MANAGEMENT OF

POST-PARTUM HEMORRHAGE

Dr. Doddy Gultom, SpOG.Mkes

RSUD Tarakan

post-partum
hemorrhage?
Haemorrhage

is the largest direct

cause of maternal death
PPH is mostly unpredictable
Most PPH is caused by uterine atony
Evidence-based, feasible, low-cost
interventions exist
Active management at the third stage
of labour can prevent 60% of PPH

Difficulties associated with

comparing
post-partum hemorrhage studies
Method

to determine blood loss

Visual underestimation 7080%

Conduct

during third stage of labour

Confounding factors in
epidemiological studies
58% of trials do not report their
definition of PPH

Maternal Health:
some ( underestimated)
statistics
180200 millions
pregnancies per year
75 millions unwanted pregnancies
50 millions induced abortions
20 millions unsafe abortions
358,000 maternal deaths (1000 per
day)
1 death every 1,5 min
20 maternal morbidities per minute
10-15 millions disabilities each year

WHO, 2010

Maternal Death Clock

Every Minute...

380 women become pregnant

190 women face unplanned
or unwanted pregnancy
110 women experience a
pregnancy related
complication
40 women have an unsafe
abortion
1 woman dies from a
pregnancy-related
complication
20 women suffer of a
disabilty related to childbirth

WHO, 2010

About two thirds of maternal deaths are

due to

Anemia-Hemorrhage
Obstructed

delivery

Eclampsia
Sepsis
Unsafe

abortion

They can
be
treated
by a
health
professio
nal

Causes of maternal
mortality

post-partum hemorrhage in
the UK
Maternal mortality rate/million

6
5
4
3
2
1
0

8587

8890

9193
9496
Year

Hall M. 2004; Why mothers die (20002002) CEMACH.

9799

0002

88% received substandard care

Sub-standard care

Organisational problems
Inappropriate booking
Inadequate blood transfusion
Intensive care facilities
Poor quality of resuscitation
Inadequate transfusion
Blood products
Equipment failure
Malfunctioning of specimen transport system
Failure to recognise or treat antenatal medical conditions
Inherited bleeding disorders
Failure of senior staff to attend
Concerns about the quality of surgical treatment given

Hall M. 2004; Why mothers die (20002002) CEMACH.

As with many
problems, there seems
to be two different
kinds of emergencies...
...depending on whether
the patient is in a
developed or undeveloped
country

Developed countries
Sequence:

Diagnosis

PPH

Protocol-

management
Treatment
Success

(>98%)

Undeveloped countries
Sequence:

Diagnosis PPH (?)

Emergency (?)
Transfer (?)
Centre (?)
Treatment (?)
Success (<60%)

Post-partum hemorrhage
Equal
opportunity
occurrence
2/3

no risk
factors

Not equal
opportunity
killer
Poor
Malnourished
Unhealthy

What is post-partum
hemorrhage?

Excess blood loss

after the birth of a
baby
PPH >500 ml (3.5
30%)
Severe PPH >1000 ml
(1.55.0%)

Immediate PPH:
Onset within 24 h of birth
PPH late:
not accepted
by24all!!
Onset after
h of birth

These definitions are

One of the main

problem
UNDERESTIMATION OF BLOOD
LOSS

Methods used to diagnose

post-partum hemorrhage
Clinical

methods

Physiological response to blood loss

Quantitative

methods

Visual assessment
Direct collection of blood into bedpan or plastic
bags
Gravimetric method
Changes in hematocrit and haemoglobin
Others
Plasma volume
Tagged erythrocytes

Estimated blood loss

Estimated blood loss (%)

30

Visual
Measured

25
20
15
10
5
0

>500 ml
Prasertcharoensuk et al. IJGO 2000

>1,000 ml

Calibrated bag
(Brass-V)

Risk factors
1.
2.
3.
4.
5.
6.

placenta previa with or without

previous uterine surgery.
previous myomectomy.
previous cesarean delivery.
Asherman's syndrome. (treated surgically)
submucous leiomyomata.
maternal age of 36 years and older.

