any loss which results in or could result in hemodynamic instability if untreated. Based on amount of blood loss, change in Hct, rapidity of blood loss, volume deficit, Classification based on clinical signs and symptoms
The Interval between onset of complications and death ----------------------------------------------------------------------- Conditions Interval ----------------------------------------------------------------------- PPH 2 hr APH 12 hr Rupture Uterus 1 day Eclampsia 2 days Obstructed labour 3 days Sepsis 6 days --------------------------------------------------------------
Estimate blood loss accurately. Evaluate all bleeding, including slow bleeds. If mother develops hypotension, tachycardia or pain…rule out intra-abdominal blood loss.
Identify possible post partum hemorrhage. Simultaneous evaluation and treatment. Remember ABCs. Use O2 4L/min. If bleeding does not readily resolve, call for help. Start two 16g or 18g
Bimanual exam Confirms diagnosis of uterine atony. Massage is often adequate for stimulating uterine involution.
C.I.Pregnancy Hypersensitivity to carbetocin or oxytocin Hepatic and renal diseases Pre-eclampsia, eclampsia Serious cardiovascular disorders Epilepsy
Costly Dose 40-90mcg /kgIV Max dose 4-5 doses [ when 10/8/8/10 rbc ffp platelets cryoprecipitates ] NOVOSEVEN 1.2MG 2.4 MG VIALS Tranexamic acid EACA Aprotinin Significantly decrease bleeding but not useful in massive haemorrhage Desmopressin is synthetic analog of vasopressin can be given iv intranasally as spray Increase coagulation factor VIII
It shunts blood from capacitance vessels to vital organs. improves BP, sensorium, allows moribund patient to be transported safely. Lightweight,reusable,inexpensive , safe and can be used at the lowest level of healthcare system can greatly reduce MMR
Medical management of pph
MEDICAL MANAGEMENT OF POST PARTUM HAEMORRHAGE DR VIDYA THOBBI PROFESSOR OF OBG AL AMEEN MEDICAL COLLEGE BIJAPUR
Magnitude of the Problem WHO estimates 529,000 maternal deaths occur from complications of pregnancy and childbirth every year. 99% of maternal deaths occur in the III world countries; More than 60 % of maternal deaths occur in the postpartum period, when prevention strategies are often lacking. PPH is 50 times commoner in these countries. 14 million cases of PPH per year•World Health Organization. Global estimates of maternal mortalityfor 1995: results of an in-depth review,& .analysis and estimation strategy Statement . Geneva: World HealthOrganization, 1995:2001.•Network: Summer 1997, Vol. 17, No. 4
Definition Any blood losss from genital tract during delivery > 500ml. (WHO) ACOG- decline in haematocrit by 10% or need of RBC transfusion. PRIMARY PPH- Within 24 hours SECONDARY PPH- upto 12 weeks . is more likely due to infection and retained placental tissue
REMEMBEREvery woman in labor is at risk of PPH.2/3 of those with PPH –have no identifiablerisk factors.Be prepared in all laborsActive management of third stage of laborshould be practiced on ALL women in labor. It prevents 60% of atonic PPHAll post partum women must be closelymonitored for PPH. 5
Assess risk factors Ante partum Intrapartum Post Partum APH/ Previous Operative delivery, Genital tract injury PPH / MRP Manipulations Over distended Prolonged labor Retained placenta uterus Adherent Infection Uterine inversion placenta Congenital or Acquired Coagulopathy 6
Easy to miss Physicians underestimate blood loss by 50% Slow steady bleeding can be fatal Most deaths from hemorrhage seen after 5h Abdominal or pelvic bleeding can be hidden
PREVENTION ACTIVE MANAGEMENT OF THIRD STAGE LABOUR (AMTSL)Adminstration ofuterotonic drugs within1min of delivery of baby Uterine massage OXYTOCIN Controlled after10 units IM cord traction delivery of placenta
Assessment of Shock Compensatio Mild Moderate Severe nSympto Palpitation, Weakness, Restlessnes Collapse,ms & dizziness, sweating, s, pallor, air-hunger,signs tachycardia tachycardia oliguria anuriaBP Slight fall Marked fall Profound(Systoli Normal 80- 70-80mmHg fallc) 100mmHg 50-70mmHgBlood 500-1000ml 1000-1500ml 1500-2000ml 2000-3000mlloss 10-15% 15-25% 25-35% 35-45%Bloodvolume 11
General Management Shout for help. Rapid evaluation of vitals. Oxygen by mask. Uterine massage. Oxytocin Draw & Send lab test Site 2 large bore (16G-gray color) IV cannula, The blood for lab test Save blood for Infuse IV fluid – NS / RL- run it fast. Catheterize bladder. Check the placenta – If it has been expelled If it is expelled , re examine & make sure it is complete. Examine vagina, perineum and cervix for tears. 12
FLUID RESUCITATATIONMaintanance of tissue perfusion.Multiple large bore IV access.Crystalloids[1:3]Colloids & Blood products to maintain Hbnear 10gm% during active bleeding.. >80% volume replacement causesdilutional coagulopathyCoagulopathy&thrombocytopenia-PLT&FFP.
