AHMED HASSAN KHEDR
POSTPARTUM HEMORRHAGE
POSTPARTUM HEMORRHAGE
• Postpartum hemorrhage is one of the major causes of maternal death and it
accounts for about 28 % of maternal mortality
POSTPARTUM HEMORRHAGE
DEFINITIONS
• Loss of greater than 500 cc of blood after vaginal delivery or in excess of 1000
cc after Caesarean delivery often used to define PPH (WHO)
• This definition is not a satisfactory one as the visual estimation of blood loss is
usually inaccurate and the amount of blood is not important as the effect of
blood loss due to the changes on blood volume of the pregnant woman
POSTPARTUM HEMORRHAGE
• So …
Any blood loss that causes a major physiological changes (hypotension and/or
tachycardia) considered PPH , not only depending on the amount or rate of
blood loss but also on the health of the woman
ACOG also recommended that loss of 1000 cc or more with hypovolemia is considered a postpartum hemorrhage
POSTPARTUM HEMORRHAGE
TYPES
▸ PRIMARY POSTPARTUM HEMORRHAGE:
Hemorrhage within the first 24 hours after delivery of the baby (may be third
stage during delivery of the placenta or true after delivery of the placenta)
▸ SECONDARY POSTPARTUM HEMORRHAGE:
Hemorrhage after the first 24 hours after delivery of the baby and with 6 weeks of
delivery of the baby
POSTPARTUM HEMORRHAGE
CAUSES OF PRIMARY POSTPARTUM HEMORRHAGE:
4 Ts
Tone (atonic postpartum)
Tissue(retained products of conception)
Trauma(traumatic ospartum)
Thrombin(coagulation defect)
POSTPARTUM HEMORRHAGE
CAUSES OF SECONDARY POSTPARTUM HEMORRHAGE
▸ Infections ( endometritis)
▸ Placental site (retained placenta fragments , adherent placenta )
▸ Preexisting uterine causes (fibroid, polyps, cervical neoplasms , AV fistulas)
▸ Coagulopathies ( VW , hemophilia , aquired)
PRIMARY POSTPARTUM HEMORRHAGE
RISK FACTORS FOR ATONY
▸ Fetal macrosomia
▸ Polyhydramnios
▸ Multiple pregnancy
▸ Grandmultipaity
▸ Prolonged labour and perfected labour
▸ Abnormal uterine anatomy (malformations anf fibroid)
▸ APH
▸ History of postpartum hemorrhage
▸ Anemia
PRIMARY POSTPARTUM HEMORRHAGE
RISK FACTORS FOR TRAUMA
▸ Instrumental delivery and complicated delivery
▸ Ruptured uterus
▸ Broad ligament hematoma
▸ Extension of uterine incision (CS)
▸ Uterine inversion
PRIMARY POSTPARTUM HEMORRHAGE
PREVENTION
Unfortunately … Only 40 % of cases of PPH have an identified risk
But we have to identify the cases at risk to develop PPH and offered a
modified care planes
All the upcoming steps should be offered to all the cases to avoid PPH
PRIMARY POSTPARTUM HEMORRHAGE
PREVENTION
ANTENATAL :
▸ Identify high risk group
▸ ANC with Correction of anemia
‣ All women who have had a previous caesarean section must have their placental site
determined by ultrasound.
• MRI shoud be offered if placenta accreta/percreta is suspected.
• Available evidence on prophylactic occlusion or embolisation of pelvic arteries in the
management of women with placenta accreta is equivocal. The outcomes of prophylactic
arterial occlusion require further evaluation.
PRIMARY POSTPARTUM HEMORRHAGE
PREVENTION
INTRANATAL :
▸ AMTSL
▸ Check the placenta for missing parts
▸ Explore for lacerations and trauma
POSTNATAL :
▸ 2 ours observation postpartum
PRIMARY POSTPARTUM HEMORRHAGE
AMTSL (ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR)
lowers maternal blood loss and reduces the risk of PPH , it should be done
routinely with delayed cord clamping
1) Administration of a uterotonic, preferably oxytocin (10 IU ; IV,IM, immediately
after birth of the baby;
2) Controlled cord traction (CCT) to deliver the placenta; and
3) Massage of the uterine fundus after the placenta is delivered and then every
15 minutes for 2 hours
PRIMARY POSTPARTUM HEMORRHAGE
ADMINISTRATION OF A UTEROTONIC, PREFERABLY OXYTOCIN (10 IU ; IV,IM, IMMEDIATELY AFTER BIRTH OF THE BABY;
ALTERNATIVES..
