Postpartum hemorrhage power point presentation

EPIDEMIOLOGY
• PPH is the most common cause of maternal death, accounting for
about 35% of all maternal deaths world wide
• The incidence of PPH is 2-4% after vaginal delivery and 6 % after a
cesarean section
• MMR of india has declined over the years to 103 per 100,000 in 2017-
19 from 113 per 100,000 in 2016-18

• Most deaths due to severe PPH occur during the first 24 hours after
birth.
The transition of hemorrhage from the compensated to
decompensated stage is rapid and easily overlooked. Hence prediction,
early recognition, and intervention are crucial for lowering the risk of
severe PPH or improving its clinical outcomes.

DEFINITION
• According to the WHO, PPH is defined as a blood loss of more than
500 ml from the genital tract after vaginal delivery.
• The most recent WHO definitions of PPH (2012), for vaginal births,
PPH is defined as blood loss >500ml, and severe PPH is defined as loss
of >1000ml. In cases of caesarean birth, PPH is defined as blood loss
more than 1000ml

• According to ACOG, the definition of PPH is cumulative blood loss
more than or equal to 1000ml that is associated with signs or
symptoms reflecting hypovolemia within the first 24 hours of the
birthing process.

RISK ASESSMENT TOOL
• Pre natal risk assessment is crucial
• Early identification and management preparation for patient enable
better outcomes.
• Patients with 2 or more risk factors should be considered as high risk.

Risk category
Low risk
No previous uterine incision • Singleton pregnancy • No medical disorder
• No known bleeding disorder • No history of PPH • Optimal hemoglobin
MEDIUM RISK
Induction of labor (with oxytocin) or Cervical ripening • Multiple
gestations • >4 previous vaginal birth • Prior cesarean birth or prior
uterine incision • Large uterine fibroids • History of one previous PPH •
Family history in first-degree relatives who experienced PPH (known or
unknown etiology with possible coagulopathy) • Chorioamnionitis • Fetal
demise • Polyhydramnios

HIGH RISK
• Has two or more medium-risk actors • Active bleeding more than a
“bloody show” • Suspected placenta accrete or percreta • Placenta
previa, low-lying placenta • Known coagulopathy • History of more
than one previous PPH • Hematocrit <30 and other risk factors
platelet <100,000/mm3

PATHOPHISIOLOGY
Physiology of uterine contractions
• Parturition involves two main steps
• A long conditioning phase
• A short secondary phase (active labor)
The “Conditioning” step leads to softening of the cervix. In the
myometrium, the preparatory process involves changes in transduction
mechanisms and synthesis of several proteins including connexins, ion
channels, and receptors for uterotonics. The downregulation of nitric
oxide leads to the withdrawal of uterine relaxation.

Uterine atony
• Primary PPH due to uterine atony occurs when the relaxed
myometrium fails to constrict the blood vessels, causing hemorrhage.
As up to one-fifth of maternal cardiac output (1000 ml/min) entersthe
uteroplacental circulation at term, PPH can lead to a severe loss of
blood within a short time.
• Uterine atony is responsible for 75%–90% of primary PPH

The lower segment as an implantation site
• In placenta previa, the placental site is located in an abnormally low
position. In lower segment implantation, the muscle around the
placental bed is inadequate for the task of postpartum
contraction/retraction, and thus hemorrhage is initiated

The 4 T’s: Tone, Tissue, trauma, thrombin
• Tone/abnormality of uterine contraction
Uterine atony is the most common cause of PPH (80%).
Patients with an overly distended uterus (twins, macrosomia, or hydramnios) is also at
risk.
Other causes include intraamniotic infection and functional/ anatomic distortion of
the uterus
• Tissue (retained product of conception)
Retained placenta (failure of the placenta to deliver within 30 minutes of birth) occurs
in 3%–5% of the cases.
Retained products of conception or invasive attachments of the placenta to the
uterine wall (accreta, percreta, or increta) can cause massive PPH.
PPH has also been linked to blood clots and cotyledons.

