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Obstetrical Hemorrhage

International

Obstetrical
Hemorrhage

Obstetrical Hemorrhage
International

Obstetrical Hemorrhage

Principles
Prompt diagnosis
Recognize reserve and ability to
compensate
Resuscitate vigorously
Identify underlying cause
Treat underlying cause

Obstetrical Hemorrhage
International

A 25 year- old G3 woman presents to the


maternity unit with vaginal bleeding.
Fetal heart rate is 140/mnt and her BP is
110/60mmHg and her HR 85/mnt. Fundal height
is 28cm. She has been given nothing.
What are the possible diagnosis ?
--------------------------------------------------------------How would you distinguish between the
diagnosis ? ----------------------------------------------

Obstetrical Hemorrhage
International

Estimated average interval between onset of major


obstetric complications and death, in the absence of
medical interventions
Complication
Haemorrhage
Postpartum
Antepartum
Ruptured uterus
Eclampsia
Obstructed labour
Infection

Hours

Days

2
12
1
2
3
6

From Maine, D. Prevention of Maternal Deaths in Developing Countries: Program Options and
Practical Considerations, in International Safe Motherhood Conference. 1987. npublished data:
Nairobi
WHO, UNPF, UNICEF, Health MSoP. Monitoring emergency obstetric care: a handbook 2009

Obstetrical Hemorrhage
International

Sebagian besar kematian maternal terjadi pada trimester ketiga dan satu minggu
pasca persalinan.
Dari penelitian di Matlab Bangladesh didapatkan lebih dari separuh kematian
maternal terjadi dalam minggu pertama setelah persalinan (gambar 1 dan 2). 2, 4

Obstetrical Hemorrhage
International

RS

Rumah

FasKes

Perjalanan

Tempat lain

Obstetrical Hemorrhage
International

Numbers of maternal deaths by clinical area

Qomariyah SN, Bell JS, Pambudi ES, Anggondowati T, Latief K, Achadi EL, et al. A practical approach to identifying maternal
deaths missed from routine hospital reports: lessons from Indonesia: Global Health Action 2009.

Obstetrical Hemorrhage
International

Modified early warning scoring


system
3

2
<40
30%
8
<35,0

1
40-50
15%

0
1
HR (bpm)
51-100
101-110
BP
>45%
Normal
15%
RR (/min)
9-14
15-20
Temp (oC)
35,0-38,4
CNS
A
V
Urine
0,5-1
Nil
<1ml/kg/2h <1ml/kg/h
>3ml/kg/2 h
Output
mL/kg/h

2
111-129
30%
21-29
>38,5
P

3
130
>45%
30
U

A = Alert V = Responds to Verbal commands P = Responds to Pain U = Unresponsive.

Intensive Care Society. Guidelines for the Introduction of Outreach Services. Intensive Care Society; 2002. In :Kakar V, OSullivan G. Management of obstetric
hemorrhage: anesthetic management. In: Briley A, Bewley S, editors. The Obstetric Hematology Manual. Cambridge: Cambridge University Press; 2010. p. 159-

Obstetrical Hemorrhage
International

Classification (EBV Maternal 100 mL/kgBW)


Hemorrhage
class

Estimated blood
loss (ml)

Blood volume
loss (%)

0 (normal
loss)

< 500

< 10

Clinical signs and


symptoms

Action

none

ALERT LINE

5001000

< 15

minimal

Need observation replacement


therapy

ACTION LINE

12001500

2025

18002100

3035

> 2400

> 40

urine output
pulse rate
Replacement therapy and oxytocics
respiratory rate
postural hypotension
narrow pulse pressure
hypotension
tachycardia
Urgent active management
cold clammy
tachypnea
Critical active management (50%
profound shock
mortality if not managed actively)

Benedetti T. Obstetric haemorrhage. In Gabbe SG, Niebyl JR, Simpson JL, eds. A Pocket Companion to Obstetrics, 4th edn. New York: Churchill Livingstone,
2002:Ch 17. In: B-Lynch C, Keith LG, Lalonde AB, Karoshi M, editors. A Textbook Of Postpartum Hemorrhage-A comprehensive guide to evaluation, management
and surgical intervention. Dumfriesshire: Sapiens Publishing; 2007. p. 35-44.

