Post partum Haemorrhage

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CME Hospital segamat by Dr Azreen

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Post partum Haemorrhage

  1. 1. POSTPARTUM HAEMORRHAGE (PPH)
  2. 2. Definition • Loss of blood more than 500 ml from the genital tract post delivery of a baby (WHO) • Excessive PVB that cause haematocrit drop more than 10% that require immediate transfusion (ACOG)
  3. 3. • PRIMARY PPH – Loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby Minor : 500-1000 ml with no clinical shock Major : > 1000 ml • SECONDARY PPH – Abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally
  4. 4. • Visual blood loss estimation often underestimates • More accurate method – Blood collection drapes – Weighing swabs
  5. 5. Estimated Blood Pad 120 cc Tampon 50 cc Gauze 30 cc Small Abdominal Pack 250cc Large Abdominal Pack 450 cc
  6. 6. Haemorrhagic Shock • Classification of haemorrhagic shock in relation to clinical criteria and percentage of total blood volume lost • Total blood volume at term is approximately 100ml/kg • Blood loss >40% of total blood volume consider life-threatening
  7. 7. Class % bld. loss BP (mmHg) Sn & Sym Compensated Shock 10 - 15 normal Palp, dizzy, tachy Mild 15 - 30 Slight fall Palp, Thirst, Tachy, weak, sweaty Moderate 30 - 35 70 - 80 Restless, pallor, oliguria Severe 35 - 40 50 - 70 Pallor, cyanosis, collapse Profound 40 - 50 50 Collapse, air hunger, anuria
  8. 8. Causes of PPH •4 T – Tone (abnormality of uterine contraction – UTERINE ATONY) – Tissue (retained products of conception) – Trauma (of genital tract) – Thrombin (abnormality of coagulation)
  9. 9. TONE (UTERINE ATONY) • 75-90% of cases • Uterine hyperdistension – Macrosomic baby – Multiple pregnancy • Previous PPH • High parity • Precipitated or prolonged labour
  10. 10. • Chorioamnionitis • Obesity (BMI > 35) • Age > 40 years old • Anemia
  11. 11. TISSUE • Retained placenta
  12. 12. TRAUMA • 5-10% of cases • Operative vaginal delivery (vacuum / forcep)
  13. 13. • Caesarean section • Mediolateral episiotomy • Poor skill in guarding the perineum
  14. 14. THROMBIN • Pyrexia in labour • Placental abruption • Pre-existing bleeding disorder like haemophilia • Patient on anti-coagulant
  15. 15. PREVENTION • Identify the risk factors that may present antenatally or intrapartum will help us to plan the delivery • However, most cases of PPH have no identifiable risk factors • Active management of 3rd stage of labour lowers maternal blood loss and reduce risk of PPH
  16. 16. • Active management of 3rd stage – Use of uterotonic – Uterine massage – Control cord traction for delivery of placenta
  17. 17. • Prophylactic oxytocics should be given routinely to all women • As it reduce the risk of PPH by ≈60% • Syntometrine (oxytocin + ergometrine) may be used in absence of hypertension
  18. 18. • For cases with no risk factors and delivering vaginally, give IM Oxytocin 5 iu or 10 iu • For cases of Caesarean section, IV Oxytocin 5 iu by slow infusion
  19. 19. • Syntometrine and Oxytocin have similar efficacy in prevention of PPH • However major difference in the side effect. • Syntometrine : 5-fold increase of nausea, vomiting, elevation of BP
  20. 20. • Carboprost (Haemabate®) is PGF2a • Use as treatment rather than prevention
  21. 21. • Misoprostol (600 mcg orally) may be used in home-birth setting but not as effective as oxytocin • All women with previous Caesarean section must be check for placental site and any presence of placenta accreta
  22. 22. • Patient with placenta accreta that diagnosed antenatally should be managed by consultant (O&G, Anaest) at tertiary centre • Reduce the blood loss by leaving the placenta in the uterus after delivery of the baby by fundal classical uterine incision . Followed by hysterectomy / treatment with methotrexate.
  23. 23. • Role of prophylactic interventional radiology in case of antenatally diagnosed placenta accreata –Balloon occlusion –Embolization of pelvic arteries • Studies done show the procedure have value in control of primary PPH and secondary PPH
  24. 24. MANAGEMENT COMMUNICATION RESUSCITATION MONITORING & INVESTIGATION ARREST THE BLEEDING 1. 2. 3. 4.