Trauma [at genital tract]
About 10%–15% women experience trauma, including cervix, vagina,
perineal laceration, and hematomas resulting from birth, can cause
significant blood loss.
A careful inspection of these areas should be performed, and repair of
trauma should be done.
Uterine rupture and uterine inversion have also been associated with PPH.
Thrombin [abnormality of coagulation]
Coagulation disorders are a rare cause of PPH, reported in 1% to 2% of the
cases.

CLINICAL FEATURES
• A quick history and general physical examination along with an
abdominal examination, speculum and vaginal examination, and
examination of the placenta will help to identify the probable cause.
Findings in case of PPH Probable diagnosis
Relaxed flabby uterus Atonic PPH
Contracted uterus with bleeding Traumatic PPH
Undelivered placenta/ partial expulsion
of placental tissue/ Incomplete placenta
Partial or total retained placenta
Non-palpable fundus of the uterus Inversion of uterus
Contracted uterus along with absence of
trauma or retained placental tissues,
failure of medical treatment
Disseminated intravascular coagulation
(DIC)

ASSESSMENT AND DIAGNOSIS
• An accurate assessment of blood loss continues to be challenging in
the care.
• Clinicians are prone to either underestimate or overestimate maternal
blood loss.
• Underestimation can be particularly problematic as it delays the
diagnosis of PPH, increasing maternal morbidity and mortality.
• Initial evaluation of the patient should include a rapid assessment of
the patient’s status and risk factors.

• For patient safety, a continuous assessment of vital signs and
estimation of total blood loss is an important factor.
• Patient examination at the time of hemorrhage can help to identify
the probable cause of bleeding.

Modified shock index
The modified shock index is a bedside assessment defined as Heart
rate (HR) to mean blood pressure (MAP) , with a normal range of 0.5 to
0.7 in healthy adults
MAP = DP + 1/3(SP – DP) or MAP = DP + 1/3(PP)

INVESTIGATIONS AND THEIR INTERPRETATION
Investigation for the diagnosis of PPH
• Hemoglobin and HCT
–fall in HB and hematocrit (may not be initially low)
• Bed side tests:
Bleeding time, clotting time, clot observation test

• Coagulation profile may be deranged in hemorrhage
» Bleeding time (BT) increased
» Clotting Time (CT) increased
» Platelet count (PC) decreased
» Prothrombin time (PT) increased
» International normalized ratio (INR) increased in coagulopathy
» Serum fibrinogen decreased or normal
» D-Dimers increased
• Serum electrolytes may or may not be altered

• Renal parameters: Blood urea, serum creatinine elevated in renal
failure, and hemolysis
• Serum Lactate: Elevated in sepsis
• Serum calcium, magnesium and potassium: Can be low in
hemorrhage
• Ultrasound: Retained placenta, adherent placenta, inversion, rupture
• Thromboelastogram (TEG): Wherever available and feasible
• Arterial blood gas analysis and its interpretation
• Frequency of investigations: As per the clinical situation

Prevention of PPH: Active Management of the
Third Stage of Labor (AMTSL)
• Routine active management is superior to expectant management in
terms of blood loss, postpartum hemorrhage, and other serious
complications of the third stage of labor. Active management should
be the routine management of choice for women expecting to deliver
a baby in a maternity hospital.
• All the three steps AMTSL should only be done by SBA/trained staff.
i. Administration of uterotonics after delivery of baby
ii. Delayed cord clamping
iii. Controlled cord traction

• Oxytocin IV injection has been the the uterotonic of choice for AMTSL
over the years. Oxytocin (10 IU, IM) is the preferred uterotonic based
on studies on the safety and effectiveness of uterotonics.
• If oxytocin is not available, room temperature stable carbetocin (100
mcg IM/IV), or methylergometrine (0.2 mg IV/IM), or misoprostol
(800 to 1,000 mcg rectally or 600 to 800 mcg sublingually or orally)
can be the first-line choices.
• Caution should be exercised when opting for ergot derivatives
(methylergometrine) for the prevention of PPH as these drugs have
clear contraindications in women with hypertensive disorders. Thus, it
is probably safer to avoid the use of ergot derivatives in unscreened
populations.

