Post Partum
Haemorrhage
seminar
10th October 2015
HoSHAS
Definition and
Causes of PPH Dr Riduan bin Mohd Tahar Dept of O&G, HoSHAS Introduc*on •  There has been a significant decline in maternal mortality from 540 per 100,000 live births in I957 to 28 per 100,000 in 2012 •  PPH used to be the 1st leading cause of death in Malaysia •  Now PPH is the 3rd leading cause of death Definition of PPH
Introduc*on •  Conven*onally, the term ‘postpartum hemorrhage’ (PPH) is applied to pregnancies beyond 20 weeks’ gesta*on. •  There is no single sa*sfactory defini*on of post partum haemorrhage Defini*on in use 1.
2.
3.
4.
5.
Timing of the onset of bleeding Amount of blood loss Decline in hematocrit – 10% Reduc*on in haemoglobin level Rapidity of the blood loss –  Severe haemorrhage, 150ml/min, 50% blood loss in 20 minutes 6.  Volume deficit 7.  Base on clinical sign Defini*on •  The World Health Organiza*on (WHO) •  1990 –  Any blood loss from the genital tract during delivery above 500 ml •  2003 –  Revise; to include the first 24 hours a\er delivery. Primary PPH •  Defined as blood loss above 500 ml following vaginal delivery and above 1000 ml a\er abdominal delivery (Caesarean sec*on). •  Massive PPH is defined as PPH with blood loss in excess of 1500 ml. Secondary PPH •  Excessive blood loss between 24 hours and 6 weeks post partum •  Physiological changes –  Pregnancy induced hypervolaemia –  Increase by 30 – 60% (1500 – 2000ml) for an average size women –  Most average size healthy women can cope with the blood loss of more than 500mls –  The average blood loss during a normal vaginal delivery -­‐ 500 ml –  approximately 5% of women about 1000 ml during a vaginal birth. •  Co-­‐morbid –  Anaemia –  Severe PE, intravascular deple*on •  BMI –  Small size women cannot tolerate well with small blood loss •  This is an ‘arbitrary’ value •  Tends to be underes*mate !! •  Remains a major challenge in management. How to improve •  Regular training / drill / courses •  More accurate method es*ma*on –  Blood collec*on drapes –  Weighing swabs –  Pictorial blood loss •  Associated risk factor •  A appropriate or more clinical defini*on of PPH is any blood loss sufficient enough to cause haemodynamic instability. •  Preven*on is becer •  Reduce morbidity if detected earlier Purpose of defini*on •  Standardize •  500ml blood loss should be consider as an alert line •  Easily underes*mate –  It may be dangerous not to ins*tute simple therapeu*c/prophylac*c measures e.g. uterine massage, uterotonic agent and inspec*on of lower genital tract Purpose of defini*on •  Effec*ve communica*on –  Ini*al assessment usually done by JM, Staff nurse, H.O –  Early recogni*on and prompts basic measures •  To determine the most suitable line of management –  To guide the degree of aggressiveness of treatment e.g. rapidly bleeding àsurgical management Causes of PPH
CAUSES OF PPH
TONE (70%)
(Atonic uterus,
distended
bladder)
TRAUMA
(20%)
(Uterine,
cervical or
vaginal injury)
(the 4 'T's)
TISSUE (10%)
(Retained
products of
conception)
THROMBIN
(<1%)
(Pre-existing
or acquired
coagulopathy)
Tone •  Uterine atony is the most common cause of PPH – 70% of cases •  Uterine contrac*on à living ligatures Tone •  Uterine over-­‐distension –  Mul*ple pregnancy –  Macrosomic fetus –  Polyhydramnios –  Fetal abnormali*es e.g. severe hydrocephalus Tone •  Uterine muscle fa*que –  Prolonged labour –  Precipitate labour –  Augmented labour with oxytocin –  High parity (20 fold increased risk) –  Prolonged 3rd stage –  Previous pregnancy with PPH Tone •  Intra-­‐amnio*c infec*on –  Prolonged SROM –  Chorioamnioni*s •  Uterine distor*on/abnormality –  Fibroid uterus –  Uterine anomalies –  Placenta praevia •  Placenta praevia –  Lower segment takes *me to contract –  Defensive medicineà increase rate of LSCS –  Increase risk of placenta accreta –  2 previous scar 50% of accreta –  Mul*disciplinary approach –  Morbidity and mortality Tone •  Bladder distension –  Urinary reten*on •  Uterine relaxing drugs –  Anaesthe*c drugs, nifedipine, NSAIDs, beta-­‐
mime*cs, MgS04 Trauma •  20% of case •  Commonly the lower genital tract trauma •  Obese pa*ent à limited access for repair Trauma •  Cervical / vagina / perineal tears –  Precipitous delivery –  Manipula*ons at delivery –  Opera*ve delivery –  Episiotomy especially with varicose vulva Trauma •  Extended tear at CS –  Malposi*on –  Fetal manipula*on e.g. version of second twin –  Deep engagement •  Upper segment CS –  Lower segment not well formed –  Severe adhesions at lower segment –  Transverse lie Trauma •  Uterine rupture –  Previous uterine surgery •  Uterine inversion –  Mismanagement of third stage of labour –  High parity –  Fundal placenta Tissue •  10% of cases •  Foreign body •  Ineffec*ve uterine contrac*on Tissue •  Retained placenta / membranes –  Retained placenta 10% –  Increase the risk up to 20% –  History of retained placenta –  Undiagnosed morbidly adhere placenta –  Incomplete placenta at delivery, especially< 24 weeks Tissue •  Abnormal placenta – succinturiate /accessory lobe –  Previous uterine surgery –  Abnormal placenta on ultrasound –  Undiagnosed incomplete placenta at delivery –  Systema*c method to check for placenta completeness Thrombin •  1% of cases •  Mul*disciplinary care Thrombin •  Pre-­‐exis*ng clokng abnormality –  E.g. haemophilia A / vWD / hypofibrinogenaemia / ITP –  Family history •  An*coagulant –  History of DVT / PE –  Aspirin –  Heparin Thrombin •  Acquired in pregnancy –  Gesta*onal thrombocytopenia –  Severe PE with thrombocytopenia (HELLP) –  DIVC secondary to abrup*on, AFE, severe sepsis –  Dilu*onal coagulopathy e.g. massive transfusion Risk factors •  Antenatal 1.  Age 2.  Ethnicity 3.  BMI 4.  Parity 5.  Medical condi*on e.g. type II DM, hypertension, haematology 6.  Prolonged pregnancy Risk factors •  Antenatal 7.  Macrosomic 8.  Mul*ple pregnancies 9.  Fibroids 10. Antepartum haemorrhage 11. Previous history of PPH 12. Previous caesarean Risk factors •  Intrapartum 1.
2.
3.
4.
5.
6.
7.
First stage Second stage Third stage Analgesia Delivery methods Episiotomy Chorioamnioni*s Secondary PPH •  Excessive blood loss between 24 hours and 6 weeks post partum •  The commonest cause is infec*on (endometri*s) •  O\en secondary to retained product of concep*on •  Management includes an*bio*c and evacua*on retained product of concep*on Summary •  Defini*on –  Primary PPH, >500ml within 24 hours of delivery –  Secondary PPH a\er 24 hours to 6 weeks post delivery –  Massive PPH, > 1500ml –  Underes*mate –  Risk factor •  Causes of PPH – 4T 1. Tone – 70% 2. Trauma – 20% 3. Tissue – 10% 4. Thrombin -­‐ < 1% ANTICIPATION remains the goal of PPH
management
Thank You