Obstetrical Hemorrhage
International

Modified Early Obstetric


Warning Scoring system
(MEOWS)

Aberdeen Maternity Hospital


and Liverpool Womens
Hospital

Risk management and medicolegal issues related to


postpartum haemorrhage
Upadhyay, Kalpana, MRCOG, Best Practice & Research:
Clinical Obstetrics & Gynaecology, Volume 22, Issue 6,
1149-1169

Obstetrical Hemorrhage

Shock

International

The Course of Hypovolaemic Shock in Absence of Therapy


Blood Pressure (mm Hg)

Blood Pressure

Heart Rate

Heart rate (min)


150

Bleeding

100

50

Compensation

Decompensation
Shock Phases

Irreversibility

(Time)

Obstetrical Hemorrhage
International

Antepartum
Hemorrhage

Obstetrical Hemorrhage
International

Objectives

Definitions and Incidence


Etiology and Risk Factors
Diagnosis
Management
- maternal and fetal assessment
- appropriate resuscitation
- no vaginal exam prior to determining
placental location
Individual Causes

Obstetrical Hemorrhage
International

Definition
vaginal bleeding between 20 weeks and delivery

Incidence
2% to 5% of all pregnancies
various causes of antepartum haemorrhage
- abruptio placenta
40% - 1% of
pregnancies
- unclassified
35%
- placenta previa
20% - % of
pregnancies
- lower genital tract lesion 5%
- other

Obstetrical Hemorrhage
International

Etiology of APH

Cervical
contact bleeding (e.g. intercourse, pap, neoplasia, examination
inflammation (e.g. infection)
effacement and dilatation (e.g. labour, cervical incompetence)
Placental
abruptio
previa
marginal sinus rupture
Vasa previa

Other - abnormal coagulation

Obstetrical Hemorrhage
International

Diagnostic Procedures
History and physical - No digital pelvic exam
Ultrasound
definitive test for previa
less useful in abruptio
Electronic Fetal Monitoring
for fetal compromise and uterine tone
Speculum
do ultrasound first if possible
No digital pelvic exam

Obstetrical Hemorrhage
International

Laboratory
CBC, blood type, Rh, Coombs
coagulation status
INR, PTT, fibrinogen
2 - 4 units of PRBC cross matched as
appropriate
bedside clot test
Kleihauer-Betke or Neirhaus test
vaginal and/or maternal blood
fetal lung maturity indices if appropriate

Obstetrical Hemorrhage
International

Vaginal Bleeding
Risk Factors Tests (No vaginal exam)
Fetal / Maternal Assessment

Mother or fetus unstable


Hemodynamic Resuscitation

Mother and fetus stable


Labs / Fetal Monitoring
U/S vaginal exam

Mother or fetus unstable


Delivery

Expectant
consider ongoing loss, etiology,
gestation

Obstetrical Hemorrhage
International

Management - ABC s
talk to and observe mother and fetus
large bore IV access
crystalloid (N/S)
CBC and coagulation status

cross-match and type


get HELP!

Obstetrical Hemorrhage
International

Hemodynamic Resuscitation
early aggressive resuscitation to protect fetus and
maternal organs from hypoperfusion and to prevent
DIC
stabilize vital signs
large bore IV crystalloid infusion, plasma expanders
follow hemoglobin and coagulation status
oxygen
consumption is up 20% in pregnancy

Obstetrical Hemorrhage
International

Fetal Considerations
lateral position increases cardiac output up to
30%
consider amniocentesis for lung indices
external fetal and labor monitoring
Kleihauer-Betke if suspected abruption

post-trauma monitor at least 4 hours for


evidence of fetal insult, abruptio, fetal
maternal transfusion

Obstetrical Hemorrhage
International

Abruptio Placenta - Definition


premature separation of normally implanted
placenta

Abruptio Placenta - Classification


Total fetal death
Partial fetus may tolerate up to 30-50%
abruption

Obstetrical Hemorrhage
International

Risk Factors for Abruption

hypertension: gestational and pre-existing


abdominal trauma
cocaine or crack abuse
previous abruption
overdistended uterus
multiple gestation, polyhydramnios
smoking, especially >1 pack/day

Obstetrical Hemorrhage
International

Clinical Presentation of Abruption


vaginal bleeding usually painful, unremitting
presence of risk factor
hemodynamic status may not correlate with amount
of vaginal blood loss concealed abruption
may be evidence of fetal compromise
uterus - tender, irritable, contracting or tetanic
ultrasound rules out previa and may show clot

Obstetrical Hemorrhage
International

ABRUPTION
Live Fetus

Dead Fetus
coagulopathy
Delivery
(watch for DIC)
Assess Maturity

Maturity
Vaginal delivery or C/S

Immaturity
Steroids plus expectancy
Transfusion? Transfer?

