THE MEDICAL MANAGEMENT OF THE MEDICAL MANAGEMENT OF POSTPARTUM HEMORRHAGEPOSTPARTUM HEMORRHAGE

Chukwuma I. Onyeije, M.D.,Chukwuma I. Onyeije, M.D.,Atlanta Perinatal AssociatesAtlanta Perinatal Associates

•Provide a definition of PPH

•Review the risk factors for PPH

•Understand the nature and importance of rapid diagnosis and treatment

OBJECTIVES

For your convenience,A digital copy of this

lecture is also located at:

http://onyeije.net/present

Mary

24 year old G2P2

Underwent a routine cesarean section at 7.30 pm

Pre-operativeHb was 13 g/dl.

Blood loss of 500cc.

Mary

4 hours post-partum

Pulse at 100-120 otherwise stable.

BP: 70-90 / 50-60

Analgesia and Hydration provided.

5 hours postpartum: Seizure with obtundation.

Hemoglobin: 7 g/dl,

6 Hours post partum: Elevated cardiac enzymesDIC Myocardial Infarction & Liver failure

9 Hours postpartum: Failed arterial embolization

10 Hours postpartum Uterine packing done.

11 Hours Postpartum: Hysterectomy

2 Days Postpartum: Flatline EKG

‘‘‘‘She died in She died in childbirth’’childbirth’’

Hemorrhage has probably killed

more women than any other complication of pregnancy in the history of mankind.

An estimated150,000 maternal deaths

worldwide result from obstetric

hemorrhage each year

90% of deaths fromPostpartum

hemorrhage are preventable.

WE HAVE THE

TOOLS

GOOD NEWS

Those caring for pregnant women must be

prepared to aggressively treat

this complication when it occurs.

What What can be can be done?done?

THE STEPS TO PPH:

POSTPARTUM HEMORRHAGE:

PREDICT

HANDLE

PREPARE

THE STEPS TO PPH:

POSTPARTUM HEMORRHAGE:

PREDICT HANDLEPREPARE

Identify patients at risk

Use a multi-

disciplinary Approach

Optimize clinical

management

Uterine Blood FlowUterine Blood Flow

Large amou

nts

of blood c

an

be lost

rapidly

following

delivery.

Uterine cont

raction is m

ore

important th

an clot form

ation

or platelet

aggregatio

n as

a mechanism

of hemostasi

s

1. PREDICT:

THE STEPS TO PPH:

POSTPARTUM HEMORRHAGE:

Can we Predict PPH?

Who is at

risk?

Risk Factors for Postpartum Hemorrhage

What Should we do with a list like this?

Prior postpartum hemorrhage

Advanced maternal age

Multifetal gestations

Prolonged labor

Polyhydramnios

Instrumental delivery

Fetal demise

Placental abruption

Anticoagulation therapy

Multiparity

Fibroids

Prolonged use of oxytocin

Macrosomia

Cesarean delivery

Placenta previa and accreta

Chorioamnionitis

General anesthesia

Clinically Important Risk Factors for Postpartum

Hemorrhage

Prior postpartum hemorrhageAbnormal placentationOperative delivery

Risk Factors for Postpartum Hemorrhage under Clinical

Control

Prolonged labor

Instrumental delivery

Anticoagulation therapy

Prolonged use of oxytocin

Cesarean delivery

General anesthesia

Causes of Postpartum Hemorrhage(another busy slide)

Primary causes

Uterine atony

Genital tract lacerations

Retained products

Abnormal placentation

Coagulopathies and anticoagulation

Uterine inversion

Amniotic fluid embolism

Secondary causes

Retained products

Uterine infection

Subinvolution

Anticoagulation

80% OF CASES OF POSTPARTUM HEMORRHAGE

ARE DUE TO UTERINE ATONY

(a less busy slide)

What about DIC?

Coagulopathy is a relatively uncommon cause of primary PPH

Coagulopathy most commonly occurs when another cause of PPH already has produced significant blood loss.

