bleeding in pregnancy (post partum).pptx

management of postpartum bleeding

1. POSTPARTUM HAEMORRHAGE DR. JUDITH DEPARTMENT OF FAMILY MEDICINE

2. OUTLINE INTRODUCTION/OVERVIEW DEFINITIONS & CATEGORIES RISK FACTORS FOR PPH CAUSES OF PRIMARY & SECONDARY PPH ASSESSMENT OF BLOOD LOSS AT DELIVERY MANAGEMENT TREATMENT FEW COMPLICATIONS PREVENTIVE MEASURES CONCLUSION & TAKE HOME

3. INTRODUCTION Obstetric Haemorrhage ranks as the a leading cause of maternal mortality accounting for approx. 25% of maternal deaths The term obstetric hemorrhage covers hemorrhage incurred ante-partum, intrapartum, and post-partum, but post-partum hemorrhage is estimated to account for 60% of all. Although post-partum hemorrhage (PPH) is one of the most preventable obstetric disorders, recent population based studies reveal that it is still the leading cause of maternal mortality in developing countries and severe maternal morbidity in advanced countries.

4. DEFINITION QUANTITAIVE DEFINITION- Blood loss of more than or equal 500ml following delivery (both spontaneous vaginal delivery or caesarean section(1000mls)). CLINICAL DEFINTION Post- partum haemorrhage refers to any amount of bleeding from or into the genital tract following birth of a baby up to the end of puerperium which adversely affect the general condition of the patient evidence by- rise in pulse rate Falling blood pressure or a decrease of 10% or more in haematocrit between admission and postpartum period or any loss enough to cause cardiovascular instability

5. EPIDEMIOLOGY The loss of blood in excess of 500mls has been estimated to complicate 2% of all child birth involving about 13.8 million parturient and recent reviews suggests its occurrence is on the increase in sub Sahara Africa. Each year 14 million women experience PPH resulting in about 70,000 maternal deaths globally. Even when women survive, they often need urgent surgical interventions to control the bleeding and may be left with life-long disability.

6. TYPES Essentially 2 Categories of PPH PRIMARY PPH Occurs within the first 24 hours of delivery Most common SECONDARY PPH Occurs after 24 hours to the end of 6 weeks after delivery

7. RISK FACTORS Prolonged third stage of labor Multiple delivery Episiotomy Fetal macrosomia Previous history Grandmultiparity Placenta previa Placenta abruption Infection

8. CAUSES OF PPH ‘The Four T’s” Tone – uterine atony Tissues –retained placenta, invasive placenta. Trauma – of any part of the genital tract, inverted uterus Thrombin – coagulopathy, DIC

9. 1-TONE- 70% This is a failure of the myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by a living ligature action. Failure of uterus to contract and retract effectively after delivery of placenta

10. Risk factors include- Polyhydramnios, Foetal macrosomia, Multiple gestation, Co-existing Uterine mass, Previous hx of uterine atony, Grandmultiparity , Prolonged/Precipitate labour, oxytocin driven labour, Halogenated Anaesthetic agents,, Tocolytics use, Hx of APH, Full bladder et Common presentation include- Excessive bright red bleeding Boggy uterus High fundus with non- contracting uterus Abnormal clots

11. 2- TRAUMA 20% Usually occurs following operative delivery. Common sites include- Vulva, vagina, cervix, perineum, paraurethral region Rupture uterus

12. 3-TISSUE- Retained products Abnormal placenta Placenta praevia /abruptio placenta Blood clot 4- THROMBIN Congenital or acquired Maybe due to diminished pro coagulants(washed out effect) or increased fibrinolytic activity. common cause include- placental abruption, jaundice in pregnancy, dead fetus, HELLP syndrome

13. UTERINE INVERSION Mostly iatrogenic resulting from mismanagement of 3rd stage - strong traction on the cord with a relaxed uterus/adherent placenta The uterine fundus falls into the endometrial cavity and may descend to the cervix (Incomplete Inversion- Fundus felt through the Cx ) or beyond the cervix (Complete inversion) Four Degrees

