Post-partum haemorrhage

An overview of post-partum haemorrhage

1. Post Partum H aemorrhage Dhammike Silva Senior Lecturer Faculty of Medicine USJP

2. Primary Loss of 500ml of blood within 24hrs after delivery Major PPH >1000ml Secondary Blood loss greater than expected 24hrs to 12 weeks Definition

3. Developed countries 5% Sri Lankan 2014 Maternal mortality 113 (MMR 33.7) PPH 11 2015 Maternal mortality 112 (MMR 32.03) PPH 10 Morbidity & near misses are much more higher than mortalities Incidence Family Health Bureau Sri Lanka

4. TOO LITTLE ….... TOO LATE …... Blood transfusion in PPH

5. Antenatal diagnosis Oral iron Parental iron Active management of third stage Reducing Risk of BT

6. CONSENT SAMPLES FOR CROSS MATCHING ABO, Rh D and KELL CMV SERONEGATIVE RED CELL AND PLATELETS – UNIVERSAL LEUCOCYTE DEPLETION GROUP O ,Rh D NEGATIVE ,KELL NEGATIVE

7. PROPERATIVE/PREDELIVERY AUTOLOGOUS BLOOD DEPOSIT INTRAOPERATIVE CELL SALVAGE MINIMISING USE OF BANKED BLOOD

8. PROTOCOL SKILLS AND DRILLS MECHANICAL STRATEGIES MANAGEMENT

9. WHEN ? O , Rh D NEGATIVE WHAT COMPONENTS ?

10. Ideally same group but others possible 12-15 ml / kg Maintain PT and APTT Regular FBC, and coagulation screen during PPH Cryoprecipitate – standard dose of two 5 unit pools then according to Fibrinogen ( aim at levels > 1.5 g/l ) Fibrinogen 2.9 g / l ( normal 3.5 – 6.5 in pregnancy ) Viral transmission FFP and CRYOPRECIPITATE

11. Aim Transfusion trigger Ideally Group compatible ABO Non identical possible – HLA matched Anti D P latelets

12. Initiates blood coagulation Arterial thrombosis No RCT’S in PPH Incidence of Thrombotic complications 2.5 % Recombinant factor VII a

13. THROMBOELASTOGRAPHY ( TEG) ROTATION THROMBOELASTOMETRY ( ROTEM) VALIDATED TRANSFUSION ALGORITHM PROTOCOL QUALITY ASSURANCE MEASURES NO RCT’s NEAR PATIENT TESTING

14. No place still Fibrinogen concentrate

15. Tranexamic Acid Misoprostol Antifibrinolytics and Misoprostol

16. Aetiology

17. B Lynch

18. Airway, breathing, O2 10-15L/min, RR Consciousness Reassurance 14G cannula, Blood 20ml  FBC Coag , cross match Hartmann 2L Colloids 1.5L Blood, FFP, Platelets, Cryoprecipitate Monitoring Oxytocin bolus  infusion Ergometrine bolus PGF2 alpha IM/ direct Tranexemic acid/ Factor VII Foley catheter Misoprostol 1000mg Tone, Trauma, Retained products Uterine massage Communication

19. Thank you.....