Obsterics & Gynecology Hospital of Fudan University Weirong Gu

Blood loss in excess of 500 ml following birth within the first 24 hours of delivery◦ Serious intrapartum complication◦ The most significant cause of maternal death worldwide,

mortality : 140 000 per year (1 maternal death every 4 minutes)◦ Incidence: 4–6% of pregnancies◦ Actual incidence: more high because of inaccurate, significant

underreporting

Primary PPH◦ Occurring within the first 24 hours of delivery◦ 4–6% of pregnancies◦ Caused by uterine atony in 80% or more of cases

Secondary PPH◦ Occurring between 24 hours and 6–12 weeks postpartum◦ 1% of pregnancies

4 “ T ”◦Tone: uterine atony◦Tissue: retained placenta◦Trauma: vaginal, cervical, or uterine injury◦Thrombin: coagulopathy (pre-existing or acquired)

——SOGC guideline (number 235, October 2009): Active Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage

The most common and important cause of PPH

The primary protective mechanism for immediate hemostasis after delivery:◦ Myometrial contraction causing occlusion of uterine blood

vessels ——living ligatures of the uterus◦ Blood flow from the vascular space to the uterine cavity via

the myometrium is impeded

Etiologic category and process Clinical risk factors

Overdistension of uterus Polyhydramnios, Multiple gestation, Macrosomia

Uterine muscle exhaustion Rapid labor, Prolonged labor, High parity, Oxytocin use

Intra-amniotic infection Fever, Prolonged rupture of membranes

Functional/anatomic distortion of uterus

Fibroids, Placenta previa, Uterine anomalies

Uterine-relaxing medications Halogenated anesthetics, Nitroglycerin

Bladder distension

Placenta abruptionPlacenta abruption

胎儿胎儿子宫内膜子宫内膜

胎盘胎盘脐带脐带

宫颈宫颈

出血出血

Placenta previaPlacenta previa

Twin pregnancyTwin pregnancy

胎儿胎儿胎儿胎儿

胎盘胎盘

宫颈宫颈

脐带脐带脐带脐带

阴道阴道

fibroidfibroid

肌壁间肌肌壁间肌瘤瘤 浆膜下肌浆膜下肌瘤瘤内膜下肌内膜下肌瘤瘤带蒂带蒂浆膜下肌浆膜下肌瘤瘤

带蒂带蒂内膜下肌内膜下肌瘤瘤

Uterine anomalies

Etiologic category and process

Clinical risk factors

Avulsed lobule, Succenturiate lobe

Incomplete placenta at delivery

Abnormally adhered: Accreta, Increta, Percreta

Placenta previa with or without previous uterine surgery,

Prior myomectomy,Prior cesarean delivery,Asherman’s syndrome,Submucous leiomyomata,Maternal age older than 35 years

Succenturiate lobe

Placenta villi attach Placenta villi invade Placenta villi penetrate to the myometrium into the myometrium through the myometrium

Accreta Increta Percreta

Etioiogic category and process Clinical risk factors

Lacerations of the cervix, vaginal, or perineum

Precipitous deliveryOperative delivery

Puerperal Hematomas Nulliparity, episiotomy, and forceps delivery

Laceration of cervix

I II

III

Lacerations of perineum

Etioiogic category and process Clinical risk factors

Pre-existing states Primary thrombocytopeniaAplastic anemia

Acquired in pregnancy HELLP syndrome Abruption placenta Prolonged intrauterine fetal demise Sepsis

Amniotic fluid embolism Significant hemorrhage

Elevated blood pressureAntepartum hemorrhageFetal demiseFeverSudden collapse

Vaginal bleeding◦ Bleeding with characteristic soft, poorly contracted (“boggy”) uterus on

bimanual pelvic examination ——uterine atony◦ Bleeding while the uterus is firmly contracted —— retained placenta ——genital tract laceration ◦ Bleeding without clot ——coagulopathy◦ Pelvic or rectal pressure and pain ——genital tract hematomas

