Massive Postpartum haemorrhage

Postpartum haemorrhage (PPH) is commonly defined as a blood loss of 500 ml or more within 24 hours after birth.
It affects about 5% of all women giving birth around the world.
Globally, nearly one quarter of all maternal deaths are associated with PPH. In most low-income countries, it is the main cause of maternal mortality.

1. Dr. RokeyaBegum
HonararyAdviser
Department of Obs& Gynae
USTC
Bangladesh
Massive postpartum
haemorrhage

2. Postpartumhaemorrhage(PPH)is
commonlydefinedasabloodlossof
500mlormorewithin24hoursafter
birth.

3. .
It affects about 5% of all women
giving birth around the world.

4. Globally,nearlyonequarterofall
maternaldeathsareassociatedwith
PPH.Inmostlow-incomecountries,it
isthemaincauseofmaternal
mortality.

5. Massive obstetric haemorrhage
(MOH)
By
Volumes
By
Transfusion
WHO (2012) servereppH= 1000ml
within 24 hours
RCOG (2016) major ppH= >2000ml
NHS England maternity
Dashboard metrics (2017) = 1500ml
Scottish CASMM 2500ml
Scottish CASMM 5 unit or
treatment for coagulopathy
UKOSS > 8 unit of blood within 24
hours of delivery
By rate of
Blood loss
BCSH (2006)
Blood loss 150ml per minute
Loss of 50% blood volume in 3 hours
Loss of 100% blood volume in 24
hours
MOH

6. Small women have small blood volumes.
Small loss produce great impact.
Blood volume varies with maternal size

7. PPHis an obstetric emergency that
can develop rapidlyand
unexpectedly.

8. “Of particular concern is the rising rate of maternal death in
association with placenta accreta”.

9. 176 maternal death/100000 live
birth

10. Quantification of haemorrhage is
particularly difficultduring
deliveryand/or C/S.
Blood mixed with other fluid.
Large amount of blood may be
retained within the uterus .

11. Specific problems
of obstetric
patient
I.20-30% increase in red cell mass
II.50% increase in plasma volume
Women is in dilutional anaemia.
1.Tachycardia and hypotension –
misleading
2. Relative haemodilutionand
increase cardiac out
3.Drop of Hb% and haematocrit.

12. Pregnancy is hyper
coagulablestate
1. Plasma concentration of almost all the
coagulation factors -increase.
2. Decrease fibrinolyticsystem-increase
plasminogen activator inhibitor type-2.
3.Natural anticoagulant protein S 
4. Thrombocytopenia

13. These changes result in a
shortening of prothombin time
(PT) and activated partial
thromboplastin time (APTT).

14. Cunnigham et al : Williams
obstetrics, 21
st
ed. 2001
Obstetrics
is bloody
business

15. Massive obstetric haemorrhage
Prediction
Prevention
Prepare
Handle

16. Identification of
Risk factor
Prepregnancy
Ovulation induction/SET
Family planning
Pregnancy
Multipara, Multiple Pregnancy, placenta
previa .
Placenta acreta with previous history of
caesarean section.
Pregnancy with fibriod
Localization of placenta by USG
Identification and correction of anaemia

17. Prevention
Prophylactic use of Oxytocic drug during each
and every delivery.
Active management of third stage of labour.
Fourth Stage of labour

18. Prepare for PPH-Pre delivery
Personnel /Skilled man power
Drug/Equipment
Place of delivery
Blood ready at hand
Timing of delivery -Schedule for C/S
Consent for Hysterectomy
Type of anaesthesia
Two I/V line.
Modify Obstetric management
Place ment of Balloon cather inside uterine artery before C/S for embolisation

20. HANDLE

21. Recognize
massive ppH
1. Measuring blood loss
2. Clinical signs
3. Blood test/laboratory test

22. Not all haemorrhage is visible.
Visual estimation consistently underestimates large EBL
volumes by 30-50%.
Training can improve visual EBL skill but skill deteriorates
within 9 months of training.
Quantification of blood loss (QBL) significantly more accurate
than EBL.
QBL reduces risk of underestimation and treatment delay.
Seeing is not believing for blood loss

23. How to QBL Difficult task
Dr. Mohammad Abdul Quaiyumdesigned a
simple cotton and tissue paper birth mat to
identify post-partum haemorrhage. Photo:
Amy Yee

24. Rule of 30
30%loss of blood volume = moderate shock
-
Systolic BP fall by 30mm/hg
Heart rate rise by 30 beats/min
Respiration rate rise by 30 breaths/min
Urine output < 30ml/hr
Haemoglobin(Haematocrit) drop by
30%