RDFSRDFS is retained dead fetus syndrome

Well described in most obstetrics texts

Clinically manifested at about 6 weeks after fetal death

Rarely seen in modern obstetrics.

Congenital coagulation disorders

Uncommon individually

As a class are present more frequently than commonly thought

Examples:VonWillebrand’s disease

Specific factor deficiencies (factors II, VII, VIII, IX, X, and XI)

80% OF CASES OF POSTPARTUM HEMORRHAGE ARE DUE TO UTERINE

ATONY

(Did I mention that…)

Question: What causes uterine atony and is there

anything we can do to prevent uterine atony induced postpartum hemorrhage?

•Causes of Uterine Atony:

Overdistension of the uterus

Myometrial laxity as seen in:

Multiparity,

Prolonged labor,

Use of large quantities of oxytocin,

Tocolytic therapy,

General anesthesia.

Trends in postpartum hemorrhage: United States, 1994–2006

Source: American Journal of Obstetrics & Gynecology 2010; 202:353.e1-353.e6 (DOI:10.1016/j.ajog.2010.01.011 )

Copyright © 2010 Terms and Conditions

William M. Callaghan, MD, MPH, Elena V. Kuklina, MD, PhD and Cynthia J. Berg, MD, MPH

American Journal of Obstetrics & GynecologyVolume 202, Issue 4, Pages 353.e1-353.e6 (April 2010)

DOI: 10.1016/j.ajog.2010.01.011

Upper Genital Tract Trauma

Most often is the result of uterine ruptureBleeding from direct uterine injury during cesarean

Injury of associated vascular structures (uterine, artery or broad ligament varicosities) during cesarean

Lower Genital Tract Trauma

May occur spontaneously or result from episiotomy, obstetric maneuvers, or operative instrumented deliveries.

Involve perineum, cervix and vagina.

2. PREPARE:

THE STEPS TO PPH:

POSTPARTUM HEMORRHAGE:

1.- Prepare for PPH

2.- Optimize patient’s hemodynamic status

3.- Timing of Delivery

4.- Surgical planning

5.- Anesthesia /I.V. access/ invasive monitoring

6.- Modify obsterical management

7.- Increased postpartum/postop surveillance

Patients at risk

Pre-delivery management

Preparation for Postpartum Hemorrhage

“Perhaps the most important aspect in the management of PPH

is the attitude of the attendant in charge. It is

critical to maintain equanimity in what can be a chaotic and

stressful environment”.

Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441

Analysis Paralysis

An excessive number of well-meaning individuals increases the ambient noise, adds to confusion, and opens the door to communication errors.

Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441

1.- Prepare for PPH

-Nursing -Anesthesia - Surgical assistance - Others (I.R.)

Drugs/Equipment

-Methergine-Hemabate-Cytotec-Colloids-Blood/Bl.products

-Surg. Instruments-Hemostatic ballons

Personnel

Anesthesia / I.V. Access Obtain

Anesthesia consultation

•Type of anesthesia

•Need for invasive monitoring

• (A line, Swan-Ganz, etc)

• Physicians underestimate blood loss by 50%

• Slow steady bleeding can be fatal

• Most deaths from hemorrhage seen after 5h

• Abdominal or pelvic bleeding can be hidden

Postpartum Hemorrhage is Easy to miss

• Estimate blood loss accurately.

• Evaluate all bleeding, including slow bleeds.

• If mother develops hypotension, tachycardia or pain…rule out intra-abdominal blood loss.

Always look for signs of bleeding

Identify possible post partum hemorrhage.

Simultaneous evaluation and treatment.

Remember ABCs.

Use O2 4L/min.

If bleeding does not readily resolve, call for help.

Start two 16g or 18g IVs.

Initial Assessment

Initial Steps for PPHInitial Steps for PPH

Bimanual compression

Manual exploration of the uterus

Empty the bladder

Administer uterotonic agents

Examine lower genital tract for lacerations.

