This document discusses massive obstetric hemorrhage (MOH), including its definition, causes, incidence, impact on maternal health, clinical presentation, management, and prognosis. Some key points: - MOH is a leading cause of maternal death worldwide and in sub-Saharan Africa. It is defined as blood loss greater than 1500ml or a decrease in hemoglobin of more than 4g/dl. - Common causes of MOH include uterine atony, genital tract trauma, and retained placenta. Early diagnosis and treatment with uterotonics, fluid resuscitation, blood transfusions, and potential interventions like hysterectomy can help manage MOH. - Outcomes are better when treatment

1. Massive obstetric hemorrhage
DR TJ MASHAMBA

2. FORMAT
• Cardiovascular changes in pregnancy
• Definition
• Incidence and impact on maternal health
• Predisposing factors
• Clinical presentation
• Management
• Prediction of outcome/prognosis

3. Cadiovascular changes in pregnancy
• Pregnancy induced cardiovascular changes protect against the
effects of haemorrhage.
• By term, cardiac output has increased by 50%.
• Stroke volume by 25%
• Blood volume increase from 70 ml kg to almost 100 ml kg.
• Uterine blood flow increases from <5% to 12% of cardiac output
during pregnancy (700–900 ml/min).

4. Effect on presentation
• Tachycardia may be the only sign of haemorrhage until
30–40% of the circulating volume has been lost.
• Aortocaval compression during pregnancy will compound
the haemodynamic instability caused by haemorrhage.
• Blood loss from the uteroplacental bed can be
cardiotocographic signs of foetal distress, attributable
• to uterine hypoperfusion, can precede
• maternal evidence of haemodynamic compromise brisk
and difficult to control.

5. Massive obstetric haemorrhage(MOH)
• There is no universally accepted definition of MOH
• An agreed defined volume should be used to trigger the MOH
protocol.
• Blood loss in excess of 1500 ml will be considered as MOH.
• (Massive blood loss -- blood loss>/= 2500mls) in SA
• A decrease in haemoglobin >4 g dl.
• Acute transfusion requirement >4 units.

6. Causes of DIC related to
obstetrics
• Intrauterine death (>2 weeks previously)
• Amniotic fluid embolus
• Sepsis
• Pre-eclampsia
• Placental abruption
• Retained products of conception
• Induced abortion
• Excessive bleeding
• Acute fatty liver

7. Incidence
• Major cause of maternal mortality globally.
• World Health Organisation estimates that at least 166,000 deaths
annually are due to PPH accounting for 28% of direct maternal
deaths.
• It is a leading cause of maternal death and severe morbidity in Sub-
Saharan Africa.
• Obstetric haemorrhage (OH) was the third most common cause of
maternal death in South Africa for the triennium 2014 to 2016
• Accounting for 624 deaths or 16.9 per cent of the total.
• OH related maternal mortality ratio (MMR) was 22.67 deaths per
100 000 live births.

8. Incidence and impact on maternal health

11. • Maternal deaths are strongly associated with CD.
• Table 2.4.1 Risk of caesarean delivery Primary obstetric problems All Delivered Vaginal
delivery Number CD % CD CFR/100000 CD CFR/100000 vaginal deliveries
Risk
• Medical and surgical disorders 262 125 137 52.3 19.35 6.12
3.2
• Non-pregnancy-related infections 511 387 124 24.3 17.51 18.93
0.9
• Ectopic pregnancy 2 1 1 50.0 0.14 0.05 2.9
• Miscarriage 4 4 0 0.0 0.00 0.20 0.0
• Pregnancy-related sepsis 184 84 100 54.3 14.12 4.11
3.4
• Obstetric haemorrhage 552 207 345 62.5 48.73 10.13
4.8
• Hypertension 446 149 297 66.6 41.95 7.29 5.8
• Anaesthetic complications 67 3 64 95.5 9.04 0.15
61.6
• Adverse drug reactions 27 18 9 33.3 1.27 0.88
1.4
• Embolism 76 33 43 56.6 6.07 1.61 3.8
• Acute collapse - cause unknown 46 23 23 50.0 3.25 1.13
2.9
• Miscellaneous 7 4 3 42.9 0.42 0.20 2.2
• Unknown 83 45 38 45.8 5.37 2.20 2.4
• Total 2 267 1 083 1 184 45.8 167.23 52.98 3.2

12. Classification of massive obstetric haemorrhage
• Antepartum (APH); bleeding occurring after 20-24 weeks gestation
and before delivery.
• Postpartum (PPH).