  25. 25. 1. COMMUNICATION • Alert all relevant professionals • For major PPH, activate RED ALERT – Call experienced Midwife – Call Specialist – Alert Consultant
  26. 26. – Call Anaesthetist (specialist) – Alert Consultant clinical Haemotologist on call – Alert blood bank – Call PPK for delivery of specimens / blood – Alert one member of team to record the events, fluid, drugs and vital sign
  27. 27. • Communicate with patient and the partner with clear information of what happening
  28. 28. 2. RESUSCITATION • A B C • The measurement for resuscitation depend on condition and degree of shock • Assess Airway and Breathing – Give oxygen 10-15 L/min via face mask regardless the maternal [O2] – If airway is compromised due to impaired conscious level, need to intubate with anaesthetic assistance
  29. 29. • Evaluate Circulation – 2 large-bore branula (14-16 gauge) (Take blood for FBC, coagulation profile, BUSE/Cr/LFT, Fibrinogen, GXM 4 units) – Position flat, lateral tilt – Keep patient warm – Give crystalloid infusion (Hartmann) • In Major PPH, add – Tranfuse blood asap
  30. 30. – Until blood is available, total volume of 3.5 litres crystalloid infuse up to 2 L of warmed crystalloid Hartmann solution and/or colloid (1-2 L) as rapidly as required if blood still not available. – May require DIVC regime • FFP : 4 units for every 4 units of Pack Cells or PT/APTT > 1.5 x normal • Platelet concentration : if Plt < 50 x 109 /L • Cryoprecipitate : if fibrinogen < 1g/L
  31. 31. • Aim to restore the both blood volume and oxygen-carrying capacity • Volume replacement must be undertaken on the basis that blood loss is often grossly underestimated
  32. 32. • The therapeutic goals of management of massive blood loss is to maintain – Hb > 8 g/dL – Plt count > 75 x 109 /L – PT < 1.5 x mean control – APTT < 1.5 x mean control – Fibrinogen > 1.0 g/L 2006 Guideline of British Committee for Standards in Haematology
  33. 33. • Role of recombinant factor VIIa therapy (rFVIIa) – Used in treatment of haemophilia – Used in reducing the bleeding in PPH – In life-threatening PPH and in consultation with a haematologist, rFVIIa is used as an adjuvant therapy – Dose 90 mcg/kg
  34. 34. • Role of anti fibrinolytic drugs – there is role of management of obstetric hemorrhage.
  35. 35. 3. MONITORING & INVESTIGATION • Take blood as mentioned • Monitor BP/PR every 15 minute is Minor PPH • Continous BP/PR/RR in Major PPH (using oximeter, cardiac monitoring, automated BP recording) • Put Foley catheter to monitor urine output
  36. 36. • In certain cases, consider arterial line monitoring by experienced staff • Transfer to ICU or HDW once bleeding is controlled • Documentation of fluid balance, blood, blood products and procedure • Central line by senior skilled-anaesthetist may required
  37. 37. • Recommendation for central line and arterial line for pressure monitoring when CVS is compromised by haemorrhage or heart disease
  38. 38. Anaesthetic management • Anaeshetist needs to asses woman quickly , to initiate or continue resuscitation to restore intravascular volume and provide adequate anaesthesia. • Presence of cardiovascular instability is a relative contraindication to regional anaesthesia. • Blockage of sympathetic system can potentially lead to worsening hypotension due to hemorrhage. • General anaesthesia is more appropriate when there is continuing bleeding and the cardiovascular instability. • Ventilator with high oxygen concentrations may be needed
  39. 39. 4. ARREST THE BLEEDING • Depends on the cause of the massive bleeding • Common cause – Uterine Atony – Mechanical – Pharmacological – Surgical
  40. 40. Mechanical • Bimanual uterine compression to stimulate uterus to contract External Internal
  41. 41. - Aortic Compression
  42. 42. Pharmacology • Repeat IM Syntocinon or Syntometrine • IV Pitocin 40 units in 500 ml Hartmann’s solution, run at 125ml/hr • IM Carboprost (Haemabate®) 0.25mg, may repeated at interval not less than 15 min to a maximum 8 doses (contraindicated in Asthma)
  43. 43. • Intramyometrial of Carboprost 0.25-0.5mg • Misoprostol 1000 mcg rectally or cervagem per rectally
  44. 44. TABLE 1 Drug Used to Manage Postpartum Hemorrhage OXYTOCIN (PITOCIN) METHYLERGO NOVINE(METH ERGINE) PROSTAGLAND IN F2α (PROSTIN/15M; HEMABATE) Action Contraction of uterus; decreases bleeding Contraction of uterus Contraction of uterus Side effect Infrequent; water intoxication; nausea and vomiting Hypertension, nausea, vomiting, headache Headache, nausea, vomiting, fever Contrain dications None forPPH Hypertension, cardiac disease Asthma, hypersensitivity