14. COMMON CAUSES OF SECONDARY PPH Retention of placenta tissue Endometritis Delayed placental bed involution Other less common aetiologies: Congenital coagulopathies Sub-mucous fibroids, Adherent Placenta Caesarean scar dehiscence Ruptured uterine pseudo-aneurysm Uterine rupture

15. ASSESSMENT OF BLOOD LOSS AFTER DELIVERY Difficult Mostly Visual estimation (Subjective & Inaccurate) Under-estimation very much likely Clinical picture – Often manifest late & can be misleading Our Mothers - Malnourished, Anaemic, Small built, Less blood volume

16. Table showing the staging scheme for Assessment of Obstetric hemorrhage. Severity of shock Findings % Blood loss None None < 15- 20% Mild Pulse rate <100bpm Mild hypotension Peripheral vasoconstriction 20-25% Moderate Pulse rate 100 – 120bpm Hypotension systolic bp 80-100mmhg Restlessness Oliguria 25-35% Severe Pulse rate >120bpm Hypotension (systolic bp <60bpm) Altered consciousness Anuria >35%

17. PRINCIPLE OF MANAGEMENT OF PPH MULTIDISCIPLINARY TEAM WORK 2. PROMPT & EFFECTIVE RESUSCITATION 3. PURPOSEFUL INVESTIGATION & ONGOING MONITORING 4. MITIGATION & TREATMENT OF COMPLICATION

18. 1. MULTIDISCIPLINARY TEAM WORK Call for HELP Multidisciplinary approach Alert Midwife, Senior Obstetrician, Anaesthetist & Theatre Alert Blood transfusion service & Haematologist Alert paramedical services - Porters for transport of blood samples & collection of blood products Allocate distinct roles to team members.

19. 2. PROMPT & EFFECTIVE RESUSCITATION Assess Airway, Breathing and Circulation Remove obstructions and suction secretions Head down tilt and to increase venous return to the heart help preserve cardiac output Give supplemental oxygen by face mask at 10–15L/min Secure IV access with 2 large bore cannulae Obtain blood for haematological investigations & GXM Blood Catheterisation to empty bladder & monitor urine output

20. PROMPT & EFFECTIVE RESUSCITATION ( Contd ) Commence fluid resuscitation using 2 – 3L of IV fluids (warm crystalloids (RL) -3ml/ml of blood loss, Haemacel can also be helpful, if available) After 3L of IV fluids, further resuscitation should be with cross matched fresh whole blood or O Rh - ve blood FFP may be necessary if clotting derangement suspected (12–15 ml/kg, after 4 units of blood) IV Calcium gluconate after 5 units of blood transfusion to counter anticoagulant in blood transfused Thrombocytopenia - Platelets concentrates Hypofibrinogenemia - Cryoprecipitate

21. 3. PURPOSEFUL INVESTIGATION & ONGOING MONITORING FBC, Coagulation screen, baseline E & U + Cr and LFT Cross-match at least 4 units of blood minimum Continuous monitoring of pulse, blood pressure, respiratory rate oxygen saturation (>95%) and urine output (> 30ml/hr) Temperature monitoring every 15 minutes (Avoid cold transfusions) Consider arterial line monitoring and HDU/ICU transfer

22. 4. MITIGATION & TREATMENT OF COMPLICATIONS Interventions are physical, pharmacological, surgical & radiological Ensure the bladder is empty Check for completeness of placenta delivery Uterine massage and Bimanual uterine compression Oxytocin 10 units bolus, followed by high dose oxytocin infusion to maintain contraction (safe with empty uterus), as first-line treatment

23. TREATMENT OF PRIMARY PPH Multidisciplinary - Obstetrician, Anaesthetist, Haematologist and Blood Bank Correction of hypovolaemia Ascertain origin of bleeding Ensure uterine contraction Surgical management Management of special situation

