Post Partum

Haemorrhage

Francoise Iossifidis

Darent Valley Hospital

� Background

� Definitions

� Risk Factors/Etiology

� PPH Management

� Communication, Resuscitation, Monitoring & Ix, Arresting the bleeding,

drugs used

� Patients who refuse blood

� How to survive your first PPH

PREVENTION AND MANAGEMENT

OF POSTPARTUM HAEMORRHAGE

Background

� Major cause of maternal death and morbidity despite a fall in

number in this triennium

� In the UK major obstetric haemorrhage is 3.7/1000

� 50% of the 500 000 maternal death globally is due to

haemorrhage

� All units should have protocols in place for its identification and

management.

� CMACE 2006-08 9 deaths 0.39/100 000

� Majority of these considered preventable

� Obstetric haemorrhage encompasses antepartum and

postpartum

� APH often associated with subsequent PPH

� 1 -Sepsis (26)

� 2 -Pre-eclampsia and eclampsia (19)

� 3 -Thromboembolism (18)

� 4- Amniotic fluid embolism (13)

� 5- Early pregnancy deaths (13)

� 6 -Haemorrhage (9)

Volume 118, Supplement 1, March 2011 BJOG An International

Journal of

Obstetrics and Gynaecology

Saving Mothers’ Lives

Reviewing maternal deaths to make

motherhood safer: 2006–2008March 2011

The Eighth Report of the Confidential

Enquiries into Maternal

Deaths in the United Kingdom

Definitions

� Primary PPH

� Loss of >500 ml blood from genital tract within 24h of birth of baby

� Minor (500-1000ml)

� Major (>1000ml)

� Moderate 1000-2000ml

� Severe >2000ml

� Secondary PPH

� Abnormal/excessive bleeding from birth canal between 24h and 12/52

postnatally

All PPH are audited and reported on a monthly basis

Issues

International definition of PPH not unified:

� Traditional WHO definition of primary PPH encompasses all

blood losses > 500ml

� Est loss >1000ml appropriate cut off for major PPH and

initiation of emergency protocol measures other 1500ml

� Estimations of blood volume based on weight (weight kg/12)

� Allowing for physiological increase in pregnancy blood vol at

term = 100ml/kg

Issues

� Blood loss of >40% (approx 2800ml) total bld vol : ‘life-

threatening’

� Consideration of antenatal Hb (<11g/dl Ix and Rx pre delivery)

� Evidence that iron-def anaemia assoc with atony secondary to

depleted uterine myoglobin levels (needed for muscle action)

� Visual blood loss estimates often underestimate true loss

Risk Factors for PPH

Most cases of PPH have no identifiable risk factors however the following increase the risk of PPH:

� Increased BMI� Fibroids� Polyhydramnios� Twin pregnancy� Previous LSCS� Pre-eclampsia….

Four T’s (Society of Obs and Gynae of Canada)

� Tone 80% Uterine atony

� Trauma 10% Lacerations, uterine rupture

� Tissue 9% Retained products

� Thrombin 1% Coagulation disorders

PPH Management

� Team management/communication

� Protocol

� Regular skill drills

� Resuscitation

� Monitoring & Investigation

� Arresting the bleeding

Team management� Basic measures for minor PPH (500-1000ml)

� Alert midwife-in-charge

� Alert first-line obstetric and anesthetic staff

� Full protocol for major PPH

� Call experienced midwife (in addition to midwife in charge)

� Declare “code blue”

� Call obstetric middle grade and alert consultant

� Call anaesthetic middle grade and alert consultant

� Call ODP

� Alert consultant clinical haematologist on call

If no code blue in place

� Alert blood transfusion laboratory

� Call porters for delivery of specimens/blood

One member of the team designated to record events, fluids, drugs and vital signs

Resuscitation

� Assess A, B, C

� O2 10-15l/min

� IV access (14G x2)

� Position flat

� Patient warming blanket

� Transfuse PRC ASAP

� Until available infuse up to 3.5l: of warmed crystalloid: Hartmann’s solution 2l +/- colloid 1-2l as rapidly as required

� Use best device available to achieve RAPID WARMED infusion of fluids (eg level 1 rapid infusor)

� Special blood filters should NOT be used acutely - slow infusions

� Recombinant factor VIIa therapy should be based on the results of coagulation (Protocol)

QuickTime™ and a decompressor

are needed to see this picture.

