine oxytocin, controlled cord traction or combination of two during third stage of labour. ►Nipple stimulation to increase uterine contractions during third stage. Category D: Practices which are frequently used inappropriately. ►Manual exploration of uterus after delivery.

SOME HARD FACTS ABOUT PPH • • • • • • • • • •

11% OF live Birth-Severe PPH. 14 Million / Year Globally. 3.9% of Vaginal Deliveries. 6.4% of C.S. 1.4 Million Women die yearly. 15/25% Maternal Death in India-Due to PPH. 12% Severe Anaemia – Post Delivery. About 10% Obstetric Hystrectomy due to PPH. Increased Obstetrics care decreases PPH related problem. ( In U.K. only one death out of 271 from PPH 0.35%!!) Blood Component thraoy is better than whole blood. Awareness, Information & Training in surgical management is LIFE SAVING!

PPH at a Glance Stage 0 (Normal loss )

Approximately Blood loss (ml) <500

Volume loss %

Sings & Symptoms

<10

None

ALERT LINE 1

500-1000

15

Minimal

ACTION LINE 2

1200-1500

20-25

↓ urine output ↑ pulse rate ↑respiratory rate Postural hypotension Narrow pulse pressure

3

18002100

30-35

hypotension Tachycardia Cold clammy Techypnea

4

>2400

>40

Profound shock

STAGE WISE MANAGEMENT 1= Need Observation + replacement therapy 2= Replacement therapy and oxytocics 3= Urgent active management 4= Critical active management ( 50% mortality if not managed actively )

ROLE OF EMBLOZATION OF Ut. ARTERY This is a relatively new technique which required the help of a trained interventional radiologist and a good fluoroscopy setup.