Postpartum Hemorrhage Lecture Notes


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Postpartum Hemorrhage Lecture Notes

  1. 1. 1 THE MEDICAL MANAGEMENT OFTHE MEDICAL MANAGEMENT OF POSTPARTUM HEMORRHAGEPOSTPARTUM HEMORRHAGE Chukwuma I. Onyeije, M.D.,Chukwuma I. Onyeije, M.D., Atlanta Perinatal AssociatesAtlanta Perinatal Associates 2 •Provide a definition of PPH •Review the risk factors for PPH •Understand the nature and importance of rapid diagnosis and treatment OBJECTIVES
  2. 2. 3 For your convenience, A digital copy of this lecture is also located at: 4 Mary 24 year old G2P2 Underwent a routine cesarean section at 7.30 pm Pre-operative Hb was 13 g/dl. Blood loss of 500cc. 5 Mary 4 hours post-partum Pulse at 100-120 otherwise stable. BP: 70-90 / 50-60 Analgesia and Hydration provided. 5 hours postpartum: Seizure with obtundation. Hemoglobin: 7 g/dl, 6 6 Hours post partum: Elevated cardiac enzymes DIC Myocardial Infarction & Liver failure 9 Hours postpartum: Failed arterial embolization 10 Hours postpartum Uterine packing done. 11 Hours Postpartum: Hysterectomy 2 Days Postpartum: Flatline EKG 7 ‘‘‘‘She died inShe died in childbirth’’childbirth’’ 8 Hemorrhage has probably killed more women than any other complication of pregnancy in the history of mankind.
  3. 3. 9 An estimated 150,000 maternal deaths worldwide result from obstetric hemorrhage each year 10 90% of deaths from Postpartum hemorrhage are preventable. 11 WE HAVE THE TOOLS GOOD NEWS 12 Those caring for pregnant women must be prepared to aggressively treat this complication when it occurs. 13 WhatWhat can becan be done?done? 14 THE STEPS TO PPH: POSTPARTUM HEMORRHAGE: PREDICT HANDLE PREPARE
  4. 4. 15 THE STEPS TO PPH: POSTPARTUM HEMORRHAGE: PREDICT HANDLEPREPARE Identify patients at risk Use a multi- disciplinary Approach Optimize clinical management 17 Large amounts of blood can be lost rapidly following delivery. 18 Uterine contraction is more important than clot formation or platelet aggregation as a mechanism of hemostasis 19 1. PREDICT: THE STEPS TO PPH: POSTPARTUM HEMORRHAGE: 20 Can we Predict PPH? Who is at risk?
  5. 5. 21 Risk Factors for Postpartum Hemorrhage What Should we do with a list like this? Prior postpartum hemorrhage Advanced maternal age Multifetal gestations Prolonged labor Polyhydramnios Instrumental delivery Fetal demise Placental abruption Anticoagulation therapy Multiparity Fibroids Prolonged use of oxytocin Macrosomia Cesarean delivery Placenta previa and accreta Chorioamnionitis General anesthesia 22 Clinically Important Risk Factors for Postpartum Hemorrhage Prior postpartum hemorrhage Abnormal placentation Operative delivery 23 Risk Factors for Postpartum Hemorrhage under Clinical Control Prolonged labor Instrumental delivery Anticoagulation therapy Prolonged use of oxytocin Cesarean delivery General anesthesia 24 Causes of Postpartum Hemorrhage (another busy slide) Primary causes Uterine atony Genital tract lacerations Retained products Abnormal placentation Coagulopathies and anticoagulation Uterine inversion Amniotic fluid embolism Secondary causes Retained products Uterine infection Subinvolution Anticoagulation 25 80% OF CASES OF POSTPARTUM HEMORRHAGE ARE DUE TO UTERINE ATONY (a less busy slide) 26 What about DIC? Coagulopathy is a relatively uncommon cause of primary PPH Coagulopathy most commonly occurs when another cause of PPH already has produced significant blood loss.