Other drugs used Tranexamic Acid Recombinant Factor VII a01/25/13 16
OXYTOCIN1. Oxytocin promotes rhythmic contractions ofupper uterine segment.Short plasma half life-3 min.Continuos I.V.infusion required.Dose 20 units in 500 ml crystalloid(250ml/hr)Give IM or IU, not IV. (Can cause ↓ BP)Max dose 40 units
Important side effects of oxytocin Sudden hypotension Antidiuresis with hyponatremia, > 100 miu/min Neonatal jaundice01/25/13 18
The Uniject device Single dose—to minimize wastage Prefilled—ensuring correct dose Nonreusable—to minimize patient-to-patient transmission of blood borne pathogens Easy to use—to allow use by health workers who do not normally give injections Compact size—for easy transport and disposal
Carbetocin- what is it? And what are the advantages Long acting ,synthetic octapeptide analogue of oxytocin 100 mcg of single carbetocin V/s 10 u oxytocin infusion -faster involution -lesser blood loss - fewer additional oxytocics - lesser need for uterine massage Obst & gynae survey, 2010, vol 65:3, 148-14901/25/13 20
Carbetocin Given as IVbolus 100ug Acts within 2 min Peak concentration within 30min Longer half life 80-90 min 80% Bioavailability IM effect lasts twice as long as IV 21 Contraindicated in hepatic and renal dis
MethergineSustained tonic uterine contraction.I.M. 0.25 Mg.Onset of action-2 to 5 min.Mean plasma half life 30 min.Clinical effect persists 3 hrs.Can cause Hypertension, especially IV.Precautions-in hypertensive,preeclampsia.Refrigeration storage 2-8c
CARBOPROST 0.25mg IM or Intramyometrium.PGF2Controls hemorrhage in 86% when usedalone, and 95% in combination with othersCan repeat up to eight times.Contraindicated in active Br.AsthmaCan cause nausea/vomiting/diarrhea, ↑ BP.
MISOPROSTPGE1Prompt uterine contraction.Routes-oral/sublingual/rectal/vg/intrauterine.Stable at room temp.Long shelf lifeEasy to administer.Cheap.
MISOPROSTOL Routes of Onset of action Duration administrationOral Fastest shortestRectal Slow prolongedSublingual Rapid prolonged
MISOPROST Dose-600 to 800 micrograms. S/E- minor, dose related. fever,shivering,diarrhea.Rectal –longer onset of action. lower peak levels, more favourable side effect profile.FIGO 600mcg orally after delivery of baby if oxytocin is not available
WHORECOMMONDATIONSMISOPROSTOLAbsence of skilled caregivers to offer controlled cord tractionNon availability of injectablesDifficulties in ensuring safe injection practicesDifficulties in refrigeration preventing the use of oxytocinSBA should not offer sublingual or rectal misoprostol for prevention of PPH in preference to oxytocin
Pharmacokinetic Oral misoprostol reaches its peak at 20 minutes. Its action is slow in comparison to intra muscular oxytocin. http://www.misoprostol.org/File/news.php
TRANEXAMIC ACIDAnti-fibrinolytic agent to reduce blood lossand the need for blood transfusion. The WHO panel in systematic review ofrandomized controlled trials showed that insurgical patients tranexamic acid reducedthe risk of blood transfusion by 39%Tranexamic acid may be offered as atreatment for PPH if uterotonic options havefailed, or trauma is the causeDoses of 60-120 ug/kg intravenously were
r FVIIa in the management of PPH It has potential to become universal hemostatic agent It is a safe effective hemostatic measure in severe obstetric hemorrhage , both as 1.adjunctive treatment to surgical hemostasis and 2.rescue therapy where PPH is refractory to current medical and uterus sparing surgeries. Dose 40-90mcg/kg i.v.[NOVOSEVEN]01/25/13 30
The WHO has published guidelines for the management of PPH based on areview of the evidence by an expert panelFor prevention of PPH, syntometrine compared with oxytocin isassociatedwith a trend to reduced blood loss >1000ml (odds ratio (OR) 0.78, 0.58-1.03); no difference in blood transfusion (OR 1.37, 0.89 to 2.10), and less usof additional uterotonics (risk ratio (RR) 0.83, 0.72-0.96), but more sideeffects, particularly hypertension (RR 2.40, 1.58-3.64).1Oxytocin compared with ergometrine is associated with no statisticallysignificant difference in blood loss >1000ml (RR 1.09, 0.45-2.66) and use ofadditional uterotonics (RR 1.02, 0.67-1.55); and fewer adverse side effects:vomiting (RR 0.09, 0.05-0.16); elevated blood pressure (RR 0.01, 0.00-0.15)There were insufficient data to compare the outcome blood transfusion.2,,3There were no clear benefits for the use of carbetocin4, intramuscularprostaglandins5 or sulprostone6,7 over oxytocin and/or ergometrine.For prevention of PPH, misoprostol (400 to 800 mcg) compared withinjectable uterotonics is associated with increased blood loss of ≥ 1000ml(RR 1.32; 95% CI 1.16-1.51), but no statistical difference in the incidence ofsevere morbidity, including maternal death (RR 1.00, 95% CI 0.14- 7.10)55