• If a skilled attendant is not present, and oxytocin is not available (such as
at an unattended home birth), administer 600 mcg of oral misoprostol.
Women delivering without a skilled attendant also need uterotonic for
PPH prevention, so oral misoprostol should be given by a community
health worker who is present.
• Delayed cord clamping (performed after 1 to 3 minutes after birth) is still
recommended for all births to reduce newborn anemia while beginning
essential newborn care at the same time.
• The uterus is palpated abdominally, and when it is contracted (this
happens in 1 to 3 minutes of administration of uterotonics), controlled
cord traction is done to deliver the placenta.

• Control Cord Traction (CCT) is not recommended in situations where
SBA is not available.
• Suture any perineal or labial tears/ episiotomy quickly.
• Continue to palpate the uterus frequently to see that it stays
contracted.

ZERO HOUR CHECKLIST IN PPH
MANAGEMENT
• Once a woman has been assessed to have PPH, call the Emergency
Response Team (ERT) for help.
• Initial resuscitation with ABCDE (Airway, Breathing, Circulation, Disability,
Exposure) approach is to be done.
• IV access with two wide bore cannula #14/16
• Blood sample for investigations to be collected and adequate blood and
blood products to be arranged.
• Catheterization is mandatory.
• The vitals- Shock Index must be recorded.
• Quick history and rapid initial assessment

RESUCITATIVE MEASURES
Fluid replacement
• Aim should be to replace 2-3 times the estimated blood loss.
• Crystalloids (NS or RL) are rapidly infused at the rate of 1L in 15-20
min.
• Crystalloid is preferred over colloids for the initial resuscitation.
• A central venous pressure (CVP) can be introduced, after the initial
resuscitation, CVP should rise between 10-12 mmHg

BLOOD COMPONENT THERAPY
• Crossmatched blood should be given as rapidly as possible.
• Each packed red cell will restore hb concentration by 1 gm/dl.
• This should be accompanied by FFP and platelet concentrate. Ratio
should be 1:1:1
• Each FFP will restore procoagulant activity by 10%and raise fibrinogen
level by 25mg/dl. Fibrinogen level should be maintained at 200mg/dL

• Platelet concentrats also shiuld be given as part of MTP and also if plt
concentrate is below 75,000/L. Each adult dose of platelet
concentrate will raise the platelet count by 20,000/L. Platelets should
also be group compatible.
• Cryprecipitate contains factor viii, fibrinogen and Von willibrand factor
and is indicated if fibrinogen level is <100mg/dL. Each unit of CP will
raise fibrinogen level by 100mg/dL.

Oxygen delivery
• Oxygen by mask or nasal cannula @ 10-15L/min
Other measures
• Minimise the risk of aspiration
• Keep patient warm, as hypothermia exacerbate poor peripheral
perfusion.

CARBETOCIN: An update
• Carbetocin is the carba analog that has prolonged activity and a long
half-life due to deamination, which protects carbetocin from
aminopeptidase cleavage, and its lipophilicity.
• Carbetocin is a newer long-acting synthetic analogue of oxytocin with
agonist properties.
• Carbetocin is available as room temperature formulation in India.

Pharmacokinetics
• After IV administration, the tetanic contraction have a mean time (±
SD) of 1.2 ± 0.5 min and last for 6.9 ± 2.1 min, followed by rhythmic
contraction for 60 ± 18 min.
• After IM administration, the onset is 1.9 ± 0.6 min, with tetanic
contractions lasting for 11.3 ± 3 min, followed by rhythmic
contractions for 119 ± 69 min.