Risk factors
(multivariable analysis)

Retained placenta, OR=3.5

Failure to progress to second stage, OR=3.4
Placenta accreta, OR=3.3
Lacerations, OR=2.4
Instrumental delivery, OR=2.3
Newborn large for gestational age, OR=1.9
Hypertensive disorders, OR=1.7
Induction of labour, OR=1.4
Augmentation of labour with oxytocin, OR=1.4

Sheiner E, et al. J Matern Fetal Neonatal Med 2005.

Obstetrics & Gynecology 1985;66:89-92

Placenta Previa/Accreta and Prior Cesarean Section
STEVEN L. CLARK Et al

The risk of placenta previa was 0.26% with an unscarred

uterus and increased almost linearly with the number of
prior cesarean sections to 10% in patients with four or
more.
With a placenta previa and one previous cesarean section,
the risk of placenta accreta was 24%; this risk continued
to increase to 67% (two of three) with a placenta previa
and four or more cesarean sections.

MANAGEMENT

Ch. B- Lynch

1 ed 2006
2 ed 2012

( FIGO 2009 Cape Town)

COMPREHENSIVE
Medical

Mechanical

Surgical

Joint statement management of the third

stage
of labour to prevent post-partum hemorrhage

Active management of the third stage of labour should be offered

to women since it reduces the incidence of post-partum
haemorrhage due to uterine atony
Consists of interventions designed to facilitate the delivery of
the placenta by increasing uterine contractions and to prevent
PPH by averting uterine atony. The usual components include:
Administration of uterotonic agents
Controlled cord traction
Uterine massage after delivery of the placenta, as
appropriate
Every attendant at birth needs to have the knowledge, skills and
critical judgment needed to carry out active management of the
third stage of labour and access to needed supplies and
equipment

active management
trials
Active management
Physiological management

Patients (%)

30

20

10

0
Transfusion Prolonged Therapeutic
Low
Retained
third stage uterotonic haemoglobin placenta
drugs

McCormick et al, IJGO 2002

POSTPARTUM HEMORRHAGE
need of action in the golden hour
in order to increase the probability of patient survival:

The mnemonic HAEMOSTASIS can assist in remembering

the sequence of events to confront

HAEMOSTASIS
H: Get HELP

HAEMOSTASIS

A: evaluate the vital parameters of the patient and the amount of blood
loss

HAEMOSTASIS

E: identify the cause (ethiology) and the appropriate

treatment (4T)
Tone
Tissue
Trauma
Trombin

Causes of post-partum
hemorrhage (4T)
TONE

TRAUMA

(70%)

TISSUE

CAUSE

(19%)

(10%)

THROMBIN
Anderson et al. Am Fam Physician 2007.

(1%)

RISK FACTORS
Etiology Process
Tone

Tissue

Trauma

Thrombin

Clinical Risk Factors

Overdistended Uterus

Polyhydramnios, Multiple Gestation

Macrosomia

Uterine Muscle Fatigue

Rapid Labor, Prolonged Labor

High Parity

Intra Amniotic Infection

Fever, Prolonged ROM

Functional/Anatomic Distortion of the

Uterus

Fibroid Uterus
Placenta Previa
Uterine Anomalies

Retained Products
Abnormal Placenta

Incomplete Placenta at Delivery

Previous Uterine Scar
High Parity

Retained Blood Clots

Atonic Uterus

Lacerations

Precipitous or Operative Delivery

Extensions at C/S

Malposition, Deep Engagement

Uterine Rupture

Previous Uterine Surgery

Uterine Inversion

High Parity, Fundal Placenta

Pre-existing

Coagulopaties, Liver Disease

Acquired in Pregnancy

ITP, DIC

Therapeutic Anti-coag

History of DVT or PE

HAEMOSTASIS

O: proceed with oxytocin infusion, prostaglandins

( via rectal, intramuscolar, IV, intramyometrial)

First line
Second line
Third line
(off label)

Drugs to prevent and treat uterine atony

Prophylactic syntometrine versus oxytocin

Prophylactic use of oxytocin
Carbetocin
Injectable prostaglandins
Misoprostol

Ancient Oxytocics

Egyptian Papyrus Ebers, 1500 BC

contract uterus: speed birth, stem haemorrhage
hemp in honey
celery in milk
juniper berries
fly excrement (in many ancient pharmacopoeias)

