1) Prevention & Management of PPH 2024.pptx

obstetric emergency

1. PPH

2. Vaginal delivery : EBL> 500ml CS : EBL>1000ml Definition EBL > 1500ml PPH Massive PPH

3. Bleeding occurs within 24 hours postpartum definition Bleeding occur after 24 hours till 6 weeks post partum primary secondary

4. epidemiology

5. Post-partum haemorrhage (PPH), the leading cause of maternal death worldwide , accounts for about 19.7% of maternal deaths  There are considerable variations across regions with for instance PPH accounting for about 8.0% of maternal deaths in developed countries compared to 19.7% in the developing countries Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, Gulmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–33 .

6. Maternal outcomes for obstetric haemorrhages , e.g. PPH, are also more severe in developing countries Maswime S, Buchmann E. A systematic review of maternal near miss and mortality due to postpartum hemorrhage. Int J Gynaecol Obstet. 2017;137(1):1–7.

7. Maternal outcomes for obstetric haemorrhages , e.g. PPH, are also more severe in developing countries Maswime S, Buchmann E. A systematic review of maternal near miss and mortality due to postpartum hemorrhage. Int J Gynaecol Obstet. 2017;137(1):1–7.

8. Statistic in malaysia

9. 4,497,374 Big numbers catch your audience’s attention

10. A woman Delivered vaginally in a private clinic to a stillbirth. … Referred to our unit with post-partum haemorrhage . Admitted in our unit at midnight in shock, no recordable blood pressure, cold extremities, pre renal failure, gasping breath sounds, atonic uterus. Evacuated more than one litre of blood clots from her uterus. The amount of blood loss before admission not mentioned in the referral note. Started on IV fluids ... Started on blood transfusion, bleeding stopped one hour later at 2am, uterus well contracted. Blood pressure improved to 90/50. Received 2 units of whole blood and 2 units of fresh frozen plasma. At 5am, she again developed profuse vaginal bleeding with atonic uterus, prepared for theatre, no more blood available in our blood bank, intubated but arrested before further treatment .”. She only stayed with us for about 40 minutes and died during resuscitation before she was transfused.” “ PPH is an emergency and usually many things are done simultaneously, … she died because of severe blood loss/preexisting anaemia and lack of more blood for transfusion.”

11. Prevention & Management of PPH

12. “ An Ounce of prevention is worth a pound of cure” Benjamin Franklin Life, 4 th of July, safety

13. ANTICIPATION IS CRUCIAL ANTENATAL THOROUGH HISTORY & PHYSICAL EXAMINATION INTRAPARTUM THOROUGH DOCUMENTATION POST PARTUM IDENTIFY HIGH RISK PATIENT

14. PREVENTION RISK REDUCTION MANAGEMENT!

15. PREVENTION (ANTENATAL 1) 1. ALL PREGNANT WOMEN Documented risk assesement at booking, admission & in labour with appropriate risk stratification (based on risk factor of PPH)

16. PREVENTION (ANTENATAL 2) 2. ROUTINE CARE – Optimize pre-delivery haemoglobin

17. PREVENTION (ANTENATAL 3) 3. MATERNAL BLOOD DISORDER COAGULATION Haemophilia , VWD, HELLP THROMBOCYTOPAENIA/ PLATELET DYSFUCTION ITP, dengue VESSEL WALL vasculitis, connective tissue

18. PREVENTION (ANTENATAL 4) 4. PREVIOUS CAESARIAN SECTION

19. PREVENTION (ANTENATAL 5) 5. ELECTIVE CAESARIAN SECTION & INDUCTION OF LABOUR

20. OTHER RISK FACTORS - Grandmultipara - Fetal macrosomia - Multiple pregnancy - Polyhdramnious - Fibroid in pregnancy - h/o indeterminate APH

21. PREVENTION (INTRAPARTUM 1) CLINICAL ASPECT RISK REDUCTION MEASURES 1. EPISIOTOMY SELECTIVE USE OF EPISIOTOMY CAUTION IN PATIENTS WITH PROMINENT VULVA VARICOSITIES 2. 3 rd STAGE OF LABOUR - ACTIVE MANAGEMENT 3 RD STAGE 3. MORE THAN 1 IDENTIFIED RISK FACTOR DELIVER IN HOSPITAL WITH SPECIALIST IV ACCESS IN ACTIVE PHASE OF LABOUR FBC AND GSH ACTIVE MANAGEMENT OF 3 rd STAGE 4. CHORIOAMNIONITIS - BROAD SPECTRUM ANTIBIOTIC - CLOSE BP,PR,RR, TEMPERATURE MONITORING

