THE MEDICAL MANAGEMENT OF THE MEDICAL MANAGEMENT OF POSTPARTUM HEMORRHAGEPOSTPARTUM HEMORRHAGE
Chukwuma I. Onyeije, M.D.,Chukwuma I. Onyeije, M.D.,Atlanta Perinatal AssociatesAtlanta Perinatal Associates
•Provide a definition of PPH
•Review the risk factors for PPH
•Understand the nature and importance of rapid diagnosis and treatment
OBJECTIVES
For your convenience,A digital copy of this
lecture is also located at:
http://onyeije.net/present
Mary
24 year old G2P2
Underwent a routine cesarean section at 7.30 pm
Pre-operativeHb was 13 g/dl.
Blood loss of 500cc.
Mary
4 hours post-partum
Pulse at 100-120 otherwise stable.
BP: 70-90 / 50-60
Analgesia and Hydration provided.
5 hours postpartum: Seizure with obtundation.
Hemoglobin: 7 g/dl,
6 Hours post partum: Elevated cardiac enzymesDIC Myocardial Infarction & Liver failure
9 Hours postpartum: Failed arterial embolization
10 Hours postpartum Uterine packing done.
11 Hours Postpartum: Hysterectomy
2 Days Postpartum: Flatline EKG
‘‘‘‘She died in She died in childbirth’’childbirth’’
Hemorrhage has probably killed
more women than any other complication of pregnancy in the history of mankind.
An estimated150,000 maternal deaths
worldwide result from obstetric
hemorrhage each year
90% of deaths fromPostpartum
hemorrhage are preventable.
WE HAVE THE
TOOLS
GOOD NEWS
Those caring for pregnant women must be
prepared to aggressively treat
this complication when it occurs.
What What can be can be done?done?
THE STEPS TO PPH:
POSTPARTUM HEMORRHAGE:
PREDICT
HANDLE
PREPARE
THE STEPS TO PPH:
POSTPARTUM HEMORRHAGE:
PREDICT HANDLEPREPARE
Identify patients at risk
Use a multi-
disciplinary Approach
Optimize clinical
management
Uterine Blood FlowUterine Blood Flow
Large amou
nts
of blood c
an
be lost
rapidly
following
delivery.
Uterine cont
raction is m
ore
important th
an clot form
ation
or platelet
aggregatio
n as
a mechanism
of hemostasi
s
1. PREDICT:
THE STEPS TO PPH:
POSTPARTUM HEMORRHAGE:
Can we Predict PPH?
Who is at
risk?
Risk Factors for Postpartum Hemorrhage
What Should we do with a list like this?
Prior postpartum hemorrhage
Advanced maternal age
Multifetal gestations
Prolonged labor
Polyhydramnios
Instrumental delivery
Fetal demise
Placental abruption
Anticoagulation therapy
Multiparity
Fibroids
Prolonged use of oxytocin
Macrosomia
Cesarean delivery
Placenta previa and accreta
Chorioamnionitis
General anesthesia
Clinically Important Risk Factors for Postpartum
Hemorrhage
Prior postpartum hemorrhageAbnormal placentationOperative delivery
Risk Factors for Postpartum Hemorrhage under Clinical
Control
Prolonged labor
Instrumental delivery
Anticoagulation therapy
Prolonged use of oxytocin
Cesarean delivery
General anesthesia
Causes of Postpartum Hemorrhage(another busy slide)
Primary causes
Uterine atony
Genital tract lacerations
Retained products
Abnormal placentation
Coagulopathies and anticoagulation
Uterine inversion
Amniotic fluid embolism
Secondary causes
Retained products
Uterine infection
Subinvolution
Anticoagulation
80% OF CASES OF POSTPARTUM HEMORRHAGE
ARE DUE TO UTERINE ATONY
(a less busy slide)
What about DIC?
Coagulopathy is a relatively uncommon cause of primary PPH
Coagulopathy most commonly occurs when another cause of PPH already has produced significant blood loss.
