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Postpartum Hemorrhage
Dr.Rafi Rozan
Obstetrician & Gynecologist
OBGYN – GPHC.
The highest duty of medicine is to save threatened human lives , and it is
in Obstetrics where this duty is most obvious!
Obstetrical hemorrhage continues along with hypertension and infections as
the “triad” of causes of maternal deaths in both developed and
underdeveloped countries. Hemorrhage is the single most important cause of
maternal death worldwide and is responsible for half of all postpartum deaths
in developing countries. More than half of all maternal deaths occur within 24
hours of delivery, most commonly from excessive bleeding. It is estimated that,
worldwide 140, 000 women die of PPH each year – one every 4 minutes. In
addition to death, serious morbidity may follow PPH. Although many risk
factors have been associated with postpartum hemorrhage, it often occurs
without warning.
Introduction
Background
The physiological changes over the course of pregnancy, including a plasma
volume increase of approximately 40% and a red cell mass increase of
approximately 25%. There is no single, satisfactory definition of postpartum
hemorrhage. Postpartum hemorrhage generally is classified as:
Primary hemorrhage: occur-ring within the first 24 hours of delivery
Secondary hemorrhage: occurring between 24 hours and 6–12 weeks
Traditionally, PPH has been defined as blood loss in excess of 500 cc in vaginal
deliveries and in excess of 1,000 cc in cesarean section deliveries.
This is problematic because studies showed that estimated blood loss is only
approximately half the actual loss. Blood loss has been estimated by several
methods such as measuring the loss directly, using predetermined decline in
hematocrit or hemoglobin concentration, counting the number of women
transfused or using the formula of Hernandez. For clinical purposes, any blood
loss that has the potential to produce hemodynamic compromise should be
considered a PPH.
Blood Loss Estimation
Estimated blood loss—like beauty—is in the eye of the beholder.
Estimation is notoriously inaccurate, especially with excessive bleeding. Instead
of sudden massive hemorrhage, postpartum bleeding is frequently steady.
Bleeding may appear to be only mild at any given instant but may continue until
serious hypovolemia develops. Bleeding from an episiotomy or a vaginal
laceration can also appear to be minimal BUT constant seepage can lead to
enormous blood loss relatively quickly. In some cases, after placental
separation, blood may not escape vaginally but instead may collect within the
uterine cavity. In others, postpartum uterine massage is applied to a roll of
abdominal fat mistaken for the uterus. Thus, monitoring of the uterus
immediately postpartum must be done by an experienced person.
All of these factors can lead to an under appreciation of the
magnitude of hemorrhage over time. The effects of hemorrhage
depend considerably on the maternal nonpregnant blood volume
and the corresponding degree of pregnancy-induced
hypervolemia. For this and other reasons, hypovolemia may not be
recognized until very late. A treacherous feature of postpartum
hemorrhage is the failure of the pulse and blood pressure to
undergo more than moderate alterations until large amounts of
blood have been lost. The normotensive woman may actually
become somewhat hypertensive from catecholamine release in
response to hemorrhage. Moreover, women with preeclampsia
may become “normotensive” despite remarkable hypovolemia.
The blood volume of a pregnant woman with normal pregnancy induced
hypervolemia usually increases by half, but increases range from 30 to 60
percent for an average sized woman. The equation to calculate blood volume:
It is axiomatic that a normal pregnant woman tolerates, without
any decrease in postpartum hematocrit, blood loss at delivery
that approaches the volume of blood that she added during
pregnancy. Thus, if blood loss is less than the pregnancy-added
volume, the hematocrit remains the same acutely and during
the first several days. It then increases as nonpregnant plasma
volume normalizes during the next week or so. Whenever the
postpartum hematocrit is lower than one obtained on admission
for delivery, blood loss can be estimated as the sum of the calculated
pregnancy-added volume plus 500 mL for each 3 volume percent
decrease of the hematocrit.