13. Antepartum haemorrhage
• Defined as bleeding from or in to the genital tract, occurring from
20 or 24+0weeks of pregnancy (fetus ≥500g) and prior to the birth
of the baby.
• The bleeding can be so severe that it can endanger the life of both
the mother and fetus.
• Abruptio placentae is a common cause of antepartum haemorrhage
and an important cause of perinatal death in many communities.

14. Antepartum haemorrhage
• Complicates 3% of pregnancies.
• One-third APHs are due to placental abruption.
• One-third APHs are due to placenta praevia.
• One-third APHs are due to other causes, such as uterine rupture.

15. Early pregnancy
• Incomplete abortion
• Septic abortion
• Ruptured ectopic

16. • The definition of PPH is somewhat arbitrary and problematic.
• PPH is defined as blood loss of more than 500 mls following vaginal
delivery or more than 1000 mls following caesarean delivery.
• Estimates of blood loss at delivery are subjective and generally
inaccurate.
• Studies have suggested that caregivers consistently underestimate
actual blood loss.
• 10% fall in haematocrit value to define PPH
• This change is dependent on the timing of the test and the amount
of fluid resuscitation given.
• The diagnosis would be retrospective, perhaps useful for research
but not so in the clinical setting.
Post partum haemorrhage(PPH)

17. Primary postpartum haemorrhage
• Uterine atony
• Retained products of conception
• Genital tract trauma
• Abnormally adherent placenta
• Clotting defects
• Acute uterine inversion

18. Secondary postpartum
haemorrhage
• Puerperal sepsis
• Retained products of conception

19. Causes of PPH
• Uterine atony is responsible for 70% of cases.
• Associated with -placenta praevia
- multiple pregnancy
- polyhydramnios
- previous PPH
- Asian ethnicity
- obesity
- prolonged labour
-primiparae over 40 yr.

20. Four T’s in PPH
• Tone (uterine atony),
• Trauma,
• Tissue (retained placenta),
• Thrombin (coagulopathy).

21. Management of Massive Obstetric
Haemorrhage
• Management requires a multidisciplinary team approach which
should be practiced regularly.
• Early transfusion of blood and blood products reduced incidence
and severity of coagulopathy.
• Point of care testing of coagulation is recommended to allow
rational use of products.

22. Management of Massive Obstetric
Haemorrhage
• Primary treatment is evacuation of the uterine contents.
• Maintenance of contracted uterus.
• Replace intravascular volume.

23. REQUEST:
• Cell saver
• Bakri balloon
• Hysterectomy set
• Uterine artery
• Embolisation team on standby (if available)
• Anaesthetist
• ICU team

24. Management plan for massive
obstetric haemorrhage
• Restore normovolaemia, monitor haematocrit and haemoglobin
• If massive bleeding continues, give FFP 1 litre, cryoprecipitate
10 units while awaiting lab results
• Use coagulation screens to guide and monitor use of blood
products
• Monitor pulse rate, blood pressure, blood gases and urine output
• Consider invasive monitoring to guide therapy

25. Management plan for massive
obstetric haemorrhage
• Call for senior help
• Alert haematologist, mobilize portering service
• Transfuse red cells as soon as possible
• Until then:
• Crystalloid, maximum 2 litre.
• Colloid, maximum 1.5 litre.
• Use group specific or O RH negative blood.
• Warm resuscitation fluids.

26. Management plan for massive
obstetric haemorrhage
• Two large-bore i.v. cannulae
• Commence rapid saline infusion
• Full left lateral if APH – head down, feet up
• Oxygen 100% via facemask
• Send blood for:
• Crossmatch 6 units
• Full blood count
• Coagulation screen

27. PPH following trauma
• Caesarean section (emergency>elective)
• Mediolateral episiotomy
• Operative vaginal delivery
• Delivery of a neonate >4 kg.