RDFSRDFS is retained dead fetus syndrome
Well described in most obstetrics texts
Clinically manifested at about 6 weeks after fetal death
Rarely seen in modern obstetrics.
Congenital coagulation disorders
Uncommon individually
As a class are present more frequently than commonly thought
Examples:VonWillebrand’s disease
Specific factor deficiencies (factors II, VII, VIII, IX, X, and XI)
80% OF CASES OF POSTPARTUM HEMORRHAGE ARE DUE TO UTERINE
ATONY
(Did I mention that…)
Question: What causes uterine atony and is there
anything we can do to prevent uterine atony induced postpartum hemorrhage?
•Causes of Uterine Atony:
Overdistension of the uterus
Myometrial laxity as seen in:
Multiparity,
Prolonged labor,
Use of large quantities of oxytocin,
Tocolytic therapy,
General anesthesia.
Trends in postpartum hemorrhage: United States, 1994–2006
Source: American Journal of Obstetrics & Gynecology 2010; 202:353.e1-353.e6 (DOI:10.1016/j.ajog.2010.01.011 )
Copyright © 2010 Terms and Conditions
William M. Callaghan, MD, MPH, Elena V. Kuklina, MD, PhD and Cynthia J. Berg, MD, MPH
American Journal of Obstetrics & GynecologyVolume 202, Issue 4, Pages 353.e1-353.e6 (April 2010)
DOI: 10.1016/j.ajog.2010.01.011
Upper Genital Tract Trauma
Most often is the result of uterine ruptureBleeding from direct uterine injury during cesarean
Injury of associated vascular structures (uterine, artery or broad ligament varicosities) during cesarean
Lower Genital Tract Trauma
May occur spontaneously or result from episiotomy, obstetric maneuvers, or operative instrumented deliveries.
Involve perineum, cervix and vagina.
2. PREPARE:
THE STEPS TO PPH:
POSTPARTUM HEMORRHAGE:
1.- Prepare for PPH
2.- Optimize patient’s hemodynamic status
3.- Timing of Delivery
4.- Surgical planning
5.- Anesthesia /I.V. access/ invasive monitoring
6.- Modify obsterical management
7.- Increased postpartum/postop surveillance
Patients at risk
Pre-delivery management
Preparation for Postpartum Hemorrhage
“Perhaps the most important aspect in the management of PPH
is the attitude of the attendant in charge. It is
critical to maintain equanimity in what can be a chaotic and
stressful environment”.
Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441
Analysis Paralysis
An excessive number of well-meaning individuals increases the ambient noise, adds to confusion, and opens the door to communication errors.
Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441
1.- Prepare for PPH
-Nursing -Anesthesia - Surgical assistance - Others (I.R.)
Drugs/Equipment
-Methergine-Hemabate-Cytotec-Colloids-Blood/Bl.products
-Surg. Instruments-Hemostatic ballons
Personnel
Anesthesia / I.V. Access Obtain
Anesthesia consultation
•Type of anesthesia
•Need for invasive monitoring
• (A line, Swan-Ganz, etc)
• Physicians underestimate blood loss by 50%
• Slow steady bleeding can be fatal
• Most deaths from hemorrhage seen after 5h
• Abdominal or pelvic bleeding can be hidden
Postpartum Hemorrhage is Easy to miss
• Estimate blood loss accurately.
• Evaluate all bleeding, including slow bleeds.
• If mother develops hypotension, tachycardia or pain…rule out intra-abdominal blood loss.
Always look for signs of bleeding
Identify possible post partum hemorrhage.
Simultaneous evaluation and treatment.
Remember ABCs.
Use O2 4L/min.
If bleeding does not readily resolve, call for help.
Start two 16g or 18g IVs.
Initial Assessment
Initial Steps for PPHInitial Steps for PPH
Bimanual compression
Manual exploration of the uterus
Empty the bladder
Administer uterotonic agents
Examine lower genital tract for lacerations.
