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  2. 2. PPH today living in the shadow of TAJMAHAL
  3. 3. PPHPPHSingle most important cause of maternalSingle most important cause of maternalmortality worldwide.mortality worldwide.Accounts for 34% of maternal deaths inAccounts for 34% of maternal deaths indeveloping countries.developing countries.
  4. 4. DefinitionDefinitionAny blood loss than has potential toAny blood loss than has potential toproduce or produces hemodynamicproduce or produces hemodynamicinstabilityinstability
  5. 5. DefinitionDefinitionBlood loss > 500 ml after deliveryBlood loss > 500 ml after delivery> 1000 ml after LSCS> 1000 ml after LSCSMinor : 500-1000 mlMinor : 500-1000 mlModerate : 1000-2000 mlModerate : 1000-2000 mlSevere : > 2000 mlSevere : > 2000 ml
  6. 6. Proposed classification. adapted fromProposed classification. adapted fromBenedetti,2002Benedetti,2002HemorrhageHemorrhageclassclassEstimated bloodEstimated bloodlossloss(ml)(ml)Blood volumeBlood volumelossloss(%)(%)Clinical signs &Clinical signs &symptomsymptommanagementmanagement00 <500<500 <10<10 nonenone nonenone11 500-1000500-1000 1515 minimalminimal Observation+/-RPObservation+/-RPTxTx22 1200-15001200-1500 20-2520-25↓↓urine outputurine output↑↑pulse ratepulse rate↑↑respiratory raterespiratory ratePosturalPosturalhypotensionhypotensionNarrow pulse prNarrow pulse prReplacementReplacementtherapy withtherapy withoxytocicsoxytocics33 1800-21001800-2100 30-3530-35 HypotensionHypotensionTachycardiaTachycardiaTachypneaTachypneaCold clammyCold clammyUrgentUrgent activeactivemanagementmanagement44 >2400>2400 >40>40 Profound shockProfound shock Critical active MxCritical active Mx
  7. 7. PREDICTION AND PREVENTIONPREDICTION AND PREVENTIONIdentify pt. at riskIdentify pt. at risk-- Pl previa/accretaPl previa/accreta- Anticoagulation RxAnticoagulation Rx- CoagulopathyCoagulopathy- Overdistended uterusOverdistended uterus- Grand multiparityGrand multiparity- Abn labor patternAbn labor pattern- ChorioamnionitisChorioamnionitis- Large myomasLarge myomas- Previous history ofPrevious history ofPPHPPH
  8. 8. PREVENTIONPREVENTION Regular ANCRegular ANC Correction of anaemiaCorrection of anaemia Identification of high risk casesIdentification of high risk cases Delivery in hospital with facility for EmergencyDelivery in hospital with facility for EmergencyObstetric Care.Obstetric Care. Otherwise transport to the nearest such hospital atOtherwise transport to the nearest such hospital atthe earliest.the earliest. Keep speedy transport availableKeep speedy transport available ACTIVE MANAGEMENT OF 3ACTIVE MANAGEMENT OF 3RDRDSTAGE OF LABOURSTAGE OF LABOUR 44ththStage of labour - Observation, OxytocinStage of labour - Observation, Oxytocin
  9. 9. ACTIVE MANAGEMENT OF 3ACTIVE MANAGEMENT OF 3RDRDSTAGE OF LABOUR (WHO-1989)STAGE OF LABOUR (WHO-1989) Oxytocics - Routine use in third stageOxytocics - Routine use in third stage →→ bloodbloodlossloss ↓↓ by 30-40% and risk of PPH by 60%by 30-40% and risk of PPH by 60% 5 or 10 U Oxytocin IM5 or 10 U Oxytocin IM Syntometrine 1 Amp IMSyntometrine 1 Amp IM Ergometrine 1 Amp IV/IMErgometrine 1 Amp IV/IM-- Misoprost in home birth settings-- Misoprost in home birth settings Early cord clampingEarly cord clamping Controlled cord tractionControlled cord traction Inspection of placenta & lower genital tractInspection of placenta & lower genital tract CS settings -5 U of oxytocin IV bolus , CarbetocinCS settings -5 U of oxytocin IV bolus , Carbetocin
  11. 11. It is an EnigmaIt is an Enigma IIt is sudden often unpredicted assessed subjectively Can be catastrophic.The clinical picture changes so rapidly that unlesstimely action is taken maternal death occurs withina short period.
