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Primary postpartum haemorrage
- 1. Presentation on Primary Postpartum Hemorrhage by Dr.Ahmed H. Yakubu (H.O.) DEPARTMENT OF O & G FEDERAL MEDICAL CENTRE, KATSINA presented on 6TH January, 2018 supervised by Dr. Kundil
- 2. Outline • Introduction • Definition •Classification • Epidemiology • Etiology/Risk factors • Pathophysiology • Prevention • Management • Conclusion • References
- 3. Introduction • Primary PPHis a frequently encountered obstetric emergency. • Systemic reviews suggest that the burden of the condition varies from region to region however it is agreed among respected colleges that its attendant mortality and morbidity is significant both in developed and developing countries. • WHO statistics suggest that 25% of maternal deaths in developing countries are due to PPH. • Unpredictable and relatively common, it is pertinent at the very least identify women at risk and take appropriate measures to limit the prevalence of the emergency.
- 4. Definition of PrimaryPostpartum hemorrhage 1. Blood loss in excess of 500mls following vaginal delivery or In excess of 1000mls following caesarean section or in excess of 1500mls following caesarean hysterectomy… 2. Blood loss that is significant enough to cause hemodynamic instability… 3. Decline in hematocrit value by up to 10% or more from the premorbid value… *Any of the above occurring after the age of viability (28weeks) and within the first 24hours after delivery.
- 5. Classification Minor: Estimated blood lossis 500mls – 1000mls Major: Estimated blood loss is in excess of 1000mls or clinical shock or presence of ongoing or continuous hemorrhage. • Moderate: 1000 – 2000mls • Severe: >2000mls
- 6. Epidemiology A systematic reviewand meta-analysis by Clara Calvert et al in 2012 reported the highest rates of PPH in Africa (27.5%), and the lowest in Oceania (7.2%), with an overall rate globally of 10.8%. Both Europe and North America was around 13%. High rates: • Multiple pregnancies (32.4% compared with 10.6% for singletons) • The overall rate of major PPH (>1000mls) was much lower at an overall rate of 2.8%, again with highest rate in Africa (5.1%).
- 7. Etiology/Risk factors (The4T’s) 1. Tone (Uterine atony): a. Over distension: i. Multifetal Gestation ii. Grandmultiparity iii. Fetal Macrosomia iv. Fetal Abnormalities v. Polyhydramnios vi. Retained Placenta vii. Retained blood clots viii. Uterine Structural Abnormalities
- 8. Etiology/Risk factors (The5 T’s) 1. Tone (Uterine atony): b. Poor myometrial activity: i. Prolong labour ii. Precipitous labour iii. Placenta implantation in lower uterine segment iv. Drugs v. chorioamnionitis vi. Hypoxia vii. Hypothermia viii. Uterine anomalies ix. Uterine inversion
- 9. Etiology/Risk factors (The5 T’s) 2. Tissue: a. Retained placenta b. Retained blood clots 3. Trauma: Spontaneous or Iatrogenic: a. Uterine Rupture b. Cervical, vaginal or perineal lacerations
- 10. Etiology/Risk factors (The5 T’s) 4. Thrombi (Coagulopathy): a. Consumptive coagulopathy DIC Dilutional coagulopathy Thrombocytopenia: ITP, TTP b. Pharmacological inhibition Warfarin Heparin Dextran infusion c. Hereditary coagulation Disorders Familial Hypofibroginaemia Von Wille Brand disease
- 11. Risk assessment: Low riskModerate risk High risk Singleton pregnancy Prior C/S or uterine surgery Previa, accreta, percreta, increta < 4 previous deliveries > 4 previous deliveries PCV <30% Unscarred uterus Multiple gestation Bleeding at presentation No previous Hx Large uterine fibroids Known Coagulation defects Chorioamnionitis Positive Previous Hx MgSo4 use Abnormal vital signs Prolonged us of oxytocin
- 12. Pathophysiology Physiological changes duringpregnancy: Hematological: • Progressive decline in Platelet count, (5 – 10%) 100 – 150 x 109 cells/l Cardiovascular: • Blood flow to the uterus at term is 500 – 800mls/min (10 – 15% of cardiac output)
