Post-Partum Hemorrhage:Management and Complications

Max Max MongelliMongelliClinical Associate Professor Clinical Associate Professor

Western Clinical SchoolWestern Clinical School

University of SydneyUniversity of Sydney

Nepean HospitalNepean Hospital

Third stage of labour

�� From delivery of the baby to delivery of the From delivery of the baby to delivery of the placenta < 20minutes.placenta < 20minutes.

�� Cessation of umbilical artery pulsation, Cessation of umbilical artery pulsation, placenta separates from uterine wall through placenta separates from uterine wall through the the deciduadeciduaspongiosaspongiosaand is deliveredand is delivered

�� Capillary haemorrhage and shearing effect Capillary haemorrhage and shearing effect of uterine muscle.of uterine muscle.

Amount of blood loss depends on:

�� How quickly the placenta separates from How quickly the placenta separates from uterine wall.uterine wall.

�� How effectively the uterine muscle How effectively the uterine muscle contracts around the placental bed during contracts around the placental bed during and after separation.and after separation.

�� Intact coagulation system.Intact coagulation system.

Active management

�� ““ Standard practiceStandard practice””

�� Administration of an Administration of an oxytocicoxytocicat the at the delivery of the anterior shoulder/after the delivery of the anterior shoulder/after the baby has been delivered.baby has been delivered.

�� Early cord clamping and cuttingEarly cord clamping and cutting

�� Controlled cord traction of the umbilical Controlled cord traction of the umbilical cordcord

Expectant management

�� ““ ConservativeConservative”” ““ PhysiologicalPhysiological””

�� Waiting for the umbilical cord to cease Waiting for the umbilical cord to cease pulsationpulsation

�� Waiting for signs of placental separationWaiting for signs of placental separation

�� Allowing placenta to deliver spontaneously Allowing placenta to deliver spontaneously

�� Aided by gravity/nipple stimulation/breast Aided by gravity/nipple stimulation/breast feedingfeeding

Active vs Expectant Management

�� Reduced maternal blood lossReduced maternal blood loss�� Reduced PPH rates (0.38, CI 0.32 to 0.46)Reduced PPH rates (0.38, CI 0.32 to 0.46)��

�� Shortening of 3Shortening of 3rdrd stage of labour stage of labour ((--9.77, CI 9.77, CI ––10.0 to 10.0 to ––9.53)9.53)��

�� Increased maternal nausea Increased maternal nausea (1.83, CI 1.51 to 2.23)(1.83, CI 1.51 to 2.23)��

�� Increased vomiting and raised BP Increased vomiting and raised BP (probably due to use of (probably due to use of ergometrineergometrine)) ��

Cochrane Database of SyCochrane Database of Systematic Reviews 2000stematic Reviews 2000

PPH�� Definition Definition ––

primary >500ml primary >500ml secondarysecondary

�� PPH ratesPPH rates�� Maternal risksMaternal risks

�� mortalitymortality�� morbiditymorbidity

�� Risk factorsRisk factors�� PreventionPrevention�� ManagementManagement

Definition

�� Blood loss from the genital tract >500ml in Blood loss from the genital tract >500ml in the first 24 hours following deliverythe first 24 hours following delivery

�� ““ normal blood lossnormal blood loss”” ((BonnarBonnar2000) 2000) -- at vaginal delivery: 600ml at vaginal delivery: 600ml -- at Caesarean section: 1000mlat Caesarean section: 1000ml

PPH

�� Haemorrhage is the main cause of death in a Haemorrhage is the main cause of death in a number of countriesnumber of countries

�� At least 25% of maternal deaths worldwide At least 25% of maternal deaths worldwide due to haemorrhage due to haemorrhage –– the majority the majority postpartum haemorrhagepostpartum haemorrhage

�� Vast majority in the developing worldVast majority in the developing world�� Most important complication of the 3Most important complication of the 3rdrd stage stage

of labourof labour

Massive haemorrhage

�� >1500ml>1500ml�� Blood loss requiring replacement of the Blood loss requiring replacement of the

patientpatient’’ s total blood volumes total blood volume�� Transfusion >10 units blood within 24 hoursTransfusion >10 units blood within 24 hours�� Replacement of 50% circulating blood Replacement of 50% circulating blood

volume in <3hours volume in <3hours �� Loss of >150ml/minuteLoss of >150ml/minute

PPH rates

�� Depend on the definition usedDepend on the definition used�� KEMH >500ml 12%, >600ml 9.45%, >1000ml KEMH >500ml 12%, >600ml 9.45%, >1000ml