22. PREVENTION (INTRAPARTUM 2) CLINICAL ASPECT RISK REDUCTION MEASURES 5. INSTRUMENTAL DELIVERY ENSURE VALID INDICATION ENSURE PEREQUISITES ARE FULLFILLED PERFORMED BY TRAINED PERSONNEL 6. TRIAL OF VAGINAL BIRTH AFTER CAESARIAN SECTION (VBAC) - CLOSE MONITORING FOR ANY EARLY SIGN OF UTERINE RUPTURE/ DEHISCENCE

23. PREVENTION (INTRAPARTUM 3) CLINICAL ASPECT RISK REDUCTION MEASURES 7. EMERGENCY CAESARIAN SECTION ENSURE IV ACCESS DO GXM ENSURE REGISTRAR / SPECIALIST PRESENT IF Increased risk of extended uterine tear Deeply engaged fetal head ( prolonged 2 nd stage, failed instrumental) Transverse lie Placenta praevia / abruptio Evidence of abnormal coagulation

24. PREVENTION POST PARTUM RISK REDUCTION MEASURES CLINICAL ASPECTS RISK REDUCTION MEASURES More than 1 risk factors for PPH – observation following vaginal delivery & caesarian section Monitor in HDU/ labour room ( at least for first 2 hours using MOMS chart) Oxytocin infusion Consider carbetocin in selected patient if available Actively encourage / assist women to void soon after birth Fascilitate skin-to-skin contact with baby, under supervision Promote endogenous release of oxytocin by :- keeping woman calm & warm assisting early breast feeding

25. PREVENTION POST PARTUM RISK REDUCTION MEASURES CLINICAL ASPECTS RISK REDUCTION MEASURES Early recognition of perineal haematoma Look for peritoneal haematoma if : Hypovolemic shock disproportionate to the revealed blood loss Feelings of pelvic pressure Urinary retention Excessive or persistent perineal pain

26. Prevention of PPH could be achieved through identification of women at highest risk , allowing for measures to be taken for active management of third stage of labour , t he presence of experienced clinicians and immediate access to resources such as oxytocin infusion and tranexamic acid. Predicting risk of postpartum haemorrhage : a systematic review

27. In settings where multiple uterotonic options are available, oxytocin (10 IU, IM/IV) is the recommended uterotonic agent during 3 rd stage of labour for the prevention of PPH for all birth 2018 Recommendations (PPH Prevention)

28. In settings where oxytocin is unavailable (or its quality cannot be guaranteed), the use of other injectable uterotonics ( carbetocin , or if appropriate ergometrine/ methylergo or oxytocin and ergometrine fixed-dose combination) or oral misoprostol is recommended In settings where skilled health personnel are not present to administer injectable uterotonics, the administration of misoprostol (either 400 µg or 600 µg PO) by community health care workers and lay health workers is recommended for the prevention of PPH. 2018 Recommendations (PPH Prevention)

29. 2020 Recommendations (PPH Prevention) WHO recommendation on routes of oxytocin administration for the prevention of postpartum haemorrhage after vaginal birth The use of oxytocin (10 international units [IU], intramuscular / intravenous) is recommended for the prevention of postpartum haemorrhage for all births . In situations where women giving birth vaginally already have intravenous access, the slow intravenous administration of 10 IU oxytocin is recommended in preference to intramuscular administration. (Context-specific recommendation)

30. 2020 Recommendations (PPH Prevention) WHO recommendation on advance misoprostol distribution to pregnant women for prevention of postpartum haemorrhage In settings where women give birth outside of a health facility and in the absence of skilled health personne l, a strategy of antenatal distribution of misoprostol to pregnant women for self-administration is recommended for prevention of postpartum haemorrhage , only with targeted monitoring and evaluation. (Context-specific recommendation)

31. MANAGEMENT OF PPH - component - shock - secondary PPH

32. All FOUR components MUST BE done SIMULTANEOUSLY !!!!!

33. Call for help Activate Red Alert Alert Senior Obstetrician Alert Anaesthetic team : to support in resuscitation & intensive monitoring in the intensive care Alert Blood Bank Alert Porter Check blood availability Allocate roles to team members Alert one member to record events, fluids, drugs & vital sign Keep patient’s next-of-kin informed