Obstetrical Hemorrhage
International

Placenta Previa - Definition


placenta covers or lies near the cervix

Placenta Previa - Classification


total
- entirely covers the os
partial
- partially covers the os
marginal - close enough to the os to increase risk
of bleeding as cervical effacement and dilatation
occur

Obstetrical Hemorrhage
International

Risk Factors for Previa


previous placenta previa
previous caesarian section or uterine surgery
multiparity (5% in grand multiparous patients)
advanced maternal age
multiple gestation
smoking

Obstetrical Hemorrhage
International

Clinical Presentation of Previa


vaginal bleeding usually painless (unless in labour)
maternal hemodynamic status corresponds to
amount of vaginal blood loss
well tolerated by fetus unless maternal instability
uterus - non-tender, not irritable, soft
may have abnormal lie
ultrasound shows previa !

Obstetrical Hemorrhage
International

PREVIA
Assess maturity

Maturity

Delivery by C/S (consider accreta)


May try vaginal if marginal

Immaturity

Steroids plus expectancy


Transfusion? Transfer?

Obstetrical Hemorrhage
International

Cesarean deliveries and the risk of


abnormal placentation and hysterectomy
Cesarean
Primary
Second
Third
Fourth
Fifth

Accreta (%)
0,24
0,31
0,57
2,13
2,33

Previa (%) Previa-Accreta (%) Hysterectomy (%)


0,26
3-5
0,65
0,65
11-24
0,42
1,8
39-47
0,9
3
40-60
2,41
10
67
3,49

Clark SL, Koonings PP, Phelan JP. Placenta previa / accreta and prior cesarean section. Obstet Gynecol 1985;66:8992.
Grobman WA, Gersnoviez R, Landon MB, et al. Pregnancy outcomes for women with placenta previa in relation to the number of prior
cesarean deliveries. Obstet Gynecol 2007;110:124955.
Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. NICHD-MFMU Network.
Obstet Gynecol 2006; 107:122632.

Lee YM, D'Alton ME. Cesarean delivery on maternal request: maternal and neonatal complications. Curr Opin Obstet Gynecol. 2008 Dec;20(6):597-601.

Obstetrical Hemorrhage
International

Vasa Previa - Definition

blood vessels in the membranes run across the cervix


requires a vellamentous insertion or succenturiate lobe

Complication

ex-sanguination following amniotomy or ROM

Diagnosis

Apt test or Kleihauer test on vaginal blood


terminal fetal bradycardia initial tachycardia or
sinusoidal FH

Prognosis

fetal mortality as high as 50-70%

Obstetrical Hemorrhage
International

Conclusions

assess maternal status and stability


assess fetal well-being
resuscitate appropriately
assess cause of bleeding - avoid vaginal exam
expectant management if appropriate
deliver if indicated based on maternal or fetal
status

Obstetrical Hemorrhage
International

Postpartum Hemorrhage

Obstetrical Hemorrhage
International

You have just delivered a 37 week twin


pregnancy per vagina. The third stage is
complicated by post partum hemorrhage
unresponsive to uterine message and the
use of oxytocin.
What would your next management
steps be ---------------------------------- ?

Obstetrical Hemorrhage
International

Objectives
Definition

Etiology
Risk Factors
Prevention
Management

Obstetrical Hemorrhage
International

Traditional Definition
blood loss of > 500 mL following vaginal delivery
blood loss of > 1000 mL following cesarean
delivery

Functional Definition
any blood loss that has the potential to produce or
produces hemodynamic instability

Incidence
about 5% of all deliveries

Obstetrical Hemorrhage
International

Jumlah Perdarahan Dalam Bedah


Obstetri
Prosedur

Jumlah Perdarahan
(mL)

Persalinan pervaginam

450

Seksio sesarea

1000

Seksio histerektomi elektif

1400

Seksio histerektomi darurat

3200

Clark, 1984; Chestnut, 1985; Gahres, 1962; Gilbert, 1987; Newton, 1961; Pritchard, 1962; and all of their
colleagues.