25. Shock index:
HR/SBP
Normal 0.5-0.7
Shock > 0.9

26. Classification of Shock
Blood
loss
Stage-I
upto15%
(750ml)
Stage-II
15-30%
(750-
1500ml)
Stage-III
30-40%
(1500-
2000ml)
Stage-IV
Over 40%
(over
2000ml)
BP Normal
(maintained By
vasoconstriction)
Increase
diastolic BP
Systolic
BP
< 100
Systolic
BP
< 70
Heart
Rate
Normal Slight
tachycordia
> 100bpm
Tachycardia
> 120bpm
Extreme
Tachycardia
>140bpm with
Weak pulse
Respiratory Normal Increase >20Tachyponeic
> 30%
Extreme
Tachypnoea
Mental
state
Normal restless Altered
confused
Lethergy/coma

27. Skin Pallor Pate Cord
Clamuy
Increase
diaphoresis
Extreme
Diaphoresis
Mottling
possible
Capillary
refill
Normal Delayed Delayed Absent
Urine
output
Normal 20-30ml/hl < 20 ml/hl Negligible
Shock < 0.6 > 0.6 -< 1.0 ≥ 1.0 to
< 1.4
≥ 1.4
Base deficit≥ 2.0 > 2 to 6.0 > 6.0-10 > 10
Classification of Shock

28. Complication of massive
postpartum haemorrhage
Hypovolaemicshock
Coagulopathy
Blood transfusion hazard
Lactation failure
Multi organ failure
Death
Anaemia

29. Fire in house

30. 1. MDT : -Obstetrician
-Midwifes
-Anaethetist
-Haemotologist
2. Relatives
3. Theatre team /OT
4. Porteringservice/ward boy
5. Record keeping
Communication

31. Stop the
bleeding
Re-assessResuscitation

32. 1. Call for help.
2. High flow oxygen via face mask.
3. Head low down .
4. I/V access-Two large bore cannula (Green Cannula)
5. I/V fluid-warm 2L crystalloid +1.5 L colloid –[3500ml]
Resuscitation
and
immediate management

33. Fluid Type Comments
Normal salineCrystalloidInexpensive readily
available.
Lactated CrystalloidInexpensive readily
available.
Fluid Choices
Fluid Type Comments
? Albumin Colloid More expensive
Hydroxyethylstarch Colloid More expensive
Hypertonic saline with dextranColloid Expensive
Blood Blood Expensive /clinical supply
Avoid dextrose containing fluids

34. 6. Send blood for -
a)grouping + cross matching
b)Laboratory -FBC, Coagulation screening
-renal and liver function rest
7. Foley’s catheter in situ
-Empty bladder
-monitor urine output .
8. O negative blood –better avoid.
9. Group specific cross match blood.

36. What has been lost in PPH
Plasma volume –Required for perfusion
Replace after 1L loss (fluid replacement)
Red cells-Required to carry 02 to cell
Replace after 2L loss( Blood transfusion).
Coagulation factors / platelets for clots
Replace after 5L loss
(FFP, cryo, platelet)

37. 1. >50% blood volume loss without fluid
replacement will be fatal.
2. Hb < 50g/L despite fluid replacement
may cause organ failure/death.
The 50 rule

38. 1.Assess for shock and effectiveness of resuscitation
regular and repeated observation.
2. Respiratory rate and capillary refill useful signs.
3. Do not rely on systolic BP as main sign.
4. Measure and record Urine output.
5. Document resuscitation and treatment.
Monitor the resuscitation

39. Mentalstatus Responsive to commands
Systolic BP 80-90m of Hg
Heart rate < 120/min
Pulse oximeter Saturation > 95%
Urine output Present
Targets of resuscitation

40. Hb% 8m/dl
Haematocrit >25%
Platelet count >50,000mm3
Fibrinogen >100mg/dl
PH >7.3
S lactate Improving

41. Clinical Features
1. Oozing from puncture site, injection sites, surgical
field.
2. Haematuria.
3. Petechae, subconjunctival/submucosalhaemorrhage.
4. Blood does not clot.
Coagulopathy

42. Coagulopathy
develops rapidly
-Metabolic acidosis
-Hypothermia
-obstetric Causes like PET

43. After 4U RBC give one unit of
FFP for each further unit of
blood.
Aggressive replacement of
coagulation factors may
improve outcome.

44. Target Ration
Hb > 8gm/100ml if less transfused RBCs.
INR < 1.5 if prolonged transfused fresh
frozen plasma.
Platelet > 50,000/mm
3
if less -transfused platelet.
Fibrinogen > 1.5gm/L if less-transfused cryoprecipitate
1 unit/5kg.
Guideline to use of blood product

45. Coagulation monitoring to
prevent
dilutional coagulopathy
Conventional laboratory
test : 40-60 minutes
Point of care coagulation test
-Thrombo-elastography
&
Thrombo-elastometry

Viscoelastic properties of coagulation.

