Overview and medical management of pph

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By Dr. Suhas Otiv

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Overview and medical management of pph

  1. 1. Overview and medical management of PPH Dr. Suhas OtivConsultant, KEM Hospital, Pune
  2. 2. Lancet 2006; l368:1189-200
  3. 3. Mortality from PPH• Half of 500,000 maternal deaths globally• 28 % of maternal deaths in developing countries• Risk of death from PPH 1 in 1000 deliveries - developing countries 1 in 100,000 deliveries – developed countries
  4. 4. Lancet 2006; l367:1066-72
  5. 5. Incidence of PPHPPH 5 – 17 % of all deliveries> 500mlMajor PPH 1.3 – 2.5 % of all deliveries> 1000 mlACOG 3.9 % of all deliveries
  6. 6. Definition of PPHPrimary PPH: 0 – 24 hours; Secondary PPH: 1 - 84 daysBlood loss > 500 ml at vaginal delivery > 750 - 1000 ml at CesareanSevere PPH > 1000 ml loss at vaginal deliveryACOG: - Fall in hematocrit 10% - Need for PRBC transfusionRate of blood loss: > 150ml/min or sudden loss > 1.5 – 2 l
  7. 7. PPH can occur with minimal vaginal bleeding !!!!
  8. 8. Accuracy of visual estimation of blood loss
  9. 9. Modified –WHOBlood collection method
  10. 10. Modified –WHOWeighing Blood loss
  11. 11. Modified –WHOMeasuring volume of blood loss-Transfer of blood-Mops squeezed
  12. 12. BRASSS-V®BloodCollectionDrape withCalibratedReceptacle
  13. 13. Etiology of PPH• Uterine Atony > 80 %• Lacerations of vagina, cervix• Uterine rupture 10%• Uterine inversion• Retained placental fragments• Placental accreta / increta / percreta 5%• Coagulopathy 1%
  14. 14. Risk factors for PPH• Nulliparity • Advanced maternal age• Obesity • PIH• Large baby • PPH in previous delivery• Prolonged labor • Augmented labor• APH • Forceps delivery• Multiple pregnancy • Use of tocolytics• Cesarean delivery х Grand multiparity 65 % cases of PPH occur with no risk factors
  15. 15. PPH at Cesarean delivery: Risk Factors• General anesthesia• Chorio-Amnionitis• Pre-eclampsia• Protracted active phase of labor• Second-stage arrest• Classic uterine incisionObstet Gynecol 1991 Jan;77(1):77-82
  16. 16. Risk factors for PPH: a case control studycomparing 666 cases with controls in 154311 deliveries• Retained placenta (OR 3.5, 95% CI 2.1-5.8)• Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)• Placenta accreta (OR 3.3, 95% CI 1.7-6.4)• Lacerations (OR 2.4, 95% CI 2.0-2.8)• Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)• Large for gestational age new born (eg, >4000 g) (OR 1.9, 95% CI 1.6-2.4)• Hypertensive disorders (OR 1.7, 95% CI 1.2-2.1)• Induction of labor (OR 1.4, 95% CI 1.1-1.7)• Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7) J Matern Fetal Neonatal Med. 2005;18(3):149
  17. 17. Management of PPH• Scenarios – labor room, OR, wards, peripheral hospital• Effective management – Prompt response – Organized team work – Clear priorities, decisive• Help: communication, monitoring, assistance, documentation
  18. 18. Being prepared for PPH• Team: Nursing, doctors, surgical expertise, critical care physician / anesthesiologist• Drugs: Oxytocin, Methergin, Carboprost, volume expanders, resuscitation• Equipment: Monitoring, resuscitation, Blood bank, Lab, ICU, OR
  19. 19. Management of PPH at vaginal deliveryFirst line Management• Call for help• Uterine massage• IV access: X-match, labs• Infuse NS rapidly,• BP, Foley catheter, pulse oximeter,• Prompt Uterotonic drugs Carboprost 250 mcg, 2 doses 15 minutes apart Oxytocin infusion 40 units / 500 ml in 30 – 60 min Methylergometrine 0.2mg i.m. one dose Misoprostol 400 - 800mcg• Rapidly evaluate for vaginal / cervical lacerations• Warmth, oxygen
  20. 20. Oxytocic drugs• Oxytocin• Methyl ergometrine• Misoprostol• Carboprost
  21. 21. Oxytocin• Storage: Between 2-8 *C, avoid freezing• Adverse effects: anti-diuretic effect, hypotension, arrhythmias• Incompatible with noradrenaline, warfarin• 10 – 40 IU / L of infusate
