faktor risiko HPP
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National Womenrsquos Health Clinical Guideline Recommended Best Practice
Note The electronic version of this guideline is the version currently in use Any printed version can notbe assumed to be current Please remember to read our disclaimer
POSTPARTUM HAEMORRHAGE
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Postpartum Haemorrhage Page 1 of 20
Associated Documents Primary Postpartum Haemorrhage
Defini tions amp Management Primary PPH Flowchart ndash Management
from Labour amp Bir thing Unit ndash (modif iedfrom PROMPT course)
Immediate Management from Labour ampBirthing
Assess Replace Arrest Bleeding
Ongoing Monitoring Appendix 1 Primary PPH ndash Further
Detail Including Risk Factors Appendix 2 Uter ine Vaginal
Tamponade Appendix 3 Laparotomy for Further
Surgical Measures Including BLynch Appendix 4 Recombinant Factor VIIA Appendix 5 Secondary Postpartum
Haemorrhage References
Associated Documents
Type Document Titles
Board Clinical Blood Components amp Blood Products Administration
Surgical Safety Checklist ( under development)
National WomenrsquosClinical
Group amp Screen Requirements - Inpatients
Intrapartum Care - Normal Labour amp Birth
Intra-Operative Cell Salvage (IOCS) - Obstetrics
NZBS ADHB Blood Resource httpwwwnzbloodconzdhbaucklandindexhtm
Primary Postpartum Haemorrhage Definitions Management
Term Definition
Primary Within 24 hours of delivery
Secondary After 24 hours post partum
PostpartumHaemorrhage
Blood loss gt=500ml
MajorPostpartum
Haemorrhage
Blood loss gt=1000ml andor unstable
Management
Identify PPH
Get help
Assess arrest and replace bleeding s imultaneously ndash see flowchart
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Postpartum Haemorrhage Page 2 of 20
Primary PPH Flowchart ndash Management from Labour BirthingUnit ndash (modified from PROMPT course)
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Immediate Management from Labour Birthing
Call for Help early
Call Clinical Charge Midwife and Registrar for all PPH
If gt 500ml and clinical concerns push emergency bell and dial 777 and state ldquoObstetricemergency room helliprdquo
Send for blood
1000-1500 mls Call in Obstetric Consultant notify Anaesthetist gt 2000 ml Call in 2nd Obstetric Consultant and Anaesthetist
gt 2000 ml notify Blood Bank
If pre-eclampsia or significant medical history notify Obstetric Physician
Delegate Tasks
Identify Team Leader
IV lines (2X 1416 gauge cannulae
Running total of blood loss
Vital signs and communication with woman
Fluid replacement Runner to organise theatre bloodextra help
Documentation
Communicate with family
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Postpartum Haemorrhage Page 4 of 20
Assess
Rapid Evaluation
Shock this is a late sign
Blood pressure pulse respirations peripheral perfusion colour cerebral function
Estimate blood loss and keep ongoing record
Document blood and blood products as requested and actually transfused laboratory
coagulation results Use automated BP and SpO2 monitoring every 3 minutes
DEGREE OF SHOCK (see 30)
COMPENSATION MILDSHOCK
MODERATESHOCK
SEVERESHOCK
Blood loss 500 ndash 1000ml10 ndash 15
1000 ndash 1500ml15 ndash 25
1500 ndash 2000ml25 ndash 35
2000 ndash 3000ml35 ndash 45
Blood pressurechange(systolic
pressure)
none Slight fall(90 ndash 100 mmHg)
Marked fall(70-80 mmHg)
Profound fall(50-70 mmHg)
Signs andsymptoms
palpitationsdizzinesstachycardia
weaknesssweatingtachycardia
restlessnesspalloroliguria
collapseair hungeranuria
Four Trsquos
Tone Uterine Massage
Tissue Check placenta complete
Trauma Examine perineum cervix vagina uterine scar
Thrombin Think Coagulation
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Postpartum Haemorrhage Page 5 of 20
Replace
Administer oxygen by mask 6Lmin
Keep the patient warm
Act resuscitation
Insert two 1416 gauge cannulas
Draw blood for group and Ab screen send to Blood Bank- URGENT STICKER
Draw blood for FBC amp coagulation send to Haematology- URGENT STICKER PHONE Blood Bank and Haematology to process urgently
Plasmalyte first line
Infuse one litre rapidly ASSESS response as above
Infuse 2nd or 3rd litre if indicated ndash WARMED FOR ALL ONGOING FLUIDS
Use pressure infusers where available
If further fluid required give BLOOD but can use colloid while waiting
Act give blood ( see 28)
Use a blood giving set
Blood should be used as soon as possible gt 1500ml with ongoing bleeding andor ifhaemodynamically unstable ie if systolic BP lt = 90 mmHg or significant fall from baseline
If no ongoing bleeding then Hb can be used to guide transfusion requirements
Note Group and Ab screen takes 40 minutes but then if negative Ab screen compatibleblood can be issued quickly
Phone Blood Bank request blood specify amount and timeframe advise them of activebleeding and need for ongoing support
If compatible blood is not available after a blood loss of 2000mls or haemodynamicallyunstable then uncrossmatched blood (desperate blood or emergency blood) must be given
Phone blood bank and give Drs name no of units and send sticker down the tube StateldquoWe need blood NOWrdquo
Further products eg FFP platelets cryoprecipitate will be required if massive transfusionor coagulopathy request early seek advice from senior colleague
Transfusion Medicine Specialist available for consultation 247 ( via Blood Bank)
Obstetric Physic ians on call 247
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Postpartum Haemorrhage Page 6 of 20
Arrest Bleeding
Tone
Massage the uterus firmly expel any clots
First ndashline drug therapy
Syntometrine one ampoule IM (if not already given and no history of hypertension)
Syntocinon 5 units IV
IV infusion Syntocinon (20units in 1000mls Plasmalyte at 250mlshour)If the Syntocinon infusion fails to achieve uterine contraction additional medical treatmentshould be instituted rather than increasing the dose or rate of syntocinon
Second line drugs
Misoprostol (Cytotec) 800mgs PR
Carboprost (Haemabate) IM 250mcg Q15min up to 8 doses
further Syntometrine IM ergometrine IV slowly - only one more dose(see appendix 1 for doses and maximums)
Insert Indwelling Catheter
Internal Bimanual Compression
Tissue
Retained placenta with postpartum haemorrhageUrgent transfer to theatre for manual removal
Acui ty One if gt=1000ml actively bleeding or unstable
Consider possibility of placenta accreta
Trauma
Repair the Tear
Apply pressure as initial measure
Stabilise the mother and
Repair the tearlacerations as soon as possible (theatre may be required)
Ensure that swab and instrument counts are correct in all cases
Thrombin
Check coagulation results
OampG staff to consult asap if initial results show PR gt 15 APTT gt 40 fibrinogen lt 15 platelets lt 100 Hb lt 80
See Blood Components amp Blood Products Administration Massive Transfusion Protocol fortreatment of coagulopathy
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Postpartum Haemorrhage Page 7 of 20
Ongoing Monitoring
After a significant PPH the following are recommended for ongoing monitoring
NIBP monitoring
Pulse oximetry
ECG
Strict fluid balance with hourly urine measures
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors
Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500000maternal pregnancy related deaths each year accounting for 11 of the total number (see 7) It isalso a potent cause of postnatal iron deficiency in women The case fatality is approximately 1 in