28. Uterotonics
• Several drugs are available to treat bleeding from uterine atony.
• Oxytocin used prophylactically in the third stage of labour reduces
the risk of PPH by 60%.
• Oxytocin causes vascular smooth muscle relaxation which can cause
hypotension with a reflex tachycardia.
• This may occur particularly if syntocinon is given as a bolus.
• This bolus should not exceed 5 units i.v
• This is different from the 10 units intramuscularly.
• Ergometrine is recommended as a second.
• Carboprost is a third-line uterotonic.
• Misoprostol is active via rectal, sublingual, and oral routes and thus
can be used before i.v. access has been obtained.

29. Ergometrine
• Acts on uterine and other smooth muscle.
• It may cause diarrhoea, nausea, and vomiting.
• Contra-indicated in pre-eclampsia or other hypertensive conditions.
• Duration of action is ∼3 h after i.m. dose.
• Ergometrine can be given i.v., but the risk of severe adverse
reactions is increased.
• Intramuscular use (500 μg) or slow i.v. (250–500 μg) use in a life-
threatening emergency.

30. Carboprost
• Given by intramuscular injection.
• Not licensed for intra-uterine injection.
• 250ug may be given at 15 min intervals to a maximum of 2 mg.
• May precipitate bronchospasm.
• Contra-indicated in asthmatics.

31. Blood products
• Greater and earlier use of FFP and platelets is recommended.
• Ratios of packed red cells and FFP should be given in ratios close to
1:1 with early use of platelets.
• Fibrinogen is a vital component of the coagulation pathway and
levels decrease early and rapidly during haemorrhage.
• Low fibrinogen level is associated with greater blood loss.
• Fibrinogen concentration <2 g litre−1 has been shown to have a
100% positive predictive value for severe PPH.
• Cell salvage in obstetric practice has caused debate because of the
potential risk of amniotic fluid embolism and rhesus
isoimmunization.

32. Treatment goals
• Hct >0.3.
• Plt >100×109 litre−1.
• Fibrinogen >2 g litre−1.
• Ionized Ca >1.
• Temp. >36°C.

33. Initial management of Massive
Obstetric Haemorrhage
• High flow oxygen.
• Place the woman in the left lateral position if ante-partum or head
down if post-partum.
• I.V. access—two large-bore cannulae (≥16 G). Start infusion of
crystalloid (warmed) until blood available.
• Send blood for group specific/X-matched blood (6 units), and fresh-
frozen plasma (FFP) (4–6 units) FBC, clotting, urea, and electrolytes.
• Put out ‘MOH call’—to alert anaesthetist, obstetrician, senior
midwife, blood bank, and porters.

34. If blood loss ongoing
• Aim to replace losses with blood and products as soon as possible
and to warm all fluids.
• Give O Rh negative blood if group specific/cross-matched blood not
available in the presence of worsening cardiovascular instability.

35. If blood loss has stopped
• Fluid replacement with crystalloid and blood products until clinical
signs of normovolaemia.
• Monitor Hb with point-of-care tests (Hemocue or blood gas).
• Consider transfer to a critical care area for monitoring.
• Further steps will depend on the cause of haemorrhage and
treatment should be tailored to individual patients.

36. Non-blood products
• Hypothermia and acidosis significantly impair coagulation.
• i.v. fluids should be warmed and the patient's temperature must be
maintained if necessary by active warming.
• Hypo-perfusion should be aggressively treated to avoid acidosis.
• Maintenance of calcium concentrations during haemorrhage helps
prevent coagulopathy.
• 10mls of 10% calcium chloride per 4 units packed red cells or blood
are part of the routine management of haemorrhage.

37. Effect of early tranexamic acid administration on mortality, hysterectomy, and other
morbidities in women with post-partum haemorrhage (WOMAN): an international,
randomised, double-blind, placebo-controlled trial (Lancet 2017)
• 20 060 women were enrolled and randomly assigned to receive
tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036
and 9985, respectively, were included in the analysis.
• Death due to bleeding was significantly reduced in women given
tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of
9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00;
p=0·045), especially in women given treatment within 3 h of giving
birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the
placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008).
• Tranexamic acid reduces death due to bleeding in women
with post-partum haemorrhage with no adverse effects.