  12. 12. ““The golden hour” of resuscitationThe golden hour” of resuscitation““Rule of 30”Rule of 30” if SBP falls by 30mmHg,if SBP falls by 30mmHg, HR rises by 30 beats/min,HR rises by 30 beats/min, RR ↑to 30breaths/min,RR ↑to 30breaths/min, HCT drop by 30%,HCT drop by 30%, urine output <30ml/hrurine output <30ml/hr lost at least 30% of her blood volumelost at least 30% of her blood volume
  15. 15. COMMUNICATECOMMUNICATE CallCall experienced midwifeexperienced midwife CallCall OObstetric registrar & alert consultantbstetric registrar & alert consultant CallCall anaesthetic registrar , alert consultantanaesthetic registrar , alert consultant AlertAlert haematologisthaematologist AlertAlert Blood Transfusion ServiceBlood Transfusion Service CallCall porters for delivery of specimens / bloodporters for delivery of specimens / blood Alert one member of the team to record events,fluids, drugs and vital signs
  16. 16. RESUSCITATERESUSCITATEMINOR PPH (blood loss 500–1000 ml, noclinical shock): Intravenous access (14-G cannula x 1). Commence crystalloid infusion. Consider venepuncture (20 ml) for:Group and screenFull blood countCoagulation screen including fibrinogen Pulse and blood pressure recording every 15minutes.
  17. 17. Full protocol for MAJOR PPH (blood loss >1000 ml and continuing to bleed OR clinicalshock): AssessAirway.Breathing.Circulation Oxygen by mask at 10–15 litres/minute. Intravenous access (14-gauge cannula x 2, orangecannulae). Position flat. Keep the woman warm using appropriate availablemeasures.
  18. 18.  Transfuse blood as soon as possible. Until blood is available, Infuse up to 3.5litres of warmed Crystalloid Hartmann’ssolution (2 litres) and or Colloid (1–2 litres)as rapidly as required. The best equipment available should beused to achieve RAPID WARMEDinfusion of fluids.
  19. 19. Fluid Therapy and Blood ProductsFluid Therapy and Blood Products Crystalloid Up to 2 litres Hartmann’s solution Colloid Up to 1–2 litres colloid until bloodarrives Blood If crossmatched blood is stillunavailable, give uncrossmatchedgroup-specific blood OR give ‘O RhDnegative’ blood Fresh Frozen Plasma 4 units for every 6 units of red cellsor PT/ APTT > 1.5 x normal(12–15 ml/kg or total 1 litre) Platelets concentrates if PLT count < 50 x 109 Cryoprecipitate If fibrinogen < 1 g/lUpto 1 litre of FFP and 10 units of Cryoprecipitate can begiven in case of relentless bleeding.
  20. 20. Main Therapeutic GoalsMain Therapeutic Goals Main therapeutic goals of management ofmassive blood loss is to maintain: haemoglobin > 8g/dl platelet count > 75 x 109/l prothrombin < 1.5 x mean control activated prothrombin times < 1.5 x meancontrol fibrinogen > 1.0 g/l.
  21. 21. Recombinant Factor VIIRecombinant Factor VII In the face of life-threatening PPH, and inconsultation with a haematologist, rFVIIa maybe used as an adjuvant Dose is 90 micrograms/kg, repeated in theabsence of clinical response within 15–30minutes. Fibrinogen should be above 1g/l and plateletsgreater than 20 x 109/l before rFVIIa is given
  22. 22. MONITOR / INVESTIGATEMONITOR / INVESTIGATE Consider venepuncture (20 ml) for: Crossmatch (4 units minimum) full blood count coagulation screen including fibrinogen renal and liver function for baseline. Monitor temperature every 15 minutes. Continuous pulse, blood pressure recordingand respiratory rate (using oximeter,electrocardiogram and automated blood pressurerecording). Foley catheter to monitor urine output.
  23. 23.  Consider arterial line monitoring (onceappropriately experienced staff available forinsertion). Consider transfer to ITU once the bleeding iscontrolled or monitoring at high dependency uniton delivery suite, if appropriate. Recording of parameters on a flow chartsuch as the modified obstetric early warningsystem charts. Documentation of fluid balance, blood,blood products and procedures.
