Primary Postpartum

Haemorrhage

Max Brinsmead MB BS PhD

June 2018
Introduction
 The average gravida carries 1 - 1.5 l of
“extra blood” in pregnancy as prophylaxis
against PPH but…

 PPH is still the major cause of obstetric

death especially in developing countries

 10 - 15% of women lose >600 ml of blood at

delivery and…

 For 1 - 2% the blood loss can be life

threatening
This presentation will address…

 Current guidelines for the management of

the third stage of labour and their evidence
base

 Emergency (First aid) and

 Advanced Measures for the management of

excessive blood loss in the first 24 hours
after birth
From the Cochrane
Database

 Active vs Expectant Management of the 3rd

stage of labour
• Now withdrawn as out of date

 Oxytocin vs Ergometrine

 Oxytocin vs Prostaglandins

 Uterine massage in preventing PPH

 Active vs Expectant Management
of 3rd Stage Labour

 4 studies - all in the UK

 Active management associated with:

 Reduced blood loss (-79 ml, CI 64-94 mls less)

 Fewer PPH >500 ml (OR=0.34, CI 0.28-0.41)

 Shorter 3rd stage (-3.4 min, CI 4.66-2.13 min

less)
 Active vs Expectant Management
of 3rd Stage Labour

For the individual patient this may mean:

If she declines the administration of an oxytocic

drug she has a 1:6 chance of losing >500 ml
blood

If she has an oxytocic drug this is reduced to a

1:20 chance of losing >500 ml blood
 Active vs Expectant Management
of 3rd Stage Labour

Active management is associated with:

 Increased rate of maternal nausea &

vomiting (OR 1.95, CI 1.58 - 2.42)

 Increased rate of maternal hypertension

 Delayed vs Early (within 60
sec) Cord Clamping
Is associated with:
 No difference in the rate of PPH (RR 1.22 CI
0.96–1.55)

 Increased rates of jaundice requiring

phototherapy

 Neonatal advantages in terms of Hb levels

and Ferritin up to 6 months of age
 NICE Guidelines (2007) for
management of the 3rd Stage

 Active management is recommended i.e.

• IM Oxytocin 10 IU
• Early cord clamping
• Cord traction
 Women at low risk of PPH who elect to have physiological
management should have their choice respected
 Active management is required if
• There is PPH
• The placenta is not delivered within 60 min
• Patient requests earlier intervention
 Cord traction and uterine palpation should only be used after an
oxytocic has been given
 Syntometrine vs Syntocinon
for 3rd Stage Labour
 Use of Syntometrine results in:

 Fewer PPHs (OR 0.74, CI 0.65-0.85)

 BUT

 More vomiting
 Greater risk maternal hypertension
 And greater risk of retained placenta
 Prostaglandins for the
Prevention of PPH
Injected PG s resulted in:

 Reduced mean blood loss

 Shorter 3rd stage
 Non sigificant reduction in rate PPH but…
 Shivering (almost 20%)
 Diarrhoea
 Abdominal pain
 Increased cost
Rectal Misoprostol

 PPH rate reduced from 7.0% to 4.8% (not

significant in the study reported) but

 Fewer side effects than after IM or oral use

of PG’s

 This drug is cheap and stable and could

have an enormous impact on maternal
mortality in developing countries
Carbetocin

A heat-stable form of this synthetic oxytocin is

valuable when refrigeration is not available

Danseraua et al Am J Obstet Gynecol March 99

 694 women in a Canadian multicentre trial

 One dose Carbetocin 100 ug cf 8 hour
Oxytocin infusion
 Outcome studied “additional oxytocic required”
 Fewer patients requiring additional oxytocic
after Carbetocin (OR = 2.03, CI 1.1 - 2.8)
 Uterine massage after
delivery of the placenta…
 Only one study of 200 patients and that was with
active management of 3rd stage:
 The rate of PPH was halved but not statistically
significant
 BUT
 Mean blood loss reduced by massage (-42 ml CI -8
to -75)
 Reduced need for extra oxytocic (RR 0.20 CI 0.08-
0.50)
 2 transfusions required in the no massage group
Also from the Cochrane
Database

 No benefit from cord drainage

 No benefit from umbilical vein injection of

oxytocic

 No benefit from early suckling

 Chinese traditional medicine report pending

Risk factors for Primary PPH
 Prolonged labour
 APH
 Pre eclampsia
 Maternal obesity
 Multiple pregnancy
 Birth weight >4000g
 Advanced maternal age
 Previous PPH
 Assisted delivery
 Low lying placenta
 But >50% occur in women without identified risk
factors and…
 90% are associated with uterine atony
 And all studies of massive PPH fail to identify
consistent risk factors
 Patient Assessment

 Objective measure of blood loss is desirable

 Postural hypotension the earliest sign
 Tachycardia is usual
 Air hunger and loss of consciousness is
serious
 Urine output a good measure of treatment
 CVP sometimes
 A bedside test of blood clotting desirable
 Emergency Measures
 Rub up a contraction
 Deliver the placenta
• If you can
 Gain IV access (large bore cannula)
 Additional oxytocic
• IV Ergometrine 0.25 mg
• Syntocinon infusion
• Rectal Cervagem or Misoprostol
 (Empty the bladder)
 Bimanual uterine compression
 Aortic compression
Advanced Measures 1

 Get help
 Check coagulation - use
cryoprecipitate etc.
 EUA is mandatory
 Myometrial PG F2 alpha
 Uterine Packing
• Intrauterine balloon catheter
 Consider activated Factor VII
Intrauterine Balloon Tamponade
BJOG Review May 2009
 Was effective in 91.5% of cases
• Combined retrospective and prospective studies
• But only a total of 106 patients
 Types of balloons
• Sengstaken Blakemore (GI use)
• Rusch (Urological)
• Foley (often multiple)
• Bakri (Specifically designed for obstetrics)
• Condom (+/- Foley)
 But there remain many unanswered
questions
Questions concerning intrauterine balloon
tamponade
BJOG Review May 2009
 Is it effective
• There are no RCTs
 Risks and contraindications
 Which balloon to use, how to insert it
and what volume to inflate it
 Is a vaginal pack required
 Is an oxytocin infusion required
 Antibioitics and analgesia
 When to deflate and or remove it
 Advanced Measures 2

 Get more help

• Medical – haematologist
• Surgical colleague
• Radiologist for…
 Uterine artery embolisation
 Laparotomy and…
 B-Lynch suture
 Internal iliac artery ligation
 Aortic clamping
 Hysterectomy
 Any Questions or
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