Post partum haemorrhage

o&g update course 2012 hospital segamat

1. Management of Post
Partum Haemorrhage
DR HUSSEINH AKL
O&G SPECIALIST
HOSPITAL SEGAMAT
17 NOV.2012

3. The confidential enquiry into maternal
death (CEMACH)
Why CEMACH is important?
200 million global pregnancies
30 million globally experiences ill health due to pregnancy
8 millions have life threatened condition
Over half million women dies as result of pregnancy &
delivery
88-98% of MMR in the world are avoidable with timely
and effective care.
In UK, MMR 14 per 100.000 (2003-2005) live birth
In Malaysia half million deliveries per year.
MMR in Malaysia in 1947 - 700 per 100.000 deliveries
 in 1999 – 30 per 100.000 live birth
MMR now 27.4 per 100.000 live birth target according
To MDG5 EXPECTED TO BE 14/100.000 BY 2015
AND FURTHER DECLINE TO 10/100.000 IN 2020
PPH COMPLICATES 2-4% of births

4. Successes in Maternal Mortality Reduction
-
200
400
600
800
1,000
1,200
1,400
1,600
1840 1860 1880 1900 1920 1940 1960 1980 2000
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L
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B
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China
Malaysia
USA
England
& Wales
Sweden
Source: England, Wales, Sweden, USA: VanLerberghe and DeBrouwere,
Safe Motherhood Strategies, A Review of the Evidence, 2001
Malaysia, China: Koblinsky, Et al., Issues in Programming for Safe Motherhood, 2000

5. Causes of Maternal Deaths Malaysia
1991-1996
0%
5%
10%
15%
20%
25%
30%
35%
40%
PPH HDP Embolism Medical Ob trauma Others
1991
1992
1993
1994
1995
1996

6. What we can do?
Explain to parents
Be vigilant & aggressive management of
massive obstetric haemorrhage
Don’t promise perfect outcome for mother
& the baby
We can identify and treat problems that
arises but we cannot prevent all
complications

7. PPH
PPH is a major cause of maternal morbidity & mortality
world wide accounting for at least 25% of maternal
deaths accounting 30% of MMR in Malaysia
Globally > 125.000 women die of PPH each year
Major cause of maternal deaths in the UK (often after
CS)
Incidence is 2-11% in the UK
With a low BMI or low Hb, <500ml loss may cause
heamodynamic disturbances requiring prompt and
appropriate management

8. PPH is the 2
nd
leading cause of pregnancy-related death
in USA accounting 17% of MMR.
WHO shows PPH occurs in 10-15% of births in
developing countries.
14 millions cases of PPH occurs per year globally with
case fatality 1-2%.
PPH creates a great morbidity causing physical/
psychological/ social/ economic impacts on the society.

10. PPH - definitions
Primary PPH – is defined as blood loss of ≥ 500ml for
vaginal delivery and ≥ 1000ml for caesarean delivery
from the genital tract occurring within 24H of delivery.
Secondary PPH – is defined as excessive loss occurring
between 24H and 6-12 weeks after delivery.
10% change of haematocrite between admission and
post partum period.
Excessive bleeding producing symptoms and requiring
blood tx.

11. Causes of primary PPH
Uterine atony
Genital tract trauma
Coagulation disorders
Large placenta
Abnormal placental site
Retained placenta
Uterine inversion
Uterine rupture

12. Uterine Atony ( 90%)
Caused by failure of uterus to contract after
delivery
Predisposing factors;
over distended uterus with twins or polyhydramnios, big
babies,
prolonged labour
 infections
retained tissue
failure to actively managed 3
rd
stage of labour
or rarely due to placenta abruption (diffuse bleeding into
the uterine muscle that prevents contractions)

13. Genital Tract Trauma (7%)
Vulva, vaginal tears
episiotomy
lacerations of cervix
Rupture of the uterus.

15. Coagulation Disorders
Severe PET, placenta abruption and
sepsis may contribute to PPH.
Autoimmune disease, liver disease,
inherited or acquired coagulation
disorders are rare causes.
Sometimes the patient on heparin can
lead to excessive bleeding.

16. Abnormal Placental Site
Placenta previa, placenta accreta and
percreta.
Appropriate preplanning is needed to
avoid morbidity &mortality.
Uterine inversion & rupture are rare
causes of excessive bleeding.

17. Causes of secondary PPH
Infection - endometritis
Retained placenta parts & membranes
Subinvolution of the placenta site
Rarely trophoblastic disease
Pre-existing uterine lesion like submucous
uterine fibroid
Very rarely uterine Arterial Venous Malformation
Inherited coagulation defect

18. Antenatal Risk Factors for PPH
Previous PPH
Previous retained
placenta
Maternal Hb ≤ 8.5g/dl at
onset of labour.
↑ BMI
Para 4 or more
Antepartum haemorrhage
Overdistention of uterus
Uterine abnormities
Low-lying placenta
Maternal age > 35 years
The presence of any risk
factors for PPH should
lead to the woman being
advised to deliver in an
obstetric unit (facilities for
blood transfusion &
surgical management of
PPH)

19. Intrapartum Risk Factors for PPH
Induction of labour
Prolonged 1
st
, 2
nd
or 3
rd
stage
Use of oxytocin
Precipitate labour
Vaginal operative delivery
CS

21. Massive Obstetric Haemorrhage 2
nd
to
PPH
This is an important cause of maternal
morbidity & mortality
Identification of the risk factors , institution
of preventive measures and prompt &
appropriate management of the blood loss
is likely to improve the outcome.
Massive PPH loss of 30-40% of the pt’s
blood volume (about 2L).