46. Intra operative blood
salvage.
Intra operative salvage
involves the collection of
blood from surgical field,
followed by washing and
filtration reinfusion to the
patient.

47. Treat theCause
There may be more thanone!
Tone
70%
Tissue
9%
Thrombin
1%
Trauma
20%

48. H –Help and Hand over the uterine fundus for massage.
A –Assess (ABC) and resuscitation.
E –Establish Etiology and use of Ecbolics
HAEMOSTASIS
Oxytocin–5 IU slow I/V may be repeat to 10 IU
Infusion -30-40 unit in 500ml N/S over 4 hours
[30 drops/min]
Ergometrine–0.5mg I/V or I/M
Carbitocin-100gm IM / IV
Misoprostol –1000 gmper rectal
Carboprost–250mg I/M repeated every 15 min
total 2 mg –8 doses

49. M -Massage the uterus
S -Shift to theatre/Higher center
(EUA and removal of retained product)
Shift to higher center –Apply Non
pneumatic anti shock garment.
Non pneumatic anti shock garment

50. T-Tamponade
-Several balloon can acts as tamponade
-CONDOM cather
A-Apply compression suture
( -lynch suture).
Tamponade test
Positive test -control
bleeding following
inflation
Negative test –indicates
Laceration/other.

51. S -Systematic pelvic devascularisation
I-Interventional radiology
S -Subtotal or total Abdominal hysterectomy
-Bilateral uterine artery ligation.
-Bilateral ovarian artery ligation.
-Internal iliac artery ligation.

52. The focus of treatment should be
preservation of the woman’s life rather
than preservation of her uterus.
Hysterectomy
sooner is better
than late.

53. PROF SYEDA NURJAHAN BHUIYAN

54. Pharmacological manipulation of
coagulation
1.

55. Recombinant factor VII a
–90 microgram/kg
2.
Ensure adequate level of fibrinogen and platelets
prior to administration of recombinant factor VIIa
COSTLY
It is useful in refractory PPH.

56. Human Prothrombincomplex
(Octaplex)
3.

57. Additional challenges
Morbidly adherent placenta.
Unresponsive to treatment.
Non surgical PPH(Coagulopathy).
Refusal of blood and blood product.

58. Morbid Adherent placenta
Hysterectomy
Intentional retention of placenta.
Plan expectant management.
Triple P Technique for
preserving the uterus.
Balloon catheter in uterine artery
for embolisation.

59. Unresponsive to
resuscitation
A. Consider “BAD”
1. Broad ligament Haematoma.
2. Abdominal cavity (slippage of ligature).
3. Deeper planes-Para vaginal/suburethral
B. Consider “wash out” phenomena
Coagulopathy/
Recombinant activated factor VII

60. Survivality improves
immediate
resuscitation and
timely intervention.

61. WINDOW OF OPPORTUNITY

62. Many near miss.
Survivor often have multiple scars.
(Abdomen, uterus genital tract &
psychological scars.

63. Taj Mahal to be built in the memory
of MumtazMahal, who died during birth of her 14th child

64. Short and long term implications
in family and faminity.
Peripartum hysterectomy
Separation/Divorce
Surrogacy

65. No mother should die due to
pregnancy
and
child birth.

66. The position of a woman in any civilization is
an index of the advancement of that
civilization; is gauged best by the caregiven to
her at the birth of her child.

67. Mortality and morbidity due to substandard care 66%
( 2008 CMACE )
Too little done too late
Too little Awareness :
-Risk assessment
-Underestimation of blood loss
Too little responsibility:
(I/V fluid , Oxytocics, Blood Clotting factors
Too late action :
(Blood replacement, Decision for surgery and
to get skilled senior input and MDT input)

68. 1. Labour ward floor –PPH BOX
(Medicine, Fluid, Condom, Foleys Cather)
2. Monitor –Dash Board
(LESSON And LEARN,Practice improve)
FIRE DRILL

69. 3. Hospital protocol
I. Obs+ Anae+ Haemotologist
II.Forms : (Blood order form,Resuscitation form,Transfer form,
Interventional radiological form).
III.Mandatory training-doctor ,nurse and midwife
(WORK SHOP IN YOUR INSTITUITION)
4. Feed Back :
-Congratulation to whole staff after successful management.
-Discussion after failure What we have missing.
5. Continuous learning and explore new things :
-Heat stable carbitocin
-Triple P technique

70. Summary
Be prepared
Recognize
Communication
Team Work
Resuscitation
Stop bleeding
postpartum/postoperative care