5.5%5.5%�� Similar rates in Australasian tertiary institutionsSimilar rates in Australasian tertiary institutions�� Most of Australasia: Most of Australasia:

�� >500ml 8%, >500ml 8%, �� >1000ml 4.27%, >1000ml 4.27%, �� >1500ml 1.83%, >1500ml 1.83%, �� >2000ml 0.6%>2000ml 0.6%

Maternal risks

�� MortalityMortality�� Triennial reports from UK 1985Triennial reports from UK 1985--96 show no 96 show no

significant reduction in the number of deaths from significant reduction in the number of deaths from haemorrhage (30 each triennia)haemorrhage (30 each triennia)��

�� Majority due to substandard careMajority due to substandard care�� DELAY in DELAY in -- correction of correction of hypovolaemiahypovolaemia, ,

-- diagnosis and treatment of defective diagnosis and treatment of defective coagulation coagulation

-- surgical control of bleedingsurgical control of bleeding�� ““ TOO LITTLE TOO LATETOO LITTLE TOO LATE””

Mortality

�� Developing countries PPH 125,000 deaths/yrDeveloping countries PPH 125,000 deaths/yr

�� 28% of maternal deaths28% of maternal deaths

�� Risk 1 in 1000Risk 1 in 1000

�� Australia 1 in 100,000 deliveries die of PPHAustralia 1 in 100,000 deliveries die of PPH

�� Life threatening haemorrhage 1 in 1000 deliveriesLife threatening haemorrhage 1 in 1000 deliveries

�� Risk increases with increasing maternal age Risk increases with increasing maternal age especially >35 yearsespecially >35 years

Morbidity

�� CoagulopathyCoagulopathy(DIC)(DIC) ��

�� Fluid overload/Pulmonary Fluid overload/Pulmonary edemaedema

�� Left ventricular failureLeft ventricular failure

Morbidity

�� Injury to Injury to ureterureterand bladder from surgical and bladder from surgical interventionintervention

�� SheehansSheehanssyndrome syndrome �� permanent permanent hypopituitarismhypopituitarismcaused by caused by

avascularavascularnecrosis of the anterior necrosis of the anterior pituitary gland, pituitary gland,

�� failure of lactation, amenorrhoea, failure of lactation, amenorrhoea, hypothyroidism and hypothyroidism and adrenocorticaladrenocorticalinsufficiencyinsufficiency

Blood Changes in Pregnancy

�� Normal adult blood volume 70ml/kg Normal adult blood volume 70ml/kg egeg 50kg50kg3.5L 3.5L

60kg 4.2L 60kg 4.2L 70kg 5.0L, 70kg 5.0L,

etcetc

�� The healthy pregnant woman has a blood The healthy pregnant woman has a blood volume of 6volume of 6--7L in late pregnancy7L in late pregnancy

Blood Changes in Pregnancy

�� During pregnancy:During pregnancy:

�� 40% increase in blood 40% increase in blood volvol--increase in red cell massincrease in red cell mass

�� Lowering of Lowering of haematocrithaematocritby 10%by 10%

�� Marked increase in fibrinogen Marked increase in fibrinogen and factors VII, and factors VII,

VIII and X VIII and X

Adaptation to blood loss

�� Blood loss <1000ml induces little or no Blood loss <1000ml induces little or no change in pulse or BPchange in pulse or BP

�� Catecholamine Catecholamine –– induced vasoconstriction induced vasoconstriction maintains perfusion of the maternal heart maintains perfusion of the maternal heart and brain at the expense of diminished and brain at the expense of diminished uteroutero--placental blood flowplacental blood flow

�� Tachycardia may be absent in up to 25% of Tachycardia may be absent in up to 25% of cases with severe blood loss.cases with severe blood loss.

