Postpartum haemorrhage


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Postpartum haemorrhage

  1. 1. Prevention and medicalmanagement of uterine atony By Cheong Lu Jeat, Laow Yee Kean Supervised by Dr Munis
  2. 2. Definition Postpartum hemorrhage is 1) loss of 500mls or more during vaginal delivery; 2) more than 1000mls during caesarean section 3) blood loss significant enough to cause hemodynamic instability Primary PPH – first 24H of delivery Secondary PPH from 24H to 12 weeks after delivery
  3. 3.  Total blood volume at term is approximately 100 ml/kg (an average 70 kg woman-total blood volume of 7000) loss of more than 40% of total blood volume (approx 2800 ml) is generally regarded as ‘life-threatening’. aim of management is to prevent hemorrhage escalating to the point where it is life-threatening.
  4. 4. Causes Primary Uterine atony - 80% Retained placenta Morbidly adherent placenta Abruptio placentae Low placental implantation Extended tears, broad ligament haematoma Cervical tears, vulvovaginal haemotoma Defects in coagulation Uterine inversion Amniotic fluid embolism Secondary Retained products of conception Infection Inherited coagulation defects
  5. 5. Risk Factors for Postpartum Hemorrhage Prolonged labor grandmultipara Augmented labor Precipitated labor History of postpartum hemorrhage Overdistended uterus (macrosomia, twins,polyhydramnios) Operative delivery Chorioamnionitis
  6. 6. Prevention Active management of 3rd stage IM syntometrine 1ml during delivery of anterior shoulder Controlled cord traction Early cord clamping - controversial For high risk patients (eg grandmultipara) -IV pitocin 40 units @125ml/H
  7. 7. Simple measures in districthospital Identify all high risk patients – antenatal risk stratification– deliver in tertiary centre Strict adherence to partogram Scan for placental location of patients with previous scar!! BE careful during second stage caesarean section No fundal pressure!! Know your guidelines!! Ensure flowchart is placed in labour room Know the Sarawak PPH box
  8. 8. drug Medical management Dose/route Frequency commentOxytocin (pitocin) IV: 5-40 U in 1L NS continuous Avoid undiluted rapid IV IM: 5IU infusion, which causes hypotensionSyntometrine (ergometrine IM 1 ml WHO recommendation500mcg + oxytocin 5U) unless contraindicated (hypertension)15-methyl IM: 0.25mg Every 15-90min, 8 doses Avoid in asthmatic patients;PGF2a(carboprost) maximum relative CI if hepatic, renal(hemabate) and cardiac disease. Diarrhea, fever, tachycardia can occurMisoprostol (cytotec, 800-1000mcg rectallyPGE1)
  9. 9. Physiology of fluidsBlood loss (% of MAP Clinical effectsblood volume)500 – 1000 ml (10 – Normal Postural hypotension15%) Mild tacchycardia1000 ml – 1500 ml (15 Slight fall Tacchycardia– 30%) Thirst Weakness1500 ml – 2000 ml ( 30 50 – 70 mmhg Tacchycardia– 40%) Pallor Oligouria Confusion Restlessness> 2000 ml (> 40%) < 50 mmhg Tacchycardia Anuria Air hunger Coma Death
  10. 10. Fluid therapy and blood producttransfusion Crystalloid Up to 2 litres Hartmann’s solution Colloid up to 1–2 litres colloid until blood arrives Blood Crossmatched FFP 4 units Platelets 2 units Cryoprecipitate 6units
  11. 11. ‘the golden first hour’ Isthe time at which resuscitation must be commenced to ensure the best of survival use of the ‘shock index’ (SI) is invaluable in the monitoring and management of women with PPH. It refers to HR divided by the SBP. The normal value is 0.5–0.7. With significant haemorrhage,it increases to 0.9–1.1
  12. 12. Coagulopathy(DIVC) occurs due to the consumption of clotting factors (disseminated intravascular coagulation or DIC) or due to the dilutional effects of massive blood loss on clotting factors, platelets and fibrinogen (‘washout phenomenon’)
  13. 13. Monitoring and investigation Blood ix – FBC, PT/PTT/INR V/S monitoring To start DIVC regime based clinical judgment!! Biochemical confirmation takes time!!Aims:Haemoglobin > 8 g/dlPlatelet count > 75 109/lProthrombin time < 1.5 mean controlActivated prothrombin time < 1.5 mean controlFibrinogen > 1.0 g/l
  14. 14. Blood component therapy product Volume (ml) contents Effect(per unit) Packed red cells 240 RBC, WBC, Increase Plasma hematocrit 3%, Hb 1g platelets 50 Platelets, RBC, Increase plt count WBC, Plasma 5k-10k per unit FFP 250 Fibrinogen,antithr Increase ombin 3,f V and fibrinogen by VIII 10mg/dl cryoprecipitate 40 Fibrinogen, f VIII Increase and XIII, Von fibrinogen by willebrand factor 10mg/dl
  15. 15. Recombinant activated Factor VII Natural initiator of coagulation cascade Lead to stable formation of fibrin clots at site of injury Indications: life-threatening massive postpartum hemorrhage which fails to respond to surgical and medical mx Refractory DIVC Dosage: 60-120mcg/kg
  16. 16. Other measures Uterine packing Bakri balloon Rusch catheter Sengstaken-blakemore tube
  17. 17. Surgical management technique comment B-lynch suture Uterine artery Bilateral; also can ligate uteroovarian vessels ligation Internal iliac Less successful than earlier though; difficult artery ligation technique; generally reserved for practitioners Repair of rupture hysterectomy
  18. 18.  Labour ward manual of SGH RCOG Green-top guideline No.52 ACOG Clinical Guidelines O & G and reproductive medicine 20 : 6 O & G and reproductive medicine 19 : 5