Management of Post Partum Haemorrhage

DR HUSSEINH AKL O&G SPECIALIST

HOSPITAL SEGAMAT17 NOV.2012

The confidential enquiry into maternal death (CEMACH)

Why CEMACH is important?200 million global pregnancies30 million globally experiences ill health due to pregnancy8 millions have life threatened conditionOver half million women dies as result of pregnancy &

delivery88-98% of MMR in the world are avoidable with timely

and effective care. In UK, MMR 14 per 100.000 (2003-2005) live birth In Malaysia half million deliveries per year.MMR in Malaysia in 1947 - 700 per 100.000 deliveries in 1999 – 30 per 100.000 live birthMMR now 27.4 per 100.000 live birth target according To MDG5 EXPECTED TO BE 14/100.000 BY 2015AND FURTHER DECLINE TO 10/100.000 IN 2020PPH COMPLICATES 2-4% of births

Successes in Maternal Mortality Reduction

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200

400

600

800

1,000

1,200

1,400

1,600

1840 1860 1880 1900 1920 1940 1960 1980 2000

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Malaysia

USA

England & Wales

Sweden

Source: England, Wales, Sweden, USA: VanLerberghe and DeBrouwere, Safe Motherhood Strategies, A Review of the Evidence, 2001 Malaysia, China: Koblinsky, Et al., Issues in Programming for Safe Motherhood, 2000

Causes of Maternal Deaths Malaysia

1991-1996

0%

5%

10%

15%

20%

25%

30%

35%

40%

PPH HDP Embolism Medical Ob trauma Others

199119921993199419951996

What we can do?

Explain to parents Be vigilant & aggressive management of

massive obstetric haemorrhageDon’t promise perfect outcome for mother

& the babyWe can identify and treat problems that

arises but we cannot prevent all complications

PPH

PPH is a major cause of maternal morbidity & mortality world wide accounting for at least 25% of maternal deaths accounting 30% of MMR in Malaysia

Globally > 125.000 women die of PPH each year

Major cause of maternal deaths in the UK (often after CS)

Incidence is 2-11% in the UK

With a low BMI or low Hb, <500ml loss may cause heamodynamic disturbances requiring prompt and appropriate management

PPH is the 2nd leading cause of pregnancy-related death in USA accounting 17% of MMR.

WHO shows PPH occurs in 10-15% of births in developing countries.

14 millions cases of PPH occurs per year globally with case fatality 1-2%.

PPH creates a great morbidity causing physical/ psychological/ social/ economic impacts on the society.

PPH - definitions

Primary PPH – is defined as blood loss of ≥ 500ml for vaginal delivery and ≥ 1000ml for caesarean delivery from the genital tract occurring within 24H of delivery.

Secondary PPH – is defined as excessive loss occurring between 24H and 6-12 weeks after delivery.

10% change of haematocrite between admission and post partum period.

Excessive bleeding producing symptoms and requiring blood tx.

Causes of primary PPH

Uterine atonyGenital tract traumaCoagulation disordersLarge placentaAbnormal placental siteRetained placentaUterine inversionUterine rupture

Uterine Atony ( 90%)

Caused by failure of uterus to contract after delivery

Predisposing factors; over distended uterus with twins or polyhydramnios, big

babies, prolonged labour infectionsretained tissue failure to actively managed 3rd stage of labour or rarely due to placenta abruption (diffuse bleeding into

the uterine muscle that prevents contractions)

Genital Tract Trauma (7%)

Vulva, vaginal tearsepisiotomylacerations of cervix Rupture of the uterus.

Coagulation Disorders

Severe PET, placenta abruption and sepsis may contribute to PPH.

Autoimmune disease, liver disease, inherited or acquired coagulation disorders are rare causes.

Sometimes the patient on heparin can lead to excessive bleeding.

Abnormal Placental Site

Placenta previa, placenta accreta and percreta.

Appropriate preplanning is needed to avoid morbidity &mortality.

Uterine inversion & rupture are rare causes of excessive bleeding.

Causes of secondary PPH

Infection - endometritisRetained placenta parts & membranesSubinvolution of the placenta siteRarely trophoblastic diseasePre-existing uterine lesion like submucous

uterine fibroidVery rarely uterine Arterial Venous MalformationInherited coagulation defect

Antenatal Risk Factors for PPH

Previous PPHPrevious retained

placentaMaternal Hb ≤ 8.5g/dl at

onset of labour.↑ BMIPara 4 or moreAntepartum haemorrhageOverdistention of uterus

Uterine abnormitiesLow-lying placentaMaternal age > 35 years

The presence of any risk factors for PPH should lead to the woman being advised to deliver in an obstetric unit (facilities for blood transfusion & surgical management of PPH)

Intrapartum Risk Factors for PPH

Induction of labourProlonged 1st, 2nd or 3rd stageUse of oxytocinPrecipitate labourVaginal operative deliveryCS

Massive Obstetric Haemorrhage 2nd to PPH

This is an important cause of maternal morbidity & mortality

Identification of the risk factors , institution of preventive measures and prompt & appropriate management of the blood loss is likely to improve the outcome.