24. MANAGEMENT OF UTERINE ATONY Examine the vulva/ vagina for any trauma. Palpate fundus Uterine massage Bimanual compression Pneumatic Anti-Shock Garment (PASG)

25. Bimanual uterine compression

26. TREATMENT OF PRIMARY PPH (Cont.) Oxytocin: Bolus of 10 units IV followed by Continuous Infusion 100 Miu /min Ergometrine given parenterally (0.25mg IV is an alternative if oxytocin is unavailable & not a known Htn dx), or if the bleeding does not respond to oxytocin OTHERS Oxytocin–ergometrine fixed dose ( syntometrine ) Prostaglandin drug (e.g. Oral misoprostol 600 - 800μg or Carboprost I.M 0.25mg stat, Rpt 15-30 min, Maximum 2.0mg, Routes - IM/Intra-myometrial)

27. Early use of IV TXA as soon as PPH is diagnosed but NOT after 3 hours of birth is recommended Give 1g TXA IV at 1 ml/min, over 10 min. If bleeding continues after 30 mins or restarts 24 hours after 1 st dose, give second dose of 1g IV N:B – Latest evidence indicates that I.M TXA equally effective [ BJOG. 2023;00:1-10 ]

28. Use of the Non-pneumatic Anti-shock Garment is recommended as a temporizing measure until appropriate care is available

29. PNEUMATIC ANTI-SHOCK GARMENT

30. TRAUMA LACERATION AND HAEMATOMA- resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. UTERINE RUPTURE- symptomatic uterine rupture requires surgical repair of defect or hysterectomy UTERINE INVERSION- rare

31. TREATMENT OF PPH UTERINE INVERSION Manual replacement - - Under GA/Uterine relaxant – Tocolytics (terbutaline, nitro-glycerine, MgSO4) - Oxytocin infusion post-replacement Placenta adherent, LEAVE IN SITU, attempt to deliver may cause MASSIVE HAEMORRHAGE and/or shock. Prompt manually replace the inverted uterus to its normal position. A hand inside the vagina and pushing the fundus along the long axis of the vagina toward the umbilicus (Johnson’s Manoeuvres). Hydrostatic method. Surgical method (delayed procedure) Huntington & Haultain procedures

32. TISSUE Failure of expulsion of the placenta and membrane. Classic signs of placental separation include small gush of blood with lengthening of the umbilical cord and slight rise of the uterus in the pelvis. Placental delivery can be achieved by the use of the Brandt-Andrews maneuver, which involves applying firm traction on the umbilical cord with one hand while the other applies suprapubic counter- pressure. At term 90% of placenta will be delivered within 15minutes if it exceeds 30mins= retained placenta

33. Management of retained placenta Placenta not separated at all- Give oxytocic drugs Deliver the placenta by Brandt’s Andrew method. Uterotonic agents down the umbilical cord by PIPING’S method If not successful MANUAL REMOVAL UNDER GA after urinary catheterization. Placenta partially separated- A whole placenta is retained Resuscitation and manual removal under GA after urinary catheterization and antibiotics

34. If there are retained fragments Curettage with blunt instruments under GA under antibiotics cover 3- trapped placenta- Trapped cervix (closed cervix) Give uterine relaxants, IV glyceryl trinitrate and controlled cord traction. If unsuccessful, then manual removal under Ga

35. THROMBIN Coagulation disorders , a rare cause of post-partum hemorrhage are unlikely to respond to the measures described above. Most coagulopathies are identified before delivery allowing for advance planning preventing PPH

36. SURGICAL TREATMENT OF PPH Surgical approach to treatment options are considered when conservative treatments fails Depends on: Extent & cause of haemorrhage General condition of patient Future reproduction desire Experience & skill of Surgeon