Clinical efficacy
• Elbohoty et al compared carbetocin with oxytocin versus misoprostol
in women with cesarean delivery. In the study, the need for further
uterotonics was 5, 11 and 20 in women receiving carbetocin, oxytocin
10 IU/mL injection, and misoprostol respectively
• The prevention of uterine atony: carbetocin is comparable with
oxytocin [RR = 0.41 (95% CI, 0.14 to 1.25)] and superior to
misoprostol [RR = 0.21 (95% CI, 0.07 to 0.58)].

• In December 2018, WHO updated the its recommendations on
uterotonics for the prevention of PPH and recommended the use of
room temperature stable carbetocin (100 mg, IM/IV) for the
prevention of PPH for all births in contexts where its cost is
comparable to that of other effective uterotonics. This
recommendation was based on the evidence extracted from the
updated Cochrane NMA of the seven uterotonic options

Role of Tranexamic acid in management of
PPH
• Tranexamic acid is an antifibrinolytic agent that blocks lysine-binding
sites on plasminogen molecules. It reduces bleeding-related mortality
in women with PPH especially when administered soon after delivery.
• The WHO recommends that women with PPH receive an IV of 1 g
tranexamic acid soon after giving birth, followed by a second dose if
bleeding continues after 30 min or restarts within 24 h after the first
dose.
• Urgent treatment is critical, and tranexamic acid is most effective
when given early; evidence suggests there is no benefit when the drug
is given more than 3 hours after bleeding onset.

Special Circumstances
• It is recommended that awareness and individualization of
management be used in special situations such as multifetal
pregnancy, VBAC, and other high-risk pregnancies
• In cases of multifetal pregnancy, all fetuses must be delivered prior to
the administration of oxytocic drugs to avoid intrauterine asphyxia.
• Methylergometrine should not be given to women with hypertension,
cardiac disease, severe anemia, and Rh-negative mothers.
• Injectable prostaglandins can be used in special situations where
women at are at high risk of PPH. However, it should not be given to
women with bronchial asthma and heart disease.

• Misoprostol is a synthetic analogue of prostaglandin E1 (PGE1) and is
safe for women with bronchial asthma and heart disease.
• In obese, nulliparous women undergoing emergency cesarean
delivery, a single 100 mcg IV carbetocin infusion is more effective than
IV oxytocin infusion for maintaining adequate uterine tone and
preventing postpartum bleeding.
• Carbetocin is as effective as oxytocin in the prevention of PPH in
women with severe preeclampsia but without any association with the
development of oliguria or hypertension.

Management for Delayed PPH
• Hemorrhage between 24 hours and 6 weeks postpartum is termed “delayed
PPH.”
• Common causes include retention of placental tissue and/or membranes and
infection leading to endometritis, endomyometritis, and parametritis.
• Bleeding can be sudden and profound, resulting in rapid cardiovascular collapse.
• Septic shock may also be present due to infection.
• The investigations in these cases are similar to atonic PPH; however, some
additional investigations of septic foci to isolate organisms for culture and
antibiotic sensitivity are mandatory.
• These cases may have early features of DIC, so a blood coagulation profile should
be done earlier

The main stay of management include:
• Resuscitation and fluid therapy.
• Broad spectrum intravenous antibiotic therapy (to cover gram positive, gram
negative, and anaerobes) according to the hospital antibiotic policy. It can be
changed according to the culture report and antibiotic sensitivity pattern.
• Evacuation of the uterus/surgical management for any septic foci.
Individualized surgical procedure may be adopted depending on the case.
• Uterotonics and tranexamic acid may be needed.
• Blood and blood products may be given depending on the haemoglobin and
coagulation profile.

Mechanical and surgical methods of
management of refractory PPH
• Bi-manual compression
• Uterine balloon tamponade
• Uterine artery ligation
• Arterial embolisation
• Aortic compression
• Uterine compression sutures

Bi-manual compression
• The posterior uterine wall is massaged by one hand on the abdomen,
while the other hand is made into a fist and placed in the vagina.This
fist kneads the anterior uterine wall through the anterior vaginal wal,
and the uterus is compressed between the two hands.

