Downloaded 67 times
More Related Content
Similar to Postpartum Hemorrhage
Postpartum Hemorrhage
- 1. Max Mongelli Clinical AssociateProfessor Western Clinical School University of Sydney Nepean Hospital Post-Partum Hemorrhage: Management and Complications
- 2. Third stage oflabour From delivery of the baby to delivery of the placenta < 20minutes. Cessation of umbilical artery pulsation, placenta separates from uterine wall through the decidua spongiosa and is delivered Capillary haemorrhage and shearing effect of uterine muscle.
- 3. Amount of bloodloss depends on: How quickly the placenta separates from uterine wall. How effectively the uterine muscle contracts around the placental bed during and after separation. Intact coagulation system.
- 4. Active management “Standard practice” Administrationof an oxytocic at the delivery of the anterior shoulder/after the baby has been delivered. Early cord clamping and cutting Controlled cord traction of the umbilical cord
- 5. Expectant management “Conservative” “Physiological” Waitingfor the umbilical cord to pulsation cease Waiting for signs of placental separation Allowing placenta to deliver spontaneously Aided by gravity/nipple stimulation/breast feeding
- 6. Active vs Expectant Management Reducedmaternal blood loss Reduced PPH rates (0.38, CI 0.32 to 0.46) 3rdShortening of stage of labour (-9.77, CI –10.0 to –9.53) Increased maternal nausea (1.83, CI 1.51 to 2.23) Increased vomiting and raised BP (probably due to use of ergometrine) Cochrane Database of Systematic Reviews 2000
- 7. PPH Definition – primary >500ml secondary PPHrates Maternal risks mortality morbidity Risk factors Prevention Management
- 8. Definition Blood loss fromthe genital tract >500ml in the first 24 hours following delivery “normal blood loss” (Bonnar 2000) - at vaginal delivery: 600ml - at Caesarean section: 1000ml
- 9. PPH Haemorrhage is themain cause of death in a number of countries At least 25% of maternal deaths worldwide due to haemorrhage – the majority postpartum haemorrhage Vast majority in the developing world 3rdMost important complication of the of labour stage
- 10. Massive haemorrhage >1500ml Blood lossrequiring replacement patient’s total blood volume of the Transfusion >10 units blood within 24 hours Replacement of 50% circulating blood volume in <3hours Loss of >150ml/minute
- 11. PPH rates Depend onthe definition used KEMH >500ml 12%, >600ml 9.45%, >1000ml 5.5% Similar rates in Australasian Most of Australasia: >500ml 8%, tertiary institutions >1000ml >1500ml >2000ml 4.27%, 1.83%, 0.6%
- 12. Maternal risks Mortality Triennial reportsfrom UK 1985-96 show no significant reduction in the number of deaths haemorrhage (30 each triennia) Majority due to substandard care DELAY in - correction of hypovolaemia, - diagnosis and treatment of defective coagulation - surgical control of bleeding “TOO LITTLE TOO LATE” from
- 13. Mortality Developing countries PPH125,000 deaths/yr 28% of maternal deaths Risk 1 in 1000 Australia 1 in 100,000 deliveries die of PPH Life threatening haemorrhage 1 in 1000 deliveries Risk increases with increasing maternal age especially >35 years
- 14. Morbidity Coagulopathy (DIC) Fluid overload/Pulmonary Leftventricular failure edema
- 15. Morbidity Injury to ureterand bladder intervention Sheehans syndrome from surgical permanent hypopituitarism caused by avascular necrosis of the anterior pituitary gland, failure of lactation, amenorrhoea, hypothyroidism and adrenocortical insufficiency
- 16. Blood Changes inPregnancy Normal adult blood eg 50kg 3.5L volume 70ml/kg 60kg 4.2L 70kg 5.0L, etc The healthy pregnant woman has a blood volume of 6-7L in late pregnancy
- 17. Blood Changes inPregnancy During pregnancy: 40% increase in blood vol -increase in red cell mass Lowering of haematocrit by 10% Marked increase in fibrinogen and factors VII, VIII and X
- 18. Adaptation to bloodloss Blood loss <1000ml induces little or no change in pulse or BP Catecholamine – induced vasoconstriction maintains perfusion of the maternal heart and brain at the expense of diminished utero-placental blood flow Tachycardia may be absent in up to 25% of cases with severe blood loss.