37. SURGICAL TREATMENT OF PPH ( Contd ) Repair of trauma (if any) Intrauterine balloon tamponade (Foleys catheters) Pneumatic Anti-Shock Garment (PASG Uterine Artery ligation Utero ovarian Artery Ligation Internal Iliac Artery Ligation Brace suturing of Uterus (B-Lynch) Hysterectomy Angiographic embolisation

38. TREATMENT OF PRIMARY PPH ( Contd ) Intrauterine Balloon tamponade include: SOS Bakri, Sengstaken blakemore , Rusch balloon, Foley’s catheter and Condom catheter It is an effective first line surgical measure in cases of uterine atony, after exclusion of retained product. An USS guided insertion of the balloon maybe performed to ensure correct position, followed by filling it with 200-600mls of warm water or saline depending on the size of the uterine cavity. The reported success rates are between 70% and 100%. It is reported that 80-85% of patients will avoid the need for laparotomy. Different types of balloons have been used, including Segstaken Blakemore tube, Rusch urological balloon and Barki balloon have been used.

39. INTRAUTERINE BALLON TAMPONADE

40. FEW COMPLICATIONS OF PPH Haemorrhagic shock & DIC Renal Failure Puerperal sepsis Lactation failure Blood transfusion reaction Thromboembolism Sheehan’s syndrome

41. PPH PREVENTIVE MEASURES Regular & Diligent ANC Antepartum correction of anaemia Identification of high risk cases Delivery in hospital with facility for Emergency Obstetric Care. Availability of functional Ambulances to transfer high risk cases to higher level of care facility Local/Regional anaesthesia in place of halogenated GA, as appropriate ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR 4th Stage of labour - Observation, Oxytocin infusion postpartum (as indicated)

42. Conclusion Post partum hemorrhage , defined as the loss of more than 500mls of blood after delivery. It occurs in about 25% of child birth. Uterine atony is responsible for most cases and can be managed with uterine massage in conjunction with oxytocin, prostaglandins and ergot alkaloids. The best preventive strategy is active management of the third stage of labor DILIGENT RISK IDENTIFICATION & ANTICIPATION, WITH PROMPT MULTIDISCIPLINARY INTERVENTIONS CAN REDUCE SIGNIFICANTLY the outcomes of PPH.

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44. FURTHER READING Theunissen , F.J., Chinery , L. and Pujar , Y.V. Current research on carbetocin and implications for prevention of postpartum haemorrhage. Reprod Health 2018: 15 ( Suppl 1): 94 FIGO recommendations on the management of postpartum hemorrhage . 2022. Int J Gynecol Obstet. 2022;157(Suppl. 1):3–50 Gungorduuk K, Asicioglu O, Besimoglu B, Guungorduuk OC, Yildirm G, Ark C, et al. Using intraumbilical v.ein injection of oxytocin in routine practice with active management of the third stage of labor : a randomized controlled trial. Obstet Gynecol. 2010 Sep. 116(3):619-24 WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017; 389(10084): 2105– 16. Nguyen Toan Tran, Catrin Schulte- Hillen , Sarah Bar- Zeev , Agnes Chidanyika , Willibald Zeck . How to use heat-stable carbetocin and tranexamic acid for the prevention and treatment of postpartum haemorrhage in low-resource settings. BMJ Global Health 2022;7:e008913 World Health Organization. Updated WHO Recommendation on Tranexamic Acid for the Treatment of Postpartum Haemorrhage. 2017. Haleema Shakur-Still, Ian Roberts, Stanislas Grassin-Delyle , Rizwana Chaudhri , Amber Geer, Monica Arribas , Elodie Lamy , Raoul Mansukhani , Mwansa Ketty Lubeya , Kiran Javaid et al. Alternative routes for tranexamic acid treatment in obstetric bleeding (WOMAN- PharmacoTXA trial): a randomised trial and pharmacological study in caesarean section births. BJOG. 2023;00:1-10