Aortic compression
• Can be used as an alternative to bimanual compression or if it fails
• Aorta is compressed against the lumbosacral vertebra by a closed fist

Condom/Uterine balloon tamponade
• The tip of a 24F to 30F Foley catheter with a 30-mL balloon is guided into
the uterine cavity and filled with 60 to 80 mL of saline.
• The open tip permits continuous drainage of blood from the uterus.
• If bleeding subsides, the catheter is typically removed after 12 to 24 hours.
• Similar devices for tamponade include Segstaken-Blakemore, Rusch, and
ebb balloons and condom catheters.
• Antibiotic prophylaxis using cefazolin 1 gm Q8H until removal, has recently
been suggested to reduce risk of postpartum endometritis (Martingano
2020)

• A Bakri Postpartum Balloon or BT-Cath may be inserted and inflated to
tamponade the endometrial cavity and stop bleeding.
• Insertion requires two or three team members. The first performs
abdominal sonography during the procedure. The second places the
deflated balloon into the uterus and stabilizes it. The third member
instills fluid to inflate the balloon, rapidly infusing at least 150 mL
followed by further instillation over a few minutes
of 300-500ml to arrest hemorrage.
• It is reasonable to remove the balloon after 12hrs.

Non-pneumatic anti shock garment (NASG)
• The NASG is a unique, low-technology, life-saving first-aid device made of
neoprene and Velcro, that is used on women with obstetric hemorrhage
• It can be applied by anyone, even those with very little medical training.
• The NASG has a unique role in hemorrhage and shock management
because it is meant to be used with, not instead of, other technologies.
• Currently, it is the only tool that aids in stabilizing pulse and
bp after a woman has gone into shock from a obstetric
hemorrhage.

Uterine packing
• This had been advocated especially before transporting to a tertiary
centre.
• Not recommended today

Surgical management and radiological methods,
along with blood and blood product transfusions
• The surgery for controlling PPH should be used immediately after the
failure of drug therapy, preferably within the “golden hour”. In the
surgical treatment of PPH, vascular ligation, and uterine compression
sutures must precede hysterectomy.
• The main technique of vascular ligation is bilateral uterine artery
occlusion, although progressive devascularization techniques may
optimize the surgical approach.

UTERINE COMPRESSION SUTURES
B-Lynch or Brace suture
• This surgical technique uses a no. 2 chromic suture to compress the
anterior and posterior uterine walls together (B-Lynch, 1997).
Because they give the appearance of suspenders, they are also called
braces.
• Rare complications include uterine ischemic
necrosis with peritonitis, uterine wall defects
or uterine cavity synechiae.

Hayman suture
• Two vertical compression sutures placed on either side of the fundus
• Quicker than B lynch
• Does not require a low transverse incision,
hence useful following vaginal delivery.

Pereira technique
• Several transverse and vertical sutures are placed without entering
the cavity.

Cho’s multiple block sutures
• Involves approximation of anterior and posterior walls with mulyiple
squares until no space is left in the uterine cavity.

Stepwise pelvic devascularisation
1.Uterine Artery Ligation
• The technique for unilateral or bilateral uterine artery ligation is used
primarily for lacerations at the lateral part of a hysterotomy incision.
• This procedure is less helpful for hemorrhage from uterine atony.
• The suture goes through the lateral uterine wall anteriorly, curves
around posteriorly, then re-enters anteriorly. When tied, it
encompasses the uterine artery.
• In 75% cases, bleeding will be stopped by bilateral uterine artery
ligation.

2.Utero ovarian and ovarian vessel ligation
3.Bilateral looped uterine vessel suture(B-LUVS)
Absorbable sutures are looped bilaterally through the myometrium
around the uterine vessels from lower segment right up to cornual
region.

