POSTPARTUM POSTPARTUM HAEMORRHAGEHAEMORRHAGE

DR. JYOTI BHASKAR MD MRCOG

Director LIFECAREIVF

Senior Consultant PUSHPANJALI CROSSLAY, LIFECARE

PPH today living in the shadow of TAJMAHAL

PPHPPHSingle most important cause of maternal Single most important cause of maternal

mortality worldwide.mortality worldwide.

Accounts for 34% of maternal deaths in Accounts for 34% of maternal deaths in developing countries.developing countries.

DefinitionDefinition

Any blood loss than has potential to Any blood loss than has potential to produce or produces hemodynamic produce or produces hemodynamic instability instability

DefinitionDefinitionBlood loss > 500 ml after delivery Blood loss > 500 ml after delivery

> 1000 ml after LSCS> 1000 ml after LSCS

Minor : 500-1000 mlMinor : 500-1000 mlModerate : 1000-2000 mlModerate : 1000-2000 mlSevere : > 2000 mlSevere : > 2000 ml

Proposed classification. Proposed classification. adapted from Benedetti,2002adapted from Benedetti,2002

Hemorrhage Hemorrhage classclass

Estimated Estimated blood lossblood loss (ml)(ml)

Blood Blood volume lossvolume loss (%)(%)

Clinical Clinical signs & signs & symptomsymptom

managemenmanagementt

00 <500<500 <10<10 nonenone nonenone

11 500-1000500-1000 1515 minimalminimal Observation+/-RP Observation+/-RP TxTx

2 2 1200-15001200-1500 20-2520-25↓↓urine outputurine output↑↑pulse ratepulse rate↑↑respiratory raterespiratory ratePostural Postural hypotensionhypotensionNarrow pulse prNarrow pulse pr

Replacement Replacement therapy with therapy with oxytocicsoxytocics

33 1800-21001800-2100 30-3530-35 HypotensionHypotensionTachycardia Tachycardia TachypneaTachypneaCold clammyCold clammy

UrgentUrgent activeactive managementmanagement

44 >2400>2400 >40>40 Profound shockProfound shock Critical active MxCritical active Mx

PREDICTION AND PREVENTIONPREDICTION AND PREVENTION

Identify pt. at riskIdentify pt. at risk

- - Pl previa/accretaPl previa/accreta

- Anticoagulation RxAnticoagulation Rx

- CoagulopathyCoagulopathy

- Overdistended uterusOverdistended uterus

- Grand multiparityGrand multiparity

- Abn labor patternAbn labor pattern

- ChorioamnionitisChorioamnionitis

- Large myomasLarge myomas

- Previous history of PPHPrevious history of PPH

PREVENTIONPREVENTION Regular ANCRegular ANC Correction of anaemiaCorrection of anaemia Identification of high risk casesIdentification of high risk cases Delivery in hospital with facility for Delivery in hospital with facility for

Emergency Obstetric Care. Emergency Obstetric Care. Otherwise transport to the nearest Otherwise transport to the nearest

such hospital at the earliest.such hospital at the earliest. Keep speedy transport availableKeep speedy transport available

ACTIVE MANAGEMENT OF 3ACTIVE MANAGEMENT OF 3RDRD STAGE OF STAGE OF LABOURLABOUR

44thth Stage of labour - Observation, Oxytocin Stage of labour - Observation, Oxytocin

ACTIVE MANAGEMENT OF ACTIVE MANAGEMENT OF 33RDRD STAGE OF LABOUR STAGE OF LABOUR

(WHO-1989)(WHO-1989) Oxytocics - Routine use in third stage Oxytocics - Routine use in third stage

blood loss blood loss by 30-40% and risk of PPH by 30-40% and risk of PPH by 60%by 60% 5 or 10 U Oxytocin IM5 or 10 U Oxytocin IM Syntometrine 1 Amp IMSyntometrine 1 Amp IM Ergometrine 1 Amp IV/IMErgometrine 1 Amp IV/IM-- Misoprost in home birth settings-- Misoprost in home birth settings

Early cord clampingEarly cord clamping Controlled cord tractionControlled cord traction Inspection of placenta & lower genital tractInspection of placenta & lower genital tract CS settings -5 U of oxytocin IV bolus , CS settings -5 U of oxytocin IV bolus ,

CarbetocinCarbetocin

DIAGNOSISDIAGNOSIS&&

MANAGEMENTMANAGEMENT

It is an EnigmaIt is an Enigma

IIt is sudden often unpredicted assessed subjectively Can be catastrophic.