  22. 22. Ergometrine• Storage: Refrigerate, protect from light, stable for 60-90 days, discoloration – discard• Avoid : heart disease, hypertension, peripheral vascular disease, hepatic or renal impairment; with antiretroviral and macrolide antibiotics• Adverse : Vomiting, nausea, HT, CVA• Route: IM preferred, IV dilute in 5 ml NS
  23. 23. Carboprost – PGF2 alpha• Caution : Asthma, cardiac disease, epilepsy, liver disease• Storage: Refrigerate• Adverse: Vomiting, diarrhea, flushing,• Dosage: 250 mcg IM, repeat every 15 - 90 minutes, maximum 8 doses = 2 mg.• IV injection - bronchospasm, hypertension, vomiting, and anaphylaxis
  24. 24. Misoprostol• PGE1 analogue• Adverse effects – vomiting, shivering at higher doses. No broncho-constriction.• Storage: Stable at or below 25*C• Route: Oral, buccal, rectal, vaginal• Rapid onset of action lasting 4-6 h
  25. 25. Misoprostol as an adjunct to standarduterotonics for treatment of PPHLancet. 2010;375(9728):18081422 women with atonic PPH treated with routineuterotonic agents randomized to 600 mcg misoprostol sublingually Placebo sublinguallyFound no difference in blood loss > 500 ml in next 1hour
  26. 26. Treatment of PPH with sublingual misoprostol versusoxytocin in women receiving prophylactic oxytocinLancet. 2010;375(9710):21731055 women delivered with prophylactic oxytocin in III stage,809 (3%) who had atonic PPH were randomized to Misoprostol 800mcg sl Oxytocin 40 u infusion in 15 minutesSimilar outcomes in both groups90% women had bleeding controlled in 20 minutes;30% women had additional blood loss of > 300 ml after Rx
  27. 27. After initial treatment• Evaluate for retained placental fragment uterine inversion lacerations coagulopathy• Check urine output, response to resuscitation, time volume of blood lost
  28. 28. Volume replacement• Crystalloid: Ringer Lactate, Hartmann, NS RL similar to plasma only 20% retained in circulation Dextrose: only 10% retained, interferes with X matching NS avoid in pre-eclamptic patient• Blood volume changes last for 40 minutes only• Infuse 3 L for each 1 L of estimated blood loss• Target 90mm systolic pressure, UOP 30ml/hr• Give colloids after 2 L of crystalloids given
  29. 29. Colloids• Gelatin polymers - Hemaccel rapid urinary excretion anaphylaxis• Hydroxyethyl starch – Hetastarch, Pentastarch increases plasma volume by 70 – 230% dose 20 ml/kg = 1 to 1.5 L no anaphylactic reactions well tolerated lasts for 4 hours in circulation
  30. 30. Blood transfusion• No universally accepted guidelines for trigger• PRBC x 2 if no improvement after 2-3 L of crystalloids or if ongoing blood loss likely• Warm carefully. > 40 *C – severe transfusion reactions• Admin 1 FFP for every 1-2 units of PRBC, at 12-15ml/kg• No drugs / injections with blood
  31. 31. Target• Hb > 7,• Platelets > 50,000 /ml• Fibrogen > 100mg/dl• PT < 1.5 times control
  32. 32. Massive hemorrhage• Defined as > 10 units of BT required / 24 h• Likely when persistent SBP < 90, Loss more than 1500ml• Cryoprecipitate if no response to FFP or Fibrogen level < 100• Expect platelet count < 50,000 after > 2 L blood loss. Platelets to maintain counts 25-50,000, 1:1
  33. 33. Secondary interventions• Repeated doses of Carboprost max 8 doses• Intramyometrial Carboprost - off label• Carboprost uterine irrigation• Rectal Misoprostol - high doses >800mcg• Intra-uterine Misoprostol• Tamponade – Sengstaken tube,• Uterine Packing
  34. 34. Indications for laparotomy• Unabated blood loss• Atony unresponsive to Rx• Vital signs out of proportion to blood loss• Vaginal laceration extending above fornix
  35. 35. Summary• Symptoms and vital signs of blood loss are more important than visual assessment of blood loss• Team approach with protocols and regular drills• Prompt, sequential use of utero-tonic agents and replacement of volume are mainstay of Rx• Low Fibrinogen, abn PT, tachycardia and abnormalities of placental implantation and detectable troponin are predictors of increased morbidity
  36. 36. Thank you !

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