- 19. Haemorrhagic shock and bloodloss Symptoms and signs Palpitations, Blood volume loss 10-15% (500-1000ml) BP Degree of shock CompensatedNormal dizziness, HR incr 15-25% (1000-1500ml) Slight fall Weakness, sweating, tachycardia Mild 25-35% (1500-2000ml) 35-45% (2000-3000ml) 70-80mmHg Pallor Moderate 60-70mmHg Collapse, air hunger, anuria Severe
- 20. Disseminated Intravascular Coagulation Depletionof fibrinogen, coagulation circulating platelets Haemostatic failure Microvascular bleeding Increased blood loss Unlikely if platelet count is normal factors and
- 21. Risk Factors forPPH (1) Placenta praevia, especially accreta/percreta/increta Previous history of PPH Previous history of retained if associated with placenta, Ashermans syndrome, endometrial ablation Hypertensive disorders Manual removal of retained placenta Refusal of blood transfusion
- 22. Risk Factors forPPH (2) Maternal obesity Large baby APH/abruption Multiple pregnancy Previous PPH (recurrence rate 8-10%) Operative delivery – Emergency CS substantially increases the risk
- 23. Risk Factors forPPH (3) Anaemia Induction/augmentation Instrumental delivery of labour (1st 2ndProlonged labour or stage) Grand multiparity (>5) Bleeding disorder (eg Von Willebrandt’s) Use of anti-epileptic medications
- 24. Prevention of PPH: Antenatalperiod Identification and correction of anemia pregnancy in Detection Detection Care plan of sub-clinical bleeding disorders of placenta accreta/percreta for management of third stage if risk factors detected
- 25. Prevention of PPH(2) Oxytocic policy Venous access, G+H, active management of third stage, oxytocin infusion in those identified as at risk Senior obstetrician/anaesthetist at placenta praevia CS +/-gynae oncologist at placenta accreta CS
- 26. Management of PPH Callfor help Resuscitate Restore circulating blood volume Identify and treat the cause
- 27. Resuscitation Massage fundus Venous access,16 gauge cannula, Tilt head down, O2 by face mask Bloods:FBC, Coags, X-match IDC Monitoring x2
- 28. Volume replacement Crystalloids 80% infusedfluid leave the intravascular AVOID DEXTROSE O negative blood if torrential loss Packed cells 4 units FFP for every 6 packed cells Platelets/cryoprecipitate Involve haematologist early on Avoid colloids space
- 29. Monitoring Pulse, BP Respiratory rate Temperature Urineoutput 0.5 ml/kg/hour Pulse oximetry (30ml/hour) HDU: Arterial catheterisation
- 30. Identify Tone and treat thecause Bimanual compression, oxytocics Remove retained placenta/membranes Tissue Trauma Repair genital tract tears Thrombin Correct/prevent coagulopathy
- 31. Uterine atony Most commoncause of PPH Oxytocin infusion (as per local Ergometrine IM protocol) Rectal misoprostol (up to 800mcg) Rectal PGE2 (20 mg) Intra-myometrial PG F2 alpha (250 mcg)
- 32. Examination under anaesthetic Removeretained placental tissue ensuring the uterus is empty Detailed examination of cervix and vagina to exclude and repair any lacerations More oxytocics Antibiotic cover Medical – PgF2alpha
- 33. Case Scenario You arethe SR/consultant called to theatre. Junior registar has a patient who has lost 1500ml has done EUA, given oxytocics including PgF2alpha and the patient is continuing to bleed. What are you going to do?