  6. 6. 27 RDFS RDFS is retained dead fetus syndrome Well described in most obstetrics texts Clinically manifested at about 6 weeks after fetal death Rarely seen in modern obstetrics. 28 Congenital coagulation disorders Uncommon individually As a class are present more frequently than commonly thought Examples: VonWillebrand’s disease Specific factor deficiencies (factors II, VII, VIII, IX, X, and XI) 29 80% OF CASES OF POSTPARTUM HEMORRHAGE ARE DUE TO UTERINE ATONY (Did I mention that…) 30 Question: What causes uterine atony and is there anything we can do to prevent uterine atony induced postpartum hemorrhage? 31 • Causes of Uterine Atony: Overdistension of the uterus Myometrial laxity as seen in: Multiparity, Prolonged labor, Use of large quantities of oxytocin, Tocolytic therapy, General anesthesia. 32 Trends in postpartum hemorrhage: United States, 1994–2006 Source: American Journal of Obstetrics & Gynecology 2010; 202:353.e1-353.e6 (DOI:10.1016/j.ajog.2010.01.011 ) Copyright © 2010 Terms and Conditions William M. Callaghan, MD, MPH, Elena V. Kuklina, MD, PhD and Cynthia J. Berg, MD, MPH American Journal of Obstetrics & Gynecology Volume 202, Issue 4, Pages 353.e1-353.e6 (April 2010) DOI: 10.1016/j.ajog.2010.01.011
  7. 7. 33 Upper Genital Tract Trauma Most often istheresult of uterinerupture Bleeding from direct uterine injury during cesarean Injury of associated vascular structures(uterine, artery or broad ligament varicosities) during cesarean 34 Lower Genital Tract Trauma May occur spontaneously or result from episiotomy, obstetric maneuvers, or operativeinstrumented deliveries. Involveperineum, cervix and vagina. 35 2. PREPARE: THE STEPS TO PPH: POSTPARTUM HEMORRHAGE: 36 37 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5.- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management 38 Preparation for Postpartum Hemorrhage
  8. 8. 39 “Perhaps the most important aspect in the management of PPH is the attitude of the attendant in charge. It is critical to maintain equanimity in what can be a chaotic and stressful environment”. Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441 40 Analysis Paralysis An excessive number of well-meaning individuals increases the ambient noise, adds to confusion, and opens the door to communication errors. Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441 41 42 1.- Prepare for PPH -Nursing -Anesthesia - Surgical assistance - Others (I.R.) Drugs/Equipment -Methergine -Hemabate -Cytotec -Colloids -Blood/Bl.products -Surg. Instruments -Hemostatic ballons Personnel 43 Anesthesia / I.V. Access Obtain Anesthesia consultation •Type of anesthesia •Need for invasive monitoring • (A line, Swan-Ganz, etc) 44 • 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 Postpartum Hemorrhage is Easy to miss
  9. 9. 45 • Estimate blood loss accurately. • Evaluate all bleeding, including slow bleeds. • If mother develops hypotension, tachycardia or pain…rule out intra-abdominal blood loss. Always look for signs of bleeding 46 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 IVs. Initial Assessment 47 Initial Steps for PPHInitial Steps for PPH Bimanual compression Manual exploration of the uterus Empty the bladder Administer uterotonic agents Examine lower genital tract for lacerations. 49 1. Tone (Uterine tone) 2. Tissue (Retained tissue--placenta) 3. Trauma (Lacerations and uterine rupture) 4. Thrombin (Bleeding disorders) The 4 Ts 50 Uterine atony causes 80% of hemorrhage Assess and treat with uterine massage Use medication early Consider prophylactic medication... T # 1: Tone: Think of Uterine Atony
  10. 10. 51 • Confirms diagnosis of uterine atony. • Massage is often adequate for stimulating uterine involution. Bimanual Uterine Exam 52 Medical Treatment ofMedical Treatment of Postpartum HemorrhagePostpartum Hemorrhage Medications that cause uterine contractions Medications that promote coagulation 54 OXYTOCIN • The common medication used to achieve uterine contraction • First-line agent to prevent and treat PPH • Given IV or IM. • May cause hypotension. OXYTOCIN “The Champ”