Dioscorides: cyclamen, 100 AD

Ergot (Claviceps purpurea), 1582 AD

40

1953: Synthesis of Oxytocin

Vincent du Vigneaud
American biochemist
discovery, isolation, and synthesis
together with ADH/vasopressin

Nobel prize in chemistry 1955

sulphur compounds of high importance
first synthesis of a polypeptide hormone

The Nobel Foundation 1955

http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/oxytocin.gif
T Reinheimer, 2009

41

Oxytocin Today
oxytocin (sometimes combined with ergometrin)

Labour induction/augmentation

Prophylaxis and Treatment of Postpartum haemorrhage

retained placenta: umbilical vein injection
milk ejection/lactation: oxytocin nasal spray

Martindale 2008
http://www.appdrugs.com/ProdJPGs/OxytocinLg.jpg
T Reinheimer, 2009

42

Oxytocin Agonists

Carbetocin (DURATOCIN, PABAL)

long-acting synthetic analogue
indication: prevention of uterine atony
veterinary medicine

Non-peptide agonists
patented for erectile dysfunction
WAY-262464: patented for anxiety, schizophrenia

Pritt et al. 2004, Manning et al. 2008

http://www.bcnpeptides.com/images/products/carbetocina.jpg
WO/2003/000692, US/20070117794
T Reinheimer, 2009

43

 30 women with elective

caesarean section
5 u of oxytocin either
as a bolus injection or
an infusion over 5 min
Heart rate and intraarterial blood pressure
recorded every 5 s

Mean change of MAP (mmHg)

Mean arterial pressure (MAP)

changes with oxytocin

Study period (s)

Thomas JS, et al. Br J Anaesth 2007

Carbetocin Pharmacodynamics
Oxytocin

Carbetocin

N=240
Study design: Prospective double-blind randomized controlled
study
Drugs: Carbetocin 100 g i.m. vs. syntometrine (5 IU of oxytocin
and
0.5 mg of ergometrine) i.m.
Primary outcome: postpartum hemorrhage requiring additional
uterotonic therapy

Authors Conclusion:
A

single dose of intramuscular

carbetocin
100g may be more effective as
compared to a single intramuscular
dose of syntometrine (5 IU of oxytocin
and 0.5 mg of ergometrine) in reducing
postpartum blood loss

Lower

incidence of adverse effects.

N=377
Study design: double-blind randomised single centre study
Drugs: carbetocin 100 g or oxytocin 5 IU, both i.v.
Primary outcome: Need of additional pharmacological oxytocic
interventions.
Secondary outcomes: Estimated blood loss, difference in
preoperative and postoperative haemoglobin, incidence of blood
transfusion and adverse effects

Authors conclusion:
Carbetocin reduces the use of
additional oxytocics following
caesarean section when compared
with the licensed dose of oxytocin
(5 IU)

Carbetocin versus oxytocin

REVIEW: Oxytocin agonists for preventing PPH

COMPARISON: 01 Carbetocin versus oxytocin
OUTCOME: 02 Use of additional uterotonic therapy

Study

Carbetocin
n/N

Oxytocin
n/N

RR (Fixed)
95% CI

Weight
(%)

RR (Fixed)
95% CI

01 Caesarean delivery
Boucher 1998
Dansereau 1999
Subtotal (95%
CI)

0/29

3/28

100

0.14 (0.01, 2.56)

15/317

32/318

900

0.47 (0.26, 0.85)

346

346

100.0

0.44 (0.25,
0.78)

Total events: 15 (carbetocin), 35 (oxytocin)

Test for heterogeneity chi-square=0.66; df=1; p=0.42; I2=0.0%
Test for overall effect z=2.81; p=0.005
02 Vaginal delivery
Boucher 2004
Subtotal (95%
CI)

12/83

12/77

100.0

0.93 (0.44, 1.94)

83

77

100.0

0.93 (0.44,
1.94)

Total events: 12 (carbetocin), 12 (oxytocin)

Test for heterogeneity not applicable
0.001
0.1
Su LL, et al. Cochrane Database Syst Rev. 2007
Test for overall effect z=0.20; p=0.8
Favours carbetocin
Jul 18;(3):CD005457

