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8/13/2019 faktor risiko HPP http://slidepdf.com/reader/full/faktor-risiko-hpp 1/20 National Women’s Health Clinical Guideline / Recommended Best Practice Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. POSTPARTUM HAEMORRHAGE Developed by: Clinical Director O&G Classification: NMP200 / SSM / 075  Authorised by: Clinical Director O&G Date Issued: Updated July 2009 Postpartum Haemorrhage Page: 1 of 20   Associated Documents   Primary Postpartum Haemorrhage Definitions & Management   Primary PPH Flowchart – Management from Labour & Birthing Unit – (modified from PROMPT course)  Immediate Management from Labour & Birthing    As ses s  Replace   Arrest Bleeding  Ongoing Monitoring   Ap pen di x 1: Pri mar y PPH – Furt her Detail Including Risk Factors    Appendix 2: Uterine / Vaginal Tamponade   Ap pen di x 3: Lap aro to my fo r Fu rt her Surgical Measures, Including BLynch    Appendix 4: Recombinant Factor VIIA   Appendix 5: Secondary Postpartum Haemorrhage  References Associated Documents Type Document Titles Board Clinical  Blood Components & Blood Products Administration  Surgical Safety Checklist ( under development) National Women’s Clinical  Group & Screen Requirements - Inpatients  Intrapartum Care - Normal Labour & Birth  Intra-Operative Cell Salvage (IOCS) - Obstetrics NZBS   ADHB Blood Resource http://www.nzblood.co.nz/dhb/auckland/index.htm Primary Postpartum Haemorrhage Definitions Management Term Definition Primary Within 24 hours of delivery Secondary  After 24 hours post partum Postpartum Haemorrhage Blood loss >=500ml Major Postpartum Haemorrhage Blood loss >=1000ml and/or unstable Management  Identify PPH  Get help   Assess, arrest and replace bleeding simultaneously – see flowchart  

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Page 1: 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

Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009

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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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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Developed by Clinical Director OampG Classification NMP200 SSM 075 Authorised by Clinical Director OampG Date Issued Updated July 2009

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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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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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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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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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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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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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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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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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 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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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 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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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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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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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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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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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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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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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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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 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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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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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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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

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

Page 11: 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 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

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 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

httpslidepdfcomreaderfullfaktor-risiko-hpp 1320

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

Page 12: faktor risiko HPP

8132019 faktor risiko HPP

httpslidepdfcomreaderfullfaktor-risiko-hpp 1220

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

httpslidepdfcomreaderfullfaktor-risiko-hpp 1320

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

httpslidepdfcomreaderfullfaktor-risiko-hpp 1420

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

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

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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)

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

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

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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

Page 14: faktor risiko HPP

8132019 faktor risiko HPP

httpslidepdfcomreaderfullfaktor-risiko-hpp 1420

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

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

Page 15: faktor risiko HPP

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

Page 16: faktor risiko HPP

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

Page 17: faktor risiko HPP

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

Page 18: faktor risiko HPP

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

Page 19: faktor risiko HPP

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

Page 20: faktor risiko HPP

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