- 34. Continued bleeding Uterine tamponade Foleycatheter Double balloon catheter Uterine packing Sengstaken-Blakemore tube Consider calling gynae oncologist Consider arterial embolisation – interventional radiologist
- 35. Laparotomy Uterine haemostatic suture BLynch suture Modified B Lynch Arterial ligation Bilateral internal artery ligation Bilateral uterine/ovarian artery ligation Hysterectomy Total Subtotal
- 36. Technique 70mm round bodiedNo.2 CCG 3cm from the right lower edge and 3cm from the right lateral border of the incision Thread through into the uterine cavity and emerge the needle 3cm above the incision Pass the CCG over the fundus 3-4cm from the right cornual border
- 37. Technique Feed CCG posteriorlyand vertically. Enter uterine cavity posteriorly at same site as superior anterior entry point Pull CCG under moderate tension, assistant applies manual compression Pass suture horizontally to emerge on posterior wall at the same level but on the left posterior side of the uterus
- 38. Technique Suture knot usingtwo or three throws whilst assistant maintains bimanual compression Close the lower transverse incision in the uterus
- 39. B Lynch suture Advantages Effectivecontrol of haemorrhage Conservation of the uterus for fertility Avoidance of more (hysterectomy) and morbidity Relatively simple Disadvantage: -paralytic ileus radical procedure its potential
- 40. Hayman compression sutures Doesnot require a lower uterine incision Uses 1-vicryl x 4 Bladder has to be reflected down Simpler than B-Lynch
- 41. Balloon Tamponade Various methodsavailable: Sengstaken tube SOS-Bakri tamponade catheter Condoms Foley’s catheters Surgical glove balloon
- 42. SOS – BakriBalloon Tamponade
- 43. SOS – BakriBalloon Tamponade The indications for use: Temporary management of lower uterine segment bleeding. Indicated in about one third of all PPH cases.
- 44.
- 45. Sengstaken-Blakemore Balloon Tamponade Esophagealballoon inflated to 250 ml with normal saline Prophylactic antibiotics Prevented major surgery in more than 70% of cases May help reduce bleeding if transfer is required.
- 46. Balloon Tamponade withCondoms The idea was first introduced by Professor Sayeba Akhter (Dhaka, Bangladesh) to save the life of a woman who had severe jaundice with intractable PPH. Condom is inflated with isotonic saline of 250 – 500 ml (sometime >500 ml – 1 L) When the bleeding is reduced considerably, further inflation is stopped. then outer end of the catheter is folded and fixed to the thigh. To keep the inflated balloon within the uterus, the post vagina is packed with sterile pack
- 47. Uterine Artery Ligation- “O’ Leary Stitch” Requires downward bladder reflection risk of ureteric injury. to reduce Bilateral ligation effective in 90% of cases High ligature may be required. Low risk of long-term complications
- 48. Interventional Radiology Percutaneous transcatheterembolisation Must be performed before uterine artery ligation Performed under fluoroscopic guidance Gelfoam is the preferred agent Angiographic occlusion balloon catheters Success rate 95-97% Useful for vulvovaginal hematomas
- 49. Interventional Radiology: Disadvantages There maybe a significant delay before personnel and equipment are in place Not widely available Contraindicated if coagulopathy is present Minimal data on subsequent pregnancy outcomes
- 50. Interventional Radiology: Complications Procedure relatedmorbidity Post-embolisation fever Buttock ischemia Vascular perforation Infection of 6%
- 51. Case scenario You area GP obstetrician delivering a low risk woman in a country hospital. You are delivering the placenta and note that her BP has suddenly fallen to 80/40, pulse What What 40. She is bleeding profusely do you do? is your differential diagnosis?
- 52. Concealed PPH If hypovolaemic……..andno overt consider Broad ligament haematoma bleeding Ischiorectal fossa haemorrhage/haematoma Paravaginal haematoma Intra abdominal bleeding Previous uterine scar – uterine rupture Rupture of vascular aneurysms Liver/spleen rupture
- 53. Conclusions Relevance of PPHworldwide Increasing incidence of PPH Prophylaxis Don’t forget the basics Good luck!