Obstetrical Hemorrhage
International

Uterine blood flow at various stages of pregnancy

Hytten F, Chamberlain G: Clinical Physiology in Obstetrics. Boston, Blackwell Scientific Publications, 1980

Obstetrical Hemorrhage
International

Empat T pengingat penyebab perdarahan


postpartum
Empat T

Perkiraan
Kejadian
(%)

Kasus

Tonus

Atonia uterus

70

Trauma

Laserasi, hematoma, inversio, ruptura

20

Tissue

Retensio plasenta, Plasenta akreta


perkreta inkreta, sisa plasenta

10

Thrombin

Koagulopati

1
Am Fam Physician 2007;75:875-82.

Obstetrical Hemorrhage
International

Risk Factors for PPH - Antepartum


previous PPH or manual removal
placental abruption, especially if concealed

intrauterine fetal demise


placenta previa
gestational hypertension with proteinuria
overdistended uterus (e.g. twins, polyhydramnios)
pre-existing maternal bleeding disorder (e.g. ITP)

Obstetrical Hemorrhage
International

Risk Factors for PPH - Intrapartum

Operative delivery - cesarean or assisted vaginal


Prolonged labour
Rapid labour
Induction or augmentation
Chorioamnionitis
Shoulder dystocia
Internal podalic version and extraction of second
twin
Acquired coagulopathy (e.G. Hellp, dic)

Obstetrical Hemorrhage
International

Risk Factors for PPH - Postpartum


Lacerations or episiotomy

Retained placenta/placental
abnormalities
Uterine rupture
Uterine inversion
Acquired coagulopathy (e.G. Dic)

Obstetrical Hemorrhage

Cara Persalinan & risiko PPH >1.000


mL

International

Mode of delivery
Emergency cesarean section
vs. elective
vs. operative vaginal delivery
vs. spontaneous vaginal delivery
Elective cesarean section
vs. operative vaginal delivery
vs. spontaneous vaginal delivery
Operative vaginal delivery
vs. spontaneous delivery
Source: Stones RW, et al.

Relative risk of PPH (99% CI)

2.2 (1.43.5)
3.7 (2.55.4)
8.8 (6.7411.6)
1.7 (0.982.8)
3.9 (2.56.2)
2.4 (1.63.5)

Obstetrical Hemorrhage
International

Prevention

be prepared
active management of the third stage
prophylactic oxytocin with delivery or with
delivery of anterior shoulder
- 10 U IM or 5 U IV bolus
- 20 U/L N/S IV run rapidly
early cord clamping and cutting
gentle cord traction with suprapubic
countertraction

Obstetrical Hemorrhage
International

Active v.s Expectant Third Stage Management


Outcome

(subjects)

PPH > 500 mL (n=4636)


PPH > 1000 mL (n=4636)
Maternal Hb < 91 (n=4256)
Blood transfusion (n=4829)
Therapeutic oxytocin (n=4829)
Nausea (n=3407)
Manual removal (n=4829)
0.1

1
Odds Ratio (95% Confidence Interval)

Cochrane Library
Issue 1, 2000

10

Obstetrical Hemorrhage
International

Postpartum Hemorrhage

Diagnosis - Is this a PPH?


consider risk factors
observe vaginal loss
express blood from vagina following C/S
REMEMBER
- blood loss is consistently underestimated
- ongoing trickling can lead to significant blood loss
- blood loss is generally well tolerated to a point

Obstetrical Hemorrhage
International

Diagnosis - What is the cause?


Assess the fundus

Inspect the lower genital tract


Explore the uterus
Retained placental fragments
Uterine rupture
Uterine inversion

Assess coagulation

Obstetrical Hemorrhage
International

Postpartum Hemorrhage

A = airway
B = breathing
C = circulation

Obstetrical Hemorrhage
International

HAEMOSTASIS Mnemonic

Mnemonic
H
Help. Ask for Help
A
Assess (vital sign, blood loss) and resucitate
Establish aetilogy, ensure aviabioity of blood, acbolic (oxytocin,
E
ergometrine, or syntometrine bolus IV/IM)
M
Massage uterus
O
S
T
A
S
I
S

Oxytocin infusion, ergometrine bolus IV/IM, prostaglandins per rectal


Shift to the theatre. Exclude retain products and trauma, bimanual
compression, abdominal aorta compression
Tamponade ballon and uterine packing
Apply compression uterus, B-Lynch technique or modified
Systemic pelvic devascularization : uterine, ovarian, quadriple, internal
iliaca, Lasso-Budiman technique

Initial Management

Medical Treatment
Conservative Non
Surgical Management

Conservative Surgical
Management

Interventional radiologist, if appropriate, uterine artery embolization


Subtotal/total hysterectomy

Last Effort- Non Conservative Surgical


Management

Mishra N, Chandraharan E. Postpartum haemorrhage (PPH). In: Warren R, Arulkumaran S, editors. Best Practice in Labour and Delivery. Cambridge: Cambridge
University Press; 2009. p. 160-70.

