Update management of postpartum haemorrhage

6. Postpartum hemorrhage (PPH) is an obstetric emergency complicating
1%–10% of all deliveries.
It continues to be the leading obstetric cause of maternal death. In
2015, it was reported to be responsible for more than 80 000 maternal
deaths worldwide.
Its distribution varies across regions, with the highest prevalence of
5.1%–25.7% reported in Africa, followed by North America at 4.3%–13%
and Asia at 1.9%–8%.
FIGO guidelines, 2022

7. in the United Kingdom postpartum haemorrhage (PPH) is still one of
the leading causes of maternal mortality with playing a significant role
in the deaths of nine women in the last triennial report.
Luesley DM, et al; 2016

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12. The differentiation between primary and secondary PPH is more than
an academic discussion, as the aetiology, clinical presentation,
treatment and prognosis of the two conditions are very different.
Luesley DM, et al; 2016
PPH is subclassified as follows:
➢ Primary Postpartum haemorrhage:
quantified bleeding of more than 500 ml for vaginal deliveries and
more than 1000 ml for cesarean deliveries, occurring within the first
24 hours of delivery
FIGO guidelines, 2022

13. Summary of postpartum hemorrhage definitions from high-quality
guidelines around the world

14. ➢ Sceondary Postpartum haemorrhage:
Its definition is blood loss from the genital tract of a volume greater
than expected after the first 24 hours, but within the first 12 weeks of
delivery.
Luesley DM, Kilby M, editors. Obstetrics & Gynaecology: An evidence-based text for
MRCOG. CRC Press; 2016 Mar 30.

15. ➢ Massive Postpartum haemorrhage:
• By volumes
o WHO (2012): Severe PPH = ≥ 1000 ml within 24 hours
o RCOG (2016): Major Severe PPH = > 2000 ml
o NHS England Maternity Dashboard Metrics (2017): ≥ 1500 ml
o Scottish CASMM: ≥ 2500mls
• By transfusion
o Scottish CASMM: ≥ 5 units or treatment for coagulopathy
o UKOSS: >8 units of blood within 24 hours of delivery
• By rate
o BCSH (2006): Blood loss ≥ 150ml per minute or Loss of 50%
Blood Volume in 3 hrs or Loss of 100% Blood Volume in 24hr

16. ➢ Massive Postpartum haemorrhage:

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19. The causes of postpartum hemorrhage include the following four Ts:
➢ Tone:
abnormalities of uterine contraction: 70%
➢ Trauma
genital tract injury: 19%
➢ Tissue
retained products of conception: 10%
➢ Thrombin
abnormalities of coagulation: 1%

20. ➢ Tone: Uterine Atony 70%
• Prolonged labor
• factors that lead to uterine overdistension such as multiple fetal
gestation, polyhydramnios, and fetal macrosomia …. etc
• Precipitate labor
• Augmented labor
• Chorioamnionitis
• Anemia
• Antepartum hemorhhage
• Multiparity

21. ➢ Tone: Uterine Atony 70%
• Excessive sedation
• Tocolytic agents
• Uterine fibroids
• Full bladder, rectum

22. ➢ Trauma: genital tract injury: 15%–20%
Lacerations and trauma including:
• Uterine rupture
• Vaginal , cervical and perineal tears, lacerations and hematomas
or episiotomies

23. ➢ Tissue: retained products of conception: 10%
• Placenta and membranes
• Blood clots

24. ➢ Thrombin: abnormalities of coagulation: 1%
• Acquired: DIC, Dilutional coagulopathy and heparin
• Congenital: Von Willebrand's disease, hemophilia and idiopathic
thrombocytopenic purpura

25. ➢ Other causes:
• uterine inversion and abnormal placentation

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28. ➢ Factors that can contribute to PPH
• Previous Cesarean (CS)
• Antepartum / Intrapartum Hemorrhage
• Emergency Cesarean
• Age ≥ 40
• Maternal Sepsis
• Suspected scar dehiscence
• Second stage section
• Polyhydramnios
• Macrosomia
• Fibroids

29. ➢ Factors that can contribute to PPH
• Preeclampsia/ Pregnancy induced hypertension
• Multiple Pregnancy
• Previous 3 CS
• Asian Ethnicity
• Grandmultiparity
• Placenta Previa
• Suspected Abruption
Dunkerton SE et al. 2018

30. ➢ PPH prediction risk assessment

31. ➢ PPH prediction risk assessment
Maher Gm, et al. 2022

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34. ➢ General examination
• the general condition is related to the amount of blood loss, so
signs of hypovolemic shock is present
➢ Abdominal examination:
• either the uterus is large, soft, lax, squeezing leads to gush of
blood through the vagina (atony – retained tissue)
• Or the uterus is hard, contracted (trauma – coagulopathy)