600 to 1 in 800 cases of obstetric bleeding ( CEMACH)
Definitions
Until recent times Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of gt =500 ml from the genital tract in first 24 hours post delivery (see 7) This definition however isbased on subjective observations making accurate assessment of excessive blood loss difficultRecent research indicates that clinical estimates of blood loss frequently fall below the actualamount and the incidence of PPH is being under reported by 30-50 On the basis of thesefindings more objective assessment parameters have been advocated for the diagnosis of majorPPH - viz
The patient Is haemodynamically unstable
Has a blood loss of gt1000ml from genital tract
Has a gt10 change in her haematocrit between admission and the post partum period(see 8)or
Requires a transfusion of red blood cells (see 8)
Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery hasbeen estimated at 39 (see 9) and 64 (see 11) for a caesarean delivery
Continued on next page
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Postpartum Haemorrhage Page 2 of 20
Primary PPH Flowchart ndash Management from Labour BirthingUnit ndash (modified from PROMPT course)
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Immediate Management from Labour Birthing
Call for Help early
Call Clinical Charge Midwife and Registrar for all PPH
If gt 500ml and clinical concerns push emergency bell and dial 777 and state ldquoObstetricemergency room helliprdquo
Send for blood
1000-1500 mls Call in Obstetric Consultant notify Anaesthetist gt 2000 ml Call in 2nd Obstetric Consultant and Anaesthetist
gt 2000 ml notify Blood Bank
If pre-eclampsia or significant medical history notify Obstetric Physician
Delegate Tasks
Identify Team Leader
IV lines (2X 1416 gauge cannulae
Running total of blood loss
Vital signs and communication with woman
Fluid replacement Runner to organise theatre bloodextra help
Documentation
Communicate with family
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Postpartum Haemorrhage Page 4 of 20
Assess
Rapid Evaluation
Shock this is a late sign
Blood pressure pulse respirations peripheral perfusion colour cerebral function
Estimate blood loss and keep ongoing record
Document blood and blood products as requested and actually transfused laboratory
coagulation results Use automated BP and SpO2 monitoring every 3 minutes
DEGREE OF SHOCK (see 30)
COMPENSATION MILDSHOCK
MODERATESHOCK
SEVERESHOCK
Blood loss 500 ndash 1000ml10 ndash 15
1000 ndash 1500ml15 ndash 25
1500 ndash 2000ml25 ndash 35
2000 ndash 3000ml35 ndash 45
Blood pressurechange(systolic
pressure)
none Slight fall(90 ndash 100 mmHg)
Marked fall(70-80 mmHg)
Profound fall(50-70 mmHg)
Signs andsymptoms
palpitationsdizzinesstachycardia
weaknesssweatingtachycardia
restlessnesspalloroliguria
collapseair hungeranuria
Four Trsquos
Tone Uterine Massage
Tissue Check placenta complete
Trauma Examine perineum cervix vagina uterine scar
Thrombin Think Coagulation
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Postpartum Haemorrhage Page 5 of 20
Replace
Administer oxygen by mask 6Lmin
Keep the patient warm
Act resuscitation
Insert two 1416 gauge cannulas
Draw blood for group and Ab screen send to Blood Bank- URGENT STICKER
Draw blood for FBC amp coagulation send to Haematology- URGENT STICKER PHONE Blood Bank and Haematology to process urgently
Plasmalyte first line
Infuse one litre rapidly ASSESS response as above
Infuse 2nd or 3rd litre if indicated ndash WARMED FOR ALL ONGOING FLUIDS
Use pressure infusers where available
If further fluid required give BLOOD but can use colloid while waiting
Act give blood ( see 28)
Use a blood giving set
Blood should be used as soon as possible gt 1500ml with ongoing bleeding andor ifhaemodynamically unstable ie if systolic BP lt = 90 mmHg or significant fall from baseline
If no ongoing bleeding then Hb can be used to guide transfusion requirements
Note Group and Ab screen takes 40 minutes but then if negative Ab screen compatibleblood can be issued quickly
Phone Blood Bank request blood specify amount and timeframe advise them of activebleeding and need for ongoing support
If compatible blood is not available after a blood loss of 2000mls or haemodynamicallyunstable then uncrossmatched blood (desperate blood or emergency blood) must be given
Phone blood bank and give Drs name no of units and send sticker down the tube StateldquoWe need blood NOWrdquo
Further products eg FFP platelets cryoprecipitate will be required if massive transfusionor coagulopathy request early seek advice from senior colleague
Transfusion Medicine Specialist available for consultation 247 ( via Blood Bank)
Obstetric Physic ians on call 247
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Arrest Bleeding
Tone
Massage the uterus firmly expel any clots
First ndashline drug therapy
Syntometrine one ampoule IM (if not already given and no history of hypertension)
Syntocinon 5 units IV
IV infusion Syntocinon (20units in 1000mls Plasmalyte at 250mlshour)If the Syntocinon infusion fails to achieve uterine contraction additional medical treatmentshould be instituted rather than increasing the dose or rate of syntocinon
Second line drugs
Misoprostol (Cytotec) 800mgs PR
Carboprost (Haemabate) IM 250mcg Q15min up to 8 doses
further Syntometrine IM ergometrine IV slowly - only one more dose(see appendix 1 for doses and maximums)
Insert Indwelling Catheter
Internal Bimanual Compression
Tissue
Retained placenta with postpartum haemorrhageUrgent transfer to theatre for manual removal
Acui ty One if gt=1000ml actively bleeding or unstable
Consider possibility of placenta accreta
Trauma
Repair the Tear
Apply pressure as initial measure
Stabilise the mother and
Repair the tearlacerations as soon as possible (theatre may be required)
Ensure that swab and instrument counts are correct in all cases
Thrombin
Check coagulation results
OampG staff to consult asap if initial results show PR gt 15 APTT gt 40 fibrinogen lt 15 platelets lt 100 Hb lt 80
See Blood Components amp Blood Products Administration Massive Transfusion Protocol fortreatment of coagulopathy
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Postpartum Haemorrhage Page 7 of 20
Ongoing Monitoring
After a significant PPH the following are recommended for ongoing monitoring
NIBP monitoring
Pulse oximetry
ECG
Strict fluid balance with hourly urine measures
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors
Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500000maternal pregnancy related deaths each year accounting for 11 of the total number (see 7) It isalso a potent cause of postnatal iron deficiency in women The case fatality is approximately 1 in
600 to 1 in 800 cases of obstetric bleeding ( CEMACH)
Definitions
Until recent times Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of gt =500 ml from the genital tract in first 24 hours post delivery (see 7) This definition however isbased on subjective observations making accurate assessment of excessive blood loss difficultRecent research indicates that clinical estimates of blood loss frequently fall below the actualamount and the incidence of PPH is being under reported by 30-50 On the basis of thesefindings more objective assessment parameters have been advocated for the diagnosis of majorPPH - viz
The patient Is haemodynamically unstable
Has a blood loss of gt1000ml from genital tract
Has a gt10 change in her haematocrit between admission and the post partum period(see 8)or
