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Postpartum Hemorrhage:
What Does The Evidence
Show?
MAJ Katrina Walters
4 A ril 2011
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The Impact of PPH
Worldwide a woman dies every 4 minutesfrom PPH
Top 5 reasons for maternal morbidity
Affects 1 to 19% of deliveries
Incidence is increasing in high resourcecountries(BMC Pregnancy & Childbirth 2009; 9:55.)
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Complications of PPH
Anemia
PP Depression(J Nutr 2003 DEC; 133(12):4139)
Acute Renal Failure, Myocardial Infarction,ARDS, Shock
Transfusions/ Surgery
Sheehans Syndrome Death
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Outline
Definitions
Etiology/ Risk Factors
Prevention through Active Management
Initial Management
Advanced Techniques
Blood Product Utilization
Summary
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Definitions (1 of 2)
Multiple andproblematic
Traditional
> 500ml forVaginal Delivery
> 1000ml EBL
Cesareansection
Excess bleeding +s/sx hypovolemia Gabbe, CH 18
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Definitions (2 of 2)
Drop in Hct of 10% after delivery
Hct not a clear indicator of acute status
Primary vs. Secondary
Early vs. Late
Severe PPH
Recognition may be hampered by occult
bleeding
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Etiology
Bleeding from Placental Implantation Site
Trauma to Genital Tract
Coagulation Defects
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The 4 Ts of PPH
CAUSE INCIDENCE
(APPROX)
TONE Atony 70%
TRAUMA Lacerations,hematoma, inversion,rupture
20%
TISSUE Retained placenta,invasive placenta
10%
THROMBIN Coagulopathies 1%
Am Fam Physician 2007; 75:875.
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Bleeding from Placentation Site(Risk Factors)
Uterine Atony
Halogenated hydrocarbon GETA
Hypotension
Overdistended uterus
Exhausted myometrium
Prior Uterine atony
Retained Placental Tissue
Abnormal placentation
Succenturiate (Extra) Lobe
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Trauma to Genital Tract(Risk Factors)
Episiotomy/Lacerations
Instrumented
Delivery Compound Fetal
Presentation
Surgical Delivery Hematomas
Uterine Inversion
Uterine Rupture
Prior uterine scar
High parity
Hyperstimulation
Obstructed labor
Midforceps rotation
Intrauterinemanipulation
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Coagulation Defects(Risk Factors)
Abruption
Prolonged retention of dead fetus
Amniotic fluid embolism
Massive transfusions
Severe Pre-eclampsia/ Eclampsia
Congenital Coagulopathies
Anticoagulant Rx
Sepsis
Saline Induced Abortions
Placental Abruption
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Other Risk Factors (1 of 2)
Previous PPH
14.8% with 2nd Pregnancy
21.7% with 3rd Pregnancy
10.2% with 3rd if PPH in 1st but not 2ndpregnancy(Med J Aust 2007 Oct 1; 187(7):391)
Prolonged 3rd Stage
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Other Risk Factors (2 of 2)
Small Maternal Blood Volume
Small Stature
Hypervolemic constricted states (Pre-eclampsia)
Obesity
Native Americans, Hispanics, Asians
Epidural Anesthesia
Nulliparity
Women with female genital mutilation(Lancet 2006JUN3; 367 (9525):1835)
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Risk Factor Identification
Small proportion with RF develop PPH and
many women without RF have PPH
Consider early Type and Screen/Cross for RF
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P ti th h A ti
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Prevention through ActiveManagement of Third Stage
(2 of 3) Prophylactic Pitocin (SOR A)(Cochrane Database Sys Rev 2001; 4: CD001808)
Does timing matter?
(Cochrane Database Sys Rev 2010; 8: CD006173)
Are other uterotonics as effective? (SOR B)(Cochrane Database Sys Rev 2007; 2:CD005456.)
Cord Traction(Am J Obstet Gynecol 1997 Oct;177(4):770, Repro Health 2009; 6:2)
Uterine Massage after Placenta Delivery(Cochrane Database Syst Rev 2008 Jul16; 3:CD006431)
P ti th h A ti
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Prevention through ActiveManagement of Third Stage
(3 of 3) Early Cord Clamping(Pediatrics 2006 APR; 117(4):e779)
Cord Drainage
(Cochrane Database Sys Rev 2005; 4: CD004665.)
Fundal Pressure vs. Cord Traction(Cochrane Database Sys Rev 2007; 4: CD005462)
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Other Prevention Stategies
Tranexamic Acid(Cochrane Database Sys Rev 2010 JUL7; 7: CD007872)
Avoid Routine Episiotomy (SOR A)(Cochrane Database Sys Rev 1999;3:CD000081)
Continuous Presence of Midwives
Xuesaitong(Zhongguo Zhong Xi Yi Jie He Za Zhi 2002 MAR; 22(3):182 [Chinese])
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Initial Management of PPH(1 of 2)
Recognize PPH
Delay in initial care increases risk of severePPH(Obstet Gynecol 2011 JAN;117(1):21)
Fundal Massage
Intravenous Access
Follow local protocols if available (SOR B)(BJOG 2004 May; 111:495, BJOG 2010; 117:1278)
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Initial Management of PPH(2 of 2)
Treat Uterine Atony since this is mostcommon cause for PPH
Uterotonics (SOR C)
Pitocin
Ergot Alkaloids
Prostaglandins
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Uterotonics
Pitocin(Obstet Gynecol 2001; 98:386)
Methergine
Hemabate(AM J Obstet Gynecol 1990 JAN;162(1):205)
Misoprostol (SOR B)
Route?(BJOG 2004;112:547)
Is it effective?(Cochrane Database Syst Rev 2007;1:CD003249)
Does the order matter?