Mechanisms of Normal Hemostasis
A major concept in understanding the pathophysiology and management of
obstetrical hemorrhage is the mechanism by which hemostasis is achieved after
normal delivery. Recall that near term an incredible amount of blood—at least
600 mL/min flows through the intervillous space. This blood flow circulates
through the spiral arteries, which averages 120 in number. Also recall that these
vessels have no muscular layer because of their endotrophoblastic remodeling,
which creates a low-pressure system. With placental separation, these vessels at
the implantation site are avulsed, and hemostasis is achieved first by myometrial
contraction, which compresses the vessels. Contractions are followed by clotting
and obliteration of vessel lumens. If after delivery this is not acquired then fatal
hemorrhage from the placental implantation site is likely resulting from atony.
Importantly, an intact coagulation system is not necessary for postpartum
hemostasis unless there are lacerations in the uterus, birth canal, or perineum.
Adhered placental pieces or large blood clots that prevent effective myometrial
contraction will serve to impair hemostasis at the implantation site.
Etiology
It is helpful to think of the causes of PPH in terms of the 4T‘s:
Tone - uterine atony
Tissue - retained placenta or clots
Trauma - uterine, cervical, or vaginal injury
Thrombin - pre-existing or acquired coagulopathy
Pillars in Management
1. Prevention : Multiple disciplinary approach, Risks, updated labs,
blood bank, calculate Volume, delivery done by experience obstetric
personnel, less surgical time, AMTSL.
2. Early Diagnosis: subclinical and early signs of Hemorrhage
3. Initial Measures: Counselling and ABCs
4. Medical: Non Pharmacological and Pharmacological.
5. Surgical: conservative (fertility) and non conservative
Prevention
In most cases, the cause of PPH can and should be determined as it is
usually obvious. Active management of the third stage of labor (AMTSL)
is associated with reduced maternal blood loss, reduced postpartum
hemorrhage, reduced postpartum anemia, reduced need for blood
transfusions and a decrease in the incidence of prolonged third stage of
labor.
Therefore, AMTSL is strongly advocated for all births taking place in all
settings. AMTSL speeds delivery of the placenta by increasing uterine
contractions and prevents PPH by avoiding uterine atony. Counselling
and informing women about AMTSL is part of providing a
mother-friendly delivery.
AMTSL
1. Following the delivery of the baby, palpate the abdomen to rule out the
presence of an additional baby, and give oxytocin 10 units IM.
Never give an uterotonic before the delivery of the anterior shoulder.
Oxytocin may also be given by other routes including 5 units IV push or 20-50
units in 1L of normal saline at 60 drops/minute.
2. If oxytocin is not available, give:
Ergometrine 0.2 mg IM
OR
Syntometrine (1 ampoule) IM
OR
Misoprostol 400–600 µg orally
3. After delivery of the baby, wait until pulsation has stopped (approximately 2
to 5 minutes) before clamping and dividing the cord. Clamp the cord close to
the perineum. If it is your institutional policy, take the cord blood samples
including blood gases.
4. Keep slight tension on the cord while waiting for a strong uterine contraction
(approximately 2–3 minutes)
5. With the strong uterine contraction, encourage the mother to push, and very
gently pull downward and outward on the cord to deliver the placenta while
applying suprapubic counter-pressure on the uterus with the other hand.
Pulling too hard on the cord may cause the cord to tear off the placenta or
cause uterine inversion—an acute obstetrical emergency.
6. If the placenta does not descend during 30-40 seconds of controlled cord
traction , do not continue to pull on the cord:
Continue to gently hold the cord, and wait until there is another strong
contraction. With the next contraction, repeat controlled cord traction with
counter-pressure.
7. As the placenta delivers, hold the placenta in both hands. Gently turn it
until the membranes are twisted. Gently pull to complete the delivery.
8. If the membranes tear, gently examine the upper vagina and cervix
wearing sterile gloves. Use a ring (sponge) forceps to remove any pieces of
membranes.
9. Examine the placenta carefully to ensure that it is complete.
10. Check the fundus to ensure that it is well contracted. Palpate for a
contracted uterus every 15 minutes and repeat uterine massage as needed
during the first 2 hours.