Obstetrical Hemorrhage
International

Classification (EBV Maternal 100 mL/kgBW)


Hemorrhage
class

Estimated blood
loss (ml)

Blood volume
loss (%)

0 (normal
loss)

< 500

< 10

Clinical signs and


symptoms

Action

none

ALERT LINE

5001000

< 15

minimal

Need observation replacement


therapy

ACTION LINE

12001500

2025

18002100

3035

> 2400

> 40

urine output
pulse rate
Replacement therapy and oxytocics
respiratory rate
postural hypotension
narrow pulse pressure
hypotension
tachycardia
Urgent active management
cold clammy
tachypnea
Critical active management (50%
profound shock
mortality if not managed actively)

Benedetti T. Obstetric haemorrhage. In Gabbe SG, Niebyl JR, Simpson JL, eds. A Pocket Companion to Obstetrics, 4th edn. New York: Churchill Livingstone,
2002:Ch 17. In: B-Lynch C, Keith LG, Lalonde AB, Karoshi M, editors. A Textbook Of Postpartum Hemorrhage-A comprehensive guide to evaluation, management
and surgical intervention. Dumfriesshire: Sapiens Publishing; 2007. p. 35-44.

Obstetrical Hemorrhage
International

Modified Early Obstetric


Warning Scoring system
(MEOWS)

Aberdeen Maternity Hospital


and Liverpool Womens
Hospital

Risk management and medicolegal issues related to


postpartum haemorrhage
Upadhyay, Kalpana, MRCOG, Best Practice & Research:
Clinical Obstetrics & Gynaecology, Volume 22, Issue 6,
1149-1169

Obstetrical Hemorrhage
International

Shock Index

It refers to heart rate divided by the systolic blood


pressure HR/SD
The normal value is 0.50.7.
With significant haemorrhage, it increases to 0.91.1.
A shock index of over 0.9 is associated with a need for
intensive therapy on admission.
The change in shock index of an individual woman
seems to correlate better in the identification of early
acute blood loss than other parameters, such as heart
rate and blood pressure taken in isolation.
Lin Lin Su. Haematological Disorders in Pregnancy Massive obstetric haemorrhage with disseminated intravascular
coagulopathy. Best Practice & Research Clinical Obstetrics & Gynaecology, 2012, Vol, Issue 1, Pages 77-90

Obstetrical Hemorrhage
International

Management - ABC s
talk to and observe patient

large bore IV access ( No. 16 G)


crystalloid - lots!

CBC
cross-match and type
get HELP!

Obstetrical Hemorrhage
International

Flow rates through intravenous


cannulae
Gauge number*

Colour code

20G
18G
16G
14G

Pink
Green
Grey
Orange

Flow rate
mL/min**
40-80
75-120
130-220
250-360

* G refers to a wire gauge classification of the size of the internal diameter of the cannula. It is slightly different to the
American and Standard Wire Gauges.
** The British standard for determining flow rate: involves in-vitro testing using distilled water at 22 C, kept at constant
pressure. The flow rates are therefore not the same as those achievable clinically.

Obstetrical Hemorrhage
International

Postpartum Hemorrhage

Management - Assess the fundus


simultaneous with ABC s

atony is the leading cause of PPH


if boggy bimanual massage
- rules out uterine inversion
- may feel lower tract injury
- evacuate clot from vagina and/or cervix
- may consider manual exploration at this
time

Obstetrical Hemorrhage
International

Roles and goals of crisis team members

Roles
Airway manager (#1)