  45. 45. Dosage; route 10-40 U/L diluted in lactated Ringer's solution or normal saline at 125- 200mU/min IV or 10-20 U IM 0.2 mg IM every 2-4 hr up to 5 doses; 0.2 mg IV only for emergency 0.25 mg IM or intramyometrially every 15 min up to 8 doses Nursing consideratio ns Continue to monitor vaginal bleeding and uterine tone Check blood pressure before giving and do not give if >140/90 mm Hg; continue monitoring vaginal bleeding and uterine tone Continue to monitor vaginal bleeding and uterine tone
  46. 46. Surgery • If fail pharmacological • Depends on the clinical circumstances and available expertise • First line is Balloon Tamponade – Various types of hydrostatic balloon catheter – Foley catheter, Bakri balloon, Sengstaken- Blakemore oesophageal catheter and a condom catheter
  47. 47. • The intervention describe as the ‘tamponade test’ • A ‘positive test’ : able to control PPH following inflation of the balloon, indicate that laparotomy is not required • A ‘negative test’ : continued bleeding following inflation of the balloon, indication to proceed to laparotomy
  48. 48. • No evidence of how long the balloon tamponade should be left in place • Most cases, 4-6 hours of tamponade is adequate to achieve haemostasis • Should be remove during daytime hours with presence of appropriate senior staff as further intervention may be necessary
  49. 49. • Haemostatic Brace Suturing – B-Lynch suture (describe in 1997)
  50. 50. – Hayman suture, describe in 2002 with modified compressive suture which does not require hysterotomy – Vertical compression sutures • Effective technique to controlling severe PPH and reducing the need for hysterectomy • Cx : pyometria, partial uterine necrosis
  51. 51. • Bilateral ligation of uterine arteries • Bilateral ligation of internal iliac arteries • Selective arterial embolization • Hysterectomy – Need second consultant to involved in decision of hysterectomy
  52. 52. 4. ARREST THE BLEEDING • Case of RETAINED PLACENTA – empty bladder, attempt CCT – If fail, proceed with Manual Removal of Placenta (MRP) either under sedation or GA – Take consent – If under sedation, give IV Pethidine 25-50mg stat, IV Midazolam 2.5-5.0 mg stat – Continous SPO2 monitoring, Litothomy position
  53. 53. - IV Ampicillin 1g stat, IV Flagyl 500 mg stat - Fully gown, mask, long-sleeve glove - Introduce one hand into vagina along the cord
  54. 54. - Other hand grasp the fundal of uterus and the hand just now move through the cervix to the intrauterine cavity - Detaching the placenta by sideways slicing movement of the fingers
  55. 55. - Once able to detach the placenta part from the intrauterine wall, grasp the placenta and bring out in piece - Then recheck again inside the uterus for any remnant part of placenta
  56. 56. 4. ARREST THE BLEEDING • Management of Genital Tract Trauma – Suture the cervical / vaginal wall tear – May need vaginal packing – Cover with broad spectrum antibiotic
  57. 57. SECONDARY PPH • Often associated with ENDOMETRITIS • Risk factor for endometritis – Prolonged labor – PROM – Anemia – Underlying Diabetes – Chorioamnionitis – Operative deliveries: MRP, C-section, Instrumental vaginal delivery
  58. 58. • Ix : FBC, CRP, high & low vaginal swabs, blood culture if pyrexia • Pelvic ultrasound, help in presence of POC • Treatment : – Antibiotic : Ampicillin and Metronidazole – Uterotonics – If continuing bleeding, may need balloon tamponade or ERPOC
  59. 59. Flow Chart of Mx of Major PPH Major obstetric haemorrhage Blood loss > 2000 ml Continuing major obstetric haemorrhage or clinical shock
  60. 60. Call for help Senior midwife/obstetrician and anaesthetist Alert haematologist Alert blood transfusion laboratory Alert consultant obstetrician on-call
  61. 61. Resuscitation Airway Breathing Circulation Oxygen mask (15 litres) Fluid balance (2 litres Hartmann’s, 1.5 litres colloid) Blood transfusion (O RhD negative or group-specific blood) Blood products (FFP, PLT, cryoprecipitate, factor VIIa) Keep patient warm
  62. 62. Monitoring and investigations 14-g cannulae x 2 FBC, coagulation, U&Es, LFTs Crossmatch (4 units, FFP, PLT, cryoprecipitate) ECG, oximeter Foley catheter Hb bedside testing Blood products Consider central and arterial lines Commence record chart Weigh all swabs and estimate blood loss Medical treatment Bimanual uterine compression Empty bladder Oxytocin 5 iu x 2 Ergometrine 500 mcg Oxytocin infusion (40 u in 500 ml) Carboprost 250 mcg IM every 15 minutes up to 8 times Carboprost (intramyometrial) 0.5 mg Misoprostol 1000 micrograms rectally
  63. 63. Theatre Is the uterus contracted? Examination under anaesthesia Has any clotting abnormality been corrected? Intrauterine balloon tamponade Brace suture Consider interventional radiology
  64. 64. Surgery Bilateral uterine artery ligation Bilateral internal iliac ligation Hysterectomy (second consultant) Uterine artery embolisation Consider monitor at HDU or ICU

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