Massive PPH loss of 30-40% of the pt’s blood volume (about 2L).

Consequences of Massive PPH

Acute hypovolemiaSudden and rapid cardiovascular

decompensationDICIatrogenic complications associated with

massive blood transfusionPulmonary oedemaTransfusion reactionARDSSheehan’s syndrome (hypopituitarism)

Pathophysiology of Massive Obstetric haemorrhage

Blood volume increased during pregnancy.Blood flow to pregnant uterus at term 500-

800ml/minPlacenta circulation accounting for 400ml/min.Loss of 500-1000ml (10-15% of blood volume) is

usually well tolerated by a fit, healthy young woman as she is able to maintain her cardiovascular parameters by effective compensatory mechanism until 30-40% of the blood volume is loss.

Blood Loss & cardiovascular Parameters

Blood loss HR Systolic BP

Tissue perfusion

10-15% increased normal Postural hypotension

15-30% Increased+ Normal Peripheral vasoconstric

30-40% Increased++ 70-80 mmHg

Pallor, oliguria, confusion, restless

40%+ Increased+++ <60 mmHG

Collapse, anuria, dyspnoea

PPH / Massive Obstetric Heamorrhage Resuscitation

Life-threatening emergency requiring swift & appropriate treatment.

Most units have local guidelines for management such as local hosp geography, staff availability, who to contact & agreed timescales for laboratory results

Activate Red AlertManagement consist of immediate resuscitation,

restore blood volume & rapid treatment of the underlying cause to stop ongoing blood loss.

Initial measures for Resuscitation

Call for help – senior obstetrician, anaesthetists, haematologist, midwife, hospital porter, blood bank & OT staff

High flow facial Oxygen even if the SPO2 is normal.Assess airway & respiration – intubate to protect the

airway if decreased level of consciousness secondary to hypotension.

2 large bore IV cannulla (14G)Take blood for FBC, cross match, U&Es, liver functions,

coagulation screenStart IV cystalloids to correct hypovolemiaCatheterize & measure hourly urine output.

Blood Tx – O-ve blood can be given immediately until cross matched blood is available.

Replace clotting factors – FFP (4 units every 6 units of blood), cryoprecipatate, recombinant activated factor VII

As soon as appropriate in the resuscitation process, transfer the woman to place where there is adequate place, light & equipment to continue treatment (OT)

Assess for CVP lineV/S, urine output, type & quantity of fluids replaced,

drugs given & timelines of events should be recorded by the staff

Once bleeding has been stopped & pt stable, pt should be managed in HDU or ICU

Principles For Stopping the Bleeding

Empty uterus (remove the placental / membranes)

Treat uterine atony ( physically, medically & surgically)

Repair genital tract trauma in OT

Medical Mx of uterine atony

Accompanied by physical attempts to contract uterus – rubbing up the uterus & bimanual compression

500 micrograms of ergometrine IV/ can be given IM if difficulty in IV access

Start oxytocin infusion 40IUIf bleeding doesn't stop, give oxytocin

10IU IV slowly, not bolus

If atony continues, carboprost 250 micrograms IM given in the thigh or directly to myometrium & repeated at 15 min interval up to total 4 doses.

If bleeding persist or ergometrine contraindicated then 800 micrograms of misoprostol (tables) is given rectally.

Recent data shows misoprostol can be use as the 1st line drug to control PPH.

If all measures failed, retained tissue must be considered & the EUA with possible further surgical management is indicated without delay.

Surgical Management of PPH

Tamponade test A Rusch balloon catheter, Sengstaken-Blakemore tube

or Cooke’s balloon inserted into the uterine cavity & fill with 100-500ml warm N/S.

If bleeding is controlled and the balloon is left for 24H and removed.

Tamponade may be particularly useful to control PPH secondary to Placenta previa & accreta.

If conservative intervention for uterine tamponade like uterine packing or balloon tamponade failed then consideration must be given to perform an exploratory laparotomy via vertical midline incision

Several procedures may be performed the choice depends on pt’s desire for future child bearing/ extent of the haemorrhage/ experience of the surgeon.

Intervention after laparotomyMake sure uterine cavity is empty as small pieces of

tissue can cause atony.