Goals
Manages ventilation and oxygenation, intubates if
necessary
Airway assistant (#2) Provides equipment to airway manager, assists with bagmask ventilation, Check breathing,
Oxygen administered
Bedside assistant (#3) Provides patient information including AMPLE*,
medications delivery , Draws up medications, supplies crash
Equipment manager cart contents to appropriate team members
(#4)
Treatment:
IM Syntometrine, Syntocinon infusion, Misoprostol SL
Data manager/
Documentation :
recorder (#8)
Records vital signs, exam findings, test results, chart ,
Timings, drugs, persons present
Circulation (#6)
Circulation :
Lie flat or head down, Insert two large gauge cannulae, Take
blood for FBC, Clotting, Cross match 4 units, Commence 4
@ 500 mL crystalloid, FFP 4 Units or Cryoprecipitate 8 Units,
Consider O negative blood
Monitoring :
Evaluates pulses, Performs chest compressions , Blood
pressure,
Circulation, tissue perfusion, Consider CVP
Procedure MD (#7)
Performs procedures such as central lines, chest tubes,
pulse check
Treatment leader (#5) Inspection :
Blood loss, Uterine Tone, Placenta and membranes,
Perineum
Treatment :
Stop Bleeding : Uterine Massage, Bimanual compression,
Misoprostol PR, Decision for EUA

DeVita MA, Hillman K, Bellomo R, editors.


Medical Emergency Teams Implementation and
Outcome Measurement. Pittsburgh: Springer
Science+Business Media; 2006 p. 80-90.

Obstetrical Hemorrhage
International

Post partum haemorrhage clinical checklist

Call for assistance


Emergency bell activated
Airway
Check airway

Monitoring
Blood pressure
Heart rate
Circulation, tissue perfusion
Catheter and hourly urine
Consider CVP
Breathing
Inspection
Check breathing
Blood loss
Oxygen administered
Uterine Tone
Placenta and membranes
Perineum
Circulation
Treatment
Lie flat or head down
IM Syntometrine
Insert two large gauge cannulae
Syntocinon infusion
Take blood for FBC, Clotting, Cross match 6 Misoprostol PR
units
Carboprost/Hemabate IM
Commence 2 litres crystalloid
Uterine Massage
Consider O negative blood
Bimanual compression
Decision for EUA
Documentation
Timings, drugs, persons present etc

Obstetrical Hemorrhage
International

Postpartum Hemorrhage

Management - Bimanual Massage

Obstetrical Hemorrhage
International

Postpartum Hemorrhage

Management - Oxytocin
5 units IV bolus
20 units per L N/S IV wide open
10 units intramyometrial given

transabdominally

Obstetrical Hemorrhage
International

Management - Manual Exploration


if no response to bimanual massage and
oxytocin then proceed to exploration
manual exploration will:
- rule out uterine inversion
- palpate cervical injury
- remove retained placenta or clot from
uterus
- rule out uterine rupture or dehiscence

Obstetrical Hemorrhage
International

Uterotonika

Obstetrical Hemorrhage
International

Farmakodinamik Oksitosin & Misoprostol

Menit
10

20

30

40

50

60

Obstetrical Hemorrhage
International

Replacement of Inverted Uterus

Obstetrical Hemorrhage
International

Mengoreksi Inversio Uteri

Obstetrical Hemorrhage
International

Management - Additional Uterotonics


ergotamine - caution in hypertension
- 0,2 mg IM / IV, interval 15
- maximum dose 1 mg
Hemabate (carboprost) - asthma is relative
contraindication
- 15 methyl-prostaglandin F2
- 0,25 mg IM or intramyometrial
- Maximum dose 2 mg
Cytotec (misoprostol) - caution in asthma
- 400 g pr or po

Obstetrical Hemorrhage
International

Management - Bleeding with firm uterus


explore the lower genital tract

requirements -

appropriate analgesia

- good exposure and lighting


appropriate surgical repair
- may temporize with packing

Obstetrical Hemorrhage
International

Postpartum Hemorrhage

Management - Continued uterine bleeding


possible coagulopathy - INR, PTT, TCT, fibrinogen
if coagulation is abnormal:
- correct with clotting factors, platelets
if coagulation is normal:
- prepare for O.R. (may consider embolization)
- rule out uterine rupture, inadequate incision repair
- consider uterine/hypogastric ligation, hysterectomy

Obstetrical Hemorrhage
International

Management - ABC s

ENSURE that you are always


ahead with your
resuscitation!!!
consider need for Foley catheter, CVP, arterial line, etc
consider need for more expert help

Obstetrical Hemorrhage
International

HAEMOSTASIS Mnemonic

Mnemonic
H
Help. Ask for Help
A
Assess (vital sign, blood loss) and resucitate
Establish aetilogy, ensure aviabioity of blood, acbolic (oxytocin,
E
ergometrine, or syntometrine bolus IV/IM)
M
Massage uterus
O
S
T
A
S
I
S

