Post partum hemorrhage

1. Post Partum
Hemorrhage
Medical management
By
Dr Nandini Joshi
MD, D.N.B.
Assistant Professor
Dept of OBG, KAMS&RC
08-07-2015

2. OUTLINE
 INTRODUCTION
 INCIDENCE
 DEFINITION
 PHYSIOLOGY
 CLASSIFICATION
 ETIOLOGY
 RISK FACTORS
 PREVENTION
 MEDICAL MANAGEMENT

3. Is Postpartum Hemorrhage
a legacy of our Evolutionary
Past?
 PPH : “An Enigma”
 An unfortunate side effect for natural
selection for Larger brain
 The complimentary increase in neonatal
brain Extremely Invasive pattern of
placenta
 Second contributory factor “Bipedalism”
resulting into narrow pelvis , more
invasiveness of placenta and extreme
remodelling of maternal vasculature

4. PPH: Historical Aspects
Mughal Emperor Shah Jahan had 14 children with his wife, the
Empress Mumtaz.
In 1630, she died of postpartum hemorrhage.
He ordered the building of the most beautiful tomb on Earth for
her.

5. The Swedish Approach
 A different approach in
the same century (17th
century) in Sweden
 Queen Ulrika Eleonora
also lost people close
to her in childbirth
 She mandated one or
two women from each
town to come to
Stockholm for
midwifery training.
 Maternal Mortality
transformed

6. Postpartum Hemorrhage Today:
Living in the shadow of Taj
Mahal
 Most common Cause for MMR
“PPH” (25%- 55%)
 Globally 1,40,000 women die every year
due to PPH otherwise 1 mother dies every
4 minutes -ACOG practice Bulletin 2006
 MMR in India (2011-2012) – 178/100000 live
births
 PPH accounts for 30% of MMR in India

7. Incidence ~ 4.1% of all deliveries & Atonic
PPH – 3.4% - BJOG 2012
One of the Millennium Development
Goals(MDG -5 in 2000) was to reduce
maternal mortality by 75% by 2015.
 But so far only 45% reduction has been
achieved
INCIDENCE

9. DEFINITIONS
 An estimated blood loss of >
500 ml after vaginal delivery & >
1000 ml after cesarean section.
. (Pritchart etal 1962)
 A decline in hematocrit level of
10% (WHO1989)
 Any amount of blood loss that
threatens woman’s
hemodynamic stability.
 Massive PPH refers to a
blood loss of >2000 ml or
>30% of blood volume.
Pitfalls in
definition :
Arbitrary,
subjective,&
based on visual
estimation
(Underestimate
actual blood
loss)

10. CLASSIFICATION OF PPH
PRIMARY PPH SECONDARY PPH
 Occurring within 24
hrs of delivery
(4-6% of all deliveries)
 Occurring after 24hrs
to 6 wks postpartum
1-3 % of all deliveries
Cochrane Database Sits Rev
2002;(1), ACOG Practice
Bulletin 2006

11. Physiological Adaptations
during Pregnancy
 Maternal blood volume expands by 40% to 50%
during pregnancy.
 Blood flow to the gravid uterus at term is 650ml/min,
and large amounts of blood can be lost rapidly from
placental bed in the absence of uterine tone
Living Ligature :
 Myometrial fibers in middle layer, run in criss-cross
manner and have double curvature
 Contraction of these fibers occludes large (spiral
arterioles) blood vessels that run between them.

12. s

13. ETIOLOGY OF PPH 4 ‘T’s
 TONE : Uterine atony (70%), Full Bladder
 TISSUE: Retained tissue ,clots
 TRAUMA: Uterine, cervical or vaginal
laceration
 THROMBIN: Coagulopathy (Pre-existing /
Aquired)

14. ETIOLOGY OF PPH
PRIMARY PPH SECONDARY PPH
Uterine atony (80%)
 Retained products
(placenta,membranes,clot
s)
 Vaginal/cervical
lacerations or haematoma
 Rupture uterus
 Broad ligament
hematoma
 Uterine inversion.
Defects in coagulation
Subinvolution of
placental site
Retained products
of conception
Infection
Inherited
coagulation defects