1. Tone (Uterine tone)
2. Tissue (Retained tissue--placenta)
3. Trauma (Lacerations and uterine rupture)
4. Thrombin (Bleeding disorders)
The 4 Ts
Uterine atony causes 80% of hemorrhage
Assess and treat with uterine massage
Use medication early
Consider prophylactic medication...
T # 1:Tone: Think of Uterine Atony
• Confirms diagnosis of uterine atony.
• Massage is often adequate for stimulating uterine involution.
Bimanual Uterine Exam
Medical Treatment of Medical Treatment of Postpartum HemorrhagePostpartum Hemorrhage
Medications that cause
uterine contractions
Medications that
promote coagulation
METHERGINE
“Speedy”
OXYTOCIN“The Champ”
CytotecInexpensive (?) Effective
Medications for Uterine AtonyMedications for Uterine Atony
OXYTOCIN• The common medication used to achieve uterine contraction
• First-line agent to prevent and treat PPH
• Given IV or IM.
• May cause hypotension.
OXYTOCIN“The Champ”
• Causes rapid tetanic uterine contraction.
• May trap placenta.
• Can cause Hypertension
• Contraindicated in hypertensive patients and those with pre-eclampsia.
METHERGINE
METHERGINE
“Speedy”
• Hemabate 0.25mg IM or IU.
• Previously known as Prostin.
• Controls hemorrhage in 86% when used alone, and 95% in combination with above.
• Can repeat up to eight times.
• Contraindicated in asthma and (?) hypertension.
• Can cause nausea/vomiting/diarrhea
Prostaglandin F2 15-methyl
1. OXYTOCIN: promotes rhythmic contractions.• Give 10 mg IM or IV, not IU.
2. METHERGINE: promotes rapid tetanic contractions • 0.2mg (1 amp) IM
3. HEMABATE: promotes long lasting contractions• 0.25 mg IM q 15min (max X8).
4. CYTOTEC: less effective than methergine• 400 to 1000 g (oral, vaginal or rectal)
Summary of Medications Summary of Medications for Uterine Atonyfor Uterine Atony
Fluid Management of Postpartum Hemorrhage
-Balanced *(0.9% NaCl, lactated Ringers-Hypertonic (3.5,5, 7.5% NaCl)
-Hypotonic (0.45% NaCl)
* Same electrolyte concentration as the extracellular compartnt
-Albumin (5%, 25%)
-Dextran, glucose polymers (40, 70)-Hydroxyethyl starch (Hespan)
Crystalloid
Colloid
Blood/Blood Products
Fluid Management of Postpartum Hemorrhage
Acute Postpartum Blood Loss
PROBLEMS:Loss of circulatory Volume
Loss of O2 carrying capacity
Restore volume
1 - Crystalloid
2 - Colloid
SaO2 O2 carrying capacity
Supplemental O2Transfusion
61
25-30%(15-1800cc) Healthy ? Crystalloid/Colloid
Medical complications ? Consider transfusion
30-50%(18-3000cc) Crystalloid/ColloidConsider transfusion
> 50% ( > 3000cc) Crystalloid/ColloidBlood transfusionClotting factors (FFP, Cryo)
Blood Loss
Hemorrhagic Shock- Fluid Management -
Class Blood Loss Volume Deficit Spx Rx
I < 1000 cc 15% Orthostatic tachycardia Crystalloid
II 1001-1500 15-25%
Incr. HR, orthostasis, mental
Decr cap refill
Crystalloid,
III 1501-2500 25-40%Incr HR, RR Decr BP,
Oliguria
Crystalloid
Colloid, RBCs
IV > 2500> 40%
Obtunded
Oliguria/anuria
CV collapse
RBC, Crystalloid, Colloid
Managing blood loss by hemorrhage classification
Ways to Optimize
hemodynamic status
1.Acute isovolemic hemodilution
2.Acute hypervolemic hemodilution
3.Autologous donation
4.Preoperative transfusion
64
Acute isovolemic hemodilution
Withdraw 2-4 u. of Blood Replace the volume with crystalloid Lower the pre-op Hct Replace the blood at end of surgery
Acute hypervolemic hemodilution
Admin 1500-2000cc Crystalloid Hemodilution (Lowers pre-op Hct)
Ways to optimize hemodynamic status
• Delay of placental delivery > 30 minutes seen in ~ 6% of deliveries.