10 100 1000

Favours oxytocin

Conclusions
Prevention of PPH
Vaginal birth: active management, Oxytocin (3-5
IU), no prostaglandins, no ergometrin
Caesarean section: Carbetocin (Pabal), Oxytocin
5IU 2-3min no bolus, no PGs, no ergometrin
Therapy of PPH
OT (10-40 IU/liter), ergometrin (0.2mg every 2-3
hours)
PGE2/PGF2alpha (0.25 mg i.m. every 15-90 min)
Misoprostol 800-1000mcg rectally (off label)
Carbetocin (off label)

HAEMOSTASIS
S: transfer the patient to the operating room
( exclude trauma or retained products, proceed with bimanual
compression)

HAEMOSTASIS

T: Balloon Tamponade;

HAEMOSTASIS
T: Balloon Tamponade;
Uterine packing

(2009)

Traditional
method

Bakri balloon

TAMPONADE WITH
BAKRI BALLOON
Simple and efficient (87-95 % success rate)
Applicable after cesarean and vaginal births
Used as method of prevention in cesareans at
high hemorrhagic risk (placental pathologies,
uterine over-distension, preeclampsia, precedent
hysterotomy, coagulopathy, etc) and in the case of
contraindications for prostaglandins (asthma,
glaucoma, important hepatic and renal
dysfunction)
Easy to insert and remove
Continuous monitoring of blood loss

BAKRI BALLOON

The Bakri is a balloon in silicon, latex-free, which is

filled with physiological solution (500 cc max) and is
able to create a real intrinsic compression on the
myometrial walls: the filling volume can be varied in
relation to the dimension of the uterus and the
contractile response
Additionally to the ease of insertion it has the
possibility to monitor the amount of blood loss
thanks to the drainage holes located in the distal part
of the catheter, which is attached to a sac in order to
collect the fluids. This access is used also to perform
washings of the uterine cavity.
Associate adequate antibiotic coverage
Removal of the balloon within 24 hrs administering
uterotonics/uterokinetics before deflating

Bakri balloon

The intrauterine balloon

Ultrasound

Bladder
Bakri
balloon
Bakri
balloon

myoma
Catetere
vescicale

BAKRI
BALLOON

HAEMOSTASIS

A: apply sutures

HAEMOSTASIS

A: apply compression sutures

B-Lynch suture

HAEMOSTASIS

A: apply compressive sutures

Cho multiple quadrate sutures

Hayman uterine compressive sutures
Does not necessitate to open
the uterine cavity

HAEMOSTASIS

A: perform sutures

Suture of Hayman

HAEMOSTASIS

S: Systematic pelvic devascularization

Rescue Surgery:

Ligation uterine artery and ovarian artery

Triple ligation of Tsiruinikov :

ligation of the uterine arteries, round ligament and the ute

Vascular ligation
Uterine
Ovarian
Int iliac

Vascular ligation

HAEMOSTASIS

Rescue Surgery

Ligation hypogastric artery

Underneath the superior gluteal
artery

Hypogastric artery ligation

success 84%

Hansch E, etal. AJOG 1999

HAEMOSTASIS
I: Interventional radiologist Uterine Artery Embolization
(Limiting factors: hemodinamically stable cases - presence of angiographist - transport to
radiology)

Fragments of gelfoam are

injected (gelatin sponge
resorbable in 10-30 days)

HAEMOSTASIS
I: Interventional radiologist Uterine Artery Embolisation

HAEMOSTASIS
S : Subtotal or total abdominal hysterectomy
Rescue Surgery :

total hysterectomy / subtotal

1.55 % births
0.24% and 0.90% of all cesarean sections
ISTAT

2006

between 1480 and 1800 hysterectomies/year

associated with cesarean section

The ideal treatment should be:

intuitive and easy to apply
secure and effective in the
prevention and the arrest of
hemorrhages
has an immediate result
avoids hysterectomy

Our Philosophy

Team work

EFFICACY & EFFICIENCY

TEAM- Obstetricians, Anesthetists,

Blood bank, Interventional
Radiologists
Max therapeutic
efforts within 2-3 hrs

Contemporary
involvement of all
professional figures
Liberal use of all
therapeutic agents

Follow in a stepwise way the guidelines

BASICS

INFORMED CONSENT

1. INTERVENTIONAL RADIOLOGISTS IN THE THEATRE

2. CLAMPING
UTERINE
VESSELS
BEFORE
PLACENTAL DELIVERY

3. ASSOCIATION OF COMPRESSIVE SUTURES

AND BAKRI BALLOON

B-Lynch + Bakri Balloon

SANDWICH EFFECT

B-Lynch + Bakri Balloon

IT LOOKS LIKE THE LUGGAGES

OF IMMIGRANTS..