15. RISK FACTORS FOR PPH: Antenatal
 Past history of hemorrhage( risk in 1st ,2nd &
3rd pregnancy is 5.8%, 14.8%, 21.7%
respectively)
 Placental abruption & Placenta praevia
 Multiple pregnancy (3.3%), macrosomia(2%)
 Hypertension in pregnancy (pre eclamptic
state, eclampsia, HELLP) (2.2%)

16. …Antepartum
 Chorioamnionitis (2.7%)
 Polyhydramnios & Multiparity
 Fetal death
 Anemia
 Uterine myoma, or Manual Removal
of placenta

17. RISK FACTORS FOR PPH- Intrapartum
 Operative / Instrumental delivery- cesarean or
assisted vaginal.
 Prolonged labour (7.6%)
 Precipitate labour (rapid labour),
 Induction or augmentation

18. …Intrapartum
 Chorioamnionitis
 Shoulder dystocia
 Internal podalic version & extraction of 2nd
twin
 Acquired coagulopathy(e.g. HELLP, DIC)
 General anaesthesia with inhaled agents

19. RISK FACTORS FOR PPH – Postpartum
 Lacerations or episiotomy (4.7%)
 Retained placenta (7.8%)
 Placental abnormalities
 Uterine rupture
 Uterine inversion
 Acquired coagulopathy (e.g. DIC)

20. But Remember Always that PPH
is a Very unpredictable
condition and Every parturient
women is at risk of having PPH

21. CLINICAL CLASSIFICATION ADOPTED FROM
BENEDETTI 2002
Hemorrhage
class
Acute
blood loss
(ml)
Blood
loss %
Clinical signs &
symptoms
Management
1 500-1000 15 % Mild tachycardia ,
Tachypnea,
Diaphoresis
Marks Action line,
Observation +/-
Replacement
Therapy
2 1200-1500 20-25
%
Postural Hypotension,
Tachycardia,
Tachypnea, Decrease
urine output
Fluid Replacement
with oxytocics
3 1800-2100 30-35
%
Overt hypotension,
Tachycardia,Tachypne
a, Oliguria, Cold
clammy extrimities
Urgent active
management
4 2400 40% Profound shock Critical active
management

22. “It is extremely difficult to make
complex things simple whereas it is
easy to make simple things
complex”
-Steve Jobs
The Passage of time is likely to increase the complexity
of any given case because continuous bleeding, not
appropriately and adequately controlled on a timely basis,
invariably leads to coagulopathy

23.  The Golden hour
‘ Time by which resuscitation must be initiated to ensure
better survival’.
Because,if medical therapy using 3 or 4 uterotonics has
not worked within one hour, there is no logical reason to
think they will work in next hour
 “Rule of 30”
Patient has probably lost >30% blood volume if,
 Fall in systolic BP by 30mmHg
 Heart Rate rises by 30bpm
 RR rises to >30/min
 Hb or Hct drops by 30%
 Urine output < 30ml/hr
“She is in Moderate to severe Shock”

24. The Lethal Triad –
Bloody Vicious Cycle
 Hypothermia
 Acidosis
 Coagulopathy
 Plays a major role in the morbidity &
mortality of severely injured or
exsanguinating patient

25. PPH Armamentarium
 Uterotonics
 Delayed cord clamping
 Controlled cord traction
 Uterine Massage
 Bimanual compression
 Balloon tamponade
 Compression sutures
 Uterine artery embolization
 Systematic devascularization
 Hysterectomy
Components of
AMTSL

26. PREVENTION OF PPH
 Identify Predisposing Factors.
 Treat anemia & educate patients
regarding PPH.
 High risk patients to be managed in
tertiary care
 I/V access ,arrange blood if assessed as
at risk
 AMTSL (Active management of third
stage)

27. ACTIVE MANAGEMENT OF THIRD
STAGE OF LABOUR (AMTSL)

28. MANAGEMENT OF PPH
 Initial treatment of PPH includes early recognition
followed by prompt attention to the resuscitation
& a simultaneous search for the cause of the
bleeding.
 Once PPH has been identified, management
involves four components, all of which must be
undertaken SIMULTANEOUSLY:
 Communication,
 Resuscitation,
 Arresting the bleeding,
 Monitoring & investigation.
- RCOG 2009