The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

““The golden hour” of The golden hour” of resuscitation resuscitation

““Rule of 30”Rule of 30”

if SBP falls by 30mmHg,if SBP falls by 30mmHg, HR rises by 30 beats/min,HR rises by 30 beats/min, RR ↑to 30breaths/min,RR ↑to 30breaths/min, HCT drop by 30%,HCT drop by 30%, urine output <30ml/hr urine output <30ml/hr lost at least 30% of her blood lost at least 30% of her blood

volumevolume

Guidelines of RCOGGuidelines of RCOGGreen top No.52 May 2009Green top No.52 May 2009

COMMUNICATE. COMMUNICATE. RESUSCITATE.RESUSCITATE. MONITOR / INVESTIGATE. MONITOR / INVESTIGATE. STOP THE BLEEDINGSTOP THE BLEEDING..

CALL CALL FOR FOR

HELPHELP

COMMUNICATECOMMUNICATE

CallCall experienced midwifeexperienced midwife CallCall OObstetric registrar & alert consultantbstetric registrar & alert consultant CallCall anaesthetic registrar , alert consultantanaesthetic registrar , alert consultant AlertAlert haematologist haematologist Alert Alert Blood Transfusion ServiceBlood Transfusion Service CallCall porters for delivery of specimens / bloodporters for delivery of specimens / blood Alert one member of the team to record events, fluids, drugs and vital signs

RESUSCITATERESUSCITATE MINOR PPH (blood loss 500–1000

ml, no clinical shock): Intravenous access (14-G cannula x 1). Commence crystalloid infusion. Consider venepuncture (20 ml) for: Group and screen Full blood count Coagulation screen including

fibrinogen Pulse and blood pressure recording

every 15 minutes.

Full protocol for MAJOR PPH (blood loss > 1000 ml and

continuing to bleed OR clinical shock):

Assess Airway. Breathing. Circulation Oxygen by mask at 10–15 litres/minute. Intravenous access (14-gauge cannula

x 2, orange cannulae). Position flat. Keep the woman warm using

appropriate available measures.

Transfuse blood as soon as possible. Until blood is available, Infuse up to

3.5 litres of warmed Crystalloid Hartmann’s solution (2 litres) and or Colloid (1–2 litres) as rapidly as required.

The best equipment available should be used to achieve RAPID WARMED infusion of fluids.

Fluid Therapy and Blood Fluid Therapy and Blood ProductsProducts

Crystalloid Up to 2 litres Hartmann’s solution

Colloid Up to 1–2 litres colloid until blood

arrives Blood If crossmatched blood is still unavailable, give

uncrossmatched group-specific blood OR give ‘O

RhD negative’ blood Fresh Frozen Plasma 4 units for every 6 units of red

cells or PT/ APTT > 1.5 x normal (12–15 ml/kg or total 1 litre) Platelets concentrates if PLT count < 50 x 109 Cryoprecipitate If fibrinogen < 1 g/l Upto 1 litre of FFP and 10 units of Cryoprecipitate

can be given in case of relentless bleeding.

Main Therapeutic GoalsMain Therapeutic Goals

Main therapeutic goals of management of massive blood loss is to maintain:

haemoglobin > 8g/dl platelet count > 75 x 109/l prothrombin < 1.5 x mean control activated prothrombin times < 1.5 x

mean control fibrinogen > 1.0 g/l.

Recombinant Factor VII Recombinant Factor VII

In the face of life-threatening PPH, and in consultation with a haematologist, rFVIIa may be used as an adjuvant

Dose is 90 micrograms/kg, repeated in the absence of clinical response within 15–30 minutes.

Fibrinogen should be above 1g/l and platelets greater than 20 x 109/l before rFVIIa is given

MONITOR / INVESTIGATEMONITOR / INVESTIGATE Consider venepuncture (20 ml) for: Crossmatch (4 units minimum) full blood count coagulation screen including fibrinogen renal and liver function for baseline. Monitor temperature every 15

minutes. Continuous pulse, blood pressure

recording and respiratory rate (using oximeter, electrocardiogram and automated blood pressure recording).

Foley catheter to monitor urine output.