  24. 24. The Four “T”The Four “T”ToneToneTissueTissueTraumaTraumaThrombinThrombin
  25. 25. BimanualBimanualCompressionCompressionIf uterus is relaxed :If uterus is relaxed :massaging the uterusmassaging the uteruswill expel anywill expel anyretained bits &retained bits &stimulate uterinestimulate uterinecontractionscontractions
  26. 26. Administer Uterotonic DrugsAdminister Uterotonic Drugs FIRST LINEFIRST LINEOxytocin:Oxytocin:Start with 5 units slow iv or im.Start with 5 units slow iv or im.Infusion of 20 units in 1 L@ 60 dr/min.Infusion of 20 units in 1 L@ 60 dr/min.Continue same dose @ 40 dr/min until bleedingContinue same dose @ 40 dr/min until bleedingstops.stops.Maximum upto 3 L.Maximum upto 3 L.
  27. 27.  SECOND LINESECOND LINEErgometrine/ methyl ergometrine:Ergometrine/ methyl ergometrine:Dose: 0.2 mg im or slow ivDose: 0.2 mg im or slow ivRepeat 0.2 mg after 15 min.Repeat 0.2 mg after 15 min.Maximum 5 doses (1 mg)Maximum 5 doses (1 mg)SyntometrineSyntometrine imim
  28. 28.  THIRD LINETHIRD LINEPGF 2PGF 2αα::Dose: 0.25 mg im.Dose: 0.25 mg im.Can be repeated every 15 min.Can be repeated every 15 min.Maximum upto 2 mg or 8 doses.Maximum upto 2 mg or 8 doses.Misoprostol:Misoprostol:200-800 µg sublingually/per rectal200-800 µg sublingually/per rectalDo not exceed 1000 µgDo not exceed 1000 µgWHO GUIDELINES FOR MANAGEMENT OF PPH 2009WHO GUIDELINES FOR MANAGEMENT OF PPH 2009
  29. 29. If conservative measures fail to controlIf conservative measures fail to controlhaemorrhage, initiate surgical haemostasishaemorrhage, initiate surgical haemostasisSOONER RATHER THAN LATERSOONER RATHER THAN LATER Balloon tamponade Haemostatic brace suturing (such asusing procedures described by B-Lynchor modified compression sutures) Bilateral ligation of uterine arteries Bilateral ligation of internal iliac(hypogastric) arteries Selective arterial embolisation.
  30. 30. Uterine TamponadeUterine Tamponade• Bakri balloonBakri balloon• SengstakenSengstakenBlakemoreBlakemoreoesophageal catheteroesophageal catheter• Condom catheterCondom catheter• Urological RuschUrological RuschballoonballoonSuccess depends uponSuccess depends uponPositive TamponadePositive Tamponade
  31. 31. Procedure of condom BalloonProcedure of condom BallooninsertioninsertionInitialInitialAssemblyAssembly Condoms-2Condoms-2 Foley’s catheter-Foley’s catheter-no.16no.16 Saline with iv setSaline with iv set SpeculumSpeculum Sponge holdingSponge holdingforceps
  32. 32. ProcedureProcedure Lithotomy positionLithotomy position Indwelling Foley’sIndwelling Foley’scatheter.catheter. Explore uterus, cervixExplore uterus, cervixand vagina.and vagina. Inflate balloon withInflate balloon with100-300 ml warm100-300 ml warm0.9% Sodium0.9% Sodiumchloride until bleedingchloride until bleedingis controlled (is controlled (PositivePositive
  33. 33. Compression suturesCompression suturesB Lynch SutureB Lynch Suture•FundalFundalcompressioncompressionsuturesuture•ApposesApposesanterior &anterior &posterior wallposterior wall
  34. 34. Contd…Contd…Parallel Vertical compression sutures forParallel Vertical compression sutures forplacenta praeviaplacenta praevia
  35. 35. Stepwise Uterine DevascularizationStepwise Uterine Devascularization•Uterine arteriesUterine arteries•Tubal branch ofTubal branch ofovarian arteryovarian artery•Internal iliac arteryInternal iliac artery
  36. 36. Uterine Artery EmbolizationUterine Artery EmbolizationPossible only ifPossible only ifinternal arteryinternal arteryligation has not beenligation has not beendone and facility fordone and facility forinterventionalinterventionalradiology availableradiology available
  37. 37. Resort to hysterectomyResort to hysterectomySOONER RATHERSOONER RATHERTHAN LATER (especiallyTHAN LATER (especiallyin cases of placenta accretain cases of placenta accretaor uterine rupture)or uterine rupture)
  38. 38. Documentation and DebriefingDocumentation and DebriefingImportant to record:Important to record:Sequence of eventsSequence of eventsTime and sequence of administration ofTime and sequence of administration ofpharmacological agents, fluids, bloodpharmacological agents, fluids, bloodproductsproductsThe time of surgical interventionThe time of surgical interventionThe condition of mother throughout .The condition of mother throughout .