38. WHO recommendations
• Early use of intravenous tranexamic acid (TXA) within 3 hours of
birth in addition to standard care for women with clinically
diagnosed postpartum haemorrhage (PPH) following vaginal birth
or caesarean section.
• TXA should be considered as part of the standard PPH treatment
package and be administered as soon as possible after onset of
bleeding and within 3 hours of birth.
• TXA for PPH treatment should not be initiated more than 3 hours
after birth.
• TXA should be used in all cases of PPH, regardless of whether the
bleeding is due to genital tract trauma or other causes.

39. WHO recommenadtions
• TXA should be administered at a fixed dose of 1 g in 10 mL (100
mg/mL) IV at 1 mL per minute (i.e., administered over 10 minutes),
with a second dose of 1 g IV if bleeding continues after 30 minutes.
• TXA should be administered via an IV route only for treatment of
PPH. Research on other routes of TXA administration is a priority.

40. Assessment of shock
• Vital signs (for example, HR, SBP and mental status) and urinary
output has been used.
• The importance and reliability of vital signs to determine the
presence and extent of hypovolemic shock have been questioned.
• SI-the ratio of HR to SBP
• Base deficit is also used

41. Prognosis
• Shock index (SI) or heart rate (HR) divided by systolic blood pressure
(SBP) has been suggested as such a marker that can be used to
predict the severity of hypovolemic shock.
• Shock index (SI) or heart rate (HR) divided by systolic blood pressure
(SBP) has been suggested as such a marker that can be used to
predict the severity of hypovolemic shock.
• SI uses only systolic blood pressure, but, diastolic blood pressure
(DBP) is also of undeniable importance when determining patient's
clinical severity.
• Modified shock index (MSI), which is a ratio of heart rate to mean
blood pressure (MAP). MAP= [(DBP×2) + SBP] / 3

42. Shock index grading
• SI <0.6 (no shock).
• SI ≥0.6 to <1.0 (mild shock)
• SI ≥1.0 to <1.4 (moderate shock).
• SI ≥1.4 (severe shock).

43. CLINICAL ARTICLE
Causes and avoidable factors in maternal death due to cesarean-related
hemorrhage in South Africa
Salome Maswime ⁎, Eckhart Buchmann
•Failure to treat anemia during prenatal care
•Delayed decision to perform second-look surgery
•Patient refused hospital admission
•Poor prenatal care attendance by patient
•Inadequate intrapartum monitoring and prolonged labor
•Prolonged labor with delayed intervention
•Patient did not go to referral hospital
•Failure to resuscitate patient in shock
•Failure to identify cause of hemorrhage
•Failure to diagnose placental abruption preoperatively
•Caesarean delivery not indicated; inadequate postoperative observations
•Failure to achieve haemostasis intraoperatively
•Delayed transfer of patient to higher level of care
•Failure to detect shock and manage the hemorrhage

44. Recommedations
• Implementation of national protocols for (a) uterotonic drugs for
induction of labour and (b) uterotonics and Tranexamic acid for
prevention and management of PPH after vaginal delivery and at
CS.
• Implementing the Safe Caesarean Delivery package of
interventions.
• Ensure women with abruptio placentae plus fetal demise are
referred to and deliver at regional or tertiary hospitals vaginally.
• Continuous availability of blood products in hospitals and promote
rational blood usage.
• Direct Telephonic links for 24 hour specialist support to district
hospital doctors

45. Recommendations
• Ensuring earlier recourse to theatre for on-going bleeding after
vaginal delivery as well as after caesarean.
• Improve skills at District Hospitals before transfer.
• emergency transport to be onsite for transfers from lower level of
care.
• Optimise haemodynamic condition during transfer.
• The non–pneumatic anti-shock garment be available

46. 2018 Recommendations
• Intravenous oxytocin alone is the recommended uterotonic for the
treatment of PPH.
• If oxytocin is unavailable or bleeding persists , intravenous
ergometrine should be used.
• Prostaglandins including misoprostol should be considered
• Crystalloids are preferred over colloids for initial intravenous fluid
resuscitation.
• Tranexamic acid is recommended for treatment of PPH.
• Uterine massage is important.
• Intrauterine balloon tamponade is life saving
• Arterial occlusion still has a place (embolism

47. 2018 recommendations
• Bimanual uterine compression is
recommended.
• External aortic compression
• Non-pneumatic anti-shock garments
• Uterine packing
• Antibiotics for manual removal of placenta