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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. Haemorrhagic Shock.
2. Consumptive Coagulopathy.
3. Multiple organ failure ( Renal failure).
4. Death.
5. Need for internal iliac ligation and its complications.
6. Need for hystrectomy and loss of child bearing potential.
7. Complications of Blood transfusion.
8. 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

After 24 hours and within 6-12


Within 24 hours of delivery
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
4T’s
CAUSES OF PPH. 4A’s

• Tone - Atonicity
• Tissue - Abnormal ut content
• Trauma - Accidental injury
• Thrombosis - Abnormal Coagulation
TONE
Atonicity or 70% of PPH Abnormal Contraction
1. Sepsis - Chorioamnionitis
2. Overdistension - TWINS
Polyhydramnius
Macrosomia
Hydrocepahalous
3. Muscle Exhaustion - Mulliparity
Precipitate Labour
Prolonged Labour
4. 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
Halogenated anesthetic agents
Nitrates
NSAID’S
MgSo4
B Sympathomimetics ( Tocolysis)
Nifidipine
6. Antepartum Haemorrahage
Couvelaire uterus Exhastion of Muscle
7. 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
Accreta
a. Abnormal Placentation Increta
Percreta
b. Multiparity
c. Placental anomalies
d. Previous Uterus surgery
Prevention of PPH

•Active Management • Identification


of • Active
manag-
of III Stage of Woman at risk for ement of Labor
Labour PPH

•Universal
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 - Tone
2. Abnormal uterine - Tissue Content
3. Accidental - TRAUMA Injury
4. Abnormal - Thrombus
Coagulation
IDENTIFICATION OF WOMAN AT RISK FOR PPH
Risk Aetiology Clinical factors
Process Process

Atonicity or •Sepsis •Chorioamnionits


abnoraml •Over-distension •Twins
Contraction of uterus •Polyhydramnios
•Muscle •Big baby
exhaustion •Dm Multiparity
Uterine
anomalies •Prolonged/precipitate labour
Fibroid uterus
•congenital malformation
IDENTIFICATION OF WOMAN AT RISK FOR PPH

Risk Aetiology Clinical factors


Process Process

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 Aetiology Process Clinical factors
Process

Accidenta •Uterine inversion Mismanaged third stage, short cord,


l injury • Extensions at fundal placenta.
caesarean Malposition, deep engagement
•Extension at Instrumental delivery, median
vaginal delivery episiotomy, big baby, precipitate labour

Uterine rupture 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 Aetiology Process Clinical factors


Process

Abnormal Pre-existing Haemophilla A, Von Willebrand’s


Coagulati- disease, ITP, H/O liver diseases.
on
Acquired in ITP, HELLP syndrome, abruptio
pregnancy 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 Uterine Atony Genital Truma Abnormal Coagulation
placenta Profile
Clots
Adequate Bimanual compression Ask for Cervix Liaise with critical care
analgesia Exploration Set experts, hematalogist

Manual IM Carboprost tromethamine 0.25mg IMCompress Wound Blood Products


removal repeat after 15 min after I dose
IV Methyl Ergometrine 0.2 mg, IV ( III Analgesia
Uterotonic drug )
Aortic Compression Repair
Uterine packing Uterine tamponade
sengstaken tude / foley’s catheter /
Condom

TRANSFER TO A TERTIARY CARE CENTER


?
TISSUE

Retained placenta Clots

Insert image page no 281


Adequate analgesia A
Fig 39.3 Manual removal of placenta

Manual removal
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 Insert image page no 226 b
failure to respond to
oxytocics ( under proper
antibiotic cover )
UTERINE TAMPONADE
Technique Comments
Foley catheter - 4 inch gauze; can soak
with 5,000 units of
thrombin in 5mL of sterile
saline
Sengstaten- Blakemore -Insert balloon: instill 300-
tube 500 mL.
SOS Bakri tamponade
balloon
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 Class II Class III Class IV
( compensated ) (mild) (moderate ) (severe)

Percentage 500- 1,000 ml or 1,000-1,500ml 1,500-2,000ml 2,000-3,000ml


blood loss 10-15 % or 15-25 % or 25-35% or 35-45%

Signs and Plapitation, Weakness, Restlessness, Collapse, air


symptoms dizziness, sweating, oliguria, pallor hunger, anuria
tachycardia tachycardia

Pulse Normal 80-100/min 100-120/min 120-140/min

Systolic BP Normal Normal or slight 70-80mmhg 60mmHg


fall 80-100 min

Mean arterial 80-90mmHg 80_90mmHG 50-70mmHg 50mmHg


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 •Remove sample for cross matching prior
containing fluids to infusion
Normal Saline : restrict its use to 2l avoid
hypernatremia

Image @ page no 226 c


Packed Cells FFP Platelets
Indications 2 Units of FFP have to To maintain platelets
•If Blood loss is more than be given for every 6 >50,000/cumm
40% units of packed cells
transfusion
•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
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 240 Red blood cells, Increase hematocrit 3
cells white blood cells, percentage point,
plasma 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 Fibrinogen, Increase fibrinogen by


plasma antithrombin III, 10mg/dl
factors V and VIII
Cryoprcipit- 40 Fibrinogen, factors Increase fibrinogen by 10
Ate VIII and XIII, von mg/dl
Willebrand factor

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 Less successful than earlier thought; difficult


technique ; generally reserved for practitioners
experienced in the procedure

Repair of rupture

Hysterectomy
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 Continuos Avoid undiluted rapid IV infusion
saline or lactated Which causes hyotension
Ringer’s solution
IM: 10 units

Methylergonovine IM: 0.2 mg Every 2-4h Avoid if patient is hypertensive


(Methergine)
15-methyl PGF2a IM: 0.25 mg Every 15-90 min, 8Avoid in asthmatic patients;
( Carboprost ) doses maximum relative contraindication if hepatic,
(Hemabate) renal, and cardiac disease.
Diarrhea, fever, tachycardia can
occur.

Dinoprostoe Suppository : vaginal or rectal 20Every 2 h Avoid if patient is hypotensive


( Prostin E2) mg 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. 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.
2. 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.
3. 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.
4. 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 Approximately Volume loss % Sings & Symptoms
Blood loss (ml)
0 (Normal loss ) <500 <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.