22. Consequences of Massive PPH
Acute hypovolemia
Sudden and rapid cardiovascular
decompensation
DIC
Iatrogenic complications associated with
massive blood transfusion
Pulmonary oedema
Transfusion reaction
ARDS
Sheehan’s syndrome (hypopituitarism)

23. Pathophysiology of Massive Obstetric
haemorrhage
Blood volume increased during pregnancy.
Blood flow to pregnant uterus at term 500-
800ml/min
Placenta circulation accounting for 400ml/min.
Loss of 500-1000ml (10-15% of blood volume) is
usually well tolerated by a fit, healthy young
woman as she is able to maintain her
cardiovascular parameters by effective
compensatory mechanism until 30-40% of the
blood volume is loss.

24. Blood Loss & cardiovascular Parameters
Blood lossHR Systolic
BP
Tissue
perfusion
10-15% increased normal Postural
hypotension
15-30% Increased+ Normal Peripheral
vasoconstric
30-40% Increased++ 70-80
mmHg
Pallor, oliguria,
confusion,
restless
40%+ Increased+++ <60
mmHG
Collapse,
anuria,
dyspnoea

26. PPH / Massive Obstetric Heamorrhage
Resuscitation
Life-threatening emergency requiring swift &
appropriate treatment.
Most units have local guidelines for
management such as local hosp geography,
staff availability, who to contact & agreed
timescales for laboratory results
Activate Red Alert
Management consist of immediate resuscitation,
restore blood volume & rapid treatment of the
underlying cause to stop ongoing blood loss.

27. Initial measures for Resuscitation
Call for help – senior obstetrician, anaesthetists,
haematologist, midwife, hospital porter, blood bank & OT
staff
High flow facial Oxygen even if the SPO
2
is normal.
Assess airway & respiration – intubate to protect the
airway if decreased level of consciousness secondary to
hypotension.
2 large bore IV cannulla (14G)
Take blood for FBC, cross match, U&Es, liver functions,
coagulation screen
Start IV cystalloids to correct hypovolemia
Catheterize & measure hourly urine output.

28. Blood Tx – O-ve blood can be given immediately until
cross matched blood is available.
Replace clotting factors – FFP (4 units every 6 units of
blood), cryoprecipatate, recombinant activated factor VII
As soon as appropriate in the resuscitation process,
transfer the woman to place where there is adequate
place, light & equipment to continue treatment (OT)
Assess for CVP line
V/S, urine output, type & quantity of fluids replaced,
drugs given & timelines of events should be recorded by
the staff
Once bleeding has been stopped & pt stable, pt should
be managed in HDU or ICU

29. Principles For Stopping the Bleeding
Empty uterus (remove the placental /
membranes)
Treat uterine atony ( physically, medically
& surgically)
Repair genital tract trauma in OT

31. Medical Mx of uterine atony
Accompanied by physical attempts to
contract uterus – rubbing up the uterus &
bimanual compression
500 micrograms of ergometrine IV/ can be
given IM if difficulty in IV access
Start oxytocin infusion 40IU
If bleeding doesn't stop, give oxytocin
10IU IV slowly, not bolus

32. If atony continues, carboprost 250 micrograms IM given
in the thigh or directly to myometrium & repeated at 15
min interval up to total 4 doses.
If bleeding persist or ergometrine contraindicated then
800 micrograms of misoprostol (tables) is given rectally.
Recent data shows misoprostol can be use as the 1
st
line
drug to control PPH.
If all measures failed, retained tissue must be considered
& the EUA with possible further surgical management is
indicated without delay.

33. Surgical Management of PPH
Tamponade test
A Rusch balloon catheter, Sengstaken-Blakemore tube
or Cooke’s balloon inserted into the uterine cavity & fill
with 100-500ml warm N/S.
If bleeding is controlled and the balloon is left for 24H
and removed.
Tamponade may be particularly useful to control PPH
secondary to Placenta previa & accreta.
If conservative intervention for uterine tamponade like
uterine packing or balloon tamponade failed then
consideration must be given to perform an exploratory
laparotomy via vertical midline incision

34. Several procedures may be performed
the choice depends on pt’s desire for
future child bearing/ extent of the
haemorrhage/ experience of the
surgeon.