Resuscitation

� Fluid therapy

crystalloid: up to 2L Hartmann’s or Plasmalyte

colloids: up to 1-2L of colloid until the blood products

arrive

� Cell salvage if possible

� Blood products

In an organised way, “Code Blue”

� Drugs:

to contract the uterus

to help the coagulation

Resuscitation

� 2006 guideline from British Committee for Standards in

Haematology - main therapeutic goals of management of

massive blood loss is to maintain:

� Hb > 8g/dl

� PLT count > 75 x 10 9/l

� PT <1.5 x mean control

� APTT < 1.5 x mean control

� Fibrinogen > 1.0 g/l

Monitoring & Investigation� Blood

� X match if not already done(4 u min), FBC, Coagulation (incl Fib), U&Es, LFTs

� Monitor temperature every 15 min

� Continuous pulse, BP recording and RR (oximeter, ECG, NIBP)

� Foley catheter for UO monitoring

� 2 x 14/16G cannulae

� Consider IABP

� Consider transfer to ICU once bleeding controlled/ monitoring on obstetric HDU if appropriate

� TRALI

� Record parameters on HDU or equivalent chart

� Documentation of fluid balance, blood, blood products and procedures

� ABGs

How to stop the bleeding

� Causes for PPH may be considered to relate to one of the 4 Ts

� Tone, tissue, trauma, thrombin

� Most common cause of primary PPH is uterine atony

� Clinical examination necessary to exclude other causes:

� Retained products (placenta, membranes, clots)

� Vaginal/cervical lacerations or haematoma

� Ruptured uterus

� Broad ligament haematoma

� Extragenital bleeding (for example, subscapular liver

rupture)

� Uterine inversion

Uterine Atony: a team effort

� Bimanual uterine compression (rubbing up the fundus) to

stimulate contractions

� Ensure bladder is empty (Foley catheter)

� Syntocinon 5 u by slow IV injection (may have repeat dose)

� Ergometrine 0.5mg by slow IV/IM injection (C/I in HTN)

� Syntocinon infusion (40u in 500ml @ 125ml/hr) or in 50mls if

PET

� Carboprost 0.25mg IM injection repeated at intervals of not less

than 15min to max of 8 doses (C/I in asthma)

� Direct intramyometrial injection of carboprost 0.5mg (C/I in

asthma - responsibility with administering clinician as not

recommended for intramyometrial use)

� Misoprostol 1000mcg PR

Surgical Haemostasis

� Intrauterine balloon tamponade

� Haemostatic brace suturing (B Lynch suture) delayed suture

(>2h) increases the rate of hysterectomy

� Bilateral ligation of uterine arteries

� Bilateral ligation of internal iliac arteries

� Selective arterial embolisation

� Resort to hysterectomy SOONER RATHER THAN LATER (esp

if placenta accreta or uterine rupture)

� UKOSS 40.6/100 000 hysterectomies to control haemorrhage

with<1% death

� 39% morbidly adherent placenta, main cause previous LSCS

Drugs to help the coagulation

� Tranexamic acid

� Beriplex

� Recombinant Factor VIIa

� Vit K

� Management of major PPH

Prevention

� All women who have had a previous LSCS must have their

placental site determined.

� Identify women “at risk” and be prepared.

� Women delivered by LSCS must have regular obs recorded on

the MEOWS chart for the first 24hrs.

� RCOG recommend that women with major placenta praevia

who have previously bled should be admitted and managed as

in patients from 34/40

� All clinicians should be aware of the guidelines for management

of women who refuse blood.

Jehovah’s Witness

� Optimise Hb during pregnancy, oral iron, IV iron, folic acid, recombinant

human erythropoietin.

� Advance directives from hospital and JW Hospital Committee

� Anaesthetic clinic

� Plan delivery as much as possible

� Management:

� Same management as any PPH but without being able to give blood.

� Inform the consultant anaesthetist

� Alert the consultant haematologist early.

� Recombinant factor VIIa

� Tranexamic acid

� Prothrombin complex concentrate Beriplex

� Cell salvage

� Increase the dose of syntocinon, ensure good uterine contraction.

How to survive your first PPH

� Do not panic, think ABC

� Do not join in the mass hysteria

� Call for help i.e. consultant and senior ODP

� If in doubt always declare a code blue

� Beware of hidden blood loss

� Be ahead of the game

� Be assertive and ensure adequate communication.

Thank you