Medical Non Pharmacological Management
1. Rubin nipple stimulation
2. Compression of the abdominal aorta
3. Massage of the uterine fundus
4. Fochier Maneuver
5. Uterine Tamponade
Packing
Foley Catheter , Condom Catheter
Sengstaken Blakemore tube
SOS Bakri Balloon, Rusch Balloon
Pharmacological
Tranexamic acid (Lysteda): is an antifibrinolytic. It works by preventing
blood clots from breaking down too quickly. This helps to reduce
excessive bleeding.
Carbetocin: is a drug used to control postpartum hemorrhage. It is an
analogue of oxytocin, and its action is similar to that of oxytocin -- it
causes contraction of the uterus.
Human recombinant factor VIIa is a new treatment modality shown to be effective in
controlling severe, life-threatening hemorrhage by acting on the extrinsic clotting
pathway. This synthetic vitamin K-dependent protein is available as NovoSeven. It binds to
exposed tissue factor at the site of injury to generate thrombin that activates platelets
and the coagulation cascade.
Intravenous dosages vary by case and generally range from 50 to 100 mcg/kg
every 2 hours until hemostasis is achieved. Cessation of bleeding ranges from
10 minutes to 40 minutes after administration.
factor VIIa is extremely expensive
http://www.medscape.com/viewarticle/543703
Recombinant activated factor seven (VIIa):
Conservative Surgical Management
There are multiple conservative surgical procedures
and techniques that can be done particularly when
the patient wants to maintain fertility.
B – LYNCH Suture
HO – CHO Squares
HAYMAN
HACKETHAL
U-suturing Technique
An absorbable Vicryl 0 thread and an XLH needle whose curve had been straightened manually were used
for suturing. To perform an interrupted single U-suture, the needle was inserted at the ventral uterine wall,
led through the posterior wall and then passed back to the ventral wall where the thread was joined with
a flat double knot (Fig. 1a and b). While the lead surgeon was tying the suture, the assisting surgeon
performed bi-manual uterine compression. The number of sutures required depended on the size of the
uterus and the persistence of bleeding. In general, 6-16 U-sutures in horizontal rows along the
uterus, starting at the fundus and ending at the cervix. Thus, approximately 2-4 cm of tissue was compressed
within each suture.
OUAHBA
MOSTFA
Some other sutures:
KAFALI
NELSON
ZHENG
O leary
Hypogastric artery ligation
Tsirulnikov Triple Ligation
Angiographic Embolization
This tool is now used for many causes of intractable
hemorrhage when surgical access is difficult. A patient
with stable vital signs and persistent bleeding, especially
if the rate of loss is not excessive, may be a candidate for
arterial embolization. Radiographic identification of
bleeding vessels allows embolization with Gelfoam, coils,
or glue. Balloon occlusion is also a technique used in
such circumstances. Embolization can be used
for bleeding that continues after hysterectomy or can be
used as an alternative to hysterectomy to preserve
fertility.
Pelvic Umbrella Pack
The umbrella or a parachute pack was described by Logothetopulos in
1926 to arrest intractable pelvic hemorrhage following hysterectomy.
Although seldom used today, it can be life saving if all other measures
have failed. The pack is constructed of a sterile x-ray cassette bag that
is filled with gauze rolls knotted together to provide enough volume to
fill the pelvis. The pack is introduced transabdominally with the stalk
exiting the vagina. Mild traction is applied by tying the stalk to a 1-liter
fluid bag, which is hungover the foot of the bed. An indwelling urinary
catheter is placed to prevent urinary obstruction and to monitor
urinary output. Percutaneous pelvic drains can be placed to monitor
ongoing bleeding within the peritoneal cavity. Broad spectrum
antimicrobials are given, and the umbrella pack is removed vaginally
after 24 hours.
ACOG surgical Management
of Postpartum Hemorrhage
When is blood transfusion recommended?
Transfusion of blood products is necessary when the extent of blood loss is
significant and ongoing, particularly if vital signs are unstable. Clinical judgment
is an important determinant, given that estimates of blood loss often are
inaccurate, determination of hematocrit or hemoglobin concentrations may not
accurately reflect the current hematologic status, and symptoms and signs of
hemorrhage may not occur until blood loss exceeds 15% . The purpose of
transfusion of blood products is to replace coagulation factors and red cells for
oxygen-carrying capacity, not for volume replacement. To avoid dilutional
coagulopathy, concurrent replacement with coagulation factors and platelets
may be necessary.