Requires a transfusion of red blood cells (see 8)
Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery hasbeen estimated at 39 (see 9) and 64 (see 11) for a caesarean delivery
Continued on next page
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Postpartum Haemorrhage Page 9 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Postpartum Haemorrhage Page 10 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Postpartum Haemorrhage Page 3 of 20
Immediate Management from Labour Birthing
Call for Help early
Call Clinical Charge Midwife and Registrar for all PPH
If gt 500ml and clinical concerns push emergency bell and dial 777 and state ldquoObstetricemergency room helliprdquo
Send for blood
1000-1500 mls Call in Obstetric Consultant notify Anaesthetist gt 2000 ml Call in 2nd Obstetric Consultant and Anaesthetist
gt 2000 ml notify Blood Bank
If pre-eclampsia or significant medical history notify Obstetric Physician
Delegate Tasks
Identify Team Leader
IV lines (2X 1416 gauge cannulae
Running total of blood loss
Vital signs and communication with woman
Fluid replacement Runner to organise theatre bloodextra help
Documentation
Communicate with family
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Assess
Rapid Evaluation
Shock this is a late sign
Blood pressure pulse respirations peripheral perfusion colour cerebral function
Estimate blood loss and keep ongoing record
Document blood and blood products as requested and actually transfused laboratory
coagulation results Use automated BP and SpO2 monitoring every 3 minutes
DEGREE OF SHOCK (see 30)
COMPENSATION MILDSHOCK
MODERATESHOCK
SEVERESHOCK
Blood loss 500 ndash 1000ml10 ndash 15
1000 ndash 1500ml15 ndash 25
1500 ndash 2000ml25 ndash 35
2000 ndash 3000ml35 ndash 45
Blood pressurechange(systolic
pressure)
none Slight fall(90 ndash 100 mmHg)
Marked fall(70-80 mmHg)
Profound fall(50-70 mmHg)
Signs andsymptoms
palpitationsdizzinesstachycardia
weaknesssweatingtachycardia
restlessnesspalloroliguria
collapseair hungeranuria
Four Trsquos
Tone Uterine Massage
Tissue Check placenta complete
Trauma Examine perineum cervix vagina uterine scar
Thrombin Think Coagulation
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Replace
Administer oxygen by mask 6Lmin
Keep the patient warm
Act resuscitation
Insert two 1416 gauge cannulas
Draw blood for group and Ab screen send to Blood Bank- URGENT STICKER
Draw blood for FBC amp coagulation send to Haematology- URGENT STICKER PHONE Blood Bank and Haematology to process urgently
Plasmalyte first line
Infuse one litre rapidly ASSESS response as above
Infuse 2nd or 3rd litre if indicated ndash WARMED FOR ALL ONGOING FLUIDS
Use pressure infusers where available
If further fluid required give BLOOD but can use colloid while waiting
Act give blood ( see 28)
Use a blood giving set
Blood should be used as soon as possible gt 1500ml with ongoing bleeding andor ifhaemodynamically unstable ie if systolic BP lt = 90 mmHg or significant fall from baseline
If no ongoing bleeding then Hb can be used to guide transfusion requirements
Note Group and Ab screen takes 40 minutes but then if negative Ab screen compatibleblood can be issued quickly
Phone Blood Bank request blood specify amount and timeframe advise them of activebleeding and need for ongoing support
If compatible blood is not available after a blood loss of 2000mls or haemodynamicallyunstable then uncrossmatched blood (desperate blood or emergency blood) must be given
Phone blood bank and give Drs name no of units and send sticker down the tube StateldquoWe need blood NOWrdquo
Further products eg FFP platelets cryoprecipitate will be required if massive transfusionor coagulopathy request early seek advice from senior colleague
Transfusion Medicine Specialist available for consultation 247 ( via Blood Bank)
Obstetric Physic ians on call 247
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Arrest Bleeding
Tone
Massage the uterus firmly expel any clots
First ndashline drug therapy
Syntometrine one ampoule IM (if not already given and no history of hypertension)
Syntocinon 5 units IV
IV infusion Syntocinon (20units in 1000mls Plasmalyte at 250mlshour)If the Syntocinon infusion fails to achieve uterine contraction additional medical treatmentshould be instituted rather than increasing the dose or rate of syntocinon
Second line drugs
Misoprostol (Cytotec) 800mgs PR
Carboprost (Haemabate) IM 250mcg Q15min up to 8 doses
further Syntometrine IM ergometrine IV slowly - only one more dose(see appendix 1 for doses and maximums)
Insert Indwelling Catheter
Internal Bimanual Compression
Tissue
Retained placenta with postpartum haemorrhageUrgent transfer to theatre for manual removal
Acui ty One if gt=1000ml actively bleeding or unstable
Consider possibility of placenta accreta
Trauma
Repair the Tear
Apply pressure as initial measure
Stabilise the mother and
Repair the tearlacerations as soon as possible (theatre may be required)
Ensure that swab and instrument counts are correct in all cases
Thrombin
Check coagulation results
OampG staff to consult asap if initial results show PR gt 15 APTT gt 40 fibrinogen lt 15 platelets lt 100 Hb lt 80
See Blood Components amp Blood Products Administration Massive Transfusion Protocol fortreatment of coagulopathy
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Postpartum Haemorrhage Page 7 of 20
Ongoing Monitoring
After a significant PPH the following are recommended for ongoing monitoring
NIBP monitoring
Pulse oximetry
ECG
Strict fluid balance with hourly urine measures
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors
Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500000maternal pregnancy related deaths each year accounting for 11 of the total number (see 7) It isalso a potent cause of postnatal iron deficiency in women The case fatality is approximately 1 in
600 to 1 in 800 cases of obstetric bleeding ( CEMACH)
Definitions
Until recent times Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of gt =500 ml from the genital tract in first 24 hours post delivery (see 7) This definition however isbased on subjective observations making accurate assessment of excessive blood loss difficultRecent research indicates that clinical estimates of blood loss frequently fall below the actualamount and the incidence of PPH is being under reported by 30-50 On the basis of thesefindings more objective assessment parameters have been advocated for the diagnosis of majorPPH - viz
The patient Is haemodynamically unstable
Has a blood loss of gt1000ml from genital tract
Has a gt10 change in her haematocrit between admission and the post partum period(see 8)or
Requires a transfusion of red blood cells (see 8)
Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery hasbeen estimated at 39 (see 9) and 64 (see 11) for a caesarean delivery
Continued on next page
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Postpartum Haemorrhage Page 9 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Postpartum Haemorrhage Page 10 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Assess
Rapid Evaluation
Shock this is a late sign
Blood pressure pulse respirations peripheral perfusion colour cerebral function
Estimate blood loss and keep ongoing record
Document blood and blood products as requested and actually transfused laboratory
coagulation results Use automated BP and SpO2 monitoring every 3 minutes
DEGREE OF SHOCK (see 30)