34. Airway, breathing, circulation (ABC) Assess consciousness : ensure airway protected High flow oxygen 15L/min 2 large bore branula & blood for cross match Fluid Resuscitation – crystalloid (Ringer’s Lactate ) upto 2 litres (ratio volume 1:3) - preferred first as compared to colloid - colloid ( Gelofusine ) upto 1-2 litres arrives (ratio 1:1) Insert CBD, monitor I/O Blood (Emergency ‘O’ blood) , consider MTP activation

35. Ensure rapid replacement while awaiting for the blood If blood loss is > 30% - blood transfusion must be started Remember blood loss is often underestimated Avoid the vicious cycle of hypothermia, acidosis & coagulopathy in the massively transfused patient- give warm fluids & use blanket warmer Correct electrolyte imbalance esp ---- hyperkalaemia & hypocalcaemia

36. MTP Pack 1 4 PC 4 FFP MTP Pack 2 4 PC 4 FFP 4 platelet / cryoprecipitate If Ca < 1.1 mmol/L or after 8 PC – include IV calcium gluconate 10% 10ml

37. Management Goals Temp > 35º C pH >7.2 Base excess < -6 Lactate < 4mmol/L Ca² + > 1.1mmol/L Platelet >50 x10 ⁹/L PT/APTT < 1.5 x normal INR ≤ 1.5 Fibrinogen > 1g/L

38. Poor prognostic values in resuscitation Temperature < 34ºc Base deficit > -6 PH < 7.1 Lactate > 4 mmol/l Ionized calcium < 1.1 mmol/l

39. BP, PR, RR, SPO2 every 15min & document Temperature – avoid hypothermia Pain score Fluid balance – monitor input output Invasive monitoring Take blood samples for FBC, coagulation profile, ABG Assess on going bleeding *** ensure all investigation taken REVIEWED & MANAGED accordingly

40. Find the cause Uterine massage Ensure placenta and membranes are complete Administer uterotonics Specific management

41. Restoration of circulatory blood volume to maintain adequate tissue perfusion & oxygenation is the essence of PPH management THUS, early recognition & timely intervention to prevent SHOCK & its consequences Blood loss is always underestimated, Therefore PLEASE look for the clinical sign of :- Tachycardia Hypotension Reduced pulse pressure Delayed capillary refilling time Oliguria

42. Clinical correlation of blood loss in a 50 kg patient BLOOD LOSS (% blood volume) MEAN ARTERIAL BLOOD PRESSURE (mmHg) SYMPTOMS/ SIGNS 10-15% (500 ml) NORMAL 70-90 Postural hypotension Mild tachycardia (90-100bpm) 15-30% (1,000-1,500 ml) Slight fall Tachycardia (110-120 bpm) Thirst Weakness 30-40% (1,500 – 2,000 ml) 50-60 Tachycardia (120-140 bpm) Pallor Oliguria (<30 ml/ h) Confusion Restlessness >40% (>2,000 ml) <50 Tachycardia (>140 bpm) Anuria Air hunger Coma Death Clinical correlation of blood loss in a 50 kg patient

43. Shock Index may be used as an adjunct to diagnose occult shock (if >1) SHOCK INDEX - HR/SBP (normal 0.7 -0.9) MEASURE THE PHYSIOLOGICAL IMPACT OF BLOOD LOSS

44. EARLY SHOCK LATE SHOCK Awake, aware , anxious Confused or unconscious Slightly fast pulse (110 per minute or greater) Very fast and weak pulse Slighly fast breathing (30 respiration per minute or greater) Extremely fast and shallow breathing Pale Pale and cold Mild low blood pressure (systolic less than 90 mmHg) Very low blood pressure Urine output of 30 ml per hour or greater Urine output less than 30 mls per hour

45. Sequalae of shock

46. Management of specific cause

47. Management of specific cause

48. 1. UTERINE ATONY (70%)

49. PPH treatment Massage the uterus Make sure 3 rd stage oxytocin given Expel any blood clots Make sure empty bladder

50. PPH treatment oxytocin 10 IU IM or 5IU slow IV push, or 20 -40IU/I IV fluid infusion mechanism : stimulate the upper segment myometrium to contract rhythmically, decreasing blood flow to uterus by constricting spiral artery cautious : water intoxication, hypersensitivity, hypotension sYNTOMETRINE Ergometrine 0.5 mg + oxytocin 5 IU Repeat dose of 1 ml after no less than 2 hour if necessary CI : HPT and cardiac disease

51. PPH treatment carbetocin Long acting synthetic analogue of oxytocin Dose : 100 µg If inadequate contraction with single dose, DO NOT repeat dose, consider other uterotonic IV bolus over 1 minute Cautious : DO NOT give prior to delivery of fetus hypersensitivity , serious CVS disease Carboprost ( haemabate ) Prostaglandin F-2 α Dose : 250µg, repeat every 15-90 min. Max total dose is 2 mg or 8 doses IM or intramyometrial cardiac, pulmonary or hepatic disease cautious in asthma, anaemia , diabetes