Autologous transfusion (donation, storage, retransfusion) has been shown to be
safe in pregnancy and Cell saver technology has been used successfully.
Blood Component Therapy
Recommendations and Conclusions
Uterotonic agents should be the first-line treatment for
PPH due to uterine atony. Management may vary greatly
among patients, depending on etiology and available
treatment options, and often a multidisciplinary approach
is required. In the presence of conditions known to be
associated with placenta accreta, the obstetric care
provider must have a high clinical suspicion and take
appropriate precautions.
References
1. AbouZahr C. Global burden of maternal death and dis-ability. Br Med Bull 2003;67:1–11. (Level III)
2. Preventing infant death and injury during delivery. Sentinel Event ALERT No. 30. Joint Commission on
Accreditation of Healthcare Organizations. Available at:
http://www.jointcommission.org/SentinelEvents/Sentinel EventAlert/sea_30.htm. Retrieved June 12, 2006.
(Level III)
3. Chesley LC. Plasma and red cell volumes during pregnan-cy. Am J Obstet Gynecol 1972;112:440 –50. (Level III)
4. Pritchard JA, Baldwin RM, Dickey JC, Wiggins KM. Blood volume changes in pregnancy and the puerperium.
Am J Obstet Gyencol 1962;84:1271–82. (Level III)
5. Clark SL, Yeh SY, Phelan JP, Bruce S, Paul RH. Emergency hysterectomy for obstetric hemorrhage.
Obstet Gynecol 1984;64:376–80. (Level III)
6. Dildy GA 3, Paine AR, George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual
esti-mation? Obstet Gynecol 2004;104:601– 6. (Level III)
7. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth.
ObstetGynecol 1991;77:69–76. (Level II-2)
8. Williams Ch 41 24th Edition.
9. ACOG Practice Bullitin No 76
10. FOURTH EDITION OF THE ALARM INTERNATIONAL PROGRAM , CHAPTER 6 POSTPARTUM HEMORRHAGE
QUESTIONS & COMMENTS
Happy Holidays
Thank You.

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Postpartum hemorrhage (Dr.Rafi Rozan)

  • 1. Postpartum Hemorrhage Dr.Rafi Rozan Obstetrician & Gynecologist OBGYN – GPHC. The highest duty of medicine is to save threatened human lives , and it is in Obstetrics where this duty is most obvious!
  • 2. Obstetrical hemorrhage continues along with hypertension and infections as the “triad” of causes of maternal deaths in both developed and underdeveloped countries. Hemorrhage is the single most important cause of maternal death worldwide and is responsible for half of all postpartum deaths in developing countries. More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive bleeding. It is estimated that, worldwide 140, 000 women die of PPH each year – one every 4 minutes. In addition to death, serious morbidity may follow PPH. Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. Introduction
  • 3. Background The physiological changes over the course of pregnancy, including a plasma volume increase of approximately 40% and a red cell mass increase of approximately 25%. There is no single, satisfactory definition of postpartum hemorrhage. Postpartum hemorrhage generally is classified as: Primary hemorrhage: occur-ring within the first 24 hours of delivery Secondary hemorrhage: occurring between 24 hours and 6–12 weeks Traditionally, PPH has been defined as blood loss in excess of 500 cc in vaginal deliveries and in excess of 1,000 cc in cesarean section deliveries. This is problematic because studies showed that estimated blood loss is only approximately half the actual loss. Blood loss has been estimated by several methods such as measuring the loss directly, using predetermined decline in hematocrit or hemoglobin concentration, counting the number of women transfused or using the formula of Hernandez. For clinical purposes, any blood loss that has the potential to produce hemodynamic compromise should be considered a PPH.