COMPENSATION MILDSHOCK
MODERATESHOCK
SEVERESHOCK
Blood loss 500 ndash 1000ml10 ndash 15
1000 ndash 1500ml15 ndash 25
1500 ndash 2000ml25 ndash 35
2000 ndash 3000ml35 ndash 45
Blood pressurechange(systolic
pressure)
none Slight fall(90 ndash 100 mmHg)
Marked fall(70-80 mmHg)
Profound fall(50-70 mmHg)
Signs andsymptoms
palpitationsdizzinesstachycardia
weaknesssweatingtachycardia
restlessnesspalloroliguria
collapseair hungeranuria
Four Trsquos
Tone Uterine Massage
Tissue Check placenta complete
Trauma Examine perineum cervix vagina uterine scar
Thrombin Think Coagulation
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Replace
Administer oxygen by mask 6Lmin
Keep the patient warm
Act resuscitation
Insert two 1416 gauge cannulas
Draw blood for group and Ab screen send to Blood Bank- URGENT STICKER
Draw blood for FBC amp coagulation send to Haematology- URGENT STICKER PHONE Blood Bank and Haematology to process urgently
Plasmalyte first line
Infuse one litre rapidly ASSESS response as above
Infuse 2nd or 3rd litre if indicated ndash WARMED FOR ALL ONGOING FLUIDS
Use pressure infusers where available
If further fluid required give BLOOD but can use colloid while waiting
Act give blood ( see 28)
Use a blood giving set
Blood should be used as soon as possible gt 1500ml with ongoing bleeding andor ifhaemodynamically unstable ie if systolic BP lt = 90 mmHg or significant fall from baseline
If no ongoing bleeding then Hb can be used to guide transfusion requirements
Note Group and Ab screen takes 40 minutes but then if negative Ab screen compatibleblood can be issued quickly
Phone Blood Bank request blood specify amount and timeframe advise them of activebleeding and need for ongoing support
If compatible blood is not available after a blood loss of 2000mls or haemodynamicallyunstable then uncrossmatched blood (desperate blood or emergency blood) must be given
Phone blood bank and give Drs name no of units and send sticker down the tube StateldquoWe need blood NOWrdquo
Further products eg FFP platelets cryoprecipitate will be required if massive transfusionor coagulopathy request early seek advice from senior colleague
Transfusion Medicine Specialist available for consultation 247 ( via Blood Bank)
Obstetric Physic ians on call 247
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Arrest Bleeding
Tone
Massage the uterus firmly expel any clots
First ndashline drug therapy
Syntometrine one ampoule IM (if not already given and no history of hypertension)
Syntocinon 5 units IV
IV infusion Syntocinon (20units in 1000mls Plasmalyte at 250mlshour)If the Syntocinon infusion fails to achieve uterine contraction additional medical treatmentshould be instituted rather than increasing the dose or rate of syntocinon
Second line drugs
Misoprostol (Cytotec) 800mgs PR
Carboprost (Haemabate) IM 250mcg Q15min up to 8 doses
further Syntometrine IM ergometrine IV slowly - only one more dose(see appendix 1 for doses and maximums)
Insert Indwelling Catheter
Internal Bimanual Compression
Tissue
Retained placenta with postpartum haemorrhageUrgent transfer to theatre for manual removal
Acui ty One if gt=1000ml actively bleeding or unstable
Consider possibility of placenta accreta
Trauma
Repair the Tear
Apply pressure as initial measure
Stabilise the mother and
Repair the tearlacerations as soon as possible (theatre may be required)
Ensure that swab and instrument counts are correct in all cases
Thrombin
Check coagulation results
OampG staff to consult asap if initial results show PR gt 15 APTT gt 40 fibrinogen lt 15 platelets lt 100 Hb lt 80
See Blood Components amp Blood Products Administration Massive Transfusion Protocol fortreatment of coagulopathy
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Ongoing Monitoring
After a significant PPH the following are recommended for ongoing monitoring
NIBP monitoring
Pulse oximetry
ECG
Strict fluid balance with hourly urine measures
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors
Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500000maternal pregnancy related deaths each year accounting for 11 of the total number (see 7) It isalso a potent cause of postnatal iron deficiency in women The case fatality is approximately 1 in
600 to 1 in 800 cases of obstetric bleeding ( CEMACH)
Definitions
Until recent times Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of gt =500 ml from the genital tract in first 24 hours post delivery (see 7) This definition however isbased on subjective observations making accurate assessment of excessive blood loss difficultRecent research indicates that clinical estimates of blood loss frequently fall below the actualamount and the incidence of PPH is being under reported by 30-50 On the basis of thesefindings more objective assessment parameters have been advocated for the diagnosis of majorPPH - viz
The patient Is haemodynamically unstable
Has a blood loss of gt1000ml from genital tract
Has a gt10 change in her haematocrit between admission and the post partum period(see 8)or
Requires a transfusion of red blood cells (see 8)
Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery hasbeen estimated at 39 (see 9) and 64 (see 11) for a caesarean delivery
Continued on next page
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Postpartum Haemorrhage Page 9 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Replace
Administer oxygen by mask 6Lmin
Keep the patient warm
Act resuscitation
Insert two 1416 gauge cannulas
Draw blood for group and Ab screen send to Blood Bank- URGENT STICKER
Draw blood for FBC amp coagulation send to Haematology- URGENT STICKER PHONE Blood Bank and Haematology to process urgently
Plasmalyte first line
Infuse one litre rapidly ASSESS response as above
Infuse 2nd or 3rd litre if indicated ndash WARMED FOR ALL ONGOING FLUIDS
Use pressure infusers where available
If further fluid required give BLOOD but can use colloid while waiting
Act give blood ( see 28)
Use a blood giving set
Blood should be used as soon as possible gt 1500ml with ongoing bleeding andor ifhaemodynamically unstable ie if systolic BP lt = 90 mmHg or significant fall from baseline
If no ongoing bleeding then Hb can be used to guide transfusion requirements
Note Group and Ab screen takes 40 minutes but then if negative Ab screen compatibleblood can be issued quickly
Phone Blood Bank request blood specify amount and timeframe advise them of activebleeding and need for ongoing support
If compatible blood is not available after a blood loss of 2000mls or haemodynamicallyunstable then uncrossmatched blood (desperate blood or emergency blood) must be given
Phone blood bank and give Drs name no of units and send sticker down the tube StateldquoWe need blood NOWrdquo
Further products eg FFP platelets cryoprecipitate will be required if massive transfusionor coagulopathy request early seek advice from senior colleague
Transfusion Medicine Specialist available for consultation 247 ( via Blood Bank)
Obstetric Physic ians on call 247
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Arrest Bleeding
Tone
Massage the uterus firmly expel any clots
First ndashline drug therapy
Syntometrine one ampoule IM (if not already given and no history of hypertension)
Syntocinon 5 units IV
IV infusion Syntocinon (20units in 1000mls Plasmalyte at 250mlshour)If the Syntocinon infusion fails to achieve uterine contraction additional medical treatmentshould be instituted rather than increasing the dose or rate of syntocinon