1. Tone (Uterine tone)

2. Tissue (Retained tissue--placenta)

3. Trauma (Lacerations and uterine rupture)

4. Thrombin (Bleeding disorders)

The 4 Ts

Uterine atony causes 80% of hemorrhage

Assess and treat with uterine massage

Use medication early

Consider prophylactic medication...

T # 1:Tone: Think of Uterine Atony

• Confirms diagnosis of uterine atony.

• Massage is often adequate for stimulating uterine involution.

Bimanual Uterine Exam

Medical Treatment of Medical Treatment of Postpartum HemorrhagePostpartum Hemorrhage

Medications that cause

uterine contractions

Medications that

promote coagulation

METHERGINE

“Speedy”

OXYTOCIN“The Champ”

CytotecInexpensive (?) Effective

Medications for Uterine AtonyMedications for Uterine Atony

OXYTOCIN• The common medication used to achieve uterine contraction

• First-line agent to prevent and treat PPH

• Given IV or IM.

• May cause hypotension.

OXYTOCIN“The Champ”

• Causes rapid tetanic uterine contraction.

• May trap placenta.

• Can cause Hypertension

• Contraindicated in hypertensive patients and those with pre-eclampsia.

METHERGINE

METHERGINE

“Speedy”

• Hemabate 0.25mg IM or IU.

• Previously known as Prostin.

• Controls hemorrhage in 86% when used alone, and 95% in combination with above.

• Can repeat up to eight times.

• Contraindicated in asthma and (?) hypertension.

• Can cause nausea/vomiting/diarrhea

Prostaglandin F2 15-methyl

1. OXYTOCIN: promotes rhythmic contractions.• Give 10 mg IM or IV, not IU.

2. METHERGINE: promotes rapid tetanic contractions • 0.2mg (1 amp) IM

3. HEMABATE: promotes long lasting contractions• 0.25 mg IM q 15min (max X8).

4. CYTOTEC: less effective than methergine• 400 to 1000 g (oral, vaginal or rectal)

Summary of Medications Summary of Medications for Uterine Atonyfor Uterine Atony

Fluid Management of Postpartum Hemorrhage

-Balanced *(0.9% NaCl, lactated Ringers-Hypertonic (3.5,5, 7.5% NaCl)

-Hypotonic (0.45% NaCl)

* Same electrolyte concentration as the extracellular compartnt

-Albumin (5%, 25%)

-Dextran, glucose polymers (40, 70)-Hydroxyethyl starch (Hespan)

Crystalloid

Colloid

Blood/Blood Products

Fluid Management of Postpartum Hemorrhage

Acute Postpartum Blood Loss

PROBLEMS:Loss of circulatory Volume

Loss of O2 carrying capacity

Restore volume

1 - Crystalloid

2 - Colloid

SaO2 O2 carrying capacity

Supplemental O2Transfusion

61

25-30%(15-1800cc) Healthy ? Crystalloid/Colloid

Medical complications ? Consider transfusion

30-50%(18-3000cc) Crystalloid/ColloidConsider transfusion

> 50% ( > 3000cc) Crystalloid/ColloidBlood transfusionClotting factors (FFP, Cryo)

Blood Loss

Hemorrhagic Shock- Fluid Management -

Class Blood Loss Volume Deficit Spx Rx

I < 1000 cc 15% Orthostatic tachycardia Crystalloid

II 1001-1500 15-25%

Incr. HR, orthostasis, mental

Decr cap refill

Crystalloid,

III 1501-2500 25-40%Incr HR, RR Decr BP,

Oliguria

Crystalloid

Colloid, RBCs

IV > 2500> 40%

Obtunded

Oliguria/anuria

CV collapse

RBC, Crystalloid, Colloid

Managing blood loss by hemorrhage classification

Ways to Optimize

hemodynamic status

1.Acute isovolemic hemodilution

2.Acute hypervolemic hemodilution

3.Autologous donation

4.Preoperative transfusion

64

Acute isovolemic hemodilution

Withdraw 2-4 u. of Blood Replace the volume with crystalloid Lower the pre-op Hct Replace the blood at end of surgery

Acute hypervolemic hemodilution

Admin 1500-2000cc Crystalloid Hemodilution (Lowers pre-op Hct)

Ways to optimize hemodynamic status

• Delay of placental delivery > 30 minutes seen in ~ 6% of deliveries.