- 13. Pathophysiology Physiological changes afterdelivery of placenta: • Uterine contraction and retraction • Activation of coagulation system (Factor) Pathology: • Uterine atony (80%) • Trauma • Retained tissue • Coagulopathy (DIC) “Living Ligatures”
- 14. Estimation of bloodloss: • Visual inspection • Clinical signs • Hematocrit • Gravimetric method • Maximum swab (gauze) capacity: small (10 x 10cm) – 60mls, medium (30 x 30cm) – 140mls, Large (45 x 45cm): 350ml • Photometric method
- 15. Clinical features correlationwith estimated blood loss: Symptoms/Signs Systolic Blood pressure Estimated blood loss Degree of shock Palpitations, tachycardia, dizziness. Normal 500 – 1000mls 10 – 15% Compensated Tachycardia, sweating, weakness. 80 – 100mmhg 1 – 1.5L 15 – 25% Mild Restlessness, Oliguria, pallor. 70 – 80mmhg 1.5 – 2L 25 – 35% Moderate Collapse, Anuria, Air hunger. <70mmhg >2L >35 % Severe
- 16. Prevention: a. Pre-pregnancy: HealthEducation (men & women) Primary Health care Services Women Empowerment b. Pregnancy: Antenatal care: Clinical Evaluation Investigations
- 17. Labour: a. Review patientsobstetric history b. Examine c. Establish a diagnosis d. Intravenous cannula e. Investigations: Urgent Full Blood Count (Hematocrit) GXM 2pints Urinalysis f. Use of Partograph (Active Phase) g. Episiotomy???, There must be a clear indication based on the experienced judgment
- 18. ACTIVE MANAGEMENT OFTHIRD STAGE OF LABOUR: Paramount in preventing primary PPH, it involve: a. Administration of uterotonics, oxytocin, after delivery of the fetus and exclusion of a 2nd twin. b. Cord clamping & cutting after 1 – 3min after delivery of fetus c. Delivery of the placenta by control cord traction after resumption of uterine contraction (signs of separation) d. Inspect placenta for completeness e. Rub-up contraction and monitor uterine state every 15minutes for first 2hours. f. Prophylactic measures for high risk patients should be ensured. Monitor patient up to 24hours before discharge.
- 19. Management: • CALL FORHELP (4 ASSISTANTS) • Resuscitation: Airway Breathing Circulation: 2 wide-bore IV cannula in-situ, investigation samples, normal saline. Anti-shock garment • Request for 2 – 4 pints of Fresh Whole blood • Notify the theater to be on stand-bye and blood bank of the possibility of the need for more blood within a short time. • Document critical intervention/information and time, i.e. note vital signs momentarily, drugs, fluids given and volume, SPo2 and chest auscultation.
- 20. Management: 3. Tertiary levelcontinue: Examination: • Uterine palpation for atony, rupture or inversion • Inspect placenta for completeness • Inspect Genital tract for laceration • Inspect for signs of coagulopathy • Review of results
- 21. Treatment of underlyingcauses: UTERINE ATONY: • Mix 40IU Oxytocin + 1L Normal saline to over 4hours + empty urinary bladder. • Other uterotonic agents may be used: Misoprostol (800ug – 1000ug), Ergometrine or Carboprost • Bimanual compression • Uterine tamponade: SOS Bakri tamponade, Ebb uterine tamponade system, Condom or Surgical gloves
- 22. Improvised condom Tamponade BakriUterine Tamponade Baloon
- 23. UTERINE ATONY: Laparotomy, ongoinghemorrhage 2o unresponsive-atonic uterus Ancillary measures: • Bimanual compression • NASG • Uterine tamponade • External aortic compression Bimanual Uterine Compression
- 24. OPTIONS INCLUDE: • Uterine/Ovarianartery ligation or Selective Arterial Embolization • Uterine compression sutures B-lynch, Modified B-lynch, vertical uterine, square compression suture. • Hysterectomy OTHER TREATMENT: • Use of tranexamic acid • Use of antibiotic prophylaxis Further care in the Intensive Care Unit!
