Overview and medical management of pph

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By Dr. Suhas Otiv

By Dr. Suhas Otiv

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  • 1. Overview and medical management of PPH Dr. Suhas OtivConsultant, KEM Hospital, Pune
  • 2. Lancet 2006; l368:1189-200
  • 3. Mortality from PPH• Half of 500,000 maternal deaths globally• 28 % of maternal deaths in developing countries• Risk of death from PPH 1 in 1000 deliveries - developing countries 1 in 100,000 deliveries – developed countries
  • 4. Lancet 2006; l367:1066-72
  • 5. Incidence of PPHPPH 5 – 17 % of all deliveries> 500mlMajor PPH 1.3 – 2.5 % of all deliveries> 1000 mlACOG 3.9 % of all deliveries
  • 6. Definition of PPHPrimary PPH: 0 – 24 hours; Secondary PPH: 1 - 84 daysBlood loss > 500 ml at vaginal delivery > 750 - 1000 ml at CesareanSevere PPH > 1000 ml loss at vaginal deliveryACOG: - Fall in hematocrit 10% - Need for PRBC transfusionRate of blood loss: > 150ml/min or sudden loss > 1.5 – 2 l
  • 7. PPH can occur with minimal vaginal bleeding !!!!
  • 8. Accuracy of visual estimation of blood loss
  • 9. Modified –WHOBlood collection method
  • 10. Modified –WHOWeighing Blood loss
  • 11. Modified –WHOMeasuring volume of blood loss-Transfer of blood-Mops squeezed
  • 12. BRASSS-V®BloodCollectionDrape withCalibratedReceptacle
  • 13. Etiology of PPH• Uterine Atony > 80 %• Lacerations of vagina, cervix• Uterine rupture 10%• Uterine inversion• Retained placental fragments• Placental accreta / increta / percreta 5%• Coagulopathy 1%
  • 14. Risk factors for PPH• Nulliparity • Advanced maternal age• Obesity • PIH• Large baby • PPH in previous delivery• Prolonged labor • Augmented labor• APH • Forceps delivery• Multiple pregnancy • Use of tocolytics• Cesarean delivery х Grand multiparity 65 % cases of PPH occur with no risk factors
  • 15. PPH at Cesarean delivery: Risk Factors• General anesthesia• Chorio-Amnionitis• Pre-eclampsia• Protracted active phase of labor• Second-stage arrest• Classic uterine incisionObstet Gynecol 1991 Jan;77(1):77-82
  • 16. Risk factors for PPH: a case control studycomparing 666 cases with controls in 154311 deliveries• Retained placenta (OR 3.5, 95% CI 2.1-5.8)• Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)• Placenta accreta (OR 3.3, 95% CI 1.7-6.4)• Lacerations (OR 2.4, 95% CI 2.0-2.8)• Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)• Large for gestational age new born (eg, >4000 g) (OR 1.9, 95% CI 1.6-2.4)• Hypertensive disorders (OR 1.7, 95% CI 1.2-2.1)• Induction of labor (OR 1.4, 95% CI 1.1-1.7)• Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7) J Matern Fetal Neonatal Med. 2005;18(3):149
  • 17. Management of PPH• Scenarios – labor room, OR, wards, peripheral hospital• Effective management – Prompt response – Organized team work – Clear priorities, decisive• Help: communication, monitoring, assistance, documentation
  • 18. Being prepared for PPH• Team: Nursing, doctors, surgical expertise, critical care physician / anesthesiologist• Drugs: Oxytocin, Methergin, Carboprost, volume expanders, resuscitation• Equipment: Monitoring, resuscitation, Blood bank, Lab, ICU, OR
  • 19. Management of PPH at vaginal deliveryFirst line Management• Call for help• Uterine massage• IV access: X-match, labs• Infuse NS rapidly,• BP, Foley catheter, pulse oximeter,• Prompt Uterotonic drugs Carboprost 250 mcg, 2 doses 15 minutes apart Oxytocin infusion 40 units / 500 ml in 30 – 60 min Methylergometrine 0.2mg i.m. one dose Misoprostol 400 - 800mcg• Rapidly evaluate for vaginal / cervical lacerations• Warmth, oxygen
  • 20. Oxytocic drugs• Oxytocin• Methyl ergometrine• Misoprostol• Carboprost
  • 21. Oxytocin• Storage: Between 2-8 *C, avoid freezing• Adverse effects: anti-diuretic effect, hypotension, arrhythmias• Incompatible with noradrenaline, warfarin• 10 – 40 IU / L of infusate