• Prior retained placenta increases risk.

• Risk increased with: prior C/S, curettage p-pregnancy, uterine infection, AMA or increased parity.

• Prior C/S scar & previa increases risk (25%)

• Most patients have no risk factors.

• Occasionally succenturiate lobe left behind.

T # 2: TISSUE

Oxytocin 10U in 20cc of NS placed in clamped umbilical vein.

If this fails, get OB assistance.

Check Hct, type & cross 2-4 u.

Two large bore IVs.

Anesthesia and OR support.

Removal of Abnormal Placenta

• Relax uterus with halothane general anesthetic and subcutaneous terbutaline.

• Bleeding will increase dramatically.

• With fingertips, identify cleavage plane between placenta and uterus.

• Keep placenta intact.

• Remove all of the placenta.

Removal of Abnormal Placenta

• If successful, reverse uterine atony with oxytocin, Methergine, Hemabate.

• Consider surgical set-up prior to separation.

• If manual removal not successful, large blunt curettage or suction catheter, with high risk of perforation.

• Consider prophylactic antibiotics.

Removal of Abnormal Placenta

Episiotomy

Hematoma

Uterine inversion

Uterine rupture

T # 3: Trauma

Rare: ~1/2000 deliveries.

Causes include:

Excessive traction on cord.

Fundal pressure.

Uterine atony.

Uterine Inversion

• Blue-gray mass protruding from vagina.

• Copious bleeding.

• Hypotension worsened by vaso-vagal reaction. Consider atropine 0.5mg IV if bradycardia is severe.

• High morbidity and some mortality seen: get help and act rapidly.

Uterine Inversion

• Push center of uterus with three fingers into abdominal cavity.

• Need to replace the uterus before cervical contraction ring develops.

• Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage.

• When completed, treat uterine atony.

Uterine Inversion

• Rare: 0.04% of deliveries.

• Risk factors include:

• Prior C/S: up to 1.7% of these deliveries.

• Prior uterine surgery.

• Hyperstimulation with oxytocin.

• Trauma.

• Parity > 4.

Uterine Rupture

• Risk factors include:

• Epidural.

• Placental abruption.

• Forceps delivery (especially mid forceps).

• Breech version or extraction.

Uterine Rupture

Sometimes found incidentally.

During routine exam of uterus.

Small dehiscence, less than 2cm.

Not bleeding.

Not painful.

Can be followed expectantly.

Uterine Rupture

Vaginal bleeding.

Abdominal tenderness.

Maternal tachycardia.

Abnormal fetal heart rate tracing.

Cessation of uterine contractions.

Uterine Rupture before delivery

May be found on routine exam.

Hypotension more than expected with apparent blood loss.

Increased abdominal girth.

Uterine Rupture after delivery

Risk factors include:

Instrumented deliveries.

Primiparity.

Pre-eclampsia.

Multiple gestation.

Vulvovaginal varicosities.

Prolonged second stage.

Clotting abnormalities.

Birth Trauma

Repair of cervical laceration

• Hematomas less than 3cm in diameter can be observed expectantly.

• If larger, incision and evacuation of clot is necessary.

• Irrigate and ligate bleeding vessels.

• With diffuse oozing, perform layered closure to eliminate dead space.

• Consider prophylactic antibiotics.

Birth Trauma: Hematomas

Pelvic Hematoma

The 4 “Ts” Recalled

“THROMBIN” Check labs if suspicious.