Second line drugs
Misoprostol (Cytotec) 800mgs PR
Carboprost (Haemabate) IM 250mcg Q15min up to 8 doses
further Syntometrine IM ergometrine IV slowly - only one more dose(see appendix 1 for doses and maximums)
Insert Indwelling Catheter
Internal Bimanual Compression
Tissue
Retained placenta with postpartum haemorrhageUrgent transfer to theatre for manual removal
Acui ty One if gt=1000ml actively bleeding or unstable
Consider possibility of placenta accreta
Trauma
Repair the Tear
Apply pressure as initial measure
Stabilise the mother and
Repair the tearlacerations as soon as possible (theatre may be required)
Ensure that swab and instrument counts are correct in all cases
Thrombin
Check coagulation results
OampG staff to consult asap if initial results show PR gt 15 APTT gt 40 fibrinogen lt 15 platelets lt 100 Hb lt 80
See Blood Components amp Blood Products Administration Massive Transfusion Protocol fortreatment of coagulopathy
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Postpartum Haemorrhage Page 7 of 20
Ongoing Monitoring
After a significant PPH the following are recommended for ongoing monitoring
NIBP monitoring
Pulse oximetry
ECG
Strict fluid balance with hourly urine measures
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Postpartum Haemorrhage Page 8 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors
Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500000maternal pregnancy related deaths each year accounting for 11 of the total number (see 7) It isalso a potent cause of postnatal iron deficiency in women The case fatality is approximately 1 in
600 to 1 in 800 cases of obstetric bleeding ( CEMACH)
Definitions
Until recent times Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of gt =500 ml from the genital tract in first 24 hours post delivery (see 7) This definition however isbased on subjective observations making accurate assessment of excessive blood loss difficultRecent research indicates that clinical estimates of blood loss frequently fall below the actualamount and the incidence of PPH is being under reported by 30-50 On the basis of thesefindings more objective assessment parameters have been advocated for the diagnosis of majorPPH - viz
The patient Is haemodynamically unstable
Has a blood loss of gt1000ml from genital tract
Has a gt10 change in her haematocrit between admission and the post partum period(see 8)or
Requires a transfusion of red blood cells (see 8)
Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery hasbeen estimated at 39 (see 9) and 64 (see 11) for a caesarean delivery
Continued on next page
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Postpartum Haemorrhage Page 9 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Postpartum Haemorrhage Page 10 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Arrest Bleeding
Tone
Massage the uterus firmly expel any clots
First ndashline drug therapy
Syntometrine one ampoule IM (if not already given and no history of hypertension)
Syntocinon 5 units IV
IV infusion Syntocinon (20units in 1000mls Plasmalyte at 250mlshour)If the Syntocinon infusion fails to achieve uterine contraction additional medical treatmentshould be instituted rather than increasing the dose or rate of syntocinon
Second line drugs
Misoprostol (Cytotec) 800mgs PR
Carboprost (Haemabate) IM 250mcg Q15min up to 8 doses
further Syntometrine IM ergometrine IV slowly - only one more dose(see appendix 1 for doses and maximums)
Insert Indwelling Catheter
Internal Bimanual Compression
Tissue
Retained placenta with postpartum haemorrhageUrgent transfer to theatre for manual removal
Acui ty One if gt=1000ml actively bleeding or unstable
Consider possibility of placenta accreta
Trauma
Repair the Tear
Apply pressure as initial measure
Stabilise the mother and
Repair the tearlacerations as soon as possible (theatre may be required)
Ensure that swab and instrument counts are correct in all cases
Thrombin
Check coagulation results
OampG staff to consult asap if initial results show PR gt 15 APTT gt 40 fibrinogen lt 15 platelets lt 100 Hb lt 80
See Blood Components amp Blood Products Administration Massive Transfusion Protocol fortreatment of coagulopathy
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Ongoing Monitoring
After a significant PPH the following are recommended for ongoing monitoring
NIBP monitoring
Pulse oximetry
ECG
Strict fluid balance with hourly urine measures
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors
Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500000maternal pregnancy related deaths each year accounting for 11 of the total number (see 7) It isalso a potent cause of postnatal iron deficiency in women The case fatality is approximately 1 in
600 to 1 in 800 cases of obstetric bleeding ( CEMACH)
Definitions
Until recent times Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of gt =500 ml from the genital tract in first 24 hours post delivery (see 7) This definition however isbased on subjective observations making accurate assessment of excessive blood loss difficultRecent research indicates that clinical estimates of blood loss frequently fall below the actualamount and the incidence of PPH is being under reported by 30-50 On the basis of thesefindings more objective assessment parameters have been advocated for the diagnosis of majorPPH - viz
The patient Is haemodynamically unstable
Has a blood loss of gt1000ml from genital tract
Has a gt10 change in her haematocrit between admission and the post partum period(see 8)or
Requires a transfusion of red blood cells (see 8)
Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery hasbeen estimated at 39 (see 9) and 64 (see 11) for a caesarean delivery
Continued on next page
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Postpartum Haemorrhage Page 9 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Postpartum Haemorrhage Page 10 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Postpartum Haemorrhage Page 7 of 20
Ongoing Monitoring
After a significant PPH the following are recommended for ongoing monitoring
NIBP monitoring
Pulse oximetry
ECG
Strict fluid balance with hourly urine measures
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Postpartum Haemorrhage Page 8 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors
Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500000maternal pregnancy related deaths each year accounting for 11 of the total number (see 7) It isalso a potent cause of postnatal iron deficiency in women The case fatality is approximately 1 in
600 to 1 in 800 cases of obstetric bleeding ( CEMACH)
Definitions
Until recent times Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of gt =500 ml from the genital tract in first 24 hours post delivery (see 7) This definition however isbased on subjective observations making accurate assessment of excessive blood loss difficultRecent research indicates that clinical estimates of blood loss frequently fall below the actualamount and the incidence of PPH is being under reported by 30-50 On the basis of thesefindings more objective assessment parameters have been advocated for the diagnosis of majorPPH - viz
The patient Is haemodynamically unstable
Has a blood loss of gt1000ml from genital tract
Has a gt10 change in her haematocrit between admission and the post partum period(see 8)or
Requires a transfusion of red blood cells (see 8)
Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery hasbeen estimated at 39 (see 9) and 64 (see 11) for a caesarean delivery
Continued on next page
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Postpartum Haemorrhage Page 9 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Postpartum Haemorrhage Page 10 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Postpartum Haemorrhage Page 8 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors
Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500000maternal pregnancy related deaths each year accounting for 11 of the total number (see 7) It isalso a potent cause of postnatal iron deficiency in women The case fatality is approximately 1 in
600 to 1 in 800 cases of obstetric bleeding ( CEMACH)
Definitions
Until recent times Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of gt =500 ml from the genital tract in first 24 hours post delivery (see 7) This definition however isbased on subjective observations making accurate assessment of excessive blood loss difficultRecent research indicates that clinical estimates of blood loss frequently fall below the actualamount and the incidence of PPH is being under reported by 30-50 On the basis of thesefindings more objective assessment parameters have been advocated for the diagnosis of majorPPH - viz
The patient Is haemodynamically unstable
Has a blood loss of gt1000ml from genital tract
Has a gt10 change in her haematocrit between admission and the post partum period(see 8)or
Requires a transfusion of red blood cells (see 8)
Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery hasbeen estimated at 39 (see 9) and 64 (see 11) for a caesarean delivery
Continued on next page
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Postpartum Haemorrhage Page 9 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Postpartum Haemorrhage Page 10 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Postpartum Haemorrhage Page 9 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Aetiology and Risk Factors (modified from NSW framework)
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
atonic uterus physiological management of thirdstage
prolonged 3rd stage (gt 30 min) over distended uterus polyhydramnios
multiple gestation macrosomia
uterine muscleexhaustion
rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon
intra-amniotic infection pyrexia prolonged ROM (more than 24
hours)
drug induced hypotonia magnesium sulphate nifedipinesalbutamol
general anaesthetic
Abnormali ties ofuterine contraction
(Tone)
70
functional or anatomicdistortion of the uterus
fibroid uterus uterine anomalies
episiotomy orlacerations (cervixvagina or perineum)
labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or
forceps) extensions lacerations
at caesarean section malposition deep engagement
uterine rupture previous uterine surgery
Genital tract trauma(Trauma)
20
uterine inversion strong cord traction in 3rd stageespecially with fundal placenta
short umbilical cord high parity relaxed uterus lower segment and
cervix placenta accreta especially fundal congential uterine weakness or
anomalies antepartum use of magnesium
sulphate or oxytocin
Continued on next page
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Postpartum Haemorrhage Page 10 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Postpartum Haemorrhage Page 10 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
CAUSE ETIOLOGY PROCESS CLINICAL RISK FACTORS
Retained products ofconception (Tissue)
10
retained products abnormal placenta retained cotyledon or
succenturiate lobe
incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine
surgery high parity abnormal placenta on US
retained blood clots atonic uterus
coagulation disordersacquired in pregnancy
IdiopathicThrombocytopenicPurpura (ITP)
Von Willebrandrsquosdisease
Haemophilia or carrier
Thrombocytopenia withpre-eclampsia
DisseminatedIntravascularCoagulopathy (DIC)
pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus
bruising elevated BP HELLP fetal death pyrexia WBC antepartum haemorrhage (current or
previous) sudden collapse
Abnormali ties ofcoagulation(Thrombin)
1
therapeutic anti-coagulation
history of blood clot
Continued on next page
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Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
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Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
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Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 11 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH
Maternal Obesity (CEMACH)
Hypertensive disorders OR 17
LGA OR 19
Antepartum haemorrhage including abruption
Placenta praevia with risk of accreta increasing with each previous CS
Induction of labour OR 14
Augmented labour OR 14
Prolonged second stage OR 34
Operative vaginal delivery OR 23
Lacerations OR 24
Retained placenta OR 35
Placenta accreta OR 33
Caesarean section is strongly associated with peripartum hysterectomy (see 13)
Prevention
There is high quality evidence that active management of the third stage reduces the incidence ofPPH for all women (see 14)
Refer to the policy ldquoIntrapartum Care - Normal Labour amp Birth Management of third stagerdquo for afull description of active management of third stage
For women with risk factors for PPH the following is recommended
Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes ndash and FBC
Chase result of antibody screen and if positive request crossmatching to begin early in order toavoid delays in the event of an emergency suggest 4 - 6 units this takes about an hour
Active management of the third stage of labour with syntometrine if not contraindicated
For women who have stated a wish not to receive blood products ( CEMACH)
Ensure specific wishes are documented
Obtain informed consent for red blood cell salvage and infusion
Review by Consultant Obstetrician and Anaesthetist at the onset of labour
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1820
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 12 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Fluids drugs
Fluids
Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation
For fluid other than blood replace blood loss with 3 to 4 times the EBL
Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravasculareffect longer than Gelofusine
Warmed fluids reduce the risk of coagulopathy
Resuscitation must commence early regardless of the availability of an anaesthetist
If an anaesthetist is not available ensure there is an appropriate person in charge of fluidandor blood resuscitation at all times with close attention to total blood loss
Delivery of any drugs to the uterus especially IM will be compromised by poor circulationtherefore fluid resuscitation must be effective
Be cautious with use of syntocinon in the presence of hypovolaemia
If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment
should be instituted rather than increasing the dose or rate of syntocinon Syntometrine one ampoule intramuscular if not already administered This contains 500