Internal iliac artery ligation
• Ligation of the anterior branch of internal iliac artery is usually done
• This reduces the pulse pressure by 85% and thus reduces bleeding.
• Retroperitoneal space is entered and artery is identified-ligated about
3cm from the division of common iliac artery to ensure that the
posterior division is not included in the ligature.
• Either catgut or vicryl is used.
• If this is difficult, artery as a whole is ligated, but care should be taken
to avoid accidental tie of external iliac artey.

Angiographic embolization
• This modality is now used for many causes of intractable hemorrhage
in places with good interventional radiology dept and patient is
hemodynamically stable.
• Usually, uterine artery or internal iliac artery embolization is done.
• The arteries are catheterized and embolized with polyvinyl alcohol
particles 150-300 micron in size.
• The blood flow of vessels will be arrested, giving similar effect of the
ligation of vessels . The polyvinyl alcohol particles are usually
reabsorbed in 10 days, and recanulation of the vessels is possible.

• Advantages include: high success rate, fertility is preserved, and very
useful when surgery is difficult.
• The side effects of uterine artery embolization are endometritis,
uterine synechiae, and uterine wall necrosis.

Aortic compression
• Prophylactic use of an aortic balloon occlusion device has been
reported to reduce blood loss and the need for hysterectomy.
• Also known as resuscitative endovascular balloon occlusion of aorta
(REBOA).
• This occlusion lowers perfusion pressure distally, increases cardiac
afterload and redistributes blood volume to the heart and brain.

Hysterectomy
• Considered as the final resort
• If life threatening bleeding continues, total/subtotal hysterectomy
should be performed(WHO recommendations)

UPDATES AND RECENT ADVANCES IN PPH
MANAGEMENT
E-MOTIVE TRIAL
• The E-MOTIVE trial is the Early detection of Postpartum
Haemorrhage and treatment using the WHO MOTIVE 'first
response' bundle: a cluster randomised trial with health
economic analysis and mixed methods evaluation

CHAMPION (Carbetocin hemorrhage prevention) trial
• An international, randomized, double blind, active controlled, non
inferiority trial compared carbetocin with oxytoxin
• Heat-stable carbetocin was noninferior to oxytocin for the prevention
of blood loss of at least 500 mL or the use of additional uterotonic
agents. Noninferiority was not shown for the outcome of a blood loss
of at least 1000 mL; low event rates for this outcome reduced the
power of the trial.

TRAAP 1
• TRAAP 1, a multicenter, double-blind, randomized, controlled trial,
• Among women with vaginal deliveries who received prophylactic
oxytocin, the use of tranexamic acid reduced the rate of PPH of at
least 500 ml that was significantly low compared to PPH rates with
placebo

TRAAP 2
• Among women who underwent cesarean delivery and received
prophylactic uterotonic agents, tranexamic acid treatment resulted in
a significantly lower incidence of calculated estimated blood loss
greater than 1000 mL or red-cell transfusion by day 2 than placebo

PANIKER’S SUCTION CANNULA
• Any vacuum suction cannula system for atonic PPH works on the
principle that, after insertion of the cannula into the uterine cavity,
when negative pressure is applied, soft cervical tissues get sucked into
the small holes of the cervical portion of the cannula and become
adherent. This results in formation of closed uterine cavity, thus
assists in natural physiological process of contraction and retraction

• Beginning below the incision, the needle pierces the lower uterine
segment to enter the uterine cavity. Step 2. The needle exits the
cavity above the incision. The suture then loops up and around the
fundus to the posterior uterine surface. Step 3. The needle pierces
the posterior uterine wall to reenter the uterine cavity. The suture
then traverses to the opposite side within the cavity. Step 4. The
needle exits the uterine cavity through the posterior uterine wall.
From the back of the uterus, the suture loops up and around the
fundus to the front of the uterus. Step 5. The needle pierces the
myometrium above the incision to reenter the uterine cavity. Step 6.
The needle exits below the incision

Postpartum hemorrhage power point presentation

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