29. JOINT STATEMENT & ACTION PLAN
LAUNCHED IN 2004 BY ICM/FIGO
An algorithm has been suggested for the management of PPH
H.A.E.M.O.S.T.A.S.I.S.
General medical
H: Ask for help
A: Assess (vitals, blood loss) & resuscitate
E: Establish etiology & check Ecbolics (syntometrine, ergometrine, bolus
syntocinon) & Ensure availability of blood
M: Massage uterus
O: Oxytocin infusion, prostaglandins (i/v,rectal,i/m, intra-myometrial)
Specific surgical
S: Shift to operating room, exclude retained products & trauma,
bimanual compression, antishock Garment if transfer required
T: Tissue & Trauma to be excluded , proceed for Tamponade
balloon, uterine packing
A: Apply compression sutures
S: Systematic pelvic devascularization (uterine, ovarian, quadruple, internal
iliac)
I: Intervention radiologist, uterine artery embolization if appropriate
S: Subtotal or total abdominal hysterectomy

30. H – Ask for Help
 Multidisciplinary Approach
Alert –
 Senior obstetrician
 Anaesthetists
 Midwives/ Nursing Staff
 Theatre staff
 Haematologists
 Blood Bank
 Hospital Porters
 Intensive care units

31. A – Assess & Resuscitate
 Assess Vital signs & Estimate Blood Loss
 Adequate venous access : 2 large bore I/V
cannulas(16-18G)
 Draw Blood sample (~20ml) for CBP, Group,
Cross Match, Coagulation screen, RFT & LFT
 Foley’s catheter : Monitoring adequate renal
perfusion.

32. ESTIMATION OF BLOOD LOSS
 Visual Estimation: underestimates
blood loss by 30-50%.
 Clinical Symptoms : changes in clinical
status may lag behind blood loss.
 PPH bags

34. A conical calibrated
drape BRASSS V
DRAPE:
For objective
assessment of blood
loss (decreases error
by 15-33%)
BRASSS V DRAPE
is being used in low
resource setting

35.  Volume replacement
 Fluid of Choice – Crystalloid over colloids
 Crystalloid of choice – Ringer Lactate
 Crystalloid, 3- 5ml / ml of blood loss to maintain
urine output at > 30 ml /hr
 Loss of 1l of blood requires replacement with 4-
5l of crystalloids (NS or RL) or colloids until
Cross – matched blood is available

36. In class III – class IV haemorrhage : CAB of
basic life support should be provided
C Circulation – circulatory blood volume must
be restored & maintained. Infuse 1 litre
crystalloid solution with in 15-20 min, at least 2-3
litres of fluid in first hour to be given.
A Ensure Airway is patent
B Breathing- If respiration is not adequate,
involve anaesthesiologist and intesivist

37. Shock Index : Heart rate/ Systolic BP
 Normal value – 0.5-0.7
 In significant Haemorrhage – 0.9- 1.1
Change in SI – A better correlate in
identifying acute blood loss

38. E – establish etiology, ecbolics,
ensure availability of blood
Rule out 4 ‘T’s and act -
 Tone – Start Massage & uterotonics
 Trauma – EUA & Repair or Pressure
pack
 Tissue – manual removal under
anaesthesia
 Thrombin (coagulopathy) : correction
with FFP, cryoprecipitate

39. M – Massage the uterus
 Manually
 Bimanually

40. BIMANUAL COMPRESSION
Form a fist.
 Place the fist in anterior
fonix & apply pressure
against the anterior wall of
uterus
With the other hand press
deeply into the abdomen
behind the uterus, applying
pressure against the
posterior wall of uterus
Maintain pressure until
bleeding is controlled &
uterus contracts while
continuing resuscitate
measures

41. O – Oxytocin infusion, And
Other ecbolics
 For management of PPH, oxytocin should be
preferred over other uterotonics.
 If oxytocin is not available or alone is not effective,
ergometrine or oxytocin-ergometrine fixed-dose
combination should be offered as 2nd line
treatment.
 If the above 2nd line treatments are not available or
not effective, a prostaglandin should be offered as
the 3rd line of treatment.
-WHO 2009