  • 22. Ergometrine• Storage: Refrigerate, protect from light, stable for 60-90 days, discoloration – discard• Avoid : heart disease, hypertension, peripheral vascular disease, hepatic or renal impairment; with antiretroviral and macrolide antibiotics• Adverse : Vomiting, nausea, HT, CVA• Route: IM preferred, IV dilute in 5 ml NS
  • 23. Carboprost – PGF2 alpha• Caution : Asthma, cardiac disease, epilepsy, liver disease• Storage: Refrigerate• Adverse: Vomiting, diarrhea, flushing,• Dosage: 250 mcg IM, repeat every 15 - 90 minutes, maximum 8 doses = 2 mg.• IV injection - bronchospasm, hypertension, vomiting, and anaphylaxis
  • 24. Misoprostol• PGE1 analogue• Adverse effects – vomiting, shivering at higher doses. No broncho-constriction.• Storage: Stable at or below 25*C• Route: Oral, buccal, rectal, vaginal• Rapid onset of action lasting 4-6 h
  • 25. Misoprostol as an adjunct to standarduterotonics for treatment of PPHLancet. 2010;375(9728):18081422 women with atonic PPH treated with routineuterotonic agents randomized to 600 mcg misoprostol sublingually Placebo sublinguallyFound no difference in blood loss > 500 ml in next 1hour
  • 26. Treatment of PPH with sublingual misoprostol versusoxytocin in women receiving prophylactic oxytocinLancet. 2010;375(9710):21731055 women delivered with prophylactic oxytocin in III stage,809 (3%) who had atonic PPH were randomized to Misoprostol 800mcg sl Oxytocin 40 u infusion in 15 minutesSimilar outcomes in both groups90% women had bleeding controlled in 20 minutes;30% women had additional blood loss of > 300 ml after Rx
  • 27. After initial treatment• Evaluate for retained placental fragment uterine inversion lacerations coagulopathy• Check urine output, response to resuscitation, time volume of blood lost
  • 28. Volume replacement• Crystalloid: Ringer Lactate, Hartmann, NS RL similar to plasma only 20% retained in circulation Dextrose: only 10% retained, interferes with X matching NS avoid in pre-eclamptic patient• Blood volume changes last for 40 minutes only• Infuse 3 L for each 1 L of estimated blood loss• Target 90mm systolic pressure, UOP 30ml/hr• Give colloids after 2 L of crystalloids given
  • 29. Colloids• Gelatin polymers - Hemaccel rapid urinary excretion anaphylaxis• Hydroxyethyl starch – Hetastarch, Pentastarch increases plasma volume by 70 – 230% dose 20 ml/kg = 1 to 1.5 L no anaphylactic reactions well tolerated lasts for 4 hours in circulation
  • 30. Blood transfusion• No universally accepted guidelines for trigger• PRBC x 2 if no improvement after 2-3 L of crystalloids or if ongoing blood loss likely• Warm carefully. > 40 *C – severe transfusion reactions• Admin 1 FFP for every 1-2 units of PRBC, at 12-15ml/kg• No drugs / injections with blood
  • 31. Target• Hb > 7,• Platelets > 50,000 /ml• Fibrogen > 100mg/dl• PT < 1.5 times control
  • 32. Massive hemorrhage• Defined as > 10 units of BT required / 24 h• Likely when persistent SBP < 90, Loss more than 1500ml• Cryoprecipitate if no response to FFP or Fibrogen level < 100• Expect platelet count < 50,000 after > 2 L blood loss. Platelets to maintain counts 25-50,000, 1:1
  • 33. Secondary interventions• Repeated doses of Carboprost max 8 doses• Intramyometrial Carboprost - off label• Carboprost uterine irrigation• Rectal Misoprostol - high doses >800mcg• Intra-uterine Misoprostol• Tamponade – Sengstaken tube,• Uterine Packing
  • 34. Indications for laparotomy• Unabated blood loss• Atony unresponsive to Rx• Vital signs out of proportion to blood loss• Vaginal laceration extending above fornix
  • 35. Summary• Symptoms and vital signs of blood loss are more important than visual assessment of blood loss• Team approach with protocols and regular drills• Prompt, sequential use of utero-tonic agents and replacement of volume are mainstay of Rx• Low Fibrinogen, abn PT, tachycardia and abnormalities of placental implantation and detectable troponin are predictors of increased morbidity
  • 36. Thank you !