35. Intervention after laparotomy
Make sure uterine cavity is empty as small pieces of
tissue can cause atony.
If bleeding from large placental sinuses following CS
then undersewing the placenta bed ± insertion of Rusch
balloon may control bleeding.
If bleeding from uterine atony unresponsive to drug
treatment but ↓ with manual compression, B-Lynch or
vertical compression sutures should be attempted to
provide continuous compression & ↓ blood flow to the
uterus.
Systematic pelvic devascularization by ligation of uterine,
tubal branch of ovarian or anterior division of internal iliac
arteries.

36. Internal iliac ligation will help in controlling both the
uterine & vaginal branch bleeding ( B/L ligation results in
85% reduction of pulse pressure & 50% reduction blood
flow & bleeding reduced by 50%).
Hysterectomy is the last option. Subtotal hysterectomy is
safer & quicker to perform.
If the bleeding is from the lower segment ( placenta
previa, accreta or tears) then total hysterectomy is
carried out
The decision for hysterectomy should not be unduely
delayed as this can result in the death of the mother.

37. Procedures
1.Compressive suture – B-Lynch suture in 1997 can be effective
in uterine atony
2.B/L uterine artery ligation –safe & effective method, identify the
ureters then ascending branches of uterine artery are ligated at
the level of vesicouterine peritoneal reflection.
3.B/L internal iliac artery ligation
4.Hysterectomy –remain definitive measure for control severe
PPH, should not be delayed.Placenta accreta is the most
common indication for emergency CS hysterectomy.

39. Arterial Embolization for Massive PPH
Advantages
Less invasive than laparotomy
Help to preserve fertility
Quicker recovery than laparotomy
Disadvantages
Only available in a few centres
May not be possible to get the required equipment to
obstetric OT or transfer a woman to the radiology
department
Appropriately trained interventional radiologists must be
available

40. Method
A catheter is inserted through the femoral
artery and advanced above the bifurcation
of the aorta and a contrast dye is injected
to identify the bleeding vessels.
The catheter is then directed to the
bleeding vessels and embolized with
gelatin sponge which is usually
reabsorbed in 10 days.

41. Updates of the surgical Mx of PPH
Systematic review of conservative management
of PPH what to do when medical Tx fails
48 studies included in the review 2006
The cumulative outcome showed success rates
of 90.7% ( confidence interval 95%) for arterial
embolization – 84% for ballon tamponade –
91.7% for uterine compression sutures and
84.6% for internal iliac ligation or uterine
devascularization.

42. At present there is no evidence to suggest
that anyone method is better for the
management for severe PPH.
RCT of various treatment options may be
difficult to perform in practice.
Balloon tamponade is the least invasive
and the most rapid approach, it would be
logical to use this as the 1
st
step in the
management.

43. Case Illustration 1
27 year old G2 P1, had antenatal follow-up and
delivery at private maternity centre. Scanty
information as to what happened had ante-natally,
but was known to have had a ventouse delivery and
subsequently developed uterine atony. Transferred
out to a government hospital and arrived 2 ½ hours
after delivery. By then, patient was moribund and
very pale. Laprotomy decided upon, but patient died
before surgery could be performed.
Q1. What is the risk factor to the mother?

Q2. What are the commonest causes of uterine
atony?
Q3. Explain the management of uterine atony in
hospital.

44. Answers
A1. Ventouse delivery and subsequently developed uterine
atony.
A2. Common causes can be divided into 2 main categories:
Predetermined Risk Factors
Uterine over distension
Multiparity
Anaemia
Past obstetric history of PPH
Ante-partum haemorrhage
Uterine fibroid/retained products of conception
Controllable Risk Factors
Operative deliveries
Anaesthesia
Prolonged labour
Mismanagement of 3
rd
stage
A3. As in lecture.

46. Case Illustration 2
26 years old G2 P1 admitted to GH for post dates.
Induced with prostin and subsequently had
ventouse extraction. Developed PPH and blood loss
underestimated. Uterus was found to be atonic and
cervical tear noted. MO attempted to suture cervical
tear unsuccessfully. Meanwhile patient continued
bleeding. O&G specialist called in as patient
collapsed. Resuscitation carried out and
hysterectomy performed 1 ¼ hours after delivery. By
then, DIVC had set in. Patient died in ICU 8 hours
later.
Q1. What are the causes of death for this patient?
Q2. Explain the management of PPH secondary to

genital trauma.

47. Answer
A1.
PPH due to atonic uterus and cervical tear
Secondary to DIVC
A2.
Perform general resuscitative measures
Correct hypovolaemia/hypotension
Set up a minimum of 2 iv drips for major PPH (>1000cc blood
loss) a 3rd iv line or CV should be considered
Stabilise the patient with crystalloids (Hartman’s) or colloids
(haemacele/gelafusin)
Take blood for FBC, GXM, Plt
Place the patient in lithotomy position
Find bleeding point if visible and clamp it
Suture tear immediately
Start broad spectrum antibiotics
Place continuous bladder drainage
Watch out for bleeding

49. THANK YOU
For Attending

50. Thank You
Egypt