NO RISK OF ISCHEMIA

Prevention of Postpartum Hemorrhage

( cases with elevated hemorrhagic risk: i.e., placenta previa post-C.S.)
STEP 1

PRELIMINARY PROPHYLACTIC
CATHETERIZATION OF THE
DESCENDING AORTA

STEP 2

EXTRACTION OF THE FETUS BY C.S.

AND PLACENTAL DELIVERY

STEP 3

MULTIPLE QUADRATE ENDOUTERINE

HEMOSTATIC SUTURES

STEP 4

PREPARATION OF B-LYNCH
COMPRESSIVE SUTURES

STEP 5

APPLICATION OF HYDROSTATIC
BALLOON (BAKRI-BALLOON)

STEP 6

REPOSITIONING OF UTERUS UTERINE

SUTURES-HYDROSTATIC BALLOON
INFLATION-B-LYNCH LIGATURE

IF THESE MANEUVRES FAIL

DEVASCOLARIZATING LIGATURE /SELECTIVE EMBOLIZATION
/HYSTERECTOMY

STEP
1

transomeral/transfemoral pre-carefour

Angiography

STEP 2

DELIVERY OF THE FETUS

ADMINISTRATION OF CARBETOCIN

STEP
2

CLAMPING UTERINE VESSELS

Prevention of postpartum hemorrhage

( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )

Assistance Plan
STEP 2

Squared hemostatic endouterine sutures

Rationale: at the level of the inferior uterine segment reduced muscular

component ; incomplete mechanical hemostasis after placental delivery;
conspicuous hemorrhage
multiple
quadrate
sutures in the IUS of 23 cm, transdecidual.
(Dexon
n.1-2,needle
with large curvature )

e
m
s

Affro
nti

Retraction
of
muscular fibers
clamping
occlusion
of
vasculature

the
with
and
the

STEP 3

Squared hemostatic endouterine

sutures

Prevention of postpartum hemorrhage

( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )

Assistance Plan
STEP 3

B-Lynch compressive sutures

The ligature of the sutures follows after STEP

4

STEP 4

PREPARATION OF
B-LYNCH SUTURE

STEP 4

Prevention of postpartum
hemorrhage
STEP 4

Application of hydrostatic balloon (Bakri balloon)

Uterine closure
Hydrostatic balloon inflation
B-Lynch suture
ligature

BAKRI-BALLOON POSITIONING

STEP 5

STEP 5

MILD INFLATION OF THE BALLOON

STEP 6

REPOSITIONING THE UTERUS;

FULL INFLATION OF BALLOON;
B-LINCH SUTURE APPLIED

postpartum
( Ex adiuvantibus )
hemorrhage

postpartum hemorrhage
( Ex adiuvantibus )

Separatore cellulare a
flusso continuo

Unit di gestione della temperatura corporea

postpartum hemorrhage
ADULT INTENSIVE CARE UNIT POSTPARTUM

ONGOING

END POINT :
SURGICAL CONSERVATIVE TREATMENT
REACHED 95%
4 HYSTERECTOMIES

( 78 OUT OF 82 )

DIFFICULT CASES.

US SCAN

DIFFICULT CASES.

RMN

DIFFICULT CASES .
US SCAN CHECK AFTER 30 DAYS

DIFFICULT CASES...

( 02.09.2011)

DIFFICULT CASES......

( 02.09.2011)

DIFFICULT CASES...

( 02.09.2011)

DIFFICULT CASES...