• Prior retained placenta increases risk.
• Risk increased with: prior C/S, curettage p-pregnancy, uterine infection, AMA or increased parity.
• Prior C/S scar & previa increases risk (25%)
• Most patients have no risk factors.
• Occasionally succenturiate lobe left behind.
T # 2: TISSUE
Oxytocin 10U in 20cc of NS placed in clamped umbilical vein.
If this fails, get OB assistance.
Check Hct, type & cross 2-4 u.
Two large bore IVs.
Anesthesia and OR support.
Removal of Abnormal Placenta
• Relax uterus with halothane general anesthetic and subcutaneous terbutaline.
• Bleeding will increase dramatically.
• With fingertips, identify cleavage plane between placenta and uterus.
• Keep placenta intact.
• Remove all of the placenta.
Removal of Abnormal Placenta
• If successful, reverse uterine atony with oxytocin, Methergine, Hemabate.
• Consider surgical set-up prior to separation.
• If manual removal not successful, large blunt curettage or suction catheter, with high risk of perforation.
• Consider prophylactic antibiotics.
Removal of Abnormal Placenta
Episiotomy
Hematoma
Uterine inversion
Uterine rupture
T # 3: Trauma
Rare: ~1/2000 deliveries.
Causes include:
Excessive traction on cord.
Fundal pressure.
Uterine atony.
Uterine Inversion
• Blue-gray mass protruding from vagina.
• Copious bleeding.
• Hypotension worsened by vaso-vagal reaction. Consider atropine 0.5mg IV if bradycardia is severe.
• High morbidity and some mortality seen: get help and act rapidly.
Uterine Inversion
• Push center of uterus with three fingers into abdominal cavity.
• Need to replace the uterus before cervical contraction ring develops.
• Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage.
• When completed, treat uterine atony.
Uterine Inversion
• Rare: 0.04% of deliveries.
• Risk factors include:
• Prior C/S: up to 1.7% of these deliveries.
• Prior uterine surgery.
• Hyperstimulation with oxytocin.
• Trauma.
• Parity > 4.
Uterine Rupture
• Risk factors include:
• Epidural.
• Placental abruption.
• Forceps delivery (especially mid forceps).
• Breech version or extraction.
Uterine Rupture
Sometimes found incidentally.
During routine exam of uterus.
Small dehiscence, less than 2cm.
Not bleeding.
Not painful.
Can be followed expectantly.
Uterine Rupture
Vaginal bleeding.
Abdominal tenderness.
Maternal tachycardia.
Abnormal fetal heart rate tracing.
Cessation of uterine contractions.
Uterine Rupture before delivery
May be found on routine exam.
Hypotension more than expected with apparent blood loss.
Increased abdominal girth.
Uterine Rupture after delivery
Risk factors include:
Instrumented deliveries.
Primiparity.
Pre-eclampsia.
Multiple gestation.
Vulvovaginal varicosities.
Prolonged second stage.
Clotting abnormalities.
Birth Trauma
Repair of cervical laceration
• Hematomas less than 3cm in diameter can be observed expectantly.
• If larger, incision and evacuation of clot is necessary.
• Irrigate and ligate bleeding vessels.
• With diffuse oozing, perform layered closure to eliminate dead space.
• Consider prophylactic antibiotics.
Birth Trauma: Hematomas
Pelvic Hematoma
The 4 “Ts” Recalled
“THROMBIN” Check labs if suspicious.
Top Related