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Post Partum Hemorrhage
PPH
 Primary PPH
 Within 24 hours of birth
 >500 mL vaginal birth or >1000 mL C section
 ** Or any amount that causes symptoms
 Secondary PPH
 Abnormal or excessive bleeding
 24 hrs to 12 weeks postnatal
 Often assoc with endometritis
** Can further subdivide PPH as minor (500-1000 mL) or major (>1000 mL)
PPH
 One of leading causes of maternal mortality
 1-5% of deliveries
 #1 cause postpartum women admitted to ICU
 Blood flow to uterus at term: >700 mL/min
 Blood loss often under-estimated and bleeding not
always obvious… so what signs can we look for?
What are the signs/sympt?
Steps to managing PPH
 Predict:
 identify patients at risk
 Prepare:
 Multi-disiplinary approach, PPH protocol
 Manage:
 Timely, accurate diagnosis and appropriate interventions
 Active management of 3rd stage of labour
Causes of PPH
 Any deviation from normal
stage 3:
 Placenta completely separates
from uterus
 Myometrium contracts
 Vessles constrict
 Coagulation pathways activate
4 T’s of PPH
 Tone: Failure of uterus to contract
 Tissue: Retained products in uterus
 Trauma: Vaginal, perineal, uterine
 Thrombin: Coagulation abnormalities
TONE
 Atony of uterus
 75-90 % of PPH
 Causes:
 Overdistension of uterus (large baby, multiple gestation)
 Uterine muscle exhaustion (prolonged labour)
 Uterine infection
 Uterine relaxants (general anesthetic)
 Retained placental fragments
TISSUE
 Retained placental products
 #1 cause for massive
transfusions (>10 units RBC)
 Risks:
 Placenta previa (above cervix)
 Placenta
accreta/increta/percreta
(invade into uterus)
 Prior C-section
 Curettage
 Uterine infection
TRAUMA
 5-10% of PPH
 Lacerations, incisions, uterine rupture, hematoma
 Risks:
 Instrumented deliveries
 Primiparity
 Pre-eclampsia
 Multiple gestation
 Prolonged second stage
 Vulvovaginal varicosities
 Uterine inversion
THROMBIN
 Coagulation defects
 Risks
 Pyrexia in labour, sepsis
 Pre-eclampsia, HELLP
 Placental abruption
 Pre-existing clotting disorder or liver failure
 Anti-coagulants
 Fetal demise
Review of some risks
 Abnormal or retained placenta
 Prolonged or precipitous labour
 Lacerations or use of instruments
 Distended uterus
 Hypertensive disorders (Pre-eclampsia)
 Induction of labour or oxytocin use
 Previous PPH
 Fetal demise
 Coagulation disorders
 ….
Case - Mary
 25 year old G1P0
 Pregnancy complicated by pre-
eclampsia
 Labour has been prolonged (stage
1/2: >25 hours)
 Serial blood work stable: Hb 120,
normal CBC and lytes
 Vitals stable, but blood pressure
has been ~160/90
A Case - Mary
 Resistant to assisted delivery, but eventually agrees to
use of foreceps
 Baby is delivered soon after with 2rd degree tear
 Placenta delivered: appears intact with no missing or
extra lobes
 Bleeding estimated at 400 mL, with a slow trickle from
tear
 During suturing of her tear you note vitals deteriorating to
 HR 120, BP 90/60, pallor, feels dizzy
Management
 Bedside evaluation, frequent vitals, ABCs
 CBC, extended lytes, PT/PTT, screen and x-match
 *Hb and Hct may not reflect acute changes
 Reverse coagulopathies or electrolyte abnormalities
 Active management of 3rd stage
 Cord traction, uterine massage, remove retained products
 Uterotonics: Oxytocin, carboprost, misoprostol
 IV access & fluids, urine output, transfusion as needed
Blood products
 Blood should be drawn q30-60 min to guide replacement
(CBC, lytes, ionized calcium, PTT/INR)
 No hard/fast rules: 2 units pRBC if hemodynamics do not
improve after 2-3 liters of NS, EBL > 1500 mLs and continued
bleeding expected
 Typically FPP:pRBC = 1:2-3 (to stop dilutional coagulapathy)

 Goals:
 HB >75
 Platelets > 50 000
 PTT and INR > 1.5 control
 Fibrinogen > 200 mg/dL
Uterine massage/compression
Balloon tamponade
•Effective mainly in uterine atony
•Need to continue to monitor vitals and blood work closely.
•If fails move on to embolization or surgery
Arterial embolization
 Must be stable enough to go to interventional radiology
Aortic compression
Emergency hysterectomy
• Can try suturing
techniques first (B-Lynch
suture)
• Hysterectomy typically a
last resort
• More readily done for
uterine perforation,
placenta
accreta/increta/percreta
Case - Mary
 You suspect uterine atony so you give oxytocin (10
units IM) and call the team
 Ask nurses to start 2 large bore IVs and fluids, blood
work, foley catheter, give oxygen
 Uterine massage followed by compression
 Uterus initially feels boggy but after ~1 minute
contracts causing a large gush of pooled blood to
exit the vagina (~800 mL)
Case - Mary
 Vitals stabilize after 3 liters of NS and she is weaned off
O2
 Vaginal tear repaired
 Hb remains stable ~95-100, remaining bloodwork normal
 Urine output stays above 40 ml/hr
 Mary is closely monitored and recovers well over next
couple of days (her baby is healthy too!)