Meta-analysis of trials in theCochrane database systemic review Oxytocin alone reduces PPH by 60% ( 7 trials) Syntometrine Vs oxytocin More chances of HTN with former : otherwise both effective (6 trials) Active Vs Expectant management of 3rd stage clearly established superiority of AMTSL( 5 trials) Carboprost/ Misoprostol Vs conventional (32trials) - conventional preferred01/25/13 Carbetocin- not recommended 32
Recommendations- Prevention10 U of Oxytocin IM/ IV infusion I LineWHO doesnot recommend IV bolus RCOGdoesMethyl ergometrine 0.2 mg IV/IM II Lineif there are no contra indicationsCarboprost 250mcg IM III LineMisoprostol 600mcg oral/1000mcg P/Rwhen other drugs not available01/25/13 33
Recommendations - PPH40 u oxytocin in 500ml- 125ml/hr ( RCOG)20u in 1 L - 60 dr/min ( WHO)Methergine 0.2mg repeat 15 mins followed by 4thhrly 5 dosesCarboprost once in 15 Mins Maxm 8 dosesSyntometrine more side effects but may be usedMisoprostol Not very beneficial ( WHO)Tranexamic acid- May help if trauma is the cause01/25/13 34
WHO 2012 Recommendations Based on this direct evidences, the WHO strongly recommends Oxytocin alone should be used for the treatment of PPH in preference to adjunct misoprostol.
Choice of Blood /components O Group Rh –ve in dire emergency Grouped and cross matched Packed cells 6u of packed cells - give 4 u of FFP PT/APTT >1.5 of normal - 12-15ml FFP/KG Platelets if <50,000 or during surgery ,<80000 give 10 units Fibrinogen<100mg - cryoprecipitate upto01/25/13 37 10 units
CHOICE OF UTEROTONICSOXYTOCIN ERGOMETRINE MISOPROSTOL CARBOPROSTDose 10IU IM. or 10- Ergotmetrin 0.5mg 400-600μg 125 μg IM40U in IV Infusion Methergin 0.2mg IM oral –serum conc in Acts in <5min,C.S – 5 IU slow IV Acts in 6-7min, acts 7.5-30min(mean 18followed by infusion systemically on min)Act in 2-3min, smooth muscle Rectal- serum conc inspecific to uterine 15-60min (meansmooth muscle 40min)Short acting Long acting Long acting Long actingsafe Contraindicated in Safe , home delivery Contraindicated in HT and non skilled asthma attendentinexpensive More expensive Inexpensive expensiveMin side effect Nausea, vomiting, HT Shivering, pyrexia Bromchospasm, vomiting diarrhoea, flushingCold storage more Demands cold storage No cold storage Cold storagestable to heat andlight
Oxytocics Dose & Maintenance Max frequency Precautio route dose dose /CIOxytocin IV infusion IV infuse Not -Acts 10U/500ml 10U/500ml more within 3 60dpm 40dpm than 3lt minErgometrin IM / 0.2mg after 5 doses. 4th hourly PIH, HT,e/ slow IV of 15 min. (1mg) HeartMethergin 0.2mg disease.15methyl IM 250μg 250μg after 8 doses 15 - 90mnts Asthma,PGF2α ** 15mnts (2mg) heart disease.** NEVER GIVE PROSTAGLANDIN INTRAVENOUSLY IT MIGHT BE FATAL 39
3 Ds causing the 4th D(eath)1. Delay in recognizing & seeking help. How to diagnose2. Delay in transport & reaching medicalfacility. When to shift?3. Delay in receiving an adequate Rxcomprehensive give early & appropriate treatment ? What & how to care upon arrival 40
WHERE TO SHIFT?Delay in shifting is an important cause ofDeathThink of shifting as early as possible.• Shift as quickly as possible.• Communicate- to patient /attendant• - to the tertiary care personnelShift to a tertiary care centre with: • OT • ICU • Blood bank • Personnel 41
HOW TO SHIFT?Shift preferably in an ambulance,With nasal oxygen on flowWith 2 IV lines with fluid on flow (it can belifeline)Document• The events in sequence• IV fluids given• Drugs administeredCommunicate to personnel at tertiary care centre. 42
NASG Non inflatable anti shock garment01/25/13 43
Crash Kit (Emergency Tray)-For handling emergencies one must have a crash kit with the following ,18 ,20) Brannula (16 Hydrocortisone Bulbs- grouping and cross matching Calcium Gluconate Venesection Set Deriphylline Syringes/ Gloves Atropine Roller gauze / mops / Adrenaline sticking plaster, scissor Dopamine, Dobutamine Foley’s catheter Drip sets I. V. Fluids- RL, DNS Hemacel, Intubation materials Oxytocin,Misoprostol PGF2alpha,Methergin Oxygen with mask
Intelligent anticipation, skilled supervision, prompt detection andeffective institution of therapy canprevent disastrous consequences of PPH.