Severe Obstetric Haemorrhage

Max Brinsmead MB BS PhDMay 2015

Introduction The average gravida carries 1 - 1.5 l of “extra

blood” in pregnancy as prophylaxis against PPH but…

PPH is a major cause of obstetric death especially in 3rd world countries

10 - 15% of women lose >600 ml of blood at delivery and…

For 1 - 2% the blood loss can be life threatening

Another 0.5 - 1% have severe antepartum haemorrhage from abruption or placenta previa

This presentation will address…

Emergency (First aid) and

Diagnosis and management of severe APH

Advanced Measures for the management of excessive blood loss in the first 24 hours after birth

Risk factors for Primary PPH Prolonged labour APH Pre eclampsia Maternal obesity Multiple pregnancy Birth weight >4000g Advanced maternal age Previous PPH Assisted delivery Low lying placenta But >50% occur in women without identified risk factors

and… 90% are associated with uterine atony And all studies of massive PPH fail to identify consistent risk

factors

Patient Assessment

Objective measure of blood loss is desirable Postural hypotension the earliest sign Tachycardia is usual Air hunger and loss of consciousness is

serious Urine output a good measure of treatment CVP sometimes A bedside test of blood clotting desirable

Emergency Measures for PPH

Rub up a contraction Deliver the placenta

• If you can

Gain IV access (large bore cannula) Additional oxytocic

• IV Ergometrine 0.25 mg• Syntocinon infusion• Rectal Cervagem or Misoprostol

(Empty the bladder) Bimanual uterine compression Aortic compression

Advanced Measures 1

Get help Check coagulation - use

cryoprecipitate etc. EUA is mandatory Myometrial PG F2 alpha Uterine Packing

• Intrauterine balloon catheter Consider activated Factor VII

Whole blood All components (after 48hrs factors low)

Packed Red cells Red cells only

Frozen plasma All clotting factors except for plateletsStore up to 1 year at -20 to -30 C

Cryoprecipitate Fibrinogen, factors VIII, XIII, VWF

lacks antithromin III

Platelets Only last 5 days

Blood replacement products:

The Coagulation Mechanism

Mechanical Contraction Surgical

Coagulation Cascade Platelet plug Clotting cascade

• Thrombin > Fibrinogen to Fibrin

Termination Removal

Intrauterine Balloon TamponadeBJOG Review May 2009 Was effective in 91.5% of cases

• Combined retrospective and prospective studies• But only a total of 106 patients

Types of balloons• Sengstaken Blakemore (GI use)• Rusch (Urological)• Foley (often multiple)• Bakri (Specifically designed for obstetrics)• Condom (+/- Foley)

But there remain many unanswered questions

Questions concerning intrauterine balloon tamponadeBJOG Review May 2009 Is it effective

• There are no RCTs Risks and contraindications Which balloon to use, how to insert it

and what volume to inflate it Is a vaginal pack required Is an oxytocin infusion required Antibioitics and analgesia When to deflate and or remove it

Advanced Measures 2

Get more help• Medical – haematologist• Surgical colleague• Radiologist for…

Uterine artery embolisation Laparotomy and…

B-Lynch suture Internal iliac artery ligation Aortic clamping Hysterectomy

When confronted with a pregnant patient who is bleeding after 20w

There are five questions that need urgent answers…

How much blood has been lost What is the maternal condition What is the fetal condition Is the patient in labour What is the cause of the bleeding

THINK in terms of aetiology...

Bleeding from a normally situated placenta = Abruption

Bleeding from a low placenta = Placenta previa

Cervical bleeding:• “Show”• Ectropion or Cancer

ACT in terms of priority...

Assess maternal wellbeing Resuscitate if required Anticipate further problems

Assess fetal wellbeing Is the fetus compromised Is the fetus salvageable

Then attempt diagnosis

Essential observations

Maternal vital signs• General appearance• Pulse and BP

Uterus• Size• Tone and tenderness• Contractions• You can’t do this with CTG belts in place

Nature and amount of PV loss Just blood or blood and liquor

Fetus• Fetal heart present or absent

Essential Investigations

HB, Blood group and save or Xmatch• Depends on the amount of blood lost• And the suspected diagnosis• Remember that abruption is often associated with

a large concealed loss Ultrasound

• Best done “on the ward” if bleeding is substantial• Requires skill in distinguishing blood clot from

placenta• Vaginal scan the best way of evaluating degrees

of placenta previa Urinalysis for proteinuria

• May require bladder catheterisation• Abruption may be associated with “acute” pre

eclampsia• And the blood pressure may not be raised

Immediate management

Large bore IV line• If estimated loss is >250 ml• Or if abruption or placenta previa is diagnosed

Resuscitate with IV Fluids• Commence with saline• Colloids if shocked• Blood if estimated loss >2 L

Analgesia Corticosteroids for gestation <37wks

Monitoring response

Maternal PR and BP• Watch for pre eclampsia

Indwelling catheter• Hourly urine output• Only a few require CVP

Watch for coagulopathy• A bedside test of clotting• Prothrombin time (aPTT) and platelets• HB takes a while to adjust

CTG and umbilical Dopplers for the fetus

Definitive management

Conservative for placenta previa• Most will settle• Deliver when paediatric resources permit• But must proceed to CS at any gestation if

the blood loss is life threatening for the mother

Aggressive management for abruption

• CS sooner rather than later for fetal reasons• But vaginal delivery is usually possible with

IUFD• Give more blood than you see • Watch for coagulopathy

Any Questions or Comments?

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