postpartum haemorrhage recent advances

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postpartum haemorrhage recent advances

  1. 1. Prevention of Postpartum Hemorrhage Dr Shashwat Jani
  2. 2. ACCIDENTS AND HAEMORRHAGE
  3. 3. <ul><li>What really kills a women ? </li></ul>
  4. 4. PPH <ul><li>Three delays </li></ul><ul><ul><li>Delay in diagnosis </li></ul></ul><ul><ul><li>Delay in transfer </li></ul></ul><ul><ul><li>Delay treatment / management </li></ul></ul>
  5. 5. PPH <ul><li>Three factors </li></ul><ul><ul><li>Amount of blood loss </li></ul></ul><ul><ul><li>Rate of blood loss </li></ul></ul><ul><ul><li>Health status of woman </li></ul></ul>
  6. 6. PPH <ul><li>Time interval from onset of PPH to death is 2 hours . </li></ul><ul><li>By the time clinical signs appear lost 25% of her blood volume </li></ul>
  7. 7. BUT <ul><li>THESE </li></ul><ul><li>CAN </li></ul><ul><li>BE </li></ul><ul><li>PREVENTED. </li></ul>
  8. 8. <ul><li>HOW ? </li></ul>
  9. 9. PREVENTION <ul><li>Regular ANC </li></ul><ul><li>Correction of anaemia </li></ul><ul><li>Identification of high risk cases </li></ul><ul><li>Delivery in hospital with facility for Emergency Obstetric Care. </li></ul><ul><li>Otherwise transport to the nearest such hospital at the earliest. </li></ul><ul><ul><li>Keep speedy transport available </li></ul></ul><ul><li>Local / Regional anaesthesia </li></ul><ul><li>ACTIVE MANAGEMENT OF 3 RD STAGE OF LABOUR </li></ul><ul><li>4 th Stage of labour - Observation, Oxytocin </li></ul>
  10. 10. Prevention of PPH in labour room <ul><li>Anticipate PPH in every woman in labor </li></ul><ul><li>Keep emergency tray </li></ul>
  11. 11. ANTENATAL RISK FACTORS <ul><li>Two-thirds of women have no identifiable risk factors </li></ul><ul><li>Pre-eclampsia </li></ul><ul><li>Mediolateral episiotomy </li></ul><ul><li>Previous PPH </li></ul><ul><li>Multiple gestation </li></ul><ul><li>Previous caesarean </li></ul><ul><li>Obesity </li></ul>
  12. 12. INTRAPARTUM RISKS <ul><li>Prolonged 2 nd stage </li></ul><ul><li>Prolonged 3 rd stage > 30 min </li></ul><ul><li>Mediolateral episiotomy </li></ul><ul><li>Arrest of descent </li></ul><ul><li>General anaesthesia </li></ul><ul><li>Laceration </li></ul><ul><li>Augmented labour </li></ul><ul><li>Forceps delivery </li></ul>
  13. 13. PPH <ul><li>What must be available immediately in every place of delivery to deal such complication ? </li></ul>
  14. 14. <ul><li>For handling emergencies one must have a crash kit with the following </li></ul>Crash Kit (Emergency Tray)- Whole team with the patients <ul><li>Brannula (16 ,18 ,20) </li></ul><ul><li>Bulbs- grouping and </li></ul><ul><li>cross matching </li></ul><ul><li>Venesection Set </li></ul><ul><li>Syringes/ Gloves </li></ul><ul><li>Roller gauze / mops / </li></ul><ul><li>sticking plaster, scissor </li></ul><ul><li>Foley’s catheter </li></ul><ul><li>Drip sets </li></ul><ul><li>I. V. Fluids- RL, DNS </li></ul><ul><li>Hemacel, </li></ul><ul><li>Intubation materials </li></ul><ul><li>Oxytocin,Misoprostol </li></ul><ul><li>PGF2alpha,Methergin </li></ul><ul><li>Oxygen with mask </li></ul><ul><li>Hydrocortisone </li></ul><ul><li>Calcium Gluconate </li></ul><ul><li>Deriphylline </li></ul><ul><li>Atropine </li></ul><ul><li>Adrenaline </li></ul><ul><li>Dopamine, Dobutamine </li></ul>
  15. 16. <ul><li>THE THIRD STAGE OF LABOUR IS </li></ul><ul><li>INDEED THE UNFORGIVING STAGE </li></ul><ul><li>OF LABOUR </li></ul><ul><li>AS </li></ul><ul><li>IN IT THERE LURKS MORE </li></ul><ul><li>UNHERALDED TREACHERY THAN IN </li></ul><ul><li>FIRST TWO STAGES OF LABOUR </li></ul><ul><li>COMBINED </li></ul>
  16. 17. Mechanism of hemostasis <ul><li>Contraction & Retraction of myometrium.‘Living Ligatures or physiological sutures of uterus‘’ (Baskett 1990) </li></ul><ul><li>Coagulation pathway. </li></ul><ul><li>Myotamponade. </li></ul>