Haemorrhagic shock and blood loss

SevereCollapse, air hunger, anuria

60-70mmHg35-45%

(2000-3000ml)�

ModeratePallor70-80mmHg25-35%

(1500-2000ml)�

MildWeakness, sweating, tachycardia

Slight fall15-25% (1000-1500ml)�

CompensatedPalpitations, dizziness, HR incr

Normal10-15% (500-1000ml)�

Degree of shock

Symptoms and signs

BPBlood volume loss

Disseminated Intravascular Coagulation

�� Depletion of fibrinogen, coagulation factors and Depletion of fibrinogen, coagulation factors and circulating plateletscirculating platelets

�� Haemostatic failureHaemostatic failure

�� MicrovascularMicrovascularbleedingbleeding

�� Increased blood lossIncreased blood loss

�� Unlikely if platelet count is normalUnlikely if platelet count is normal

Risk Factors for PPH (1)

�� Placenta Placenta praeviapraevia, especially if associated with , especially if associated with accreta/percreta/incretaaccreta/percreta/increta

�� Previous history of PPH Previous history of PPH �� Previous history of retained placenta, Previous history of retained placenta, AshermansAshermans

syndrome, endometrial ablationsyndrome, endometrial ablation�� Hypertensive disordersHypertensive disorders�� Manual removal of retained placentaManual removal of retained placenta�� Refusal of blood transfusionRefusal of blood transfusion

Risk Factors for PPH (2)

�� Maternal obesity Maternal obesity �� Large babyLarge baby�� APH/abruptionAPH/abruption�� Multiple pregnancyMultiple pregnancy�� Previous PPH (recurrence rate 8Previous PPH (recurrence rate 8--10%)10%)���� Operative delivery Operative delivery –– Emergency CS Emergency CS

substantially increases the risksubstantially increases the risk

Risk Factors for PPH (3)

�� AnaemiaAnaemia

�� Induction/augmentation of labourInduction/augmentation of labour

�� Instrumental deliveryInstrumental delivery

�� Prolonged labour (1Prolonged labour (1stst or 2or 2ndnd stage)stage)��

�� Grand Grand multiparitymultiparity (>5) (>5)

�� Bleeding disorder (Bleeding disorder (egegVon Von WillebrandtWillebrandt’’ ss)) ��

�� Use of antiUse of anti--epileptic medicationsepileptic medications

Prevention of PPH:Antenatal period

�� Identification and correction of Identification and correction of anemiaanemiain in pregnancypregnancy

�� Detection of subDetection of sub--clinical bleeding disordersclinical bleeding disorders

�� Detection of placenta Detection of placenta accreta/percretaaccreta/percreta

�� Care plan for management of third stage if Care plan for management of third stage if risk factors detectedrisk factors detected

Prevention of PPH (2)�

�� OxytocicOxytocicpolicypolicy

�� Venous access, G+H, active management of Venous access, G+H, active management of third stage, third stage, oxytocinoxytocin infusion in those infusion in those identified as at riskidentified as at risk

�� Senior obstetrician/anaesthetist at placenta Senior obstetrician/anaesthetist at placenta praeviapraeviaCSCS

�� +/+/--gynaegynaeoncologist at placenta oncologist at placenta accretaaccretaCSCS

Management of PPH

�� Call for helpCall for help

�� ResuscitateResuscitate

�� Restore circulating blood volumeRestore circulating blood volume

�� Identify and treat the causeIdentify and treat the cause

Resuscitation

�� Massage Massage fundusfundus

�� Venous access, 16 gauge Venous access, 16 gauge cannulacannula, x2, x2

�� Tilt head down, O2 by face maskTilt head down, O2 by face mask

�� Bloods:FBC, Bloods:FBC, CoagsCoags, X, X--matchmatch

�� IDCIDC

�� MonitoringMonitoring

Volume replacement

�� CrystalloidsCrystalloids�� 80% infused fluid leave the intravascular space80% infused fluid leave the intravascular space

�� AVOID DEXTROSEAVOID DEXTROSE�� O negative blood if torrential lossO negative blood if torrential loss�� Packed cellsPacked cells�� 4 units FFP for every 6 packed cells4 units FFP for every 6 packed cells�� Platelets/cryoprecipitatePlatelets/cryoprecipitate�� Involve haematologist early onInvolve haematologist early on�� Avoid colloidsAvoid colloids

Monitoring

�� Pulse, BPPulse, BP

�� Respiratory rateRespiratory rate

�� TemperatureTemperature

�� Urine output 0.5 ml/kg/hour (30ml/hour)Urine output 0.5 ml/kg/hour (30ml/hour)��

�� Pulse Pulse oximetryoximetry

�� HDU: Arterial catheterisationHDU: Arterial catheterisation

Identify and treat the cause

�� ToneTone

�� TissueTissue

�� TraumaTrauma

�� ThrombinThrombin

�� Bimanual compression, Bimanual compression, oxytocicsoxytocics

�� Remove retained Remove retained placenta/membranesplacenta/membranes

�� Repair genital tract tearsRepair genital tract tears

�� Correct/prevent Correct/prevent coagulopathycoagulopathy

Uterine atony

�� Most common cause of PPHMost common cause of PPH

�� OxytocinOxytocin infusion (as per local protocol)infusion (as per local protocol)��

�� ErgometrineErgometrineIMIM

�� Rectal Rectal misoprostolmisoprostol(up to 800mcg)(up to 800mcg)��

�� Rectal PGE2 (20 mg)Rectal PGE2 (20 mg)��

�� IntraIntra--myometrialmyometrialPG F2 alpha (250 mcg)PG F2 alpha (250 mcg)��

Examination under anaesthetic

�� Remove retained placental tissue ensuring Remove retained placental tissue ensuring the uterus is emptythe uterus is empty

�� Detailed examination of cervix and vagina Detailed examination of cervix and vagina to exclude and repair any lacerationsto exclude and repair any lacerations

�� More More oxytocicsoxytocics

�� Antibiotic coverAntibiotic cover

�� Medical Medical –– PgF2alphaPgF2alpha

Case Scenario

�� You are the SR/consultant called to theatre.You are the SR/consultant called to theatre.

�� Junior Junior registarregistarhas a patient who has lost has a patient who has lost 1500ml has done EUA, given 1500ml has done EUA, given oxytocicsoxytocicsincluding PgF2alpha and the patient is including PgF2alpha and the patient is continuing to bleed.continuing to bleed.

�� What are you going to do?What are you going to do?

Continued bleeding

�� Uterine Uterine tamponadetamponade

�� Foley catheterFoley catheter

�� Double balloon catheterDouble balloon catheter

�� Uterine packingUterine packing

�� SengstakenSengstaken--Blakemore tubeBlakemore tube

�� Consider calling Consider calling gynaegynaeoncologistoncologist

�� Consider arterial Consider arterial embolisationembolisation–– interventional interventional radiologistradiologist

Laparotomy

�� Uterine haemostatic sutureUterine haemostatic suture�� B Lynch sutureB Lynch suture�� Modified B LynchModified B Lynch

�� Arterial Arterial ligationligation�� Bilateral internal artery Bilateral internal artery ligationligation�� Bilateral uterine/ovarian artery Bilateral uterine/ovarian artery

ligationligation�� HysterectomyHysterectomy

�� TotalTotal�� SubtotalSubtotal

Technique

�� 70mm round bodied No.2 CCG70mm round bodied No.2 CCG

�� 3cm from the right lower edge and 3cm 3cm from the right lower edge and 3cm from the right lateral border of the incisionfrom the right lateral border of the incision

�� Thread through into the uterine cavity and Thread through into the uterine cavity and emerge the needle 3cm above the incisionemerge the needle 3cm above the incision

�� Pass the CCG over the Pass the CCG over the fundusfundus33--4cm from 4cm from the right the right cornualcornualborderborder

Technique

�� Feed CCG Feed CCG posteriorlyposteriorlyand vertically.and vertically.�� Enter uterine cavity Enter uterine cavity posteriorlyposteriorlyat same site at same site

as superior anterior entry pointas superior anterior entry point�� Pull CCG under moderate tension, assistant Pull CCG under moderate tension, assistant

applies manual compressionapplies manual compression�� Pass suture horizontally to emerge on Pass suture horizontally to emerge on

posterior wall at the same level but on the posterior wall at the same level but on the left posterior side of the uterusleft posterior side of the uterus

Technique

�� Suture knot using two or three throws whilst Suture knot using two or three throws whilst assistant maintains bimanual compressionassistant maintains bimanual compression

�� Close the lower transverse incision in the Close the lower transverse incision in the uterusuterus

B Lynch suture

�� Advantages Advantages

�� Effective control of haemorrhageEffective control of haemorrhage

�� Conservation of the uterus for fertilityConservation of the uterus for fertility

�� Avoidance of more radical procedure Avoidance of more radical procedure (hysterectomy) and its potential (hysterectomy) and its potential morbiditymorbidity

�� Relatively simpleRelatively simple

Disadvantage:Disadvantage:

--paralytic paralytic ileusileus

Hayman compression sutures

�� Does not require a lower uterine incisionDoes not require a lower uterine incision

�� Uses 1Uses 1--vicryl x 4vicryl x 4

�� Bladder has to be reflected downBladder has to be reflected down

�� Simpler than BSimpler than B--LynchLynch

Balloon Tamponade

Various methods available:

�� SengstakenSengstakentubetube

�� SOSSOS--BakriBakri tamponadetamponadeballoon balloon

cathetercatheter

�� CondomsCondoms

�� FoleyFoley’’ s catheterss catheters

�� Surgical gloveSurgical glove

SOS – Bakri Balloon Tamponade

SOS – Bakri Balloon Tamponade

The indications for use:

� Temporary management of lower uterine segment bleeding.

� Indicated in about one third of all PPH cases.

Sengstaken-Blakemore Balloon Tamponade

Sengstaken-Blakemore Balloon Tamponade

� Esophageal balloon inflated to 250 ml with normal saline� Prophylactic antibiotics� Prevented major surgery in more than 70% of cases� May help reduce bleeding if transfer is required.

Balloon Tamponade with Condoms

� The idea was first introduced by Professor Sayeba Akhter(Dhaka, Bangladesh) to save the life of a woman who had severe jaundice with intractable PPH.

�� Condom is inflated with isotonic saline of 250 Condom is inflated with isotonic saline of 250 –– 500 ml 500 ml

(sometime >500 ml (sometime >500 ml –– 1 L)1 L) ��

�� When the bleeding is reduced considerably, further When the bleeding is reduced considerably, further

inflation is stopped. then outer end of the catheter is inflation is stopped. then outer end of the catheter is

folded and fixed to the thigh.folded and fixed to the thigh.

�� To keep the inflated balloon within the uterus, the post To keep the inflated balloon within the uterus, the post

vagina is packed with sterile packvagina is packed with sterile pack

Uterine Artery Ligation -“O’ Leary Stitch”

� Requires downward bladder reflection to reduce risk of ureteric injury.

�� Bilateral Bilateral ligationligation effective in 90% of caseseffective in 90% of cases

�� High ligature may be required.High ligature may be required.

�� Low risk of longLow risk of long--term complicationsterm complications

Interventional Radiology

�� PercutaneousPercutaneoustranscathetertranscatheterembolisationembolisation

�� Must be performed before uterine artery Must be performed before uterine artery ligationligation

�� Performed under fluoroscopic guidancePerformed under fluoroscopic guidance

�� GelfoamGelfoamis the preferred agentis the preferred agent

�� Angiographic occlusion balloon cathetersAngiographic occlusion balloon catheters

�� Success rate 95Success rate 95--97%97%

�� Useful for Useful for vulvovaginalvulvovaginalhematomashematomas

Interventional Radiology:Disadvantages

�� There may be a significant delay before There may be a significant delay before personnel and equipment are in placepersonnel and equipment are in place

�� Not widely availableNot widely available

�� Contraindicated if Contraindicated if coagulopathycoagulopathyis presentis present

�� Minimal data on subsequent pregnancy Minimal data on subsequent pregnancy outcomesoutcomes

Interventional Radiology:Complications

�� Procedure related morbidity of 6%Procedure related morbidity of 6%

�� PostPost--embolisationembolisationfeverfever

�� Buttock ischemiaButtock ischemia

�� Vascular perforationVascular perforation

�� InfectionInfection

Case scenario

�� You are a GP obstetrician delivering a low You are a GP obstetrician delivering a low risk woman in a country hospital.risk woman in a country hospital.

�� You are delivering the placenta and note You are delivering the placenta and note that her BP has suddenly fallen to 80/40, that her BP has suddenly fallen to 80/40, pulse 40. She is bleeding profuselypulse 40. She is bleeding profusely

�� What do you do?What do you do?

�� What is your differential diagnosis?What is your differential diagnosis?

Concealed PPH

�� If If hypovolaemichypovolaemic…………..and no overt bleeding ..and no overt bleeding considerconsider

�� Broad ligament haematomaBroad ligament haematoma

�� IschiorectalIschiorectalfossafossahaemorrhage/haematomahaemorrhage/haematoma

�� ParavaginalParavaginalhaematomahaematoma

�� Intra abdominal bleedingIntra abdominal bleeding

�� Previous uterine scar Previous uterine scar –– uterine ruptureuterine rupture

�� Rupture of vascular aneurysmsRupture of vascular aneurysms

�� Liver/spleen ruptureLiver/spleen rupture

Conclusions

�� Relevance of PPH worldwideRelevance of PPH worldwide

�� Increasing incidence of PPHIncreasing incidence of PPH

�� ProphylaxisProphylaxis

�� DonDon’’ t forget the basicst forget the basics

�� Good luck!Good luck!