52. PPH treatment Tranexamic acid Anti fibrinolytic loading dose of 1 gm then infusion 1 gm 30 minutes later if required Loading : infusion over 10 minutes (1 gm in 100ml 0.9% NACL) Maintanence : Infusion over 8 hours ( Igm in 100 ml 0.9% Nacl ) GIT disturbance misoprostol Cytotec , prostaglandin E1 analogue 800 - 1000µg (8 to 10 tablets) Rectal, slow onset of administration. Consider early administration Mech : generalized smooth muscle contraction Nausea, vomiting, diarhhoea , abdominal pain

53. Tranexamic acid in PPH WHO 2017 Early used of tranexamic acid (Within 3 h of birth ) in addition to standard care is recommended for women with clinically diagnosed pph following vd or cs WOMAN (World Maternal Antifbrinolytic TRIAL 20,060 in 193 hospital over 21 countries IV tranexamic 1 gm followed by 2 nd dose if bleeding continued after 30 min or restarted within 24 H of 1 st dose vs placebo Reduced death due to bleeding ACOG 2017 RECOMMENDED AS 2 nd LINE TREATMENT FIGO 2022 Early use of intravenous tranexamic acid as soon as pph is diagnosed but within 3 h of birth in addition to standard care is recommended for women with clinically diagnosed pph following vd or cs

54. INTRAUTERINE BALLON INSERTION

55. This Photo by Unknown Author is licensed under CC BY-SA RUSCH BALLON SENG STAKEN BLACKMORE BALLON

56. UTERINE COMPRESSION EXTERNAL UTERINE COMPRESSION

57. SURGICAL INTERVENTION : UTERINE COMPRESSION SUTURE - aim to exert continuous compression on the uterine vascular system B-LYNCH COMPRESSION SUTURE HAYMAN COMPRESSION SUTURE

58. SURGICAL INTERVENTION

59. SURGICAL INTERVENTION This Photo by Unknown Author is licensed under CC BY-NC HYSTERECTOMY INTERNAL ILIAC ARTERY LIGATION

60. Management of specific cause

61. 2. TRAUMA (20%) Consider to use tranexamic acid in genital tract trauma Perform a EUA if cervical or deep vaginal tears are suspected technique CERVICAL TEAR VAGINAL/VULVA TEAR @ HAEMATOMA TRAUMA DURING CAESARIAN SECTION UTERINE RUPTURE

62. Vulvo -vaginal haematoma : - conservative : if the patient stable & not imcreasing may require blood transfusion/ should be on antibiotic - surgical : unstable or increasing size evacuation of haematoma + repair +/- corrugated drain -radiological intervention- arterial embolization

63. Management of specific cause

64. PHYSIOLOGY Volume of blood loss depends on how long it takes the placenta to separate from the uterine wall and how effectively the uterine muscle contracts in the immediate postpartum period . AREN L. MAUGHAN, M.D., STEVEN W. HEIM, M.D., M.S.P.H., and SIM S. GALAZKA, M.D., University of Virginia School of Medicine, Charlottesville, Virginia Am Fam Physician. 2006 Mar 15;73(6):1025-1028.

65. CLASSIC SIGN OF PLACENTA SEPARATION

66. All patient should be adviced on modified active management of 3 rd stage Physiological management may be desirable in low risk women who are not keen for active intervention STILL require active mx if - Haemorrhage - failure to deliver placenta after 60 minutes

67. Modified active management of 3 rd stage Intramuscular injection of 10IU oxytocin after delivery of anterior fetal shoulder, before the cord is clamped and cut Delayed cord clamping, not earlier than 1 minute but before 5 minutes from fetal delivery Monitor mother;s general condition, BP,PR and vaginal blood loss Palpate the uterus an ensure that it is well contracted Deliver the placenta via CCT Document the timing of placenta delivery Examine the placenta and membranes for completeness Estimate and document the blood loss

68. MANAGEMENT ACTIVE MANAGEMENT (CURRENT PRACTICE) MODIFIED ACTIVE MANAGEMENT PHYSIOLOGICAL MANAGEMENT Prophylactic IM 1 ampoule Syntometrine or IM 10 IU oxytocin Prophylactic IM 10 IU oxytocin No routine uterotonic agents Early cord clamping Deferred clamping and cutting of the cord ( after 1 min but before 5 min from fetal delivery) No cord clamping until caessation of cord pulsation Controlled cord traction after sign of placenta separation Controlled cord traction after sign of placenta separation Spontaneous delivery od placenta

69. Delayed cord clamping Increase infant haemoglobin and serum ferritin Increase in incidence of neonatal jaundice & polycythaemia Early cord clamping Reduce infant haemoglobin and serum ferritin

70. WHO Recommendations for Active Management of the Third Stage of Labour (AMTSL), 2012 In settings where skilled birth attendants are available, controlled cord traction (CCT) is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important.

