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THE MEDICAL MANAGEMENT OF THE MEDICAL MANAGEMENT OF

POSTPARTUM HEMORRHAGEPOSTPARTUM HEMORRHAGE

Chukwuma I. Onyeije, M.D.,Chukwuma I. Onyeije, M.D.,

Atlanta Perinatal AssociatesAtlanta Perinatal Associates

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•Provide a

definition of PPH

•Review the risk

factors for PPH

•Understand the

nature and

importance of

rapid diagnosis

and treatment

OBJECTIVES

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For your convenience,A digital copy of this

lecture is also located at:

http://onyeije.net/present

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Mary

24 year old G2P2

Underwent a routine cesarean section at 7.30 pm

Pre-operativeHb was 13 g/dl.

Blood loss of 500cc.

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Mary

4 hours post-partum

Pulse at 100-120 otherwise stable.

BP: 70-90 / 50-60

Analgesia and Hydration provided.

5 hours postpartum: Seizure with obtundation.

Hemoglobin: 7 g/dl, 6

6 Hours post partum: Elevated cardiac enzymesDIC Myocardial Infarction & Liver failure

9 Hours postpartum: Failed arterial embolization

10 Hours postpartum Uterine packing done.

11 Hours Postpartum: Hysterectomy

2 Days Postpartum: Flatline EKG

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‘‘‘‘She died in She died in

childbirth’’childbirth’’

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Hemorrhage has probably killed

more women than

any other complication

of pregnancy in the

history of mankind.

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An estimated

150,000 maternal

deaths worldwide result from obstetric

hemorrhage each year

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90% of deaths fromPostpartum

hemorrhage are preventable.

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WE HAVE

THE

TOOLS

GOOD NEWS

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Those caring for pregnant women must be

prepared to aggressively treat

this complication when it occurs.

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What What

can be can be

done?done?

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THE STEPS TO PPH:

POSTPARTUM HEMORRHAGE:

PREDICT

HANDLE

PREPARE

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THE STEPS TO PPH:

POSTPARTUM HEMORRHAGE:

PREDICT HANDLEPREPARE

Identify patients at risk

Use a multi-

disciplinary Approach

Optimize clinical

management

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Large am

ounts

of blood

can

be lost

rapidly

followin

g

delivery

.

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Uterine co

ntraction

is more

important

than clot

formation

or platel

et aggreg

ation as

a mechanis

m of hemos

tasis

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1. PREDICT:

THE STEPS TO PPH:

POSTPARTUM HEMORRHAGE:

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Can we Predict

PPH?

Who is

at risk?

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Risk Factors for Postpartum

Hemorrhage What Should we do with a list like this?

Prior postpartum hemorrhage

Advanced maternal age

Multifetal gestations

Prolonged labor

Polyhydramnios

Instrumental delivery

Fetal demise

Placental abruption

Anticoagulation therapy

Multiparity

Fibroids

Prolonged use of oxytocin

Macrosomia

Cesarean delivery

Placenta previa and accreta

Chorioamnionitis

General anesthesia

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Clinically Important Risk Factors for Postpartum

Hemorrhage

Prior postpartum hemorrhage

Abnormal placentation

Operative delivery

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Risk Factors for Postpartum

Hemorrhage under Clinical

Control

Prolonged labor

Instrumental

delivery

Anticoagulation

therapy

Prolonged use of

oxytocin

Cesarean delivery

General anesthesia

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Causes of Postpartum Hemorrhage

(another busy slide)Primary causes

Uterine atony

Genital tract lacerations

Retained products

Abnormal placentation

Coagulopathies and anticoagulation

Uterine inversion

Amniotic fluid embolism

Secondary causes

Retained products

Uterine infection

Subinvolution

Anticoagulation

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80% OF CASES OF POSTPARTUM HEMORRHAGE

ARE DUE TO UTERINE ATONY

(a less busy slide)

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What about DIC?

Coagulopathy is a relatively uncommon

cause of primary PPH

Coagulopathy most commonly occurs

when another cause of PPH already

has produced significant blood

loss.

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RDFSRDFS is retained dead fetus syndrome

Well described in most obstetrics

texts

Clinically manifested at about 6

weeks after fetal death

Rarely seen in modern obstetrics.

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Congenital coagulation

disorders

Uncommon individually

As a class are present more

frequently than commonly thought

Examples:

VonWillebrand’s disease

Specific factor deficiencies (factors II,

VII, VIII, IX, X, and XI)

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80% OF CASES OF

POSTPARTUM HEMORRHAGE

ARE DUE TO UTERINE

ATONY

(Did I mention that…)

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Question: What causes

uterine atony and is there

anything we can do to prevent

uterine atony induced

postpartum hemorrhage?

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•

Causes of Uterine Atony:

Overdistension of the uterus

Myometrial laxity as seen in:

Multiparity,

Prolonged labor,

Use of large quantities of oxytocin,

Tocolytic therapy,

General anesthesia.

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Trends in postpartum hemorrhage: United States, 1994–2006

Source: American Journal of Obstetrics & Gynecology 2010; 202:353.e1-353.e6 (DOI:10.1016/j.ajog.2010.01.011 )

Copyright © 2010 Terms and Conditions

William M. Callaghan, MD, MPH, Elena V. Kuklina, MD, PhD and Cynthia J. Berg, MD, MPH

American Journal of Obstetrics & GynecologyVolume 202, Issue 4, Pages 353.e1-353.e6 (April 2010)

DOI: 10.1016/j.ajog.2010.01.011

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Upper Genital Tract Trauma

Most often is the result of

uterine rupture

Bleeding from direct uterine injury during cesarean

Injury of associated vascular structures (uterine, artery or broad ligament varicosities) during cesarean

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Lower Genital Tract Trauma

May occur spontaneously or result from episiotomy, obstetric maneuvers, or operative instrumented deliveries.

Involve perineum, cervix and vagina.

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2. PREPARE:

THE STEPS TO PPH:

POSTPARTUM HEMORRHAGE:

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1.- Prepare for PPH

2.- Optimize patient’s hemodynamic status

3.- Timing of Delivery

4.- Surgical planning

5.- Anesthesia /I.V. access/ invasive monitoring

6.- Modify obsterical management

7.- Increased postpartum/postop surveillance

Patients

at risk

Pre-delivery

management

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Preparation for Postpartum Hemorrhage

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“Perhaps the most important aspect in the management of PPH

is the attitude of the

attendant in charge. It is

critical to maintain equanimity

in what can be a chaotic and

stressful environment”.

Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34

(2007) 421–441

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Analysis Paralysis

An excessive number of well-meaning

individuals increases the ambient

noise, adds to confusion, and opens

the door to communication errors.

Yinka Oyelese, MD, Obstet Gynecol

Clin N Am 34 (2007) 421–441

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1.- Prepare for PPH

-Nursing

-Anesthesia

- Surgical assistance

- Others (I.R.)

Drugs/Equipment

-Methergine

-Hemabate

-Cytotec

-Colloids

-Blood/Bl.products

-Surg. Instruments

-Hemostatic ballons

Personnel

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Anesthesia / I.V. Access Obtain

Anesthesia consultation

•Type of anesthesia

•Need for invasive monitoring

• (A line, Swan-Ganz,

etc)

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• Physicians underestimate blood loss by 50%

• Slow steady bleeding can be fatal

• Most deaths from hemorrhage seen after 5h

• Abdominal or pelvic bleeding can be hidden

Postpartum Hemorrhage is

Easy to miss

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• Estimate blood loss accurately.

• Evaluate all bleeding, including slow bleeds.

• If mother develops hypotension, tachycardia or pain…rule out

intra-abdominal blood loss.

Always look for signs of bleeding

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Identify possible post partum hemorrhage.

Simultaneous evaluation and treatment.

Remember ABCs.

Use O2 4L/min.

If bleeding does not readily resolve, call

for help.

Start two 16g or 18g IVs.

Initial Assessment

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Initial Steps for PPHInitial Steps for PPH

Bimanual compression

Manual exploration of the uterus

Empty the bladder

Administer uterotonic agents

Examine lower genital tract for

lacerations.

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1. Tone (Uterine tone)

2. Tissue (Retained tissue--placenta)

3. Trauma (Lacerations and uterine rupture)

4. Thrombin (Bleeding disorders)

The 4 Ts

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�Uterine atony causes 80% of

hemorrhage

�Assess and treat with uterine

massage

�Use medication early

�Consider prophylactic medication...

T # 1:

Tone: Think of Uterine Atony

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• Confirms

diagnosis of

uterine atony.

• Massage is

often adequate

for

stimulating

uterine

involution.

Bimanual

Uterine

Exam

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Medical Treatment of Medical Treatment of

Postpartum HemorrhagePostpartum Hemorrhage

Medications that cause

uterine contractions

Medications that

promote coagulation

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OXYTOCIN• The common medication used to achieve uterine

contraction

• First-line agent to prevent and treat PPH

• Given IV or IM.

• May cause hypotension.

OXYTOCIN“The Champ”

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1. OXYTOCIN: promotes rhythmic contractions.• Give 10 mg IM or IV, not IU.

1. METHERGINE: promotes rapid tetanic contractions

• 0.2mg (1 amp) IM

1. HEMABATE: promotes long lasting contractions

• 0.25 mg IM q 15min (max X8).

1. CYTOTEC: less effective than methergine

• 400 to 1000 µµµµg (oral, vaginal or rectal)

Summary of Medications Summary of Medications

for Uterine Atonyfor Uterine Atony

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Fluid Management of Postpartum Hemorrhage

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-Balanced *(0.9% NaCl, lactated

Ringers-Hypertonic (3.5,5, 7.5% NaCl)

-Hypotonic (0.45% NaCl)

* Same electrolyte concentration as the extracellular

compartnt

-Albumin (5%, 25%)

-Dextran, glucose polymers (40,

70)

-Hydroxyethyl starch (Hespan)

Crystalloid

Colloid

Blood/Blood Products

Fluid Management of Postpartum Hemorrhage

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Acute Postpartum Blood Loss

PROBLEMS:

Loss of circulatory Volume

Loss of O2 carrying capacity

Restore

volume

1 - Crystalloid

2 - Colloid

�� SaO2

�� O2

carrying

capacity

Supplemental O2 Transfusion

6161

25-30%(15-1800cc) Healthy ? � Crystalloid/Colloid

Medical complications ? � Consider transfusion

30-50%(18-3000cc) Crystalloid/Colloid

Consider transfusion

> 50% ( > 3000cc) Crystalloid/Colloid

Blood transfusion

Clotting factors (FFP, Cryo)

Blood Loss

Hemorrhagic Shock- Fluid Management -

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Class Blood LossVolume Deficit

Spx Rx

I < 1000 cc 15%Orthostatic tachycardia

Crystalloid

II 1001-1500 15-25%

Incr. HR, orthostasis, mental

Decr cap refill

Crystalloid,

III 1501-2500 25-40%

Incr HR, RR Decr BP,

Oliguria

Crystalloid

Colloid, RBCs

IV > 2500> 40%

Obtunded

Oliguria/anuria

CV collapse

RBC, Crystalloid, Colloid

Managing blood loss by hemorrhage classification

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Ways to Optimize

hemodynamic status

1.Acute isovolemic hemodilution

2.Acute hypervolemic hemodilution

3.Autologous donation

4.Preoperative transfusion

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Acute isovolemic hemodilution

Withdraw 2-4 u. of Blood ����Replace the volume with crystalloid ����Lower the pre-op Hct ����Replace the blood at end of surgery

Acute hypervolemic hemodilution

Admin 1500-2000cc Crystalloid ����Hemodilution (Lowers pre-op Hct)

Ways to optimize hemodynamic status

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• Delay of placental delivery > 30 minutes

seen in ~ 6% of deliveries.

• Prior retained placenta increases risk.

• Risk increased with: prior C/S,

curettage p-pregnancy, uterine

infection, AMA or increased parity.

• Prior C/S scar & previa increases risk

(25%)

• Most patients have no risk factors.

• Occasionally succenturiate lobe left behind.

T # 2: TISSUE

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Oxytocin 10U in 20cc of NS placed in clamped

umbilical vein.

If this fails, get OB assistance.

Check Hct, type & cross 2-4 u.

Two large bore IVs.

Anesthesia and OR support.

Removal of Abnormal

Placenta

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• Relax uterus with halothane general

anesthetic and subcutaneous

terbutaline.

• Bleeding will increase dramatically.

• With fingertips, identify cleavage

plane between placenta and uterus.

• Keep placenta intact.

• Remove all of the placenta.

Removal of Abnormal Placenta

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• If successful, reverse uterine atony

with oxytocin, Methergine, Hemabate.

• Consider surgical set-up prior to

separation.

• If manual removal not successful, large

blunt curettage or suction catheter,

with high risk of perforation.

• Consider prophylactic antibiotics.

Removal of Abnormal

Placenta

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Episiotomy

Hematoma

Uterine inversion

Uterine rupture

T # 3: Trauma

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Rare: ~1/2000 deliveries.

Causes include:

Excessive traction on cord.

Fundal pressure.

Uterine atony.

Uterine Inversion

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• Blue-gray mass protruding from vagina.

• Copious bleeding.

• Hypotension worsened by vaso-vagal reaction. Consider atropine 0.5mg

IV if bradycardia is severe.

• High morbidity and some mortality seen: get help and act rapidly.

Uterine Inversion

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• Push center of uterus with three fingers into abdominal cavity.

• Need to replace the uterus before cervical contraction ring develops.

• Otherwise, will need to use MgSO4, tocolytics, anesthesia, and

treatment of massive hemorrhage.

• When completed, treat uterine atony.

Uterine Inversion

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• Rare: 0.04% of deliveries.

• Risk factors include:

• Prior C/S: up to 1.7% of these

deliveries.

• Prior uterine surgery.

• Hyperstimulation with oxytocin.

• Trauma.

• Parity > 4.

Uterine Rupture

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• Risk factors include:

• Epidural.

• Placental abruption.

• Forceps delivery (especially mid forceps).

• Breech version or extraction.

Uterine Rupture

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Sometimes found incidentally.

During routine exam of uterus.

Small dehiscence, less than 2cm.

Not bleeding.

Not painful.

Can be followed expectantly.

Uterine Rupture

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Vaginal bleeding.

Abdominal tenderness.

Maternal tachycardia.

Abnormal fetal heart rate tracing.

Cessation of uterine contractions.

Uterine Rupture before

delivery

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May be found on routine exam.

Hypotension more than expected with

apparent blood loss.

Increased abdominal girth.

Uterine Rupture after

delivery

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Risk factors include:

Instrumented deliveries.

Primiparity.

Pre-eclampsia.

Multiple gestation.

Vulvovaginal varicosities.

Prolonged second stage.

Clotting abnormalities.

Birth Trauma

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Repair of cervical laceration

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• Hematomas less than 3cm in diameter can

be observed expectantly.

• If larger, incision and evacuation of

clot is necessary.

• Irrigate and ligate bleeding vessels.

• With diffuse oozing, perform layered

closure to eliminate dead space.

• Consider prophylactic antibiotics.

Birth Trauma: Hematomas

85Pelvic Hematoma