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Post Partum Hemorrhage (PPH)

  • 2. PPH  Primary PPH  Within 24 hours of birth  >500 mL vaginal birth or >1000 mL C section  ** Or any amount that causes symptoms  Secondary PPH  Abnormal or excessive bleeding  24 hrs to 12 weeks postnatal  Often assoc with endometritis ** Can further subdivide PPH as minor (500-1000 mL) or major (>1000 mL)
  • 3. PPH  One of leading causes of maternal mortality  1-5% of deliveries  #1 cause postpartum women admitted to ICU  Blood flow to uterus at term: >700 mL/min  Blood loss often under-estimated and bleeding not always obvious… so what signs can we look for?
  • 4. What are the signs/sympt?
  • 5. Steps to managing PPH  Predict:  identify patients at risk  Prepare:  Multi-disiplinary approach, PPH protocol  Manage:  Timely, accurate diagnosis and appropriate interventions  Active management of 3rd stage of labour
  • 6. Causes of PPH  Any deviation from normal stage 3:  Placenta completely separates from uterus  Myometrium contracts  Vessles constrict  Coagulation pathways activate
  • 7. 4 T’s of PPH  Tone: Failure of uterus to contract  Tissue: Retained products in uterus  Trauma: Vaginal, perineal, uterine  Thrombin: Coagulation abnormalities
  • 8. TONE  Atony of uterus  75-90 % of PPH  Causes:  Overdistension of uterus (large baby, multiple gestation)  Uterine muscle exhaustion (prolonged labour)  Uterine infection  Uterine relaxants (general anesthetic)  Retained placental fragments
  • 9. TISSUE  Retained placental products  #1 cause for massive transfusions (>10 units RBC)  Risks:  Placenta previa (above cervix)  Placenta accreta/increta/percreta (invade into uterus)  Prior C-section  Curettage  Uterine infection
  • 10. TRAUMA  5-10% of PPH  Lacerations, incisions, uterine rupture, hematoma  Risks:  Instrumented deliveries  Primiparity  Pre-eclampsia  Multiple gestation  Prolonged second stage  Vulvovaginal varicosities  Uterine inversion
  • 11. THROMBIN  Coagulation defects  Risks  Pyrexia in labour, sepsis  Pre-eclampsia, HELLP  Placental abruption  Pre-existing clotting disorder or liver failure  Anti-coagulants  Fetal demise
  • 12. Review of some risks  Abnormal or retained placenta  Prolonged or precipitous labour  Lacerations or use of instruments  Distended uterus  Hypertensive disorders (Pre-eclampsia)  Induction of labour or oxytocin use  Previous PPH  Fetal demise  Coagulation disorders  ….
  • 13. Case - Mary  25 year old G1P0  Pregnancy complicated by pre- eclampsia  Labour has been prolonged (stage 1/2: >25 hours)  Serial blood work stable: Hb 120, normal CBC and lytes  Vitals stable, but blood pressure has been ~160/90
  • 14. A Case - Mary  Resistant to assisted delivery, but eventually agrees to use of foreceps  Baby is delivered soon after with 2rd degree tear  Placenta delivered: appears intact with no missing or extra lobes  Bleeding estimated at 400 mL, with a slow trickle from tear  During suturing of her tear you note vitals deteriorating to  HR 120, BP 90/60, pallor, feels dizzy
  • 15. Management  Bedside evaluation, frequent vitals, ABCs  CBC, extended lytes, PT/PTT, screen and x-match  *Hb and Hct may not reflect acute changes  Reverse coagulopathies or electrolyte abnormalities  Active management of 3rd stage  Cord traction, uterine massage, remove retained products  Uterotonics: Oxytocin, carboprost, misoprostol  IV access & fluids, urine output, transfusion as needed
  • 16. Blood products  Blood should be drawn q30-60 min to guide replacement (CBC, lytes, ionized calcium, PTT/INR)  No hard/fast rules: 2 units pRBC if hemodynamics do not improve after 2-3 liters of NS, EBL > 1500 mLs and continued bleeding expected  Typically FPP:pRBC = 1:2-3 (to stop dilutional coagulapathy)   Goals:  HB >75  Platelets > 50 000  PTT and INR > 1.5 control  Fibrinogen > 200 mg/dL
  • 18. Balloon tamponade •Effective mainly in uterine atony •Need to continue to monitor vitals and blood work closely. •If fails move on to embolization or surgery
  • 19. Arterial embolization  Must be stable enough to go to interventional radiology
  • 21. Emergency hysterectomy • Can try suturing techniques first (B-Lynch suture) • Hysterectomy typically a last resort • More readily done for uterine perforation, placenta accreta/increta/percreta
  • 22. Case - Mary  You suspect uterine atony so you give oxytocin (10 units IM) and call the team  Ask nurses to start 2 large bore IVs and fluids, blood work, foley catheter, give oxygen  Uterine massage followed by compression  Uterus initially feels boggy but after ~1 minute contracts causing a large gush of pooled blood to exit the vagina (~800 mL)
  • 23. Case - Mary  Vitals stabilize after 3 liters of NS and she is weaned off O2  Vaginal tear repaired  Hb remains stable ~95-100, remaining bloodwork normal  Urine output stays above 40 ml/hr  Mary is closely monitored and recovers well over next couple of days (her baby is healthy too!)

Editor's Notes

  1. 15 % of cardiac output
  2. ** Bleeding from vagina is not always obvious, and sometimes interna. Physicians typically undersetimate blood loss visually
  3. Obs, midwives, nurses, anesthesiologists, hematologists, labs, surgical subspecialists, radiology
  4. Ex/ succenturiate lobe, placental fragments, placenta accreta
  5. ** however only a small proportion of women with risk factsors for PPH develp it (other than abnormal placentation), so knowledge of risk factors are not very useful clinically.
  6. **Ionized calcium can inhibit coagulation and can get hyperkalemia from transfusions hb and hematocrit are poor reflection of blood loss as they do not decliene immediately