35. ➢ Vaginal examination:
• bright red fresh blood pass through the vagina suggest traumatic
PPH
• if the blood is dark, suggest atony or retained tissue
• may reveals tears in perineum, vagina, cervix
➢ Examination of the placenta, membranes for missed parts
➢ Persistent bleeding in absence of atony, tears is suggestive of
coagulopathy, coagulation profile should be done to ensure
diagnosis

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38. ➢ Early control of the bleeding is the most effective measure for the
treatment of PPH (THE GOLDEN HOURs)
➢ There is a relationship between the time elapsed to control the
bleeding and the chance of death
➢ Aggressive and rapid interventions
➢ Avoid the lethal triad of PPH: Acidosis, hypothermia and
coagulopathy

39. ➢ RED CODE AND TEAMWORK...
• TEAM
• LEADERSHIP
• COMUNICATION
• MONITORING
• MUTUAL SUPPORT

40. ➢ Steps of management:
1. Be prepared
2.Recognize
3.Communicate
4.Resuscitate
5.Monitor and investigate
6. Stop the bleeding:

41. 1. Be prepared → Postpartum hemorrhage bundle care
• Multimodal strategies have been implemented in high-income
countries to control pathologies with high mortality rates such as
PPH.
• These strategies involved multiple interventions and actors have
been called “bundles” or intervention packages, which consist of
the implementation of a group of interventions as well as
multidisciplinary programs.
• Bundles represent a selection of existing guidelines and
recommendations in a form that aids systematic implementation
and a consistency of practice.
FIGO guidelines, 2022

42. 1. Be prepared → Postpartum hemorrhage bundle care
1.Massachusetts General Hospital
Division of Global Health Innovation,
Boston, MA, USA
2. Mahatma Gandhi Institute of
Medical Sciences, Sevagram,
Maharashtra, India
3. Kisumu Medical and Education
Trust, Kisumu, Kenya
4. Harvard Medical School, Boston,
MA, USA
5. Harvard T.H. Chan Schoolof Public
Health, Boston, MA, USA

43. 1. Be prepared → Postpartum hemorrhage bundle care

44. 1. Be prepared → Postpartum hemorrhage bundle care
➢ :
Council on Patient Safety in Women's Health Care2022.

45. 1. Be prepared → Postpartum hemorrhage bundle care
Althabe F, et al.. 2020

46. 2. Recognize → Identification of the severity of haemorrhage:
The volume of estimated blood loss remains unreliable in many cases,
and therefore much attention should be directed to the general
clinical status of the patient instead.
Several tools for accurate estimation of blood loss have:
1. visual observation; only 50%-70% of blood loss
2. Container: kidney dish, measuring cup
3. Surface area: blood stained 10cmx10cm = 10ml
4. Weighing towels: 1.05g = 1ml
5. Hct<=30%, Hb5-7g/L indicate blood loss >1000ml
6. Hourly urine output <25ml indicates blood loss >2500ml

47. 2. Recognize → Identification of the severity of haemorrhage:
Rule of 30
30% loss in blood volume = moderate shock
• Systolic BP fall by 30mmHg
• Heart rate rise by 30 beats/min
• Respiratory rate rise by 30 breaths/min
• Urine output <30ml/hr
• Haemoglobin (hematocrit) drop by 30%

48. 2. Recognize → Identification of the severity of haemorrhage:
Pacagnella, R.C.,et al., 2013

49. 2. Recognize → Identification of the severity of haemorrhage:
Recently, some guidelines have incorporated the shock index into their
recommendations to evaluate bleeding.
Shock index: used in clinical practice to assess the amount of blood
loss and degree of hypovolemic shock
Shock index = systolic pressure / pulse rate
SI <=0.5, normal blood volume •
SI = 0.5-1, blood loss <20%, 500-750ml •
SI = 1, blood loss 20-30%, 1000-1500ml •
SI = 1.5, blood loss 30-50%, 1500-2500ml •
SI = 2, blood loss 50-70%, 2500-3500ml
FIGO guidelines, 2022

50. 2. Recognize → Identification of the severity of haemorrhage:
Pacagnella, R.C.,et al., 2013

51. 3. Communicate → Call for help
• experienced midwife
• Call obstetric registrar & alert consultant
• Call anaesthetic registrar , alert consultant
• Alert haematologist
• Alert Blood Transfusion Service
• Call porters for delivery of specimens / blood

52. 4. Resuscitate
• Measures for minor PPH (blood loss 500–1000 ml) without clinical
shock:
o intravenous access (one 14-gauge cannula)
o urgent venepuncture (20 ml) for:
I. group and screen
II. full blood count
III. coagulation screen, including fibrinogen
o pulse, respiratory rate and blood pressure every 15 minutes
o commence warmed crystalloid infusion.

