POSTPARTUM HEMORRHAGE (PPH) British Columbia Section

POSTPARTUM HEMORRHAGE
(PPH)
British Columbia
Section
2006
OVERVIEW OF PRESENTATION
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Definitions
Diagnosis
Etiologies
Risk Factors
Management Options
DEFINITION
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Excessive blood loss that makes the patient
symptomatic (ie lightheadedness, vertigo, syncope)
+/- signs of hypovolemia (ie hypotension,
tachycardia, or oliguria)
A subjective assessment
Traditionally: (although they underestimate EBL)
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EBL >=500 cc after vaginal delivery
EBL >=1000 cc after a cesarean section
Can also use a decline in Hct of 10% to define PPH
INCIDENCE
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Affects 5-15% of women giving birth
Two categories:
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Early (primary) hemorrhage: occurs within the first
24 hours postpartum
Late (secondary) hemorrhage: occurs after 24
hours postpartum
PREVENTION
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Identifying the risk factors
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Assess every woman’s risk for PPH and make
appropriate arrangements for her care
Active management of the 3rd stage of labour
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Will discuss later
ETIOLOGIES: 4 T’s
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Tone: uterine atony, ~ 1 in 20 deliveries
Tissue: retained placental tissue
Trauma: uterine, cervical or vaginal
lacerations
Thrombin: dilutional coagulopathy,
consumptive coagulopathy and coagulation
disorders
Uterine Atony
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Most common cause of PPH
Accounts for 75-80% of cases of primary
PPH
Need to be aware of risk factors
Risk Factors For Uterine Atony
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Over distended uterus
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Polyhydramnios
Multiple gestation
Macrosomia
Uterine muscle
exhaustion
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Rapid labour
Prolonged labour
High parity
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Intra amniotic infection
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Fever and/or prolonged
labour
Functional/anatomical
distortion of the uterus
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Fibroid uterus
Placenta previa
Uterine anomalies
GENITAL TRACT TRAUMA and Risk
Factors
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Second most common cause of PPH
Lacerations of cervix or vagina:
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Precipitous delivery
Operative delivery
Genital tract hematomas
Uterine rupture:
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spontaneous (1/1900 deliveries)
blunt trauma (eg. MVA)
previous uterine scar
GENITAL TRACT TRAUMA and Risk
Factors
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Lacerations/extensions at C-section:
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Prolonged labour
Malposition
Deep engagement
UTERINE INVERSION and Risk Factors
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Iatrogenic
During 3rd stage of labour:
inversion Æ traction on peritoneal structures Æ
vasovagal response Æ vasodilation Æ increased
bleeding and risk of hypovolemic shock
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Risk factors:
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High parity
Fundal placenta
Retained Products of Conception and
Risk Factors
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Retained blood clots:
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Atonic uterus
Retained products:
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Abnormal Placenta: accreta, percreta,
succenturiate lobe
Previous uterine surgery (ie: myomectomy)
High parity
Incomplete placenta at delivery
Coagulation Abnormalities and Risk
Factors
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Pre-existing states:
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Hemophilia A
Von Willebrand’s Disease
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History of hereditary coagulopathies
History of liver disease
Therapeutic anti-coagulation:
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History of blood clots
Coagulation Abnormalities and Risk
Factors – cont’d
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Acquired in pregnancy:
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ITP
Pre-eclampsia and thrombocytopenia
DIC
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Pre-eclampsia
Dead fetus in utero
Severe infection
Abruption
Amniotic fluid embolism
Active Management of the 3rd Stage
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Use of uterotonic drugs after the delivery of the
anterior shoulder:
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Oxytocin 10 U IM, 5 U by IV push or 10-20 U per litre IV drip
running at 100-150 cc/hr
Early cord clamping and controlled cord traction
Ensure continued uterine contraction post delivery of
placenta by fundal palpation and massage if
necessary
Inspect placenta for completeness
Approach to Identifying Etiology
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Abdominal palpation: boggy vs. firm uterus, ?uterine
inversion
Careful inspection of cervix, vagina, vulva and
perianal area for lacerations and/or hematomas
Manual exploration of uterine cavity: remove clots,
retained tissue?
Consider coagulopathy if no other cause identified
PRIMARY MANAGEMENT – “ABC’s”
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Notify attending physician and other staff
Monitor vital signs, urine output, possible foley
1 large bore IV
Type of cross-match 2-4 units of PRBC’s
Fluid resuscitation with crystalloids
Baseline blood work for Hgb, hematocrit, platelets
and coagulation profile
Then proceed with directed treatment
TREATMENT OF UTERINE ATONY
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Bimanual compression and massage of uterus
Drugs:
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Rapid, continuous infusion of dilute IV oxytocin (40-80 U in
1L NS)
Misoprostil (Cytotec, PGE1): 800-1000 mcg rectally
Methylergonovine maleate (Methergine): 0.2 mg IM repeat
q5mins as needed up to 5 doses:
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Contraindicated in women with hypertension
Prostaglandin F2α analogues (Hemabate): 0.25 mg IM
repeat q15 mins prn up to 8 doses
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Contraindicated in those with asthma/brochospasm
TREATMENT OF UTERINE ATONY
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Methods to Tamponade the Uterus
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Uterine packing
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SOS Bakri Balloon/other brand uterine balloons
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Pack uterus with gauze layering from one cornua to the other
with a sponge stick ending such that the gauze is allowed to
extend though the cervical os
Insert balloon
Instil 300-500cc saline
Foley catheter
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Can insert one or more bulbs
Instil 60-80cc of saline
TREATMENT OF GENITAL TRACT
TRAUMA
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Lacerations: identify and repair with
continuous interlocking sutures
Large expanding hematomas
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Sx: Pelvic or rectal pressure, pain
Tx: Drain the blood within the hematoma, can
place a drain in situ, suture the incision, vaginal
packing or interventional radiology if hematoma
expansion cannot be tempered
TREATMENT OF GENITAL TRACT
TRAUMA
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Uterine rupture: repair small defects, may
need total abdominal hysterectomy
Uterine inversion
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Can replace manually by placing the palm of the
hand against fundus and by exerting upward
pressure with the fingertips circumferentially
May need to relax uterus with agents such as
magnesium sulfate, halothane, terbutaline or
nitroglycerin in order to replace uterine corpus
TREATMENT OF RETAINED
PLACENTAL TISSUE
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Manual removal
Curettage (with a large curette)
Extensive placenta accreta may need a
hysterectomy
TREATMENT OF COAGULOPATHY
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Reverse anticoagulation
Von Willebrand’s disease:
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Desmopressin before the surgery and post for
severe hemorrhage
Replace Factors:
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Platelet concentrate, cryoprecipitate, fresh frozen
plasma, platelets, packed RBC’s
INTRACTABLE PPH
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Get help
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Local control
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Manual compression and packing of uterus
Vasopressin at site of bleeding in c-section
BP and coagulation
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Notify OB, anesthesia and ICU
Crystalloids and blood products to maintain urine output, BP
and coagulation
Consider angiographic embolization
Intractable PPH - Surgical Approach
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Repair of lacerations
Surgical uterine compression techniques
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Ligation of vessels
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Example: B-Lynch
Uterine arteries
Internal iliacs
Emergency Hysterectomy
Uterine artery/internal iliac embolization
Delayed (Secondary) PPH
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Between 24hrs and 12 weeks postpartum
Affects 0.5 – 2 % of women
Secondary to atony due to retained products
Management:
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Uterotonic agents
Antibiotics
Possible D&C
COUNSELLING
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Women with a prior PPH have ~ 10% risk of
recurrence in a subsequent pregnancy
Always consider preventative measures
Counsel appropriately
Take appropriate measures
REFERENCES:
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Prevention and Management of Postpartum
Haemorrhage. SOGC clinical guidelines. JOGC,
April 2000
Postpartum Hemorrhage. ACOG Practice Bulletin
No. 76. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006: 108:10391047.
Jacobs, A. Causes and treatment of postpartum
hemorrhage. Uptodate online (14.3)