CESAREAN
HYSTERECTOMY

CESAREAN
HYSTERECTOMY

CESAREAN
HYSTERECTOMY

CESAREAN
HYSTERECTOMY

Considerations
All pregnancies are at risk of hemorrage in the post partum
even if at the moment of birth there were no risk factors.
Because our goal is to improve maternal health and prevent the
possibility of death during the pregnancy or birth it is
fundamental
to possess, other than a
solid preparation,
a trustworthy and well trained team and
the necessary instruments.
( Bakri balloon;Cell sorter with continuous flow; FloSeal)

New conservative approach in the

management of PPH

INTRODUCTION
Postpartum hemorrhage (PPH) is the
leading cause of maternal death
worldwide. Most deaths occur within
the first 4 hours after delivery, often
as a consequence of placental
delivery. Treatment option for PPH
include conservative management
(uteritonic
drugs,
selective
devascularization by ligation or
embolization of the uterine artery,
external compression with uterine
sutures and intrauterine packing).
Failure of these options necessitates
hysterectomy.
The objective of the study is to
report our experience with a
conservative management protocol
to treat PPH in high risk patients
diagnosed
with
placenta

G. Clerici, G. Epicoco, E. Bottaccioli, S. Arena, I. Giardina, G. C. Di Renzo, G. Affonti

University Hospital of Perugia, Perugia, Italy
CONSERVATIVE MANAGEMENT
METHODS
PROTOCOL
A retrospective study of 49 patients (since
October 2007) with placenta previa/accreta
STEP 1 Preliminary prophylactic
who
underwent
a
conservative
catheterization of the descending
management protocol (see table).
aorta
RESULTS
STEP 2 Extraction of the fetus by
Conservative management of PPH was
C.S. and placental delivery
successfully achieved in 48 patients
(98%). In only one case it was necessary
STEP 3 Multiple quadrate
to perform post-partum hysterectomy for
endouterine haemostatic sutures
massive bleeding due to severe placental
accretism. In another case it was
STEP 4-Preparation of B-Lynch
necessary selective embolization of the
compressive sutures
right uterine artery due to the presence of
hematoma in the right part of the lower
STEP 5 Application of hydrostatic
uterine segment and in the right
balloon
paracolpus.
(Bakri balloon)
The mean estimated blood loss was 1620
ml (range 1100-2340 ml). The mean
STEP 6 Repositioning of uterus hospital stay was 5.5 days (range 4-10
uterine sutures - hydrostatic
days). 22 patients (45%) underwent
balloon inflation B-Lynch ligature
intraoperative and postoperative blood
transfusions and the mean transfused
If the maneuvers fail the next step
volume was 700 ml. 18 patients (37%)
is devascolarizating
were admitted for 24-48 h to intensive care
ligature/selective
embolization of
CONCLUSIONS
unit
for intensive monitoring. 30% of
the
uterine
arteries.
All pregnancies
are moderate
at risk of
PPH.
Its
patients
experienced
fever
in the
If
all
procedures
fail,
proceed with
management
is they
dictated
by several
first
24-48 h and
were treated
with
hysterectomy.
considerations including hemodynamic
antibiotics.
status and desire to preserve fertility.
Monitoring of maternal
Conservative
interventions
should
hematologic parameters 24 hrs
represent mandatory step for treatment of
before C.S. and 2 h after the
PPH in high risk patients with placenta
procedure, than every 2-4 h for the
previa/accreta.
The
results
of
this
following 24 hrs in relation to
conservative protocol are encouraging .
clinical conditions.

E
M
S
Affronti

CONCLUSIONS

FACTS:
All pregnancies are at risk of
PPH even if no predisposing
factors are present
Luis G. Keith 2007

BOTTOM LINE
Averting maternal death is
based on having a prepared
mind, a prepared team and
a full range of possible
therapies
Luis G. Keith, 2007

Postpartum Hemorrhage
Recommendations:
Every department needs to have a protocol for
management of O.E., with periodic re-evaluation (Life
Support training)
Cases at risk of E.O. need to give birth in a II-III level
structure
Uncontrollable hemorrhages may necessitate
hysterectomy: an expert surgeon needs to be avaliable
quickly 24 hrs a day
Activate the multidisciplinary team early in the
management of a case at risk
Institutional guidelines for the treatment of hemorrhages
with periodic simulation training (skills and drills)

THANK YOU