Good pph

1. Obstetric Emergencies
Postpartum Hemorrhage and Hypertension
Annelee Boyle, MD, FACOG
Assistant Professor
Department of Obstetrics and Gynecology
Division of Maternal-Fetal Medicine
University of Virginia School of Medicine

4. Disclosures

5. Pregnancy-related mortality in the United States: 1987-2010
Source: CDC Pregnancy Mortality Surveillance System

6. Obstetrics and Gynecology, May 2014

7. Causes of pregnancy-related death in the United States: 2006 -2010
Source: CDC Pregnancy Mortality Surveillance System

8. Maternal mortality is only the tip of the iceberg

9. Obstetrics and Gynecology, February 2012

10. • 93% of deaths preventable!
– Berg et al. Preventability of pregnancy related deaths: results of a statewide review.
Obstet Gynecol 2005; 106:1228-34.
• Common mistakes:
– Under-recognition of blood loss
– Under-recognition of hypovolemia
– Failure to act decisively
– Failure to restore blood volume
Postpartum Hemorrhage

11. Recognize the extent of blood loss
Dildy et al, Estimating Blood Loss: Can Teaching Significantly Improve Visual
Estimation? Obstetrics & Gynecology. 104(3):601-606, September 2004.

12. Recognize the extent of hypovolemia
Class 1 Class 2 Class 3 Class 4
EBL in ml < 750ml 750-1500ml 1500-
2000ml
>2000ml
EBL in % Vol. <15% 15-30% 30-40% >40%
Pulse <100 >100 >120 >140
BP Normal or ↑ ↓ ↓ ↓
RR 14-20 20-30 30-40 >35
UOP >30ml/h 20-30ml/h 5-15ml/h negligible
Mental
State
Slightly
anxious
Mildly
anxious
Anxious,
confused
Confused,
lethargic

13. Obstetrics and Gynecology, May 2014

14. • Systolic BP <90 or >160
• Diastolic BP >100
• Heart Rate <50 or >120
• Resp Rate <10 or >30
• Oxygen Sat <95% on room air
• Urine output <35ml/hr for 2 hours
• Agitation, confusion, or unresponsiveness
• Shortness of breath or a non-remitting headache in a
patient with pre-eclampsia
– Mhyre et al. The maternal early warning criteria: a proposal from the
national partnership for maternal safety. Obstet Gynecol
2014;124:782-6.
Early warning signs

15. Act decisively/Restore blood volume

16. • Rule number one: Postpartum Hemorrhage is a definition,
not a diagnosis!
Post-Partum Hemorrhage

17. • Actively manage the third stage of labor
Pearls for Atony

18. • Consider additional utero-tonics for those at highest risk of
PPH
Pearls for Atony

19. • Have a low threshold for going to the OR for repair.
Pearls for Lacerations

20. 0%
10%
20%
30%
40%
50%
60%
70%
80%
No prior CD 1 2 3 4 or more
Risk of accreta in the setting of placenta previa by
number of prior cesareans

21. Source: California
Maternal Quality
Care Collaborative

22. • 60% of deaths are preventable!
– Berg et al. Preventability of pregnancy related deaths: results of a statewide review.
Obstet Gynecol 2005; 106:1228-34.
• Common mistakes:
– Failure to adequately control blood pressure
– Failure to recognize HELLP syndrome
– Failure to diagnose and treat pulmonary
edema
Preelcampsia

23. • Systolic BP <90 or >160
• Diastolic BP >100
• Heart Rate <50 or >120
• Resp Rate <10 or >30
• Oxygen Sat <95% on room air
• Urine output <35ml/hr for 2 hours
• Agitation, confusion, or unresponsiveness
• Shortness of breath or a non-remitting headache in a
patient with pre-eclampsia
– Mhyre et al. The maternal early warning criteria: a proposal from the
national partnership for maternal safety. Obstet Gynecol
2014;124:782-6.
Early warning signs

24. Control Blood Pressure

25. Control Blood Pressure

26. Hi Annelee. Hope you’re doing well and liking your new
job. It’s 10:30 pm here and for me, that’s the middle of the
night so rather than be friendly and “chat”, I’m going to get
straight to the point – it’s business…
So our hospital protocol essentially regurgitates ACOG, but it
doesn’t specify that it is for use only with
preeclamptic/eclampic patients. Would you use it for someone
with chronic HTN also, barring known renal disease or other
cause of the HTN?
Thanks!
Love, Aunt Crunchy

27. Recognize HELLP Syndrome

28. The most important paper on HTN in pregnancy
in the last year

29. • SBP >160
• DBP >110
• Platelets < 100,000)
• LFTs >2x normal
• Creatinine > 1.1
• Pulmonary edema
• New-onset cerebral or visual disturbances
• Right upper quadrant pain
American College of Obstetricians and Gynecologists. Hypertension in
pregnancy: executive summary. Obstet Gynecol 2013;122:1122–31.
Severe Features of Preeclampsia

30. Recognize and treat pulmonary edema

32. “If you’re going
down take
everybody else
with you.”
– Susan Modesitt, Gyn Oncologist
The UVA way (or maybe it was UNC)

33. David Barker 1938-2013

34. The Barker Hypothesis
The Thrifty Phenotype
Fetal Origins Hypothesis

35. Intrauterine Growth Restriction

36. 30 years from now

37. Thank you!!!