  • 4. Blood Loss Estimation Estimated blood loss—like beauty—is in the eye of the beholder. Estimation is notoriously inaccurate, especially with excessive bleeding. Instead of sudden massive hemorrhage, postpartum bleeding is frequently steady. Bleeding may appear to be only mild at any given instant but may continue until serious hypovolemia develops. Bleeding from an episiotomy or a vaginal laceration can also appear to be minimal BUT constant seepage can lead to enormous blood loss relatively quickly. In some cases, after placental separation, blood may not escape vaginally but instead may collect within the uterine cavity. In others, postpartum uterine massage is applied to a roll of abdominal fat mistaken for the uterus. Thus, monitoring of the uterus immediately postpartum must be done by an experienced person.
  • 5. All of these factors can lead to an under appreciation of the magnitude of hemorrhage over time. The effects of hemorrhage depend considerably on the maternal nonpregnant blood volume and the corresponding degree of pregnancy-induced hypervolemia. For this and other reasons, hypovolemia may not be recognized until very late. A treacherous feature of postpartum hemorrhage is the failure of the pulse and blood pressure to undergo more than moderate alterations until large amounts of blood have been lost. The normotensive woman may actually become somewhat hypertensive from catecholamine release in response to hemorrhage. Moreover, women with preeclampsia may become “normotensive” despite remarkable hypovolemia.
  • 6. The blood volume of a pregnant woman with normal pregnancy induced hypervolemia usually increases by half, but increases range from 30 to 60 percent for an average sized woman. The equation to calculate blood volume:
  • 7. It is axiomatic that a normal pregnant woman tolerates, without any decrease in postpartum hematocrit, blood loss at delivery that approaches the volume of blood that she added during pregnancy. Thus, if blood loss is less than the pregnancy-added volume, the hematocrit remains the same acutely and during the first several days. It then increases as nonpregnant plasma volume normalizes during the next week or so. Whenever the postpartum hematocrit is lower than one obtained on admission for delivery, blood loss can be estimated as the sum of the calculated pregnancy-added volume plus 500 mL for each 3 volume percent decrease of the hematocrit.
  • 8. Mechanisms of Normal Hemostasis A major concept in understanding the pathophysiology and management of obstetrical hemorrhage is the mechanism by which hemostasis is achieved after normal delivery. Recall that near term an incredible amount of blood—at least 600 mL/min flows through the intervillous space. This blood flow circulates through the spiral arteries, which averages 120 in number. Also recall that these vessels have no muscular layer because of their endotrophoblastic remodeling, which creates a low-pressure system. With placental separation, these vessels at the implantation site are avulsed, and hemostasis is achieved first by myometrial contraction, which compresses the vessels. Contractions are followed by clotting and obliteration of vessel lumens. If after delivery this is not acquired then fatal hemorrhage from the placental implantation site is likely resulting from atony. Importantly, an intact coagulation system is not necessary for postpartum hemostasis unless there are lacerations in the uterus, birth canal, or perineum. Adhered placental pieces or large blood clots that prevent effective myometrial contraction will serve to impair hemostasis at the implantation site.
  • 9. Etiology It is helpful to think of the causes of PPH in terms of the 4T‘s: Tone - uterine atony Tissue - retained placenta or clots Trauma - uterine, cervical, or vaginal injury Thrombin - pre-existing or acquired coagulopathy
  • 10.
  • 11. Pillars in Management 1. Prevention : Multiple disciplinary approach, Risks, updated labs, blood bank, calculate Volume, delivery done by experience obstetric personnel, less surgical time, AMTSL. 2. Early Diagnosis: subclinical and early signs of Hemorrhage 3. Initial Measures: Counselling and ABCs 4. Medical: Non Pharmacological and Pharmacological. 5. Surgical: conservative (fertility) and non conservative
  • 12. Prevention In most cases, the cause of PPH can and should be determined as it is usually obvious. Active management of the third stage of labor (AMTSL) is associated with reduced maternal blood loss, reduced postpartum hemorrhage, reduced postpartum anemia, reduced need for blood transfusions and a decrease in the incidence of prolonged third stage of labor. Therefore, AMTSL is strongly advocated for all births taking place in all settings. AMTSL speeds delivery of the placenta by increasing uterine contractions and prevents PPH by avoiding uterine atony. Counselling and informing women about AMTSL is part of providing a mother-friendly delivery.