  39. 39. HAEMOSTASIS algorithmHAEMOSTASIS algorithm H- ask for helpH- ask for help A- assess (vitals, blood loss) & resuscitateA- assess (vitals, blood loss) & resuscitate E -E -1.1. EstablishEstablishetiology(tone,tissue,trauma,thrombine)etiology(tone,tissue,trauma,thrombine)2.2. Ecbolics (syntometrine,ergometrine)Ecbolics (syntometrine,ergometrine)3.3. Ensure availability of bloodEnsure availability of blood M - massage the uterusM - massage the uterus O – oxytocin infusion & prostaglandinO – oxytocin infusion & prostaglandin
  40. 40. § S-S-Ø shift to operating theatreshift to operating theatreØ Bimanual compressionBimanual compressionØ Pneumatic anti-shock garmentPneumatic anti-shock garment T- Tissue & trauma to be excludedT- Tissue & trauma to be excluded A- apply compression suturesA- apply compression sutures S- systematic pelvic devascularisationS- systematic pelvic devascularisation I - interventional radiologyI - interventional radiology S- subtotal/total hysterectomyS- subtotal/total hysterectomy
  41. 41. ConclusionConclusionWe NeedWe NeedIntelligent anticipationIntelligent anticipationSkilled supervisionSkilled supervisionPrompt detectionPrompt detectionEffective institution of therapyEffective institution of therapyto prevent disastrous consequences of PPHto prevent disastrous consequences of PPH..
  42. 42. To Conclude, Management of PPHTo Conclude, Management of PPHHas Evolved From:Has Evolved From: PanicPanic PanicPanic HysterectomyHysterectomyPitocinProstaglandinsHappiness
  43. 43. IncidenceIncidence PPH is one of the commonest cause of maternalPPH is one of the commonest cause of maternalmortality & accounts for 1/4mortality & accounts for 1/4ththof all maternal deathof all maternal deathworldwide. (WHO 2005)worldwide. (WHO 2005) In developing countries it accounts over 1/3In developing countries it accounts over 1/3rdrdof allof allmaternal death. (Khan KS 2006)maternal death. (Khan KS 2006) 14 million cases occur each year with a case fatality14 million cases occur each year with a case fatalityrate of 1%.(WHO 2004)rate of 1%.(WHO 2004) In India PPH responsible forIn India PPH responsible for 15-20%15-20% 0f maternal0f maternaldeath ( Mukherjee et al 2002).death ( Mukherjee et al 2002).
  44. 44. Post Partum haemorrhagePost Partum haemorrhage. . . the most common and severe type of obstetrichaemmorrhage, is an enigma even to thepresent day obstetrician as it is sudden,often unpredicted, assessed subjectivelyand can be catastrophic. The clinicalpicture changes so rapidly that unlesstimely action is taken maternal deathoccurs within a short period.
  45. 45. ““women are not dying because of awomen are not dying because of adisease we cannot treat. They aredisease we cannot treat. They aredying because societies have yet todying because societies have yet tomake decision that their lives aremake decision that their lives areworth saving”worth saving”Mamoud Fathalla,Mamoud Fathalla,President of FOGSI.19President of FOGSI.199797
  46. 46. Case ScenarioCase Scenario Doctor is delivering the placenta – afterDoctor is delivering the placenta – afterdelivery of placenta she has a sudden gushdelivery of placenta she has a sudden gushof bleeding.of bleeding.
  47. 47.  ABCABC VitalsVitals Call for helpCall for help CannulaCannula InvestigationInvestigation FluidsFluids Cause for bleedingCause for bleeding Treatment accordinglyTreatment accordingly
  48. 48. Case Scenario 2Case Scenario 2 No doctor available –No doctor available – Baby has been delivered.Baby has been delivered. Pt is known to be anaemic .Pt is known to be anaemic . How will you manage the third stage so as toHow will you manage the third stage so as toprevent PPHprevent PPH