  11. 11. 57 1. OXYTOCIN: promotes rhythmic contractions. • Give 10 mg IM or IV, not IU. 1. METHERGINE: promotes rapid tetanic contractions • 0.2mg (1 amp) IM 1. HEMABATE: promotes long lasting contractions • 0.25 mg IM q 15min (max X8). 1. CYTOTEC: less effective than methergine • 400 to 1000 µµµµg (oral, vaginal or rectal) Summary of MedicationsSummary of Medications for Uterine Atonyfor Uterine Atony 58 Fluid Management of Postpartum Hemorrhage 59 -Balanced * (0.9% NaCl, lactated Ringers -Hypertonic (3.5,5, 7.5% NaCl) -Hypotonic (0.45% NaCl) * Same electrolyte concentration as the extracellular compartnt -Albumin (5%, 25%) -Dextran, glucose polymers (40, 70) -Hydroxyethyl starch (Hespan) Crystalloid Colloid Blood/Blood Products Fluid Management of Postpartum Hemorrhage 60 Acute Postpartum Blood Loss PROBLEMS: Loss of circulatory Volume Loss of O2 carrying capacity Restore volume 1 - Crystalloid 2 - Colloid SaO2 O2 carrying capacity Supplemental O2 Transfusion 61 61 25-30%(15-1800cc) Healthy ? Crystalloid/Colloid Medical complications ? Consider transfusion 30-50%(18-3000cc) Crystalloid/Colloid Consider transfusion > 50% ( > 3000cc) Crystalloid/Colloid Blood transfusion Clotting factors (FFP, Cryo) Blood Loss Hemorrhagic Shock - Fluid Management - 62 Class Blood Loss Volume Deficit Spx Rx I < 1000 cc 15% Orthostatic tachycardia Crystalloid II 1001-1500 15-25% Incr. HR, orthostasis, mental Decr cap refill Crystalloid, III 1501-2500 25-40% Incr HR, RR Decr BP, Oliguria Crystalloid Colloid, RBCs IV > 2500 > 40% Obtunded Oliguria/anuria CV collapse RBC, Crystalloid, Colloid Managing blood loss by hemorrhage classification
  12. 12. 63 Ways to Optimize hemodynamic status 1.Acute isovolemic hemodilution 2.Acute hypervolemic hemodilution 3.Autologous donation 4.Preoperative transfusion 64 64 Acute isovolemic hemodilution Withdraw 2-4 u. of Blood Replace the volume with crystalloid Lower the pre-op Hct Replace the blood at end of surgery Acute hypervolemic hemodilution Admin 1500-2000cc Crystalloid Hemodilution (Lowers pre-op Hct) Ways to optimize hemodynamic status 65 • Delay of placental delivery > 30 minutes seen in ~ 6% of deliveries. • Prior retained placenta increases risk. • Risk increased with: prior C/S, curettage p-pregnancy, uterine infection, AMA or increased parity. • Prior C/S scar & previa increases risk (25%) • Most patients have no risk factors. • Occasionally succenturiate lobe left behind. T # 2: TISSUE 66 67 Oxytocin 10U in 20cc of NS placed in clamped umbilical vein. If this fails, get OB assistance. Check Hct, type & cross 2-4 u. Two large bore IVs. Anesthesia and OR support. Removal of Abnormal Placenta 68 • Relax uterus with halothane general anesthetic and subcutaneous terbutaline. • Bleeding will increase dramatically. • With fingertips, identify cleavage plane between placenta and uterus. • Keep placenta intact. • Remove all of the placenta. Removal of Abnormal Placenta
  13. 13. 69 70 • If successful, reverse uterine atony with oxytocin, Methergine, Hemabate. • Consider surgical set-up prior to separation. • If manual removal not successful, large blunt curettage or suction catheter, with high risk of perforation. • Consider prophylactic antibiotics. Removal of Abnormal Placenta 71 72 Episiotomy Hematoma Uterine inversion Uterine rupture T # 3: Trauma 73 Rare: ~1/2000 deliveries. Causes include: Excessive traction on cord. Fundal pressure. Uterine atony. Uterine Inversion 74 • Blue-gray mass protruding from vagina. • Copious bleeding. • Hypotension worsened by vaso-vagal reaction. Consider atropine 0.5mg IV if bradycardia is severe. • High morbidity and some mortality seen: get help and act rapidly. Uterine Inversion
  14. 14. 75 • Push center of uterus with three fingers into abdominal cavity. • Need to replace the uterus before cervical contraction ring develops. • Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage. • When completed, treat uterine atony. Uterine Inversion 76 77 • Rare: 0.04% of deliveries. • Risk factors include: • Prior C/S: up to 1.7% of these deliveries. • Prior uterine surgery. • Hyperstimulation with oxytocin. • Trauma. • Parity > 4. Uterine Rupture 78 • Risk factors include: • Epidural. • Placental abruption. • Forceps delivery (especially mid forceps). • Breech version or extraction. Uterine Rupture 79 Sometimes found incidentally. During routine exam of uterus. Small dehiscence, less than 2cm. Not bleeding. Not painful. Can be followed expectantly. Uterine Rupture 80 Vaginal bleeding. Abdominal tenderness. Maternal tachycardia. Abnormal fetal heart rate tracing. Cessation of uterine contractions. Uterine Rupture before delivery
  15. 15. 81 May be found on routine exam. Hypotension more than expected with apparent blood loss. Increased abdominal girth. Uterine Rupture after delivery 82 Risk factors include: Instrumented deliveries. Primiparity. Pre-eclampsia. Multiple gestation. Vulvovaginal varicosities. Prolonged second stage. Clotting abnormalities. Birth Trauma 83 Repair of cervical laceration 84 • Hematomas less than 3cm in diameter can be observed expectantly. • If larger, incision and evacuation of clot is necessary. • Irrigate and ligate bleeding vessels. • With diffuse oozing, perform layered closure to eliminate dead space. • Consider prophylactic antibiotics. Birth Trauma: Hematomas 85Pelvic Hematoma