  • 13. AMTSL 1. Following the delivery of the baby, palpate the abdomen to rule out the presence of an additional baby, and give oxytocin 10 units IM. Never give an uterotonic before the delivery of the anterior shoulder. Oxytocin may also be given by other routes including 5 units IV push or 20-50 units in 1L of normal saline at 60 drops/minute. 2. If oxytocin is not available, give: Ergometrine 0.2 mg IM OR Syntometrine (1 ampoule) IM OR Misoprostol 400–600 µg orally
  • 14. 3. After delivery of the baby, wait until pulsation has stopped (approximately 2 to 5 minutes) before clamping and dividing the cord. Clamp the cord close to the perineum. If it is your institutional policy, take the cord blood samples including blood gases. 4. Keep slight tension on the cord while waiting for a strong uterine contraction (approximately 2–3 minutes) 5. With the strong uterine contraction, encourage the mother to push, and very gently pull downward and outward on the cord to deliver the placenta while applying suprapubic counter-pressure on the uterus with the other hand. Pulling too hard on the cord may cause the cord to tear off the placenta or cause uterine inversion—an acute obstetrical emergency. 6. If the placenta does not descend during 30-40 seconds of controlled cord traction , do not continue to pull on the cord: Continue to gently hold the cord, and wait until there is another strong contraction. With the next contraction, repeat controlled cord traction with counter-pressure.
  • 15. 7. As the placenta delivers, hold the placenta in both hands. Gently turn it until the membranes are twisted. Gently pull to complete the delivery. 8. If the membranes tear, gently examine the upper vagina and cervix wearing sterile gloves. Use a ring (sponge) forceps to remove any pieces of membranes. 9. Examine the placenta carefully to ensure that it is complete. 10. Check the fundus to ensure that it is well contracted. Palpate for a contracted uterus every 15 minutes and repeat uterine massage as needed during the first 2 hours.
  • 16. Medical Non Pharmacological Management 1. Rubin nipple stimulation 2. Compression of the abdominal aorta 3. Massage of the uterine fundus 4. Fochier Maneuver 5. Uterine Tamponade Packing Foley Catheter , Condom Catheter Sengstaken Blakemore tube SOS Bakri Balloon, Rusch Balloon
  • 17.
  • 18.
  • 20. Tranexamic acid (Lysteda): is an antifibrinolytic. It works by preventing blood clots from breaking down too quickly. This helps to reduce excessive bleeding.
  • 21. Carbetocin: is a drug used to control postpartum hemorrhage. It is an analogue of oxytocin, and its action is similar to that of oxytocin -- it causes contraction of the uterus.
  • 22.
  • 23. Human recombinant factor VIIa is a new treatment modality shown to be effective in controlling severe, life-threatening hemorrhage by acting on the extrinsic clotting pathway. This synthetic vitamin K-dependent protein is available as NovoSeven. It binds to exposed tissue factor at the site of injury to generate thrombin that activates platelets and the coagulation cascade. Intravenous dosages vary by case and generally range from 50 to 100 mcg/kg every 2 hours until hemostasis is achieved. Cessation of bleeding ranges from 10 minutes to 40 minutes after administration. factor VIIa is extremely expensive http://www.medscape.com/viewarticle/543703 Recombinant activated factor seven (VIIa):
  • 24. Conservative Surgical Management There are multiple conservative surgical procedures and techniques that can be done particularly when the patient wants to maintain fertility.
  • 25. B – LYNCH Suture
  • 26.
  • 27. HO – CHO Squares
  • 29. HACKETHAL U-suturing Technique An absorbable Vicryl 0 thread and an XLH needle whose curve had been straightened manually were used for suturing. To perform an interrupted single U-suture, the needle was inserted at the ventral uterine wall, led through the posterior wall and then passed back to the ventral wall where the thread was joined with a flat double knot (Fig. 1a and b). While the lead surgeon was tying the suture, the assisting surgeon performed bi-manual uterine compression. The number of sutures required depended on the size of the uterus and the persistence of bleeding. In general, 6-16 U-sutures in horizontal rows along the uterus, starting at the fundus and ending at the cervix. Thus, approximately 2-4 cm of tissue was compressed within each suture.