  17. 18. <ul><li>Expectant or active management </li></ul><ul><li>of third stage ? </li></ul>
  18. 19. <ul><li>AMTSL preferred </li></ul><ul><li>-Significanty reduces PPH by 60% </li></ul><ul><li>-Significantly decrease the need for blood </li></ul><ul><li>transfusion </li></ul><ul><li>-Need for therapeutic oxytocics was reduced by </li></ul><ul><li>80% </li></ul><ul><li>( Conclusive evidence from 5 randomised controlled trial and </li></ul><ul><li>WHO meta-analysis) </li></ul>
  19. 20. Components of AMTSL <ul><li>Immediate administration of uterotonic drug </li></ul><ul><li>Delayed clamping of the cord </li></ul><ul><li>Controlled cord traction </li></ul><ul><li>Examination of the placenta </li></ul><ul><li>Palpation of the uterus to ensure contractility every 15 min. for at least 2 hrs. </li></ul>
  20. 21. OXYTOCIN PREFERRED <ul><li>Oxytocin alone is very effective </li></ul><ul><li>Oxytocin does not have the adverse effect profile as those associated with preparation containing ergot (Mc Donald 2002 ) </li></ul><ul><li>Oxytocin is more stable when exposed to heat and light than ergot preparations ( Favored by WHO 1993 ) </li></ul><ul><li>Can be used in settings where storage capabilities is an issue </li></ul>
  21. 22. <ul><li>When to administer a prophylactic </li></ul><ul><li>Oxytocin in AMTSL ? </li></ul>
  22. 23. <ul><li>In the AMTSL prophylactic oxytocin </li></ul><ul><li>administered intramuscularly after the delivery of the baby ( Bristol and Hinchingbrooke trial ) </li></ul>
  23. 24. <ul><li>Dosage of oxytocin recommended </li></ul><ul><li>Oxytocin 10 IU administered intramuscularly or 10-20 IU in 500 ml of crystalloid IV </li></ul><ul><li>At caesarean section oxytocin 5 IU intravenously </li></ul>
  24. 25. The incidence of Induction of Labour is on the rise . Even otherwise, most women in labour have an IV line . Why not use the convenient Oxytocin to prevent PPH?
  25. 26. Methyl-ergometrine <ul><li>Onset- 3 to 5 min- IM & </li></ul><ul><li>1 min for IV </li></ul><ul><li>Duration- > 3hrs-IM & 45 Min- IV </li></ul><ul><li>IV / IM 0.2 mg </li></ul>
  26. 27. <ul><li>More side effects </li></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><li>Needs refrigeration (2-8 0 c) </li></ul><ul><li>Contraindications – Hypertension, cardiac disease etc., </li></ul>
  27. 28. PGF 2 α ( Carboprost.)-IM only <ul><li>Strong uterotonic </li></ul><ul><li>125 mcg IM can be used for prevention </li></ul>
  28. 29. PPH
  29. 30. <ul><li>More side effects </li></ul><ul><ul><li>Shivering </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Diarrhoea </li></ul></ul><ul><ul><li>Abdominal cramps </li></ul></ul><ul><li>Avoid in asthmatics ( bronchospasm ) </li></ul>
  30. 31. Misoprostol (PGE 1 analogue) <ul><li>Oral / rectal / vaginal/Sublingual – accepted routes of administration </li></ul><ul><li>Can be kept it room temperature up to 27 0. </li></ul><ul><li>cheap and can be by an unskilled person </li></ul>
  31. 32. Misoprostol (PGE 1 ) <ul><li>For prevention – 600 mcg orally immediately after clamping and cutting the cord has been recommended. </li></ul>
  32. 33. How to Refer ? <ul><li>To proper place </li></ul><ul><li>Foot end elevated </li></ul><ul><li>With I.V. drip </li></ul><ul><li>Blood samples (For grouping & crossmatching) </li></ul><ul><li>Paramedical staff with emergency drugs </li></ul><ul><li>Prior information to the place of referral blood group </li></ul><ul><li>With a note (Diagnosis & treatment given) </li></ul><ul><li>Attenders – Young adults (for blood) </li></ul>
  33. 34. Non inflatable anti shock garment
  34. 35. Thank you….

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