12/7/20

Prevention of
Post Partum Hemorrage

Ali Sungkar
Fetomaternal Division, Obstetric & Ginekologi
Faculty of Medicine. Universitas Indonesia,
Cipto Mangunkusumo Hospital Jakarta – Indonesia

Obststric Bleeding
Treathening For:
§ Respirasi
§ Circulation
§ Mortality & Morbidity for Mother & Fetal
§ Trauma

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Shock
The most common types of shock:

Type of shock Aetiology

Hypovolaemic shock Acute loss of at least 20% of the
circulating volume
Cardiogenic shock Acute disease of the heart, e.g. severe
myocardial infarction
Septic shock Septic condition caused by infectious
agents and their toxic products
Neurogenic shock Head trauma, spinal cord injury
Anaphylactic shock Repeated contact with or injection of
antigenic substances

Shock
Hemorrhagic Shock – Pathophysiology
Stage 1: Compensated Stage
Mechanism: Volume depletion due to bleeding

Body detects decrease in cardiac output

Sympathetic Nervous System is stimulated releasing Epinephrine and

Norepinehrine to stimulate Alpha and Beta Receptors

Alpha = Vasoconstriction Beta = Bronchodilation

and Cardiac Stimulation

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Shock
Hemorrhagic (Classic) shock – Pathophysiology

Stage 2: Progressive Stage

Mechanism: Kidneys release anti-diuretic hormone
which increases vasoconstriction by closing the
capillary sphincters, greatly reducing peripheral
circulation

Increased hypo-perfusion causes increase in

metabolic acid build up

Shock
Hemorrhagic (Classic) shock – Pathophysiology

Stage 3: Irreversible Stage

Mechanism: Compensatory mechanisms fail

Pre-capillary sphincters open releasing metabolic

acids, micro-emboli and other wastes into
circulation

Cell damage, organ failure and death occur

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Shock
The Course of Hypovolaemic Shock in Absence of Therapy

Blood Pressure Heart Rate

Blood Pressure (mm Hg)
Heart rate (min)

150 Bleeding

100

50

0 (Time)
Compensation Decompensation Irreversibility

Shock Phases

Shock
The Influence of Volume Replacement on Tissue Perfusion and Organ Function
Cerebral Function
Tissue
(Body Control) Pulmonary Function
Perfusion
(O2 Supply)

Volume Replacement
Liver
Function
(metabolism)
Heart Function Renal Function
(cardiac output) (Diuresis)

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Circulation Failure
Bleeding:
§ Early Trimester(abortion, Ektopik
Precnancy, Molar pregnancy)
§ Late Pregnancy or Delivery persalinan
(plasenta previa, solusio placenta,
uterin rupture)
§ Poast Partum (Uterine rupture ,
uterin atonia )

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Management Massive Bleeding

§ Circulation and hemorrhage control

§ Airway
§ Breathing
§ Shock position
§ Replace blood loss
§ Stop / minimize the bleeding process

Schock Position
ANGKAT
KEDUA
TUNGKAI

300 - 500 cc
darah dari kaki
pindah ke
sirkulasi sentral

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Simultan treatment in Shock

Management :
ü Fundal massage
ü Simultaneus with CAB
ü Atonia : Main Cause PPH
ü If atonia → masase bimanual Massage
ü Prove no Inversio uteri
ü Trauma Control in Reproductive tract
ü Evakuaion blood cloth from
ü Manual Exploration

Perdarahan Pasca Persalinan

Ø Kehilangan darah > 500 cc
Ø 10% dari persalinan
Ø Dalam 24 jam pertama: Primary PPH
Ø Jika 24 jam – 6 Mg: Secondary PPH
Ø Penyebab
ü Atonia uteri –
ü Retensio placentae
ü Iversio uterin
ü Trauma Genital

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Tatalaksana Perdarahan pasca Persalinan

Perdarahan Post Partum
Tanda Vital &Pertologan
IV/Oksitocyn/Carbetocyn
Folley Cath, Flow Sheet

Atony/Tone Plasenta/Tissue Laserasi/Trauma

Kompresi Sisa Implantasi
Bimanual Plasenta Abnormal Tatalaksana
Bedah
Metergin Ultrasound Tatalaksana
Misoprostol Bedah
Prostaglandin Mnnual
Explorasi
Tatalaksana / Curretage
Bedah

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Uterine Atony
Most common cause of PP Hemorrhage
Contraction of uterus is 1° mechanism for controlling
blood loss at delivery
Oxytocin & Prostaglandins, Carbetocyn
Risk factors
üMultiple gestation Chorioamnionitis
üMacrosomia Precipitous labor
üPolyhydramnios Tocolytics
üHigh parity Halogenated agents
üProlonged labor