- 25. B lynch sutures Uterineartery ligation
- 26. Treatment of underlyingcauses: RETAINED TISSUE: Require performing a manual/digital exploration, Therapeutic indication: • Uterine atony despite optimal use of uterotonics • Incomplete Placenta • Retained placenta due to avulsion of cord • Retained blood clots. Diagnostic values: • Complete or partial uterine inversion • Detects uterine rupture • Genital tract lacerations • Retained tissue
- 27. Treatment of underlyingcauses: RETAINED TISSUE: Require performing a manual/digital exploration… • Done under anesthesia or adequate analgesic cover based on the clinical urgency of the situation. • Using elbow length surgical gloves* • Continue uterotonic infusion during evacuation or delivery of the placenta. • Resume bimanual massage/compression after evacuation. • Have an assistant examine the placenta for completeness if/when retrieved. • Short term broad spectrum antibiotics.
- 28. Treatment of underlyingcauses: TRAUMA: Uterine Rupture: Absence of contraction with abdominal pain/tenderness. repair of laceration or hysterectomy . Despite well contracted uterus bleeding persists “per vagina “… Consider cervical, vaginal or perineal lacerations or a combination. Repair immediately under • Adequate analgesia • Excellent lighting • Good positioning & exposure: realize the full extent & proper anatomy of the laceration before repair • Extensive lacerations (cervical lacerations inclusive) are best repaired in the theatre • Observe laceration for bleeding after repair
- 29. Treatment of underlyingcauses: COAGULOPATHY: • History (risk factors) • clinical signs (bleeding from puncture sites, mucous membranes or into the skin, spontaneous bruising) • Available Investigation results: Bedside clotting time Clotting profile (PT, aPTT, D-dimer) Platelet count (<50 x 109/L) • Transfuse with Fresh whole blood or • Transfuse with relevant blood component: FFP: requirement 5 pints of PRBC : 1 pint FFP (10-20ml/kg). Platelet concentrate: 1 pint increase count by 10 x 109/L, maintain count >50 x 109/L. Cryoprecipitate in isolated deficiencies.
- 30. Treatment of underlyingcause: HEMATOMA: An extravascular localized (progressive) collection or accumulation of blood associated with intense pain and localized tender swelling. This may be associated with significant deterioration in the hemodynamic state of the patient. It may occur in relation to laceration or in isolation. Rx: Vulva or vaginal hematoma: for large progressive hematomas + tachycardia, hypotension or anemia. I & D, secure hemostasis, and repair defect in layers Retroperitoneal hematoma requires Laparotomy
- 31. COMPLICATIONS: EARLY COMPLICATIONS: • Postpartumanaemia • Infections • ATN • Pulmonary edema • Thromboembolic events • Blood transfusion related (massive blood transfusion) • Gastrointestinal ulceration • Surgical related • Anesthesia related
- 32. LATE COMPLICATIONS: • SheehansSyndrome • Infertility • Uterine synechiae • Infections • Child neglect • Maternal depression • Rh Isoimmunization
- 33. CONCLUSION: AMTSL is paramountto preventing primary PPH. It is necessary to have a protocol for its management which should be communicated to medical staffs involved. Conducting periodic reviews and practice drills will enhance the efficiency of its management.
- 34. REFERENCES: 1. Textbook ofObstetrics and Gynecology for Medical Students, 2nd Edition, Edited by Akin Agboola, 2006 2. WHO Recommendation for the prevention and treatment of postpartum hemorrhage, 2012. 3. RCOG Guideline, Prevention and Management of Postpartum Hemorrhage , December 2016. 4. ACOG Practice Bulletin, Postpartum hemorrhage, October 2017. 5. Medscape, Postpartum Hemorrhage, updated August 03, 2017. 6. Monroe Kerrs, Operative Obstetrics, 11th Edition.