Hypovolemic shockIrritable,pallor and clamminess of skin, tachycardia,

narrow pulse pressure

——mild degree of shock

Weight method ：◦ Blood loss(ml) ＝（ dressing wet weight after birth － dressing dry

weight before birth ） /1.05(specific gravity of blood) Volume method:

◦ Collect blood using a container Area method ：

◦ 10cm*10cm gause soak blood = 10ml blood

Shock index =heart rate/systolic pressure （ mmHg ） （ normal <0.5 ） shock index estimate loss of blood （ ml ） loss of blood volume 0.6~0.9 <500~750 <20% =1.0 1000~1500 20~30% =1.5 1500~2500 30~50% ≥2.0 2500~3500 ≥50~70%

The initial goal◦ Identifying and treating the cause of blood loss◦ Instituting resuscitative measures to maintain hemodynamic

stability and oxygen perfusion of the tissues

Call for help Resuscitation

◦ Assess the “ABC”◦ Monitor BP, P, R◦ Empty bladder, monitor urine output ◦ IV line◦ Crystalloid, isotonic fluid replacement◦ Oxygen by mask

Laboratory tests◦ Complete blood count◦ Coagulation screen◦ Blood grouping and cross ——SOGC 2009

Uterine massage◦ Diminish bleeding, expel blood and clots, and allow time for

other measures to be implemented

Uterotonic drugs◦ Ongoing blood loss in the setting of decreased uterine tone

requires the administration of additional uterotonics as the first-line treatment for hemorrhage

Drug Dose/Route Frequency Comment

Oxytocin IV: 10–40 units in 1 liter normal saline

or lactated Ringer’s solution

IM: 10 units

Continuous Avoid undiluted rapid IV infusion, which causes hypotension

Carbetocin IV/IM：100 μg

Ergometrine IM: 0.2 mg Every 2–4 h Avoid if patient is hypertensive

Drug Dose/Route Frequency Comment

15-methyl PGF2α

(Hemabate)

IM: 0.25 mg Every 15–90 min, 8 doses maximum

Avoid in asthmatic patients

Diarrhea, fever, tachycardia can occur

Dinoprostone(PGE2)

Suppository: vaginal or rectal 20 mg

Every 2 h Avoid if patient is hypotensive. Fever is common.

Misoprostol(PGE1)

800–1,000 mcg rectally

Uterine tamponade Exploratory laparotomy Uterine artery embolization

Indication ： uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after vaginal delivery

Technique Comment

—Packing —4-inch gauze; can soak with 5,000 units of thrombin in 5 mL of sterile saline

—Foley catheter —Insert one or more bulbs; instill 60–80 mL of saline

—Sengstaken–Blakemore tube

—SOS Bakri tamponade balloon —Insert balloon; instill 300–500 mL of saline

Packing Bakri Balloon tamponade

Indication ： When uterotonic agents with or without tamponade measures fail to control bleeding in a patient who has given birth vaginally

Techniques◦ Compression sutures◦ Artery ligation ◦ Hysterectomy

B-Lynch technique◦ First reported by B-lynch in 1993 ◦ Compress the uterine corpus and decrease bleeding◦ Rare Complication ： uterine ischemic necrosis with

peritonitis

Modified B-Lynch ◦ e.g. Hemostatic multiple square suturing ◦For postpartum hemorrhage caused by uterine atony,

placenta previa, or placenta accreta◦Eliminateing space in the uterine cavity by suturing both

anterior and posterior uterine walls

Bilateral uterine arteries ligation

Bilateral internal iliac arteries ligation

Bilateral ovarian arteries ligation

Uterine arteries ligation

Internal iliac arteries ligation

Diminish the pulse pressure of blood flowing to the uterus

The timing of this intervention is important: it must be done without delay, before excessive blood loss has occurred

Surgical skill is required to avoid failure and complications such as damage to other vascular structures and the ureters

Indication: massive hemorrhage has not responded to previous interventions

Notice: If hysterectomy is performed for uterine atony, there should be documentation of other therapy attempts

overy

bladder

uterus

vagina

cervix

cavitycavity

salpinx

endometriummyometrium

subtotal

total

Hysterectomy

Indication: stable vital signs , persistent bleeding, especially if the rate of loss is not excessive

