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Management of postpartum haemorrhage
The document outlines the management of postpartum hemorrhage (PPH). It discusses forming a multidisciplinary team and performing general resuscitative measures like fluid replacement, blood transfusion, and monitoring vital signs. It also describes evaluating for causes of PPH and various medical, mechanical, surgical, and radiological methods to control bleeding, such as uterine massage, uterine packing, sutures, and arterial embolization. The principles of evaluating and treating secondary PPH related to infection are also covered.
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Introduction to PPH management.
Highlighting the role of a multidisciplinary team, resuscitation, general measures, medical and mechanical methods.
Instructions for the administration of medical agents like oxytocin and ergometrine to manage PPH.
Descriptions of mechanical methods like bimodal compression and uterine tamponade in PPH management.
Various surgical methods, including suturing techniques and hysterectomy as last resort options for severe PPH.
Introduction to radiological arterial embolisation techniques for identifying and treating bleeding vessels.
Steps to manage secondary PPH including cultures, antibiotics, ultrasound scans, and surgical options.
Final remarks on the management of PPH.
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Management of postpartum haemorrhage
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- 2. Multidisciplinary teamconsisting of obstetrician , anaesthetist, haemotologist, theatre staff and nursing staff is ideal. The patients general condition is evaluated and if he/she is in shock immediate resuscitative measures are instituted. A hand on uterus will confirm atonicity and enable uterine massage which should be done continuously.
- 3. PRINCIPLES OF MANAGEMENT 1.GENERAL MEASURES * Resuscitative measures * Investigations * Monitoring * Confirm the cause of PPH 2. MEDICAL METHODS 3. MECHANICAL METHODS 4. SURGICAL METHODS 5. RADIOLOGICAL ARTERIAL EMBOLISATION
- 4. GENERAL MEASURES RESUSCITATIVE MEASURES FLUIDREPLACEMENT Two intravenous infusions with large 14 gauge cannulae are started Aim is to replace 2-3 times the estimated blood lose Crystalloids (normal saline or Ringer lactate) infused at the rate of 1L in 15-20 min Colloids can be given until blood is available (1-2L) Crossmatch blood should be given as rapidly as possible A central venous pressure line can be introduced
- 5. BLOOD COMPONENTTHEORY Correctionof RBC deficit is guided by the rule that each unit of packed cells will restore Hb concentration by 1gm/dl If there is evidence of coagulation defects fresh frozen plasma, platelet concentrates, and cryoprecipitate are made available
- 6. For every6 units of red cells , 4 units of fresh frozen plasma can be given Each adult dose of cryoprecipitate will raise fibrinogen level by 100mg/dl Each adult dose of platelet concentrates will raise the platelet count by 20000/L
- 7. OTHER MEASURES Oxygencan be given by a mask or nasal cannula at rate of 10-15L/min Patients leg may be elevated in order to increase venous return If unconscious patient should be turned to one side to minimise aspiration in case of vomiting Important to keep patient warm as hypothermia will exacerbate poor peripheral circulation
- 8. INVESTIGATIONS LABORATORYTESTS Hb, haematocrit,bloodgrouping and crossmatching must be done Platelet count, fibrinogen assay, partial thromboplastin time, prothrombin time should be measured . Electrolytes, urea and creatinine needed in severe hemorrhage Bedside tests like clot observation test or clotting time can be done
- 9. MONITORING Pulse andBlood pressure Heart rate by ECG monitor Oxygen saturation by pulse oximetry Central venous pressure line- to assess adequacy of fluid replacement Hourly urine output Fluids and drugs given
- 10. CONFIRMATION OF DIAGNOSIS Genital tract injuries are looked for and if present, sutured If placenta is not yet expelled signs of seperation are looked for If there are retained placental fragments , they are removed Succenturiate lobe should not be missed Coagulopathy is checked
- 11. MEDICAL METHODS Oxytocin 20-40 unitsin 500ml of normal saline Ergometrine Ergometrine 0.25mg or methergin 0.2mg given Prostaglandin derivatives 15 methyl analogue of prostodin- 250microgram given.
- 12. MECHANICAL METHODS BIMANUAL COMPRESSION Abdominal hand massages the posterior aspect of uterus and the vaginal hand made into a fist presses the anterior uterine aspect through anterior fornix. Should be done continuously to promote uterine contraction Aortic compression against sacral promontory to reduce bleeding.
- 13. Other mechanicalmethods include uterine packing and balloon tamponade BIMANUAL COMPRESSION
- 14. SURGICAL METHODS UNDERSEWING CHO’s MULTIPLE BLOCK SUTURES B LYNCH OR BRACE SUTURE MODIFIED B LYNCH (HAYMAN) SYSTEMIC PELVIC DEVASCULARISATION- HYSTERECTOMY
- 15. UNDERSEWING Undersewing theplacental bed with figure of eight or purse string sutures Done at caesarean section for placenta praevia MULTIPLE BLOCK SUTURES Involve approximation of anterior and posterior uterine walls with multiple squares until no space is left in uterine cavity
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- 17. BRACE SUTURE Involvesuse of vertical brace sutures Very easy to perform Commonly performed at caesarean section but can also be done after vaginal delivery. MODIFIED B LYNCH(HAYMAN) Involves use of two vertical compression sutures placed on either side of fundus Quicker than brace suture. Does not require a low transverse incision . Hence it is useful following a vaginal delivery
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- 19. SYSTEMIC PELVIC DEVASCULARISATION Involve laparotomy and progressive stepwise devascularisation Uterine , ovarian and finally the internal iliac arteries are ligated Absorbable sutures should be used always The ascending branch of uterine artery or the anterior division of internal iliac artery are usually ligated.
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- 21. HYSTERECTOMY Considered asa last resort Indications include severe atonic hemorrhage, placenta accreta , placenta praevia and uterine rupture Subttotal hysterectomy may be easier and quicker but is inadequate in cases where bleeding is in the lower segment as in placenta praevia and adherent placenta Ovaries should be retained
- 22. RADIOLOGICAL ARTERIAL EMBOLISATION Thepatient shoud be hemodynamically stable Under angiographic guidance and percutaneous transcatheter technique , femoral artery catheterisation is done Bleeding vessels are identified Embolisation carried out with gel foam or microspheres
- 23. Management of secondaryPPH High vaginal swab should be taken for culture Broad spectrum antibiotics should be started If the ultrasound scan reveals retained products , uterus should be evacuated The tissues obtained should be sent for culture and histopathological studies If there is evidence of sepsis , evacuation should be delayed by 12-24 hours to reduce risk of septicemia If bleeding is severe uterine artery ligation or hysterectomy is done
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