Prevention and medical

management of uterine atony

By Cheong Lu Jeat, Laow Yee Kean

Supervised by Dr Munis
Definition
 Postpartum hemorrhage is loss of
blood 500mls or more during
delivery; more than 1000mls during
cesarean section and causes
hemodynamic instability
 Primary PPH – first 24H of delivery
 Secondary PPH from 24H to 12 weeks
after delivery
 Allowing for the physiological increase in
pregnancy,total blood volume at term is
approximately 100 ml/kg (an average 70 kg woman-
total blood volume of 7000 ml)
 a blood loss of more than 40% of total blood volume
(approx 2800 ml) is generally regarded as ‘life-
threatening’.
 It seems appropriate that PPH protocols should be
instituted at an estimated blood loss well below this
figure,
 as the aim of management is to prevent haemorrhage
escalating to the point where it is life-threatening.
Causes
 Primary
 Uterine atony - 80%
 Retained placenta—especially placenta
accreta
 Defects in coagulation
 Uterine inversion
 Secondary
 Subinvolution of placental site
 Retained products of conception
 Infection
 Inherited coagulation defects
Risk Factors for Postpartum
Hemorrhage
 Prolonged labor
 Augmented labor
 Rapid labor
 History of postpartum hemorrhage
 Episiotomy, especially mediolateral
 Preeclampsia
 Overdistended uterus (macrosomia, twins,
 hydramnios)
 Operative delivery
 Asian or Hispanic ethnicity
 Chorioamnionitis
Prevention
 IM syntometrine 1ml during delivery
of anterior shoulder
 Early cord clamping (used previously)
 For high risk patients (eg
grandmultipara) -IV pitocin 40 units
@125ml/H
 Scan for placenta location
 Active management also should be
done in tertiary centre
 Medical management
drug Dose/route Frequency comment

Oxytocin (pitocin) IV: 10-40 U in 1L NS continuous Avoid undiluted rapid

IM: 10 U IV infusion, which
causes hypotension

15-methyl IM: 0.25mg Every 15-90min, 8 Avoid in asthmatic

PGF2a(carboprost) doses maximum patients; relative CI if
(hemabate) hepatic, renal and
cardiac disease.
Diarrhea, fever,
tachycardia can occur
Misoprostol (cytotec, 800-1000mcg rectally
PGE1)

Syntometrine IM 1 ml WHO recommendation

(ergometrine 500mcg unless contraindicated
+ oxytocin 5U) (hypertension)
Physiology of fluids
 Mild shock - 20% of the blood volume is lost
decreased perfusion of non-vital organs and tissues
with pale and cool skin.
 Moderate shock - 20–40% of the blood volume is lost,
moderate  decreased perfusion of vital organs (i.e.
gut, kidneys, liver), oliguria and/or anuria, a drop in
blood pressure, and mottling of the skin in the legs.
 Severe shock - 40% or more of the blood volume is lost
 decreased perfusion of the heart and brain, agitation,
restlessness, coma, echocardiogram and
electroencephalogram abnormalities, and finally cardiac
arrest.
 estimated blood loss is more than one-third of the
woman’s blood volume (blood volume[ml] = weight
[kg] × 80) or more than 1000 ml or a change in
haemodynamic status.
Fluid therapy and blood product
transfusion
 Crystalloid Up to 2 litres
Hartmann’s solution
 Colloid up to 1–2 litres
colloid until blood arrives
 Blood Crossmatched
 FFP 4 units
 Platelets 2 units
 Cryoprecipitate 6units
‘the golden first hour’
 Is the time at which resuscitation must be
commenced to ensure the best of survival
 use of the ‘shock index’ (SI) is invaluable in
the monitoring and management of women
with PPH. It refers to HR divided by the
SBP. The normal value is 0.5–0.7.
 With significant haemorrhage,it increases
to 0.9–1.1
Coagulopathy(DIVC)
 occurs due to the consumption of
clotting factors (disseminated
intravascular coagulation or DIC)
 or due to the dilutional effects of
massive blood loss on clotting factors,
platelets and fibrinogen (‘washout
phenomenon’)
Monitoring and investigation
 Blood ix – FBC, PT/PTT/INR
 V/S monitoring
 To start DIVC regime according to clinical
judgement (eg, shock index > 0.9)
 Aims:
Haemoglobin > 8 g/dl
Platelet count > 75 109/l
Prothrombin time < 1.5 mean control
Activated prothrombin time < 1.5 mean
control
Fibrinogen > 1.0 g/l
Blood component therapy
product Volume (ml) contents Effect(per
unit)

Packed red 240 RBC, WBC, Increase

cells Plasma hematocrit 3%,
Hb 1g

platelets 50 Platelets, RBC, Increase plt

WBC, Plasma count 5k-10k
per unit

FFP 250 Fibrinogen,antith Increase

rombin 3,f V and fibrinogen by
VIII 10mg/dl

cryoprecipitate 40 Fibrinogen, f VIII Increase

and XIII, Von fibrinogen by
willebrand factor 10mg/dl
Recombinant activated Factor VII
 Natural initiator of coagulation
cascade
 Lead to stable formation of fibrin clots
at site of injury
 Indications: life-threatening massive
postpartym hemorrhage which fails
respond to surgical and medical mx
 Dosage: 60-120mcg/kg
Other measures
 Uterine packing
 Bakri balloon
 Rusch catheter
 Sengstaken-blakemore tube
Surgical management

technique comment

Uterine artery Bilateral; also can ligate uteroovarian vessels

ligation
B-lynch suture

Internal iliac Less successful than earlier though; difficult

artery ligation technique; generally reserved for practitioners
Repair of rupture

hysterectomy
 Thank you very much!