Medical management of postpartum hemorrhage pph lecture

Lecture regarding risk factors, causes, and medical management of postpartum hemorrhage

1. 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

2. •Provide a
definition of PPH
•Review the risk
factors for PPH
•Understand the
nature and
importance of
rapid diagnosis
and treatment
OBJECTIVES

3. For your convenience,
A digital copy of this
lecture is also
located at:
http://onyeije.net/present

4. Mary
24 year old G2P2
Underwent a
routine cesarean
section at 7.30 pm
Pre-operative
Hb was 13 g/dl.
Blood loss of
500cc.

5. 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 enzymes
DIC
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

7. ‘‘‘‘She died in She died in
childbirth’’childbirth’’

8. Hemorrhage
has probably killed
more women than
any other complication
of pregnancy in the
history of mankind.

9. An estimated
150,000
maternal
deaths
worldwide
result from
obstetric
hemorrhage
each year

10. 90% of deaths from
Postpartum
hemorrhage are
preventable.

11. WE HAVE
THE
TOOLS
GOOD NEWS

12. Those caring for
pregnant women must be
prepared to
aggressively treat
this complication when
it occurs.

13. What What
can be can be
done?done?

14. THE STEPS TO PPH:
POSTPARTUM HEMORRHAGE:
PREDICT
HANDLE
PREPARE

15. THE STEPS TO PPH:
POSTPARTUM HEMORRHAGE:
PREDICT HANDLEPREPARE
Identify
patients
at risk
Use a
multi-
disciplinary
Approach
Optimize
clinical
management

16. Uterine Blood FlowUterine Blood Flow

17. Large amounts
of blood can
be lost
rapidly
following
delivery.

18. Uterine contraction is more
important than clot formation
or platelet aggregation as
a mechanism of hemostasis

19. 1. PREDICT:
THE STEPS TO PPH:
POSTPARTUM HEMORRHAGE:

20. Can we
Predict
PPH?
Who is
at
risk?

21. 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

22. Clinically Important Risk
Factors for Postpartum
Hemorrhage
Prior postpartum hemorrhage
Abnormal placentation
Operative delivery

23. Risk Factors for Postpartum
Hemorrhage under Clinical
Control
Prolonged labor
Instrumental
delivery
Anticoagulation
therapy
Prolonged use of
oxytocin
Cesarean delivery
General anesthesia

24. 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

25. 80% OF CASES OF
POSTPARTUM HEMORRHAGE
ARE DUE TO
UTERINE ATONY
(a less busy slide)

26. 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.

27. RDFS
RDFS 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.

28. 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)

29. 80% OF CASES OF
POSTPARTUM HEMORRHAGE
ARE DUE TO UTERINE
ATONY
(Did I mention that…)

30. Question: What causes
uterine atony and is there
anything we can do to prevent
uterine atony induced
postpartum hemorrhage?

31. •
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.

32. 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 & Gynecology
Volume 202, Issue 4, Pages 353.e1-353.e6 (April 2010)
DOI: 10.1016/j.ajog.2010.01.011

33. 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

34. Lower Genital Tract Trauma
May occur spontaneously
or result from episiotomy,
obstetric maneuvers, or
operative instrumented
deliveries.
Involve perineum, cervix
and vagina.

35. 2. PREPARE:
THE STEPS TO PPH:
POSTPARTUM HEMORRHAGE:

37. 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

38. Preparation for Postpartum Hemorrhage

39. “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

40. 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

42. 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

43. Anesthesia /
I.V. Access Obtain
Anesthesia
consultation
•Type of
anesthesia
•Need for
invasive
monitoring
•(A line,
Swan-Ganz,
etc)

44. •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

45. •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

46. 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

47. 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.

49. 1.Tone (Uterine tone)
2.Tissue (Retained tissue--placenta)
3.Trauma (Lacerations and uterine rupture)
4.Thrombin (Bleeding disorders)
The 4 Ts

50. 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

51. •Confirms
diagnosis of
uterine atony.
•Massage is
often adequate
for
stimulating
uterine
involution.
Bimanual
Uterine
Exam

52. Medical Treatment of Medical Treatment of
Postpartum HemorrhagePostpartum Hemorrhage
Medications that
cause
uterine
contractions
Medications
that
promote
coagulation

53. METHERGINE
“Speedy”
OXYTOCIN
“The Champ”
Cytotec
Inexpensive (?) Effective
Medications for Uterine AtonyMedications for Uterine Atony

54. 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”

55. •Causes rapid tetanic uterine
contraction.
•May trap placenta.
•Can cause Hypertension
•Contraindicated in hypertensive
patients and those with pre-
eclampsia.
METHERGINE
METHERGINE
“Speedy”

56. •Hemabate 0.25mg IM or IU.
•Previously known as Prostin.
•Controls hemorrhage in 86% when used alone,
and 95% in combination with above.
•Can repeat up to eight times.
•Contraindicated in asthma and (?)
hypertension.
•Can cause nausea/vomiting/diarrhea
Prostaglandin F2 15-methyl

57. •OXYTOCIN: promotes rhythmic contractions.
• Give 10 mg IM or IV, not IU.
•METHERGINE: promotes rapid tetanic contractions
•0.2mg (1 amp) IM
•HEMABATE: promotes long lasting contractions
•0.25 mg IM q 15min (max X8).
•CYTOTEC: less effective than methergine
•400 to 1000 mg (oral, vaginal or rectal)
Summary of Medications Summary of Medications
for Uterine Atonyfor Uterine Atony

58. Fluid Management of
Postpartum Hemorrhage

59. -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

60. Acute Postpartum Blood Loss
PROBLEMS:
Loss of circulatory Volume
Loss of O
2
carrying capacity
Restore
volume
1 - Crystalloid
2 - Colloid
 SaO
2
 O
2

carrying
capacity
Supplemental O
2 Transfusion

61. 61
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 -

62. Class Blood Loss
Volume
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

63. Ways to Optimize
hemodynamic status
1.Acute isovolemic hemodilution
2.Acute hypervolemic hemodilution
3.Autologous donation
4.Preoperative transfusion

64. 64
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

65. •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

67. 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

68. •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

70. •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

72. Episiotomy
Hematoma
Uterine inversion
Uterine rupture
T # 3: Trauma

73. Rare: ~1/2000 deliveries.
Causes include:
Excessive traction on cord.
Fundal pressure.
Uterine atony.
Uterine Inversion

74. •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

75. •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

77. •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

78. •Risk factors include:
•Epidural.
•Placental abruption.
•Forceps delivery (especially
mid forceps).
•Breech version or extraction.
Uterine Rupture

79. Sometimes found incidentally.
During routine exam of uterus.
Small dehiscence, less than 2cm.
Not bleeding.
Not painful.
Can be followed expectantly.
Uterine Rupture

80. Vaginal bleeding.
Abdominal tenderness.
Maternal tachycardia.
Abnormal fetal heart rate tracing.
Cessation of uterine contractions.
Uterine Rupture before
delivery

81. May be found on routine exam.
Hypotension more than expected with
apparent blood loss.
Increased abdominal girth.
Uterine Rupture after
delivery

82. Risk factors include:
Instrumented deliveries.
Primiparity.
Pre-eclampsia.
Multiple gestation.
Vulvovaginal varicosities.
Prolonged second stage.
Clotting abnormalities.
Birth Trauma

83. Repair of cervical laceration

84. •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

85. Pelvic Hematoma

86. The 4 “Ts” Recalled
“THROMBIN” Check labs if
suspicious.