42. UTEROTONICS:
 Oxytocin
 Methyl Ergometrine , Syntometrine
 Prostaglandins- 15methyl PGF2α,
misoprostol (PGE1)

43. able 1. Medical Management of Postpartum Hemorrhage
Drug* Dose/Route Frequency Comment
Oxytocin (Pitocin) IV: 10–40 units in 1
liter normal saline
or lactated Ringer's
solution @125ml/hr
IM: 10 units
Continuous Avoid undiluted
rapid IV infusion,
which causes
hypotension.
Methylergonovine
(Methergine)
IM/IV: 0.2 mg Every 2–4 h upto 5
doses in 24hrs
Avoid if patient is
hypertensive.
15-methyl PGF2α
(Carboprost)
(Hemabate)
IM: 0.25 mg Every 15min, 8
doses maximum
Avoid in asthmatic
patients; relative
contraindication if
hepatic, renal, and
cardiac disease.
Diarrhea, fever,
tachycardia can
occur.
Misoprostol
(Cytotec, PGE1)
800–1,000 mcg
rectally or
sublingually

44. METHYL ERGOMETRINE
 Require very specific storage conditions, as they
deteriorate rapidly with exposure to light, heat, humidity.
 Side effects: Nausea, vomiting, paresthesias ,chest pain,
tinitus, headache, increased BP
 Contraindicated in:
Sepsis, migraine
Hypertension, heart disease,
Peripheral vascular disease, Raynaud’s phenomenon
Liver & kidney disease,

45. SYNTOMETRINE
 Combination of oxytocin 5U & Ergometrine 0.5mg
 Given I/M
 No important clinical differences in the effectiveness
of syntometrine & oxytocin for the prevention of PPH
, (Choy et al , BJOG 2002; 109,173-177)
 Associated with a higher risk of hypertension,
vomiting
 In severe PPH, syntometrine did not demonstrate a
benefit rather cause increased side effects such as
hypertension & vomiting due to the ergot component
. (Cochrane Database of Systematic Reviews. 2004;1)

46. PGF2α
It is administered in doses of 0.25 mg IM.
Contraindication is asthma due to broncho-
constrictive properties of the F class of
prostoglandins.
Produce nausea, vomiting, diarrhea &
pyrexia, case report of severe
intrapulmonary shunting & hypotension
seen. Cardiac , pulmonary ,renal & hepatic
disease are contraindications

47. MISOPROSTOL
 Synthetic PGE1 analogue
 Oral/ Vaginal/ Rectal/Sublingual
 Oral,sublingual route(faster onset of action).
Rectal & Vaginal routes(greater
bioavailability+longer duration of action).
 Inexpensive, temprature stability
 Plasma concentration peaks in 30 min(oral),
1-2 hrs (vaginal)
 Adverse factors(dose dependent); nausea,
vomiting, diarrhea, chills, shivering, fever.

48. TRANEXAMIC ACID IN PPH
WHO 2009
Tranexamic Acid may be offered in
treatment for PPH if:
(i) Uterotonics has failed to stop the bleeding
(ii) If bleeding may be partly due to trauma.
(Strength of Recommendation – Strong
- WHO 2012)
 There is a consensus view that fibrinolytic
inhibitors (such as tranexamic acid) seldom,
have a place in the management of obstetric
haemorrhage. RCOG 2009

49. BLOOD COMPONENT THERAPY
MTP – Massive Transfusion Protocol
 Involves transfusion of >10PRBCs in
24 hours
 Ideal ratio of RBC:FFP is 1:1
 Can be combined with PRPs if
thrombocytopenia in 1:1:1 ratio

51. Use of Activated Recombinant Factor VII
(Novoseven) in Obstetrics(COG 2010)

52. S – Shift to OT or higher
center
 If initial medical therapy fails within
Golden Hour, shift to a center where
multidisciplinary approach available –
“PPH precedes Death by 2 hours”
 Two important life savior methods to
transfer include
 Aortic compression by Skilled Birth
Attendant
 Non Pneumatic Anti Shock Garment

54. NNASG
 Maintains
circulations to
Vital organs –
Brain , Heart &
Kidney
 No time Limit
 No side effects
like gangrene
as it is Non
Pneumatic

55. “Women are not dying because of a
disease we cannot treat.
They are dying because societies have
yet to make the decision that their
lives are worth saving”.
Mohd. Fathalla,
President of FIGO- 1997
THANK YOU