Editor's Notes
- #5 2. This correlates to other factors like body mass, premorbid or medical state 3. Majorly a retrospective diagnosis and affected by factors such as blood transfusion or amount of fluid resuscitation.
- #7 Most reviews and updates are based on primary PPH, the more frequent and severe form of PPH
- #9 Drugs: Nitrates, NSAIDS, Nifedipine, MgSO4, B-mimetics, and Halogenated anaesthetics, oxytocin (induction of labour)
- #10 Retained placenta - Succenturiate lobe (accessory placenta)
- #11 Bleeding disorder suspected in patients with history of – *menorrhagia since menarche, *familial history, *spontaneous bruising, *bleeding from craniofacial orifices or gastrointestinal tract without obvious causes, or *epistaxis >10mins. DIC from AP, Severe PE, Eclampsia, AFE, prolong IUFD. (all associated with high tissue phospholipid)
- #13 mls/Kg: Average BV Male = 75mls, Women = 65mls, Infants = 80mls, Neonates = 85mls
- #14 Sympathetic pain receptors x platelet+collagen (release of serotonin+ADP+TXA2 ) x Endothelin = vasoconstriction Vitamin k dependent coagulation components = 1972 (10, 9, 7, 2) X IX VII II DIC:
- #15 ABL= BV [Hct(i) – Hct(f)] / Hct(m) I = initial, F = final.
- #18 Partograph – maternal: PR – Q30mins, BP, T & VE – 4hrly, Urinalysis – each time urine is voided; fetal (for 1 minute after contractions): HR - 30mins. (1st stage), Q5mins. (2nd stage); Liquor: C, M, B; Uterine contraction: Q30mins; Membranes: I, R; Molding: 0, +1, +2, +3; Record all medications given.
- #19 Prophylaxis = 20IU/L over 4hr or 600ug per rectum, commence uterine massage and empty the urinary bladder. Regular assessment of vaginal bleeding, uterine contraction, fundal height, pulse rate & temperature routinely during the first 24hours starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, second blood pressure measurement should be within 6hours. Urine voiding should be documented with 6hours. *WHO recommendation on postnatal care of mother, 2013.
- #20 Investigations: Urgent PCV & clotting profile (Bedside clotting time). In extreme situations uncrossmatched blood can be used if the benefit outweigh the risks using O RhD –ve blood or ABO Rh –ve compatible blood. 1L of blood loss require 4 – 5L crystalloid infusion. (fully crossmatched blood should be made available in 30minutes).
- #21 N/B: Based on religious grounds some patients may refuse blood transfusion, this must be respected and must not be equated with a desire for no further intervention of be taken as an excuse or suboptimal care.
- #22 Ergometrine (0.2mg): CI – hypertension, cardiovascular dx, hypersensivity, retained placenta. Carboprost (0.25mg): CI – Asthma.
- #29 Surgery in uterine rupture depends on *type, *extent, *degree of hemorrhage,*general condition of mother, and patients desire for future child-bearing.
- #30 PT: Extrinsic & final common pathway; factor I, II, III, V, VII, X; 9.5 – 13.5s aPTT: Intrinsic pathway; VIII, IX, XI, and XII >70s (aPTT) and >100s (PTT) signifies spontaneous bleeding Cryo: richly in Factor I, VIII, VWF mainly
- #32 Massive blood transfusion: 10units in 24hrs or the equivalent of patients blood volume, coagulopathy, citrate toxicity (hypocalcemia), hypothermia, acid base imbalance, hyperkalaemia, dilutional thrombocytopenia Hemolytic: acute, delayed Nonhemolytic: Febrile, anaphylactic, post-transfusion purpura, urticarial, Graft vs Host reaction, TRALI; infections