71. EXCESSIVE TRACTION OF CORD SHOULD NOT BE APPLIED TO AVOID INVERTING THE UTERUS, WHICH CAN CAUSE SEVERE PPH……..

72. Uterine inversion

73. Observations after completion of 3 rd stage General appearance Blood pressure Pulse rate Respiratory rate Uterine contractility Vaginal blood loss IDENTIFY COMPLICATION EARLY !!!! COMMUNICATION IS IMPORTANT !!!!

74. UNDERESTIMATED BLOOD LOSS

75. Retained placenta/tissue (10%)

76. definition The placenta is retained if it is not expelled within 30 minutes after delivery of the baby It can be due to “entrapped placenta” or a “morbidly adherent placenta”

77. management Ideally MRP should be performed in OT Monitor vital signs and blood loss every 15 minutes Ensure 2 large IV access (16/18G) Blood grouped and cross-matched Institute resuscitative measures if patient is haemodynamically not stable Insert CBD and monitor input output chart Uterine massage and ensure uterus well contracted Obtained consent Administer single dose of broad spectrum antibiotic before procedure * Infusion of oxytocin 40u in 500mls NS @ HM 125mls/hour while awaiting operation theatre

78. MANUAL REMOVAL OF PLACENTA (MRP) Clamped the umbilical cord Wearing the MRP gloves, insert a hand into the vagina and up into uterus along the cord

79. STEP 1 : Introducing one hand into the vagina along the cord

80. STEP 2 : Supporting the fundus while detaching the placenta

81. STEP 3 : Proceed slowly all around the placenta bed until the whole placenta is detached from the utrine wall

82. STEP 4 : Hold the placenta and slowly withdraw the hand from uterus, bringing the placenta with it

83. Care after mrp Monitor PR, BP, RR and check the amount of vaginal bleeding hourly If necessary correct dehydration or shock by giving intravenous fluids. If woman in shock start blood transfusion Ensure adequate analgesia

84. Complication of mrp Haemorrhage and shock Infection Genital tract injury

85. PLACENTA ACCRETA SPECTRUM (PAS) Morbidly Adherent Placenta - Do not attempt to remove the placenta if morbidly adherent is suspected- proceed with hysterectomy -Surgical intervention : MDT (consultant obstetric, anaesthetist , blood bank, intervention radiologist, urologist) - If placenta left in situ- Methotrexate is not recommended for expectant management - Prophylactic antibiotic and ultrasound surveillance is recommended - Risk of bleeding & infection - If failed conservative mx- hysterectomy

86. Management of specific cause

87. DIVC (< 1%)

88. POST PARTUM CARE 1. IMMEDIATE 2. THROMBOPROPHYLAXIS 3. RISK MANAGEMENT 4. LONG TERM 5. FOLLOW UP

89. SECONDARY PPH General resuscitation Start broad spectrum antibiotic after taking blood culture & high vaginal swab Transfer patient to hospital with specialist Investigation : FBC, HVS , coagulation, electrolyte Usually due to endometritis . A pelvic USG : may help in identifying retained POC Conventional treatment : antibiotic / uterotonics Surgical intervention ? If there is excessive or continuous bleeding & evidence of retained POC

90. conclusions 01 PPH is preventable 02 Regular CME & drills according to guidelines are crucial 03 Teamwork is very important so that everything can be done simultaneously

91. QUESTION 1 This is a 32-year-old G6P5 lady X at 35+6 with underlying poorly controlled GDM under insulin and pre-eclampsia. On scan, there’s a 5x6cm fundal uterine fibroid, AFI: 26cm, and EFW: 3.4kg. Admitted for poorly controlled BP and headache. Subsequently, started on MgSO4 and completed EMLSCS for AFD under GA. Is this a high-risk patient of PPH? What are the risk factors?

92. QUESTION 2 Which of the following is a risk factor for PPH? A.  Fetal macrosomia B.  Chorioamnionitis C. Prolonged labor D. All of the above