Oxytocin infusion, ergometrine bolus IV/IM, prostaglandins per rectal


Shift to the theatre. Exclude retain products and trauma, bimanual
compression, abdominal aorta compression
Tamponade ballon and uterine packing
Apply compression uterus, B-Lynch technique or modified
Systemic pelvic devascularization : uterine, ovarian, quadriple, internal
iliaca, Lasso-Budiman technique

Initial Management

Medical Treatment
Conservative Non
Surgical Management

Conservative Surgical
Management

Interventional radiologist, if appropriate, uterine artery embolization


Subtotal/total hysterectomy

Last Effort- Non Conservative Surgical


Management

Mishra N, Chandraharan E. Postpartum haemorrhage (PPH). In: Warren R, Arulkumaran S, editors. Best Practice in Labour and Delivery. Cambridge: Cambridge
University Press; 2009. p. 160-70.

Obstetrical Hemorrhage
International

Kondom Kateter

Obstetrical Hemorrhage
International

Kompresi Aortaabdominalis

Obstetrical Hemorrhage
International

Kompresi Aortaabdominalis

Obstetrical Hemorrhage
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Kompresi Aortaabdominalis

Obstetrical Hemorrhage
International

B-Lynch

Obstetrical Hemorrhage
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Hayman uterine compression suture.

Evaluation and Management of Postpartum Hemorrhage


Sibai, Baha M., M.D., Management of Acute Obstetric Emergencies: Female Pelvic Surgery Video Atlas Series, 4, 41-70, 2011

Obstetrical Hemorrhage
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Quadriple

Obstetrical Hemorrhage
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HAEMOSTASIS
Systemic pelvic devascularization

Quadruple ligation

Obstetrical Hemorrhage
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Operative technique of internal iliac artery ligation


A , The retroperitoneal
space over the right
internal and external ilia
vessels has been opened
and the ureter retracted
medially. B , A right-angled
clamp is passed between
the iliac artery and the iliac
vein to receive a ligature of
No. 0 silk. The vessel
should be doubly ligated.
Reproduced from Pauerstein C [ed]: Clinical Obstetrics. New York, Wiley, 1987.) Postpartum Hemorrhage and Other Problems of the Third Stage
Belfort, Michael A., High Risk Pregnancy: Management Options, Chapter 75, 1283-1311.e5 2011

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Indications for Peripartum


Hysterectomy
n
Kastner et al 48
Glaze et al
87
Knight et al 315
Kwee et al
48

Accreta

Atony

49%
33%
38%
50%

30%
37%
53%
27%

Uterine
Previa
Rupture
9%
2%
0%
1%
14%
8%
0%
8%

Other
12%
29%
20%
15%

Glaze S, Ekwalanga P, Roberts G, et al: Peripartum hysterectomy: 1999 to 2006. Obstet Gynecol 111:732-738, 2008
Kwee A, Bots ML, Visser GH, et al: Emergency peripartum hysterectomy: A prospective study in The Netherlands. Eur J Obstet Gynecol Reprod
Biol 124:187-192, 2006
Chestnut DH, Eden RD, Gall SA, et al: Peripartum hysterectomy: A review of cesarean and postpartum hysterectomy. Obstet Gynecol 65: 365-370,
1985
Kastner ES, Figueroa R, Garry D, et al: Emergency peripartum hysterectomy: Experience at a community teaching hospital. Obstet Gynecol
99:971-975, 2002
Shah M, Wright JD. Surgical Intervention in the Management of Postpartum Hemorrhage. Semin Perinatol. 2009;33:109-15

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Complications Associated with Peripartum Hysterectomy


Knight (n= 315)

Silver et al (n = Kastner et al (n Kwee et al (n =


216)
= 48)
48)

4,20%

Death

0,60%

Cystotomy

12,20%

12,00%

6,30%

8,30%

Ureteral injury

4,50%

2,30%

6,30%

Oophorectomy

5,80%

NA

6,30%

NA

Reoperation

19,60%

11,60%

NA

33,30%

ICU admission
Mechanical
ventilation
Thromboembolic
events
Cardiac arrest

84,00%

23,20%

20,10%

75,00%

7,20%

12,50%

NA

NA

1,30%

1,90%

4,20%

4,20%

1,90%

NA

2,10%

2,10%

Febrile morbidity

NA

NA

34%

NA

Mercier FJ, Velde MVd. Major Obstetric Hemorrhage. Anesthesiology Clin. 2008;26:53-66