If bleeding from large placental sinuses following CS then undersewing the placenta bed ± insertion of Rusch balloon may control bleeding.

If bleeding from uterine atony unresponsive to drug treatment but ↓ with manual compression, B-Lynch or vertical compression sutures should be attempted to provide continuous compression & ↓ blood flow to the uterus.

Systematic pelvic devascularization by ligation of uterine, tubal branch of ovarian or anterior division of internal iliac arteries.

Internal iliac ligation will help in controlling both the uterine & vaginal branch bleeding ( B/L ligation results in 85% reduction of pulse pressure & 50% reduction blood flow & bleeding reduced by 50%).

Hysterectomy is the last option. Subtotal hysterectomy is safer & quicker to perform.

If the bleeding is from the lower segment ( placenta previa, accreta or tears) then total hysterectomy is carried out

The decision for hysterectomy should not be unduely delayed as this can result in the death of the mother.

Procedures 1. Compressive suture – B-Lynch suture in 1997 can be effective

in uterine atony

2. B/L uterine artery ligation –safe & effective method, identify the ureters then ascending branches of uterine artery are ligated at the level of vesicouterine peritoneal reflection.

3. B/L internal iliac artery ligation

4. Hysterectomy –remain definitive measure for control severe PPH, should not be delayed.Placenta accreta is the most common indication for emergency CS hysterectomy.

Arterial Embolization for Massive PPH

AdvantagesLess invasive than laparotomyHelp to preserve fertilityQuicker recovery than laparotomy

DisadvantagesOnly available in a few centresMay not be possible to get the required equipment to

obstetric OT or transfer a woman to the radiology department

Appropriately trained interventional radiologists must be available

Method

A catheter is inserted through the femoral artery and advanced above the bifurcation of the aorta and a contrast dye is injected to identify the bleeding vessels.

The catheter is then directed to the bleeding vessels and embolized with gelatin sponge which is usually reabsorbed in 10 days.

Updates of the surgical Mx of PPH

Systematic review of conservative management of PPH what to do when medical Tx fails

48 studies included in the review 2006The cumulative outcome showed success rates

of 90.7% ( confidence interval 95%) for arterial embolization – 84% for ballon tamponade – 91.7% for uterine compression sutures and 84.6% for internal iliac ligation or uterine devascularization.

At present there is no evidence to suggest that anyone method is better for the management for severe PPH.

RCT of various treatment options may be difficult to perform in practice.

Balloon tamponade is the least invasive and the most rapid approach, it would be logical to use this as the 1st step in the management.

Case Illustration 127 year old G2 P1, had antenatal follow-up and

delivery at private maternity centre. Scanty information as to what happened had ante-natally, but was known to have had a ventouse delivery and subsequently developed uterine atony. Transferred out to a government hospital and arrived 2 ½ hours after delivery. By then, patient was moribund and very pale. Laprotomy decided upon, but patient died before surgery could be performed.

Q1. What is the risk factor to the mother? Q2. What are the commonest causes of uterine atony?

Q3. Explain the management of uterine atony in hospital.

Answers A1. Ventouse delivery and subsequently developed uterine

atony.

A2. Common causes can be divided into 2 main categories: Predetermined Risk Factors

Uterine over distensionMultiparityAnaemiaPast obstetric history of PPHAnte-partum haemorrhage Uterine fibroid/retained products of conception

Controllable Risk FactorsOperative deliveriesAnaesthesiaProlonged labourMismanagement of 3rd stage

A3. As in lecture.

Case Illustration 2

26 years old G2 P1 admitted to GH for post dates. Induced with prostin and subsequently had ventouse extraction. Developed PPH and blood loss underestimated. Uterus was found to be atonic and cervical tear noted. MO attempted to suture cervical tear unsuccessfully. Meanwhile patient continued bleeding. O&G specialist called in as patient collapsed. Resuscitation carried out and hysterectomy performed 1 ¼ hours after delivery. By then, DIVC had set in. Patient died in ICU 8 hours later.

Q1. What are the causes of death for this patient?

Q2. Explain the management of PPH secondary to genital trauma.

AnswerA1.

PPH due to atonic uterus and cervical tearSecondary to DIVC

A2. Perform general resuscitative measures

Correct hypovolaemia/hypotensionSet up a minimum of 2 iv drips for major PPH (>1000cc blood loss) a 3rd iv line or CV should be consideredStabilise the patient with crystalloids (Hartman’s) or colloids (haemacele/gelafusin)Take blood for FBC, GXM, Plt

Place the patient in lithotomy positionFind bleeding point if visible and clamp itSuture tear immediatelyStart broad spectrum antibioticsPlace continuous bladder drainageWatch out for bleeding

THANK YOU

For Attending

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Egypt