micrograms of ergometrine If ergometrine has already been administered (as Ergometrineor Syntometrine) a second dose of 250 micrograms may be given but beware of thehypertensive woman who may develop extreme hypertension following the administrationof ergometrine A second dose of ergometrine should only be used after consultation withthe on-call obstetrician The total dose of ergometrine in 24 hours must not exceed 1000micrograms Ergometrine is contraindicated with a history of maternal hypertension or pre-eclampsia regardless of actual BP readings during PPH Ref Ng SY Ithnin F Sia ATHNg CCM Ergometrine administration for postpartum haemorrhage in an undiagnosed pre-eclamptic Anaesthesia and Intensive Care 36 (1) ( pp 113 ndash 115) 2008
Misoprostol 800mcg PR This has been shown in one small trial (see 15) to be subjectively
more effective than syntometrine but the numbers are too small to draw conclusionsregarding outcomes such as hysterectomy or maternal mortality It is however quick toadminister rectally and has fewer side effects than Syntometrine It avoids the use of IMinjection (which may be less effective in the presence of shock or morbid obesity andposes risk of haematoma in the presence of coagulopathy)
Carboprost (Haemabate) has a high success rate (95 used with other ecbolics (see 16)but is third line due to side effects Give 1 ampoule (250 mcg) IM Q15 minutes up to 8doses May be given intramyometrially with caution this is best done in theatre
Interventional Radiology
This technique needs discussion with the radiologist on-call and is best undertaken whilst the
patientrsquos condition is stable since it usually involves transfer to the Interventional Radiology SuiteIt may be more suitable for recurrent primary or secondary PPH where uterine conservation isdesired or hysterectomy is too risky due to maternal medical conditionIf embolisation is expected to be required then femoral catheters with balloons can be electivelyplaced prior to Caesarean Section which can provide temporary control prior to formal embolisationandor hysterectomy
Continued on next page
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1820
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1920
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 2020
Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 13 of 20
Appendix 1 Primary PPH ndash Further Detail Including RiskFactors Continued
Management in the Operating Room
Initial Measures
Continue bi-manual compression andor firm pressure on perineum
Consider applying aortal compression via pressure through the abdominal wall (This may behelpful as a temporary measure if the patient is in shock or during CPR (see 2)
Take a few minutes for multidisciplinary plan
Request Blood Bank to send blood to OR immediately patient arrives in theatre
Examination under anaesthetic to remove retained placentatissue and repair any tearBeware uterine inversion and previously undiagnosed placenta accreta
Further measures
Consider
Inserting a central line andor arterial line earlier rather than later
Administering fresh frozen plasma cryoprecipitate and platelet concentrates
The need for antibiotic cover
Use of a cell saver
Give further ecbolics as required
IM syntometrine (maximum 2 ampoules24hr)
IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses ie 2mg)
Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used Caution must be exercised to avoid intravascular injectionwhich can cause collapse Give 125mcg in 20ml normal saline via 22G spinal needle into 3or 4 more myometrial sites can be repeated if necessary total dose 2mg)
UterineVaginal Tamponade with balloon or gauze packing (appendix 2)
Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1820
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 14 of 20
Appendix 2 Uterine Vaginal Tamponade
(consider this may mask ongoing bleeding)Possible options include
Pack the uterus using a Rusch balloonBalloon may be inflated with up to 1500ml ofsaline less will be required but tailor to thesize of the uterus usually about 300ml
Hydrostatic Catheter (Cat Ref 7015)
Intended Purpose For bladder distention
Product Description1 Portfolio Standard2 Size 16Fr3 Balloon 10ml and 1500ml4 Eye configuration One pair opposed
eyes5 Tip Configuration Standard round tip
with hydrostatic balloon over tip6 Funnel Main funnel and inflation
funnel7 End of inflation funnel is fitted with a
plastic valve held securely by acoloured rubber sleeve
8 Coating Silicone treated9 Sterility Shipped sterile
Hydrostatic Catheter
Alternatively for gauze packing tie 3-4 gauze rolls together soak in an iodine solution and packuterus and vagina Remove 24 hours later (see 10)
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1520
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1820
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
8132019 faktor risiko HPP
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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 2020
Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1520
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 15 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch
Consider calling for extra surgical assistance (eg Senior gynaecologist gynaecologicaloncologist vascular surgeon or general surgeon) It is a mistake to leave these steps until thepatient is in extremis Prompt resuscitation including correction of coagulopathy must occur tosupport early recourse to surgery but coagulation factors do not of themselves stop surgicalbleeding
Consider applying aortal compression or clamp at laparotomy see 2)
B-Lynch stitch (see 3)
Uterine artery ligation (OrsquoLeary stitch) (see 4)
Bilateral internal iliac artery ligation (see 5)
Ovarian artery ligation
Uterine devascularisation (see 6)
Hysterectomy is the definitive treatment and must be proceeded with i f bleeding is notcontrolled quickly with other measures and blood loss is gt 2000ml
Continued on next page
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1620
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1720
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1820
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1920
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 2020
Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1620
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 16 of 20
Appendix 3 Laparotomy for Further Surgical MeasuresIncluding BLynch Continued
Original B-Lynch Suture ( above)
Modified B-Lynch st itch(70mm round- bodied needle with 2 Chromic catgut suture)
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1720
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1820
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1920
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 2020
Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1720
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 17 of 20
Appendix 4 Recombinant Factor VIIA
European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massivebleeding in certain situations An American review group evaluated the literature for a number ofindications including a small number of obstetric cases and concluded that its use for PPH isappropriate only after attempted significant clotting factor replacement
There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there
are no randomised studies therefore the evidence base is limited Cost is significant but costneutrality is maintained if given relatively early ie after a 14 unit red cell transfusion
The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currentlyunder development at ADHB) and considered only as a lifesaving (or fertility saving) measure forPPH resistant to standard therapy (see 29)