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Medical Anti Schock Trouser &


Penekan Infus

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Conclusions

be prepared
practice prevention
assess the loss
assess maternal status
resuscitate vigorously and appropriately
diagnose the cause
treat the cause

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Postpartum Hemorrhage

Management - Evolution
Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness

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Thank You

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Kleihauer-Betke
Indications
Measures fetal cells in maternal circulation
Used in assessing for Rh Sensitization
Maternal blood Rh negative
Large antepartum bleed
Mechanism
Blood Film stained with acid elution
Fetal HbF more acid resistant
Fetal RBC darkly stained, Maternal RBC "ghosts"
Technique
Count Fetal cells per 50 low power fields
Five cells per 50 (lpf) = 0.5 ml bleed

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Interpretation
Calculate Maternal Blood Volume (ml) =
(Pre-pregnant weight in kg) x 70 ml/kg x (1.0 +
(0.5 x weeks gestation/36)) Estimated Blood loss (ml) at time of test
Calculate Fetal Whole Blood (ml) =
(Fetal Cell Count/Maternal Cell Count) x
Maternal Blood Volume
Rh Immune Globulin (RhoGAM) Dose
Give 300 g per 30 mL fetal whole blood or 15
mL PRBC

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Postpartum Hemorrhage

Keep your bloody fingers off


the cervix!

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Uterine Atony
most common cause of PPH (75-80%)
risk factors:

multiple gestation
polyhydramnios
macrosomia
prolonged labor
grandmultiparity
precipitous labor

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Uterine Atony
failure of the uterus to contract down on
the myometrial spiral arteries and
decidual veins
the uterus is soft and boggy
Initial Management

ABCs
large bore IVs, NS bolus
CBC, PT, PTT, crossmatch
rule out traumatic causes of PPH

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Uterine Atony
Management
bimanual massage of the uterus
oxytocin
- 5-10 U IV bolus or
- 40 U in 1 L NS @ 250 cc/hr or
- 10 U intrauterine (transabdominal)

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Uterine Atony
Management
methylergonovine
- 0.2 mg IM
- contraindicated in hypertension

Hemabate (prostaglandin F2-alpha)


- 0.25 mg IM or intrauterine
- asthma is relative contraindication

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Uterine Atony
Management
if pharmacological measures fail, surgical
intervention may be necessary
- uterine artery embolization
- uterine artery ligation
- hysterectomy

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Trauma
genital tract trauma
2nd most common cause of PPH
vaginal lacerations remember to place
first suture above the apex
cervical lacerations suture only if
actively bleeding
large/expanding hematomas require
surgical evacuation

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Trauma
Uterine inversion
1/2500 pregnancies
associated with uterine atony or
excessive cord traction during 3rd stage
sudden onset pain/shock/hemorrhage,
uterus seen in vaginal vault or introitus
should attempt immediate repositioning
may require uterine relaxant (terbutaline
0.25 mg IV followed by 2 g of MgSO4 over
10 min)

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Trauma
Uterine Rupture
1/2000 deliveries
risk factors: C-section, grand multiparity,
previous uterine surgery, advanced age
may be full or partial thickness
postpartum presents as abdominal pain/
distension, PPH, shock, palpable defect
require surgical intervention

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Tissue
retained placental fragments
prevents uterine contraction
inspect placenta for any defects
treatment requires manual removal of
retained fragments
if the placenta is abnormally adherent to
the myometrium then this is placenta
accreta

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Thrombin
coagulopathies
congenital: von Willebrands disease,
hemophilia A/B
acquired: ITP, TTP, DIC (2 sepsis,
placental abruption, amniotic fluid
embolus, pre-eclampsia
treament: platelets, cryoprecipitate, FFP

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The use of B-Iynch technique and Lasso Budiman technique


to control post partum hemorrhage due to uterine atony
Technique
B-Lynch
Lasso-Budiman
Total

Cases
26
12
38

Success
25 (96%)
11 (91%)
36 (94%)

Failure
1 (4%)
1 (7%)
2 (6%)

Complication
2 (14%)
2 (6%)

M. Nurhadi Rahman, Gulardi H.Wiknjosastro, Ali Sungkar, Novan Satya Pamungkas, Budiman, Iswan Syarif, Agung Suhadi.
The use of B-Iynch technique and Lasso Budiman technique to control post partum hemorrhage due to uterine atony. PIT

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B-Lynch