Consider arterial line monitoring (once appropriately experienced staff available for insertion).

Consider transfer to ITU once the bleeding is controlled or monitoring at high dependency unit on delivery suite, if appropriate.

Recording of parameters on a flow chart such as the modified obstetric early warning system charts.

Documentation of fluid balance, blood, blood products and procedures.

The Four “T”The Four “T”

ToneTone

TissueTissue

TraumaTrauma

ThrombinThrombin

Bimanual Bimanual CompressionCompression

If uterus is relaxed : If uterus is relaxed : massaging the uterus massaging the uterus will expel any will expel any retained bits & retained bits & stimulate uterine stimulate uterine contractionscontractions

Administer Uterotonic DrugsAdminister Uterotonic Drugs

FIRST LINEFIRST LINE

Oxytocin: Oxytocin:

Start with 5 units slow iv or im.Start with 5 units slow iv or im.

Infusion of 20 units in 1 L@ 60 dr/min.Infusion of 20 units in 1 L@ 60 dr/min.

Continue same dose @ 40 dr/min until bleeding Continue same dose @ 40 dr/min until bleeding stops.stops.

Maximum upto 3 L.Maximum upto 3 L.

SECOND LINE SECOND LINE

Ergometrine/ methyl ergometrine:Ergometrine/ methyl ergometrine:

Dose: 0.2 mg im or slow ivDose: 0.2 mg im or slow iv

Repeat 0.2 mg after 15 min.Repeat 0.2 mg after 15 min.

Maximum 5 doses (1 mg)Maximum 5 doses (1 mg)

SyntometrineSyntometrine im im

THIRD LINETHIRD LINE PGF 2PGF 2αα:: Dose: 0.25 mg im.Dose: 0.25 mg im. Can be repeated every 15 min.Can be repeated every 15 min. Maximum upto 2 mg or 8 doses.Maximum upto 2 mg or 8 doses.

Misoprostol:Misoprostol: 200-800 µg sublingually/per rectal200-800 µg sublingually/per rectal Do not exceed 1000 µg Do not exceed 1000 µg

WHO GUIDELINES FOR MANAGEMENT OF PPH 2009WHO GUIDELINES FOR MANAGEMENT OF PPH 2009

If conservative measures fail to control If conservative measures fail to control haemorrhage, initiate surgical haemostasishaemorrhage, initiate surgical haemostasis SOONER RATHER THAN LATER SOONER RATHER THAN LATER

Balloon tamponade Haemostatic brace suturing (such

as using procedures described by B-Lynch or modified compression sutures)

Bilateral ligation of uterine arteries

Bilateral ligation of internal iliac (hypogastric) arteries

Selective arterial embolisation.

Uterine TamponadeUterine Tamponade

• Bakri balloonBakri balloon• Sengstaken Blakemore Sengstaken Blakemore oesophageal catheteroesophageal catheter• Condom catheterCondom catheter• Urological Rusch Urological Rusch balloonballoonSuccess depends upon Success depends upon Positive Tamponade Positive Tamponade testtest

Procedure of condom Balloon Procedure of condom Balloon insertion insertion

Initial AssemblyInitial Assembly Condoms-2Condoms-2 Foley’s catheter-no.16Foley’s catheter-no.16 Saline with iv setSaline with iv set SpeculumSpeculum Sponge holding Sponge holding

forcepsforceps

ProcedureProcedure Lithotomy positionLithotomy position Indwelling Foley’s Indwelling Foley’s

catheter.catheter. Explore uterus, cervix and Explore uterus, cervix and

vagina.vagina. Inflate balloon with 100-Inflate balloon with 100-

300 ml warm 0.9% 300 ml warm 0.9% Sodium chloride until Sodium chloride until bleeding is controlled bleeding is controlled ((Positive Tamponade Positive Tamponade Test).Test).