Uterine Atony: Treatment

ü Uterine massage
ü Oxytocin:
Ø Produced by posterior pituitary
Ø Causes peripheral vasodilation, reflex tachycardia
Ø Administered diluted in IV fluid, not IV push
Ø Metabolized/excreted by liver, kidney, oxytocinase
ü Carbetocyn
ü Ergot derivatives
ü Prostaglandins
ü If drugs fail, embolization Arterial supply, Ligation,
or Hysterectomy

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Uterotonic agents promote uterine contractions

to prevent atony and speed up placental delivery
Class of drug Example Mechanism of action
• Binds at oxytocin receptors and stimulates
Oxytocin Oxytocin
myometrial smooth muscle contractions1
Long-acting oxytocin • Same as oxytocin, but duration of uterine
Carbetocin
agonist activity is longer1
• Significantly increase motor activity1
• Produces myometrial contractions via
Ergot alkaloids Ergometrine
calcium channel mechanism and actin–
myosin interaction1
Syntometrine • Same as ergometrine (sustained myometrial
Ergot alkaloids and
(500 mcg ergometrine contractions) and oxytocin (rapid onset of
oxytocin
+ 5 IU oxytocin) action)2
• Involved in cervical ripening3
• Increases myometrial contractions via
Prostaglandins Misoprostol
cervical smooth muscle relaxation and
increasing intracellular calcium1
1. Prendiville W, O’Connell M. in A Textbook of Postpartum Hemorrhage: A Comprehensive Guide to Evaluation, Management and Surgical Intervention 192006;98–113;
2. Alliance Pharmaceuticals. Syntometrine Summary of Product Characteristics. 2014; 3. Kelly RW. J Reprod Immunol 2002;57:217–224

Tatalaksana: Kompresi Bimanual

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Uterine Atony: Oxytocin

Oxytocin:
ü Produced by posterior pituitary
ü Causes peripheral vasodilation, reflex
tachycardia
ü Administered diluted in IV fluid, not IV
push
ü Metabolized/excreted by liver, kidney,
oxytocinase

Uterine Atony: Carbetocyn

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Carbetocin was created by making several

modifications to the oxytocin structure
Oxytocin Carbetocin

The changes made to the molecule extend the

Figure adapted from Cordovani D, et al. 2012 1
pharmacological action of carbetocin by:2
• Reducing enzymatic degradation
• Prolonging the half-life of the peptide
1. Cordovani D, et al. in A Comprehensive Textbook of Postpartum Hemorrhage. An Essential Clinical Reference for Effective Management;2012:360–368.
23
2. Sweeney G, et al. Curr Ther Res 1990;47:528−540.

Oxytocin and carbetocin bind at the oxytocin receptor to

induce uterine smooth muscle contraction1

C
C

Extrace C

llular 4
Calcium

Intracel
C Carbetocin

lular 5
IP 3 and diacylglycerol
Oxytocin receptor on
uterine smooth muscle

2
Store-operated
Intracellular calcium stores calcium channel

Voltage-operated
calcium channel
6
6

3
Calmodulin Myosin light-chain kinase Uterine contractions
24

Figure adapted from 1. Arrowsmith S, Wray S. J Neuroendocrinol 2014;26:356–369.

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Carbetocin is now amongst the uterotonics

recommended for the prevention of PPH1
Recommendation 1 The use of an effective uterotonic
for the prevention of PPH during the third stage of
labour is recommended for all births. To effectively
prevent PPH, only one of the following uterotonics
should be used:
1. Oxytocin
2. Carbetocin
3. Misoprostol
4. Ergometrine/methylergometrine
5. Oxytocin and ergometrine fixed-dose combination

Recommendation 1.1 The use of oxytocin (10 IU,

IM/IV) is recommended for the prevention of PPH for
all births

Recommendation 1.2 The use of carbetocin (100 mcg,

IM/IV) is recommended for the prevention of PPH for
all births in contexts where its cost is comparable to
other effective uterotonics
• For PPH prevention only
1. World Health Organization recommendations. Uterotonics for the prevention of postpartum haemorrhage. 2018. 25

Higher diuresis in patients treated

with carbetocin

Diuresis at 2 Hour after C section Diuresis at 12 Hour after C-section

In terms of haemodynamic profile, they reported :

• Both drugs have hypotensive effects although greater reduction of diastolic BP was shown in oxytocin
groups at the 3rd, 5th minutes after administration and 12 and 24 hours post-op
• Significantly higher diuresis in Carbetocin group were observed compared to oxytocin group (1300 ml ±
450 ml vs 1110 ml ± 250ml, p = 0.01)
Larciprete, G., et al. 2013. Carbetocin versus oxytocin in caesarean section with high risk of post-partum haemorrhage. Journal of Prenatal Medicine; 7 (1): 12-18 26

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Uterine Atony: Ergot Derivatives

Ergonovine & Methylergonovine (methergine)

ü Act via α-adrenergic mechanism
ü Adverse effects: nausea/vomiting,
vasoconstriction (including coronary), HTN,
ü Relative contraindications: chronic HTN, PIH
ü Dose: 0.2 mg IM (not IV), last 2-3 hrs.

Uterine Atony:Prostaglandins
ü ↑ myometrial intracellular free Ca++, enhance
action of other oxytocics
ü Side effects: fever, nausea/vomiting, diarrhea
ü 15-methyl PG F2α (Carboprost, Hemabate)
ü may cause bronchospasm,↑ shunt,
hypoxemia, HTN
ü 250 μg IM or intramyometrially q 15-30 min,
up to max 2 mg.
ü contraindications: asthma, hypoxemia

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Genital Trauma
ü Vaginal: associated with forceps, vacuum,
prolonged 2nd stage, multiple gestation, PIH
ü Vulvar: bleeding from branches of pudendal
arteries
ü Retroperitoneal: least common, most dangerous
ü laceration of branch of hypogastric during C/S
(or uterine rupture)
ü Dx: CT
ü Rx: expl. lap., ligation of hypogastric, hyst

Retained Placenta
Obstetric management:
ü manual removal, oxytocin
Anesthetic management:
ü Epidural or spinal anesthesia, if not
hypovolemic
ü or MAC
ü or GA (ketamine, RSI, intubate, 50% nitrous,
fentanyl)
ü Uterine relaxation may be requested (NTG)

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Placenta Accreta
Definitions:
ü Accreta vera: adherence of placenta to
myometrium
ü Increta: invasion of placenta into myometrium
ü Percreta: invasion of placenta to/thru the
serosa

Risk factors:
üPrior uterine trauma + placenta previa

Placenta Accreta II
Placenta previa + prior C/S v. accreta risk:
Number of prior C/S Incidence of accreta
0 5%
1 24%
2 47%
3 40%
4 67%
Rx: uterine curettage, oversewing of plac.
bed, usually hysterectomy (accreta is most
common indication for C-hyst)

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Uterine Inversion
Low mortality
Risk factors:
ü Uterine atony
ü Inappropriate fundal pressure
ü Umbilical cord traction
ü Uterine anomaly
Rx: replace the uterus, oxytocin, Hemabate,
methergine
ü May need uterine relaxation transiently
• NTG (50-100 μg IV) vs. halogenated agent

Invasive Treatment Options for

Obstetric Hemorrhage
ü Uterine arteries are branches of internal iliacs
(major supply to uterus)
ü Ovarian arteries also contribute during preg.
ü Options
Ø Angiographic embolization
Ø Surgical ligation of uterine, ovarian, internal
iliacs (preserves fertility): 42% success
Ø Cesarean or pp hysterectomy
Ø EBL ≈2500 cc(Emergenc), ≈1300 cc (Elective)

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Controle Bleeding

ü Kateter Foley
ü Kondom Kateter
ü Tampon uterus
ü Maier RC .Am J Obstet Gynecol 1993
Aug;169(2 pt 1):317-21

ü Medikamentosa: Metergin, Misoprostol,

Prostaglandin

Menghentikan
Perdarahan Kondom intra
uterin

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Menghentikan Perdarahan
¡ Thrombogenic uterine pack
¡ Bobrowski RA, Jones TB. Obstet Gynecol 1995 May;85(5 Pt 2):836-7

¡ Vaginal ligature of uterine arteries

¡ Philippe HJ, d'Oreye D, Lewin D. Int J Gynaecol Obstet 1997 Mar;56(3):267-70

¡ Ligasi a hipogastrika
¡ Histerektomi subtotal

Menghentikan Perdarahan
• B-Lynch suture
– Dacus JV, Busowski MT, Busowski JD, Smithson S, Masters K, Sibai BM. J Matern Fetal Med
2000 May-Jun;9(3):194-6
– Ferguson JE, Bourgeois FJ, Underwood PB. Obstet Gynecol 2000 Jun;95(6 Pt 2):1020-2

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Terima Kasih

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