53. 4. Resuscitate
• Measures for major PPH (blood loss greater than 1000 ml) and
continuing to bleed or clinical shock
o A and B – assess airway and breathing
o C – evaluate circulation
o position the patient flat
o keep the woman warm using appropriate available measures
o Two IV access with 14 G cannula
o 20 ml blood sample should be taken and sent for diagnostic
tests, including full blood count, coagulation screen, urea and
electrolytes, and to cross-match packed red cells (4 units)
o A high concentration of oxygen (10–15 l/min) via a facemask
should be administered, regardless of oxygen concentration

54. 4. Resuscitate
• Measures for major PPH (blood loss greater than 1000 ml) and
continuing to bleed or clinical shock
o Transfuse:
i. isotonic crystalloid → Up to 2 l. plus
ii. Colloids → Up to 1.5 l colloid until blood arrives.
iii. BloodIf immediate transfusion is indicated, give emergency
group O Rh-negative, red cell units. Switch to group-specific
red cells as soon as feasible.
iv. Platelet concentrates → 1 pool of platelets if platelet count
less than 75 × 109/l. and haemorrhage is continuing
v. Cryoprecipitate → 2 pools of cryoprecipitate if haemorrhage
is ongoing and fibrinogen less than 2 g/l

55. 4. Resuscitate
• Measures for major PPH (blood loss greater than 1000 ml) and
continuing to bleed or clinical shock
o Transfuse:
vi. Fresh frozen plasma (FFP) if
▪Prothrombin time (PT) or activated partial thromboplastin
time (APTT) are prolonged → administer 12–15 ml/kg of
FFP.
▪Haemorrhage continues after 4 units of red blood cells
(RBCs) and haemostatic tests are unavailable, administer 4
units of FFP.
RCOG Green-top Guideline No. 52, 2016

56. 5. Monitor and investigate
• Cross-match 4 units
• Full blood count
• Clotting screen
• Continuous pulse / BP /
• ECG / Oximeter
• Foley catheter: urine output
• CVP monitoring
• Discuss transfer to ICU

57. 6. Stop the bleeding:
• Determine the cause of pph- 4t
o Tone - is the uterus contracted ?
o Trauma - is there any tract trauma – lacerations ?
o Tissue - is there any tissue left or placenta acreta ?
o Trombin - is there any coagulophaty ?
• Treat the specific cause

58. 6. Stop the bleeding:

59. 6. Stop the bleeding:
• Exclude causes of bleeding other than uterine atony
• Ensure bladder empty
• Uterine bimanual compression
• IV syntocinon 10 units
• IV ergometrine 0.5 mg
• Syntocinon infusion (30 units in 500 ml)
• Carboprost 0.25 mg IM every 15 minutes up to 8 times
• Surgery earlier rather than late
• Hysterctomy early rather than late

60. 6. Stop the bleeding:
• Explore the uterine cavity.
• Inspect vagina and cervix for lacerations.
• If the cavity is empty, Massage and give methylergonovine 0.2 mg,
the dose can be repeated every 2 to 4 hours.
• Rectal 800mcg. Misoprostol is beneficial.
• During the administration of uterotonic agents, bimanual
compression may control hemorrhage

61. 6. Stop the bleeding:
• If conservative measures fail to control haemorrhage, initiate
surgical haemostasis SOONER RATHER THAN LATER
1. At laparotomy, direct intramyometrial injection of Carboprost
(Haemabate) 0.5mg
2.Bilateral ligation of uterine arteries
3.Bilateral ligation of internal iliac (hypogastric arteries)
4.Hysterectomy
• Resort to hysterectomy SOONER RATHER THAN LATER (especially
in cases of placenta accreta or uterine rupture)

62. Summary
of
management
of
severe
PPHge
RCOG
guidelines
2016

63. 6. Stop the bleeding:
• Genital trauma always must be eliminated first if the uterus is
firm.