See also NGROUPSEVERYONEPOLICYMaster file of IntranetClinical PracticeNationalWomensSSMnon-document controlled attachmentsPDF Guidelines VIIa Mar06pdf
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1820
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1920
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 2020
Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1820
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 18 of 20
Appendix 5 Secondary Postpartum Haemorrhage
Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tractoccurring more than 24 hrs to 6 weeks after delivery
Aetiology
Retained products of conception Infection (often secondary to retained products)
Lacerations including episiotomy
Others (rare) Blood dyscrasias Trophoblastic disease Carcinoma of cervix submucousfibroids(causing subinvolution) Placental site causing subinvolution
Management Details
There are no randomised controlled trials to inform the management of secondary PPH (see 25)The following is based on expert opinion
Assess patient
The diagnosis and management of a secondary postpartum haemorrhage primarily relies on aclinical assessment Ultrasound looking for retained products of conception should play a minorsecondary role as it has high false positive rate (low specificity) which may lead to unnecessarilyaggressive intervention with a significant risk of serious consequences Ultrasound does not easilydifferentiate between retained products and blood clot
Estimate the total blood loss and measure HB
Vital signs temperature pulse and blood pressure
Resuscitation as required as per primary PPH guidelines
Assess uterine size
Check status of cervical os and take endocervical swab
Consider B subunit HCG testing to exclude trophoblastic disease
Treat the cause ndash General principles of treatment
Bed rest and antibiotics therapy are the mainstays of treatment
Curettage is not performed routinely (risk of uterine perforation or Ashermanrsquos Syndrome)Evidence of retained products is suggested by subinvolution of the uterus an open cervical osor ultrasound findings
Oxytocics (eg Oral Ergometrine) have almost no part in the management
If vaginal bleeding continues following treatment for secondary post partum haemorrhage thenconsider the need for a pelvic trans-vaginal ultrasound scan
Retained products of conceptionBleeding in the first few days after delivery is probably due to retained products of conception
Gentle digital evacuation of the uterus under general anesthesia should be performed Antibiotictherapy is indicated prior to the procedure to reduce the risk of Ashermanrsquos syndrome
Uterine infectionBleeding occurring later in the puerperium may be due to infection of the uterus for whichantibiotics should be prescribed If bleeding continues despite antibiotics exploration of the uterusis indicated
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1920
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 2020
Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 1920
Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009
Postpartum Haemorrhage Page 19 of 20
References
1 Druzin ML 1989 Packing of lower uterine segment for control of post cesarean bleeding ininstances of placenta previa Surg Gynecol Obstet 169 543-45
2 Riley DP Burgess RW 1995 External abdominal aortic compression A study of aresuscitation manoeuver for postpartum hemorrhage Obstet Gynecol Surv 50 426-7
3 B-Lynch C Coker A Lawal AH Abu J Cowen MJ 1997 The B-Lynch surgical techniquefor the control of massive postpartum haemorrhage an alternative to hysterectomy Five cases
reported British Journal of Obstetrics amp Gynaecology 1043 372-54 OLeary JA SO 1986 Hemorrhage with uterine artery ligation Contemp ObGyn Update
Surg 27 13-165 Allahbadia G 1993 Hypogastric artery ligation A new perspective Obstet Gynecol Surv 48
613-156 AbdRabbo SA 1994 Stepwise uterine devascularization A novel technique for management
of uncontrollable postpartum hemorrhage with preservation of the uterus Am J ObstetGynecol 171 694-700
7 AbouZahr C 2003 Global burden of maternal death In British Medical Bulletin PregnancyReducing maternal death and disability British Council Oxford University Press 2003 1-13
8 Pritchard JA Baldwin RM Dickey JC Wiggins KM 1962 Blood volume changes inpregnancy and the puerperium II Red blood cell loss and changes in apparent blood volume
during and following vaginal delivery cesarean section and cesarean section plus totalhysterectomy Am J Obstet Gynecol 84 1271-1282
9 Combs CA Murphy EL LRJ 1991 Factors associated with postpartum hemorrhage withvaginal birth Obstet Gynecol 77 69-76
10 American College of Obstetricians and Gynecologists 1998 Postpartum hemorrhage ACOGEducational Bulletin Number 243 In 2001 Compendium of Selected Publications WashingtonDC ACOG
11 Combs CA Murphy EL Laros RK Jr 1991 Factors associated with postpartum hemorrhagein cesarean birth Obstet Gynecol 77 1 77-82
12 Sheiner E Sarid L Levy A et al Obstetric risk factors and outcome of pregnanciescomplicated with postpartum haemorrhage a population-based study J Matern FetalNeonatal Med Sep 2005 18 ( 3) 149-54
13 Stanco LM Schrimmer DB Paul RH Mishell DR Jr 1993 Emergency peripartumhysterectomy and associated risk factors Am J Obstet Gynecol 168 879-883
14 Prendiville WJ Elbourne D McDonald S Active versus expectant management in the thirdstage of labour Cochrane Database Syst Rev 2000 (2) CD000007Guidelines for red celltransfusions and volume replacement in adults 2008 UpToDate
15 Lokugamage AU et al 2001 A randomized study comparing rectally administered misoprostolversus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage Acta Obstetrica et Gyanecologica Scandinavica 2001 80( 9) 835ndash9
16 Oleen MA Mariano JP Controlling refractory atonic postpartum haemorrhage InternationalJournal of Gynecology amp Obstetrics 2003 80 67-8
17 Mousa HA amp Walkinshaw S 2001 Major postpartum haemorrhage Current Opinion in
Obstetrics amp Gynaecology 13 595-603
Continued on next page
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 2020
Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81
8132019 faktor risiko HPP
httpslidepdfcomreaderfullfaktor-risiko-hpp 2020
Developed by Clinical Director OampG Classification NMP200 SSM 075A th i d b Cli i l Di t OampG D t I d U d t d J l 2009
References Continued
18 WHO Policy19 Ultrasound OampG 200120 Ultrasound OampG 2001 18 p4921 Ultrasound OampG 2000 16 p64022 American Journal OampG 1970 107 p56523 BJOG 2001 p108-927
24 High Risk Pregnancy Management options Chapter 79 pages 1615 1617825 Cochrane review 2008 ndash Treatments for secondary postpartum haemorrhage26 Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007 Saving
Mothersrsquo Lives 2003 ndash 2005 Report A Report of the UK confidential Enquiries into maternaldeaths
27 Postpartum haemorrhage (PPH) ndash Framework for Prevention Early Recognition ampManagement 27 Jan 2005 NSW Health Policy Directive http wwwnswgovaupoliciesPD2005PD23005_264html
28 Murphy MF et al 2001 British Committee for Standards in Haematology Blood TransfusionTask Force Br J Haematol 2001 11324
29 Welsh A McLintock C Gatt S Somerset D Popham P Ogle R Guidelines for the use ofrecombinant activated factor VII in massive obstetric haemorrhage Australian and New
Zealand Journal of Obstetrics and Gynaecology 48 ( 1) ( pp 12-16) 200830 SOGC Prevention and management of Postpartum Haemorrhage SOGC Clinical Practice
Guidelines No 88 J Soc Obstet Gynaecol Can 2000 22(4) 271 - 81