•Misoprostol ( oral , rectal or sublingual) is not as effective as oxytocin but it may
be used when the latter is not available, such as the home-birth setting.
It may cause nausea , vomiting and diarrehia , shivering and elevated body temprature
So.. Misoprostol is not recommended as a first line preventive measure for PPH
•Carbetocin (long acting oxytocin agonist ) : longer duration of action than
oxytocin with the same safety profile than oxytocin
▸
PRIMARY POSTPARTUM HEMORRHAGE
MANAGEMENT
Always remember HAEMO-STASIS
•H - ask for Help
•A – Assess and resuscitate
•E – establish Etiology, Ecobolics , Ensure blood
•M – Massage the uterus
•O – oxytocin infusion , prostaglandins
▸
PRIMARY POSTPARTUM HEMORRHAGE
MANAGEMENT
•S – Shift to the theatre
•T – Trauma excluded - Tamponade
•A – Apply compression sutures
•S – Systemic pelvic devascularisation
•I – Interventional radiology
•S – Subtotal hysterectomy
▸
PRIMARY POSTPARTUM HEMORRHAGE
H- ASK FOR HELP
• Call obstetric middle grade and alert consultant.
• Call anesthetic middle grade and alert consultant.
• Alert blood transfusion laboratory.
• Alert one member of the team (residence) to record events, fluids, drugs and
vital signs.
PRIMARY POSTPARTUM HEMORRHAGE
A- ASSESS AND RESUSCITATE
•A B C
•Fluid and blood resusitation
•Crystalloid Up to 2 litres Hartmann’s solution
•Colloid up to 1–2 litres colloid until blood arrives
•Blood Crossmatched
•Fresh frozen plasma 4 units for every 6 units of red cells or prothrombin time/activated partial thromboplastin time > 1.5 x
normal
•Platelets concentrates if PLT count < 50 x 109
•Cryoprecipitate If fibrinogen < 1 g/l
▸
PRIMARY POSTPARTUM HEMORRHAGE
•While Assessing and resusitation
•You have to consider The golden hour .. The time at which resuscitation must be
done to commence the best chance of survival
•The probability of survival drops sharply after the first hour it not effectively
resuscitated
▸
PRIMARY POSTPARTUM HEMORRHAGE
The rule of 30
•If the systolic blood pressure falls by 30
•Heart rate rises by 30
•Respiratory rate more than 30/min
•Hematocrit drop by 30%
•Urinary output less than 30 ml /hour
This mean that the patient lost more than 30% of her blood volume .. We are going to irreversible
shock
▸
PRIMARY POSTPARTUM HEMORRHAGE
E – ESTABLISH ETIOLOGY (4TS), ECOBOLICS AND
ENSURE BLOOD
Establish etiology .. Examination of the cervix , exclude retained product of conception , massage
Ecobolics ..
• Oxytocin (20 U ) slow IV on ringer
• Ergometrin (methergin 0.5 mg IM or slow IV)
• Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes
to a maximum of 8 doses
PRIMARY POSTPARTUM HEMORRHAGE
M – MASSAGE THE UTERUS
•Manual massage
•Bimanual masage
•The use of bimanual uterine compression is recommended as a TEMPORARY
measure until appropriate care is available for the treatment of PPH due to
uterine atony after vaginal delivery
PRIMARY POSTPARTUM HEMORRHAGE
O – OXYTOCIN INFUSION AND PROSTAGALNDINS
‣ Oxytocin (up to 60 U ) slow IV on ringer or saline infused on a rate of 125 ml/hour
‣ Methergine (methyl ergometrine 0.2 if not given)
‣ Prostaglandin E1 ( misotac up to 600-800 mcg rectally)
‣ Prostaglandin E2 (prostin)
‣ Tranexemin acid 500-1000 mcg
PRIMARY POSTPARTUM HEMORRHAGE
S – SHIFT TO OPERATING ROOM (KEEP BIMANUAL COMPRESSION)
PRIMARY POSTPARTUM HEMORRHAGE
T – TAMPONADE AFTER EXCLUSION OF TISSUE AND TRAUMA UNDER ANAETHESIA
•Examination with appropriate lighting , equipment analgesia and assistance to reassess the tone and tissue Then
proceed to tamponade ..using uterine packing or balloon
•Uterine packing using towels totally omitted from the RCOG guidelines and who guidelines stated that “ The use of
uterine packing is not recommended for the treatment of PPH due to uterine atony after vaginal birth.” (Weak
recommendation, very-low-quality evidence)
•The concerns of uterine pack was due to :
It is potentially traumatic , time consuming procedure
It may conceal on-going hemorrhage
Predispose to infection (endometritis)
It represents a non-physiological approach
PRIMARY POSTPARTUM HEMORRHAGE
How to do uterine balloon tamponade ( using bakri balloon)?
•Grasp anterior lip of cervix
•Insert the balloon cathter inside uterine cavity
•Fill the balloon with warm saline or water (till the pressure exceeds the patient’s blood pressure)
•TAMPONADE TEST .. Bleeding didn’t stop –failed procedure- go for laparotomy
•Bleeding stopped .. Do fundal mark , oxytocin 40 iu on saline and antibiotics for 3 days
•Monitor the patient blood pressure and pulse every 30 minutes and temperature every 2 hours
•Removal .. After 6-8 hours
•Deflate the balloon wait 30 minutes if no bleeding .. Remove
•If bleeding stats again .. Re-inflate or go for surgery
PRIMARY POSTPARTUM HEMORRHAGE (BAKRI)
PRIMARY POSTPARTUM HEMORRHAGE
A – APPLY COMPRESSION SUTURES
• B lynch and its modifications is still of value in controlling PPH
• Fertility preservation with the relatively ease of the technique with low
complications are an advantages of this technique
• The reported disadvantages are the need to re operate and go for hystrectomy
in about 10% of cases , endometritis and pyometra and uterine necrosis
▸
PRIMARY POSTPARTUM HEMORRHAGE (B LYNCH)
PRIMARY POSTPARTUM HEMORRHAGE
S – SYSTEMIC PELVIC DEVASCULARISATION
•Using the stepwise pelvic devascularisation
•Starting with bilateral uterine artery ligation at two levels ( isthmus – 3-5 cm
below)
•Bilateral ovarian artery ligation
•Bilateral internal iliac artery ligation
PRIMARY POSTPARTUM HEMORRHAGE
I – INTERVENTIONAL RADIOLOGY
•Selective arterial embolisation to the uterine artery is a line in the management of
post partum hemorrhage but it The logistics of performing arterial occlusion or
embolisation where the equipment or an interventional radiologist may not be
available .
•But it is of great value as a prophlactic step done in the planned cesarean section
when the placenta is known to be accreta or increta.
PRIMARY POSTPARTUM HEMORRHAGE
S – SUBTOTAL HYSTRECTOMY
•Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta
accreta or uterine rupture).
•A second consultant clinician should be involved in the decision for hysterectomy.
•Subtotal hysterectomy is the operation of choice in many instances of PPH requiring
hysterectomy, unless there is trauma to the cervix or lower segment; the risk of neoplasia
developing in the cervical stump
•several years later is not relevant in the context of life-threatening haemorrhage.
PRIMARY POSTPARTUM HEMORRHAGE
N.B
•IS THERE A USE FOR RECOMBINANT FACTOR VIIA THERAPY?
•Recombinant activated factor VII (rFVIIa) was developed for the treatment of haemophilia. Over
the past decade, it has also been used to control bleeding in other circumstances.
•In the face of life-threatening PPH, and in consultation with a haematologist, rFVIIa may be used as
an adjuvant to standard pharmacological and surgical treatments. A suggested dose is 90
micrograms/kg,which may be repeated in the absence of clinical response within 15–30 minutes. If
fibrinogen should be above 1g/l and platelets greater than 20 x 109/l before rFVIIa is given.
•If there is a suboptimal clinical response to rFVIIa, these should be checked and acted on (with
cryoprecipitate, fibrinogen concentrate or platelet transfusion as appropriate) before a second
dose is given.
▸
SECONDARY POSTPARTUM HEMORRHAGE
SECONDARY POSTPARTUM HEMORRHAGE
CAUSES:
▸ Infections ( endometritis)
▸ Placental site (retained placenta fragments , adherent placenta )
▸ Preexisting uterine causes (fibroid, polyps, cervical neoplasms , AV fistulas)
▸ Coagulopathies ( VW , hemophilia , aquired)
SECONDARY POSTPARTUM HEMORRHAGE
SECONDARY POSTPARTUM HEMORRHAGE
▸ Assessment
▸ History
▸ Investigations (CBC , CRP HCG)
▸ Coagulation profile
▸ Blood culture
▸ U/S
SECONDARY POSTPARTUM HEMORRHAGETEXT
TREATMENT OF SECONDARY POSTPARTUM HEMORRHAGE
▸ Ecbolics and antibiotics for 24 hours then consider surgery
Surgical options
▸ E&C
▸ Baloon
▸ Devascularisation
▸ Interventional radiology
▸ Hysterectomy
▸ Factor VII (90UG/KG EVERY 15 M)
AHMED HASSAN KHEDR
THANK YOU