64. 6. Stop the bleeding:

65. 6. Stop the bleeding:

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68. ➢ Prophylactic oxytocin should be offered routinely in the
management of the third stage of labor as they reduce the risk of
PPH by about 60%. (Grade A)

69. ➢ Women in whom these factors have been identified should be
advised to deliver in a specialist obstetric unit (GRADE B)
odds ratio for PPH
Risk Factor
13
12
5
4
•Proven abruptio placentae
•Known placenta praevia
•Multiple pregnancy
•Pre-eclampsia/gestational hypertension

70. ➢ The following factors, becoming apparent during labour and
delivery are associated with an increased risk of PPH. (GRADE B)

71. ➢ In the event of a woman coming to delivery while receiving
therapeutic heparin, the infusion should be stopped. Heparin
activity will fall to safe levels within an hour. Protamine sulphate
will reverse activity more rapidly, if required. (Grade C)
➢ Women considered at high risk of thromboembolism may be
receiving prophylaxis in the form of Unfractionated Heparin (UH) or
Low Molecular Weight Heparin (LMWH) antenatally. And Women
with a lower risk of thromboembolism and receiving aspirin (75mg
daily) antenatally → In prophylactic dosage, these agents do not
present a haemorrhagic hazard and should be continued
intrapartum. (Grade C)

72. ➢ If women with inherited bleeding disorders present for
preconceptual counselling, they should be tested for immunity
against hepatitis B ,and immunised if required (as a safeguard
should blood products be required at delivery). Immunisation
during pregnancy is also safe. (Grade C)
RCOG Green-top Guideline No. 52, 2016

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76. 1. FIGO considers that the bundle care approach can improve patient
outcomes when adherence to all components is high. Every health
system needs to adopt a bundle. Place the bundle in every
maternity hospital and train to all elements of bundle, from arrival
on obstetrics service to transfer to higher level of care
2. FIGO recommends use of the shock index in the diagnosis and
management of PPH. FIGO considers that the shock index can be a
marker of the severity of PPH and can alert teams to hemodynamic
instabilty when its value is greater than 0.9

77. 3. FIGO recommends use of oxytocin (10 IM/IV) for prevention of
PPH for all births as a first-line uterotonic agent.
• Controlled cord traction is recommended for vaginal births in
settings where skilled birth attendants are available.
• Early cord clamping (<1 min after birth) is not recommended
unless the neonate needs immediate resuscitation.
• Postpartum assessment of uterine tonus is recommended for all
women

78. 4. FIGO recommends the preparedness of obstetric care teams for
the management of PPH according to the updated guidelines
established locally, regionally, or globally. These guidelines should
include medical and nonmedical treatment options according to
the degree of development of each country or region. This should
consider the resources available locally.
5. FIGO reaffirms its recommendation regarding oxytocin as the first
choice for prevention of PPH in vaginal and cesarean deliveries. In
settings where oxytocin is unavailable (or its quality cannot be
guaranteed), the use of other uterotonics (carbetocin,
ergometrine/methylergometrine, or misoprostol) is recommended.

79. 6. FIGO recommends administration of tranexamic acid as soon as
the diagnosis of PPH is made, as long as this is within 3 h
postpartum. One gram of tranexamic acid, intravenously over 10
min is to be given regardless of the cause of PPH. If bleeding
continues after 30 min or stops and restarts within 24 h after the
first dose, a second dose of 1 g may be given.
7. FIGO recommends that all healthcare facilities should have the
non-pneumatic anti-shock garment (NASG) as an effective
nonsurgical device that can be used as a temporary measure to
recover hemodynamic stability for the management and transfer
of a patient to a high level of care.

80. 8. FIGO recommends uterine balloon tamponade in the context of
refractory PPH. Uterine balloon tamponade has proven to be an
effective nonsurgical technique so that when employed rapidly can
potentially improve survival in women with PPH.
9. FIGO recommends uterine artery embolization for refractory
bleeding uncontrolled by medical and nonsurgical treatment
modalities with the availability of trained personnel and necessary
equipment for using this technology
10. FIGO recommends compression sutures as one of the options to
control PPH when medical and nonsurgical treatment modalities
fail.

81. 11. FIGO recommends uterine artery ligation as one of the options to
rapidly control PPH when medical, nonsurgical approaches, and
compression sutures fail
12. FIGO recommends internal iliac artery ligation as one of the
options to rapidly control PPH for management of PPH when
medical, nonsurgical approaches, and compression sutures fail.
FIGO also recommends that all obstetricians familiarize
themselves with the internal iliac artery location and with the
technique

82. 13. FIGO recommends abdominal hysterectomy as treatment for PPH
when all other medical, nonsurgical, and surgical treatment
modalities have failed to control PPH. Care must be taken to have
adequate blood supplies. Subtotal hysterectomy can shorten the
procedure and is important in a hemodynamically unstable patient.
14. FIGO recommends that damage control resuscitation (DCR) should
be implemented in the management algorithms for major obstetric
hemorrhage.nAll countries should establish one or more referral
hospital(s) and develop expert teams that are familiar with this
strategy, the technique, and indications to be able to offer DCR

83. 15. FIGO recommends that all obstetricians are familiar with
resuscitative measures in the context of PPH including massive
transfusion protocols.
FIGO guidelines, 2022

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85. (15 April 1850 – 23 July 1909)