Used for bleeding that continues after hysterectomy Used as an alternative to hysterectomy to preserve

fertility

Radiographic identification of bleeding vessels Embolization with gelfoam, coils, or glue, or balloon

occlusion

H.A.E.M.O.S.T.A.S.I.S. H: Ask for help A: Assess (vital parameters, blood loss) and resuscitate E: Establish etiology and check medication supply (oxytosin, ergometrine) and availability of blood M: Massage uterus O: Oxytocin infusion, prostaglandins (intravenous, rectal, intramuscular, intra- myometrial)

S: Shift to operating room, exclude retained products and trauma, bimanual compression T: Tamponade balloon, uterine packing A: Apply compression sutures S: Systematic pelvic devascularization (uterine, ovarian, internal iliac) I: Intervention radiologist, uterine artery embolization if appropriate S: Subtotal or total abdominal hysterectomy

——ICM/FIGO guideline 2006: Postpartum hemorrhage today: initiative 2004—2006

Diagnosis: detection of an echogenic mass in the uterus by ultrasonography

Directed therapy ◦ Whole placenta in uterus ： manual removal ◦ Incomplete separation （ avulsed lobule, succenturiate lobe ）

： gentle curettage ◦ Placenta accreta

curettage wedge resection medical management hysterectomy

Lacerations of perineum, vagina, or cervix

Genital tract hematomas

Identification and proper repair of lacerations ◦ Transfer to a well-equipped operating room ◦ Proper patient positioning◦ Adequate operative assistance◦ Good lighting◦ Appropriate instrumentation (eg, Simpson or Heaney

retractors)◦ Adequate anesthesia

May not be recognized until hours after the delivery Sometimes occur in the absence of vaginal or

perineal lacerations The main symptoms are pelvic or rectal pressure and

pain

Directed therapy ◦ Draining the blood within the hematoma (sometimes placing

a drain in situ)◦ Suturing the incision◦ Packing the vagina◦ Interventional radiology

Directed therapy◦ Appropriate testing◦ Blood products infused as indicated◦ Simultaneous surgery if the coagulopathy caused or

perpetuated by the hemorrhage

Baseline studies◦ Complete blood count with platelets◦ Prothrombin time◦ Activated partial thromboplastin time◦ Fibrinogen◦ A type and cross order

Be ordered when excessive blood loss is suspected and should be repeated periodically as clinical circumstances warrant

Response to hemorrhage before laboratory results are known

A simple measure of fibrinogen◦ A volume of 5 mL of the patient’s blood is placed into a

clean, red-topped tube and observed frequently. Normally, blood will clot within 8–10 minutes and will remain intact

◦ If the fibrinogen concentration is low, generally less than 150 mg/dL, the blood in the tube will not clot, if it does, it will undergo partial or complete dissolution in 30–60 minutes

AMTSL (active management of the third stage of labor)◦ Routine use of uterotonics◦ Early cord clamping, controlled cord traction◦ Appropriate uterine massage after delivery of the placenta

Subinvolution of placental site Retained products of conception Infection Inherited coagulation defects

The extent of bleeding usually is less than that seen with primary postpartum hemorrhage

Ultrasound evaluation can help identify intrauterine tissue or subinvolution of the placental site

Treatment may include uterotonic agents, antibiotics, and curettage

Management may vary greatly among patients, depending on etiology and available treatment options, and often a multidisciplinary approach is required

Balancing the use of conservative management techniques with the need to control the bleeding and achieve hemostasis

Uterotonic agents should be the first-line treatment for postpartum hemorrhage due to uterine atony

When uterotonics fail following vaginal delivery, exploratory laparotomy is the next step

Williams Obstetrics, 23rd Edition ACOG Practice Bulletin No. 76. 2006. Postpartum

hemorrhage ICM/FIGO guideline 2006: Postpartum hemorrhage today:

initiative 2004—2006 SOGC guideline (number 235, October 2009): Active

Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage

RCOG Green-top Guideline No. 52 May 2009:Prevention and management of postpartum haemorrhage

THANKS!