  • 36. Angiographic Embolization This tool is now used for many causes of intractable hemorrhage when surgical access is difficult. A patient with stable vital signs and persistent bleeding, especially if the rate of loss is not excessive, may be a candidate for arterial embolization. Radiographic identification of bleeding vessels allows embolization with Gelfoam, coils, or glue. Balloon occlusion is also a technique used in such circumstances. Embolization can be used for bleeding that continues after hysterectomy or can be used as an alternative to hysterectomy to preserve fertility.
  • 37. Pelvic Umbrella Pack The umbrella or a parachute pack was described by Logothetopulos in 1926 to arrest intractable pelvic hemorrhage following hysterectomy. Although seldom used today, it can be life saving if all other measures have failed. The pack is constructed of a sterile x-ray cassette bag that is filled with gauze rolls knotted together to provide enough volume to fill the pelvis. The pack is introduced transabdominally with the stalk exiting the vagina. Mild traction is applied by tying the stalk to a 1-liter fluid bag, which is hungover the foot of the bed. An indwelling urinary catheter is placed to prevent urinary obstruction and to monitor urinary output. Percutaneous pelvic drains can be placed to monitor ongoing bleeding within the peritoneal cavity. Broad spectrum antimicrobials are given, and the umbrella pack is removed vaginally after 24 hours.
  • 38. ACOG surgical Management of Postpartum Hemorrhage
  • 39. When is blood transfusion recommended? Transfusion of blood products is necessary when the extent of blood loss is significant and ongoing, particularly if vital signs are unstable. Clinical judgment is an important determinant, given that estimates of blood loss often are inaccurate, determination of hematocrit or hemoglobin concentrations may not accurately reflect the current hematologic status, and symptoms and signs of hemorrhage may not occur until blood loss exceeds 15% . The purpose of transfusion of blood products is to replace coagulation factors and red cells for oxygen-carrying capacity, not for volume replacement. To avoid dilutional coagulopathy, concurrent replacement with coagulation factors and platelets may be necessary. Autologous transfusion (donation, storage, retransfusion) has been shown to be safe in pregnancy and Cell saver technology has been used successfully.
  • 41. Recommendations and Conclusions Uterotonic agents should be the first-line treatment for PPH due to uterine atony. Management may vary greatly among patients, depending on etiology and available treatment options, and often a multidisciplinary approach is required. In the presence of conditions known to be associated with placenta accreta, the obstetric care provider must have a high clinical suspicion and take appropriate precautions.
  • 42. References 1. AbouZahr C. Global burden of maternal death and dis-ability. Br Med Bull 2003;67:1–11. (Level III) 2. Preventing infant death and injury during delivery. Sentinel Event ALERT No. 30. Joint Commission on Accreditation of Healthcare Organizations. Available at: http://www.jointcommission.org/SentinelEvents/Sentinel EventAlert/sea_30.htm. Retrieved June 12, 2006. (Level III) 3. Chesley LC. Plasma and red cell volumes during pregnan-cy. Am J Obstet Gynecol 1972;112:440 –50. (Level III) 4. Pritchard JA, Baldwin RM, Dickey JC, Wiggins KM. Blood volume changes in pregnancy and the puerperium. Am J Obstet Gyencol 1962;84:1271–82. (Level III) 5. Clark SL, Yeh SY, Phelan JP, Bruce S, Paul RH. Emergency hysterectomy for obstetric hemorrhage. Obstet Gynecol 1984;64:376–80. (Level III) 6. Dildy GA 3, Paine AR, George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual esti-mation? Obstet Gynecol 2004;104:601– 6. (Level III) 7. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. ObstetGynecol 1991;77:69–76. (Level II-2) 8. Williams Ch 41 24th Edition. 9. ACOG Practice Bullitin No 76 10. FOURTH EDITION OF THE ALARM INTERNATIONAL PROGRAM , CHAPTER 6 POSTPARTUM HEMORRHAGE
  • 43. QUESTIONS & COMMENTS Happy Holidays Thank You.