Post partum haemorrhage

PPH is the leading cause of mortality..this ppt is about the recommended management of PPH.

1. POST PARTUM HAEMORRHAGE DR. SUGUNA. R. KUMAR. MD (OBG) Suguna Maternity Hospital Sastri nagar Bijapur

2. Post partum hemorrhage (PPH) is the leading cause of maternal mortality (35-38%) If PPH is untreated death occurs in 2 hrs MMR in Karnataka is 144 / 1L birth . And of India is 178/ 1L birth ALL WOMEN who carry a pregnancy beyond 20 weeks gestation at risk of PPH

3. Defined a blood loss of >500ml in vaginal and 1000ml in caesarean, within 24 hours of delivery is primary , if occurs after 24 hours is secondary. Definition is arbitrary and problematic A woman with anemia, cardiac disease, volume contracted in preeclampsia cannot cope up . Blood loss assessment done by visual assessmen t

4. Visual assessment of blood loss – requires no expenditure, should be correlate with the clinical signs. Inaccurate, Underestimated, small “trickle” neglected Direct collection of blood bedpan and standard measuring jar, rubberized blood mat , Kelly’s Pad ( I ndia) funnels blood into a calibrated collection bowl, Kangas (large piece of African cloth), Blood drape plastic sheet into a calibrated measuring pocket , Gravimetric method dry and wet sponges weighed. Laboratory based methods – Alkaline hematin / acid hematin method of the collected blood. Currently there are no donors or projects in any of the above mentioned technologies.

5. Causes of PPH 4 TS - Tone, tissue, trauma, thrombus . Tone – 70% Atonic uterus major cause - over distended polyhydramnios , multiple pregnancy , big baby, grandmulti , prolonged labour (>12hr ), precipitated labour , placenta previa , abruptio placentae, Inversion uterus Tissue - Retained placenta, Clots, fibroid uterus Trauma - Uterine rupture, cervical tears, vaginal tears. Thrombosis - Thrombhocytopenia due to HELLP syndrome, abruptio , DIC, Sepsis . Coagulation failure disorders Most cases don’t have risk factors .

6. P revention ACTIVE MANAGEMENT OF III STAGE OF LABOUR (AMTSL) IN ALL DELIVERING WOMEN Oxytocin 10 IU IV/IM is the recommended uterotonic drug at the anterior shoulder delivery or immediately following delivery of the baby. Oxytocin unavailable / skilled birth attendants are not present then 600ug of oral misoprostol recommended. Cord clamping after 1-3min. Controlled cord traction (CCT) if skilled birth attendant are available. Sustained uterine massage not recommended Postpartum abdominal uterine tonus assessment up to 4hours recommended In CS Oxytocin 10 IU IV/IM and CCT is recommended.

7. AMTSL 60% reduction in the occurrence of PPH and Blood transfusion 80% reduction in the need for therapeutic uterotonic agents No increase in the incidence of retained placenta. Following delivery ideal to continue uterotonic for 2-3hrs - 10IU of oxytocin 500ml of IV fluid or 200 mcg of methylergometrine , 250mcg of carboprost , 600ug of misoprostol PR.

8. Clinical assessment of obstetric hemorrhage Blood volume loss BP (systolic) S/S Degree of shock 500-1000ml (10-15%) normal Palpitation, tachycardia, dizziness compensated 1000-1500ml (15-25%) Slight fall ( 80-100mmHg) Weakness , tachycardia, sweating mild 1500-2000ml (25-35%) Moderate fall (70-80mmHg) Restlessness, pallor, oliguria moderate 2000-3000ml (35-50%) Marked fall (50-70mmHg) Collapse , air hunger, anuria severe

9. Treatment of PPH Antenatal CBC and Blood grouping and typing. Hb <10gm% promptly treated During labour recent CBC Identification of at risk and thrombhocytopenia in whom 2-6 U of blood ideally reserved, require multidisciplinary approach. IV line large gauge 16 G in at risk pt.

10. Management Has the placenta been delivered and is complete? Is the uterus well contracted? Is the bleeding due to trauma?

11. PPH kit/ box IV cannula 16 G -2 with easyfix / plaster, Blood sample bottles Syringes 10ml- 4, 5ml- 2, 2ml- 4 Foleys cathetar 16 no, urosac , distilled water 10ml Drip set , blood set, RL, NS, 3 way cannula O2 face mask, Cotton swabs, scissors

12.     PPH box Uterotonics - O xytocin 5 amp Methergin 2 amp, P rostodin 2 amp, Misoprostol 600mcg Instruments – large speculum 3, sponge holder 4, condom tamponed.

13. LOW RECOURSE SETTINGS IV oxytocin is the recommended drug 20IU in 500ml NS Oxytocin is not available or bleeding not responding then IV ergometrine , syntometrine , IM Prostagