Overview and medical management of PPH

Dr. Suhas Otiv Consultant, KEM Hospital, Pune

Lancet 2006; l368:1189-200

Mortality from PPH

Half of 500,000 maternal deaths globally 28 % of maternal deaths in developing countries Risk of death from PPH 1 in 1000 deliveries - developing countries 1 in 100,000 deliveries developed countries

Lancet 2006; l367:1066-72

Incidence of PPH
PPH > 500ml Major PPH > 1000 ml ACOG 5 17 % of all deliveries

1.3 2.5 % of all deliveries

3.9 % of all deliveries

Definition of PPH
Primary PPH: 0 24 hours; Secondary PPH: 1 - 84 days Blood loss > 500 ml at vaginal delivery > 750 - 1000 ml at Cesarean > 1000 ml loss at vaginal delivery - Fall in hematocrit 10% - Need for PRBC transfusion

Severe PPH ACOG:

Rate of blood loss: > 150ml/min or sudden loss > 1.5 2 l

PPH can occur with minimal vaginal bleeding !!!!

Accuracy of visual estimation of blood loss

Modified WHO
Blood collection method

Modified WHO Weighing Blood loss

Modified WHO

Measuring volume of blood loss -Transfer of blood -Mops squeezed

BRASSS-V

Blood Collection Drape with Calibrated Receptacle

Etiology of PPH
Uterine Atony Lacerations of vagina, cervix Uterine rupture Uterine inversion Retained placental fragments Placental accreta / increta / percreta Coagulopathy > 80 %

10%

5% 1%

Risk factors for PPH

Nulliparity Obesity Large baby Prolonged labor APH Multiple pregnancy Cesarean delivery Advanced maternal age PIH PPH in previous delivery Augmented labor Forceps delivery Use of tocolytics Grand multiparity

65 % cases of PPH occur with no risk factors

PPH at Cesarean delivery: Risk Factors

General anesthesia Chorio-Amnionitis Pre-eclampsia Protracted active phase of labor Second-stage arrest Classic uterine incision

Obstet Gynecol 1991 Jan;77(1):77-82

Risk factors for PPH: a case control study

comparing 666 cases with controls in 154311 deliveries
Retained placenta (OR 3.5, 95% CI 2.1-5.8)

Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)
Placenta accreta (OR 3.3, 95% CI 1.7-6.4) Lacerations (OR 2.4, 95% CI 2.0-2.8)

Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)

Large for gestational age new born (eg, >4000 g) (OR 1.9, 95% CI 1.6-2.4) Hypertensive disorders (OR 1.7, 95% CI 1.2-2.1)

Induction of labor (OR 1.4, 95% CI 1.1-1.7)

Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7)

J Matern Fetal Neonatal Med. 2005;18(3):149

Management of PPH
Scenarios labor room, OR, wards, peripheral hospital Effective management
Prompt response Organized team work Clear priorities, decisive

Help:

communication, monitoring, assistance, documentation

Being prepared for PPH

Team: Nursing, doctors, surgical expertise, critical care physician / anesthesiologist Drugs: Oxytocin, Methergin, Carboprost, volume expanders, resuscitation

Equipment: Monitoring, resuscitation, Blood bank, Lab, ICU, OR

Management of PPH at vaginal delivery

First line Management Call for help Uterine massage IV access: X-match, labs Infuse NS rapidly, BP, Foley catheter, pulse oximeter, Prompt Uterotonic drugs Carboprost 250 mcg, 2 doses 15 minutes apart Oxytocin infusion 40 units / 500 ml in 30 60 min Methylergometrine 0.2mg i.m. one dose Misoprostol 400 - 800mcg Rapidly evaluate for vaginal / cervical lacerations Warmth, oxygen

Oxytocic drugs
Oxytocin Methyl ergometrine Misoprostol Carboprost

Oxytocin
Storage: Between 2-8 *C, avoid freezing Adverse effects: anti-diuretic effect, hypotension, arrhythmias Incompatible with noradrenaline, warfarin 10 40 IU / L of infusate

Ergometrine
Storage: Refrigerate, protect from light, stable for 60-90 days, discoloration discard Avoid : heart disease, hypertension, peripheral vascular disease, hepatic or renal impairment; with antiretroviral and macrolide antibiotics Adverse : Vomiting, nausea, HT, CVA Route: IM preferred, IV dilute in 5 ml NS

Carboprost PGF2 alpha

Caution : Asthma, cardiac disease, epilepsy, liver disease Storage: Refrigerate Adverse: Vomiting, diarrhea, flushing, Dosage: 250 mcg IM, repeat every 15 - 90 minutes, maximum 8 doses = 2 mg. IV injection - bronchospasm, hypertension, vomiting, and anaphylaxis

Misoprostol
PGE1 analogue Adverse effects vomiting, shivering at higher doses. No broncho-constriction. Storage: Stable at or below 25*C Route: Oral, buccal, rectal, vaginal Rapid onset of action lasting 4-6 h

Misoprostol as an adjunct to standard uterotonics for treatment of PPH

Lancet. 2010;375(9728):1808

1422 women with atonic PPH treated with routine uterotonic agents randomized to 600 mcg misoprostol sublingually Placebo sublingually Found no difference in blood loss > 500 ml in next 1 hour

Treatment of PPH with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin
Lancet. 2010;375(9710):217 31055 women delivered with prophylactic oxytocin in III stage, 809 (3%) who had atonic PPH were randomized to Misoprostol 800mcg sl Oxytocin 40 u infusion in 15 minutes Similar outcomes in both groups 90% women had bleeding controlled in 20 minutes; 30% women had additional blood loss of > 300 ml after Rx

After initial treatment

Evaluate for retained placental fragment uterine inversion lacerations coagulopathy Check urine output, response to resuscitation, time volume of blood lost

Volume replacement
Crystalloid: Ringer Lactate, Hartmann, NS RL similar to plasma only 20% retained in circulation Dextrose: only 10% retained, interferes with X matching NS avoid in pre-eclamptic patient Blood volume changes last for 40 minutes only Infuse 3 L for each 1 L of estimated blood loss Target 90mm systolic pressure, UOP 30ml/hr Give colloids after 2 L of crystalloids given

Colloids
Gelatin polymers - Hemaccel rapid urinary excretion anaphylaxis Hydroxyethyl starch Hetastarch, Pentastarch increases plasma volume by 70 230% dose 20 ml/kg = 1 to 1.5 L no anaphylactic reactions well tolerated lasts for 4 hours in circulation

Blood transfusion
No universally accepted guidelines for trigger PRBC x 2 if no improvement after 2-3 L of crystalloids or if ongoing blood loss likely

Warm carefully. > 40 *C severe transfusion reactions

Admin 1 FFP for every 1-2 units of PRBC, at 12-15ml/kg No drugs / injections with blood

Target
Hb > 7, Platelets > 50,000 /ml Fibrogen > 100mg/dl PT < 1.5 times control

Massive hemorrhage
Defined as > 10 units of BT required / 24 h Likely when persistent SBP < 90, Loss more than 1500ml

Cryoprecipitate if no response to FFP or Fibrogen level < 100 Expect platelet count < 50,000 after > 2 L blood loss. Platelets to maintain counts 25-50,000, 1:1

Secondary interventions
Repeated doses of Carboprost max 8 doses Intramyometrial Carboprost - off label Carboprost uterine irrigation Rectal Misoprostol - high doses >800mcg Intra-uterine Misoprostol Tamponade Sengstaken tube, Uterine Packing

Indications for laparotomy

Unabated blood loss Atony unresponsive to Rx Vital signs out of proportion to blood loss Vaginal laceration extending above fornix

Summary
Symptoms and vital signs of blood loss are more important than visual assessment of blood loss Team approach with protocols and regular drills Prompt, sequential use of utero-tonic agents and replacement of volume are mainstay of Rx

Low Fibrinogen, abn PT, tachycardia and abnormalities of placental implantation and detectable troponin are predictors of increased morbidity

Thank you !