Compression suturesCompression sutures

B Lynch SutureB Lynch Suture•Fundal Fundal compression compression suturesuture•Apposes Apposes anterior & anterior & posterior wall posterior wall

Contd…Contd…Parallel Vertical compression Parallel Vertical compression sutures for placenta praeviasutures for placenta praevia

Stepwise Uterine DevascularizationStepwise Uterine Devascularization

•Uterine arteriesUterine arteries

•Tubal branch of ovarian Tubal branch of ovarian arteryartery

•Internal iliac arteryInternal iliac artery

Uterine Artery EmbolizationUterine Artery Embolization

Possible only if Possible only if internal artery internal artery ligation has not been ligation has not been done and facility for done and facility for interventional interventional radiology availableradiology available

Resort to hysterectomy Resort to hysterectomy SOONER RATHER SOONER RATHER THAN LATER THAN LATER (especially in cases of (especially in cases of placenta accreta or placenta accreta or uterine rupture)uterine rupture)

Documentation and DebriefingDocumentation and Debriefing

Important to record:Important to record:Sequence of eventsSequence of eventsTime and sequence of administration of Time and sequence of administration of

pharmacological agents, fluids, blood pharmacological agents, fluids, blood productsproducts

The time of surgical interventionThe time of surgical interventionThe condition of mother throughout .The condition of mother throughout .

HAEMOSTASIS HAEMOSTASIS algorithmalgorithm

H- ask for helpH- ask for help A- assess (vitals, blood loss) & A- assess (vitals, blood loss) &

resuscitateresuscitate E -E -

1.1. Establish Establish etiology(tone,tissue,trauma,thrombine)etiology(tone,tissue,trauma,thrombine)

2.2. Ecbolics (syntometrine,ergometrine)Ecbolics (syntometrine,ergometrine)

3.3. Ensure availability of bloodEnsure availability of blood M - massage the uterusM - massage the uterus O – oxytocin infusion & prostaglandinO – oxytocin infusion & prostaglandin

§ S-S-Ø shift to operating theatreshift to operating theatreØ Bimanual compressionBimanual compressionØ Pneumatic anti-shock garmentPneumatic anti-shock garment T- Tissue & trauma to be T- Tissue & trauma to be

excludedexcluded A- apply compression suturesA- apply compression sutures S- systematic pelvic S- systematic pelvic

devascularisationdevascularisation I - interventional radiologyI - interventional radiology S- subtotal/total hysterectomyS- subtotal/total hysterectomy

Conclusion Conclusion We Need We Need

Intelligent anticipationIntelligent anticipation

Skilled supervisionSkilled supervision

Prompt detection Prompt detection

Effective institution of therapy Effective institution of therapy

to prevent disastrous consequences to prevent disastrous consequences of PPHof PPH..

To Conclude, Management To Conclude, Management of PPH Has Evolved From:of PPH Has Evolved From:

PanicPanic PanicPanic Hysterectomy Hysterectomy

PitocinProstaglandinsHappiness

IncidenceIncidence PPH is one of the commonest cause of PPH is one of the commonest cause of

maternal mortality & accounts for 1/4maternal mortality & accounts for 1/4thth of of all maternal death worldwide. (WHO 2005)all maternal death worldwide. (WHO 2005)

In developing countries it accounts over In developing countries it accounts over 1/31/3rdrd of all maternal death. (Khan KS 2006) of all maternal death. (Khan KS 2006)

14 million cases occur each year with a 14 million cases occur each year with a case fatality rate of 1%.(WHO 2004)case fatality rate of 1%.(WHO 2004)

In India PPH responsible for In India PPH responsible for 15-20%15-20% 0f 0f maternal death ( Mukherjee et al 2002).maternal death ( Mukherjee et al 2002).

Post Partum Post Partum haemorrhagehaemorrhage

. . . the most common and severe type of obstetric haemmorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

“ “women are not dying women are not dying because of a disease we because of a disease we cannot treat. They are dying cannot treat. They are dying because societies have yet because societies have yet to make decision that their to make decision that their lives are worth saving”lives are worth saving”

Mamoud Mamoud Fathalla, President of Fathalla, President of FOGSI.19FOGSI.1997 97

Case ScenarioCase Scenario

Doctor is delivering the placenta Doctor is delivering the placenta – after delivery of placenta she – after delivery of placenta she has a sudden gush of bleeding.has a sudden gush of bleeding.

ABCABC VitalsVitals Call for helpCall for help CannulaCannula InvestigationInvestigation FluidsFluids Cause for bleedingCause for bleeding Treatment accordinglyTreatment accordingly

Case Scenario 2Case Scenario 2

No doctor available –No doctor available – Baby has been delivered.Baby has been delivered. Pt is known to be anaemic .Pt is known to be anaemic . How will you manage the third How will you manage the third

stage so as to prevent PPHstage so as to prevent PPH