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Pitocin
Dose/
Route
Cost Mechanism Contra-
Indications
Onset Duration
10U IM
10-40Uin 1LNSover
10min
$85 IncreasedcontractionsbyincreasingintracellularCalcium
3-5 min IM
IVImmediate
2-3 hours
1 hour
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Methergine
Dose/
Route
Cost Mechanism Contra-
indications
Onset Duration
0.2mgIM Q2-4hours
Oral0.2mg
$11 perampule
$1.60per tab
UterineSmoothmusclecontraction >Vasoconstrict
Hypertension
Scleroderma,Raynauds
IM-2-5 min
Oral-5-10min
3 hours
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Hemabate
Dose/
Route
Cost Mechanism Contra-
Indications
Onset Duration
0.25 mgIM
Q15minto maxdose of2mg
$49per
dose
Prostaglandinaffect on
myometrium,also affectsarterioles andbronchioles
Asthma 2-5 min 2 hours
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Cytotec
Dose/
Route
Cost Mechanism Contra-
Indications
Onset Duration
200
1000mcg
OralSLPR
Vaginal
$0.60
per tab
Prostaglandin
affects inmyometrium
SL >
Oral >Vaginal /Rectal
Vaginal/
Rectal >SL/Oral
3-6 hours
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Unresponsive to Uterotonics
Bimanual Uterine compression
HELP! (OB, Anesthesia, Nursing, OR)
2nd Large Bore IV
Fluids + Blood Products
Anderson JM, AFP 2007
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Unresponsive to Uterotonics
Look for other causes! (SOR C)
Explore uterus for retained products
Inspect cervix and vagina
Incise and Evacuate Large Hematomas(SOR B)(South Med J 1987 AUG;80(8):991)
Consider Type and Cross Place a Foley catheter to monitor Is/ Os
Labs for coagulopathy
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Uterine Tamponade
Bakri Balloon
Foley, BT-Cath,Sengstaken-
Blakemore Tube Gauze Packing
(Obstet Gynecol Survey 2007; 62(8): 540)
Jacobs AJ, Up to Date 2009
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Shorter time to bleeding stopped
Decreased units of blood transfused
Decreased need for additional uterotonics
No increased morbidity or mortality(J Obstet Gynaecol Res 2009 JUN;35(3):453)
External Aortic CompressionDevice
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Uterine Artery Embolization
Requires available facilities/ personnel
Hemodynamically Stable Patient
Temporizing measure en route to OR
Fertility Effects(Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992)
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Surgical Intervention (1 of 4)
Gabbe, Ch 18
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Surgical Intervention (2 of 4)
Gabbe, Ch 18
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Surgical Intervention (3 of 4)
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Surgical Intervention (4 of 4)
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Recombinant Activated Factor VII
Initiates coagulation at site of tissue injury viatissue factor
Used for massive hemorrhage
$$$
Observational reports of 80% success ratebut only used when all other measures short
of hysterectomy failed(Obstet Gynecol 2007; 110:1270)
SOR C
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Blood Product Utilization
Local protocols are helpful
Dont wait for lab abnormalities if actively
bleeding!
Massive hemorrhage without replacement ofcoagulation factors (FFP) will result incoagulation abnormalities
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Product Contents Volume Effect
Whole Blood 500ml Hct 3%
PRBCs RBCs, WBCs, few
plasma proteins
300ml Hct 3%, less
fever
Platelets Pooledconcentrate
1 unit = 6 pack
50ml PLT 5-10K
FFP Fibrinogen, ATIII,
clotting factors,plasma
250ml fibrinogen 5-
10mg/dl
Cryoprecipitate Fibrinogen,Factor VIII, XIII,vWF
40ml fibrinogen 5-10mg/dl
Blood Product Utilization
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Blood Product Utilization
Active Bleeding and Hct < 25 = PRBCs
PLT < 100K or massive transfusion =Platelets
Fibrinogen < 125 = cryoprecipitate/ FFP
Massive bleeding or INR > 1.5 = Fresh frozenplasma
No consensus on ratio of RBC:FFP:PLT(J Trauma 2007; 62:307, J Trauma 2006; 60:S51)
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Refusal of Blood Products
Jehovahs Witnesses 44-fold increased risk ofdeath(Am J Obstet Gynecol 2001 Oct;185(4):893)
Intraoperative Blood Salvage andAutotransfusion
Optimize pre-delivery Hgb
Gluten as volume expander
Hyperbaric Oxygen
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Summary
Active Management of Third Stage of Labor isimperative
Always be prepared for PPH, risk factors are
not always present and prevention doesntalways work
Focus on the basics, dont forget fluid/ blood
product replacement
Bakri Balloon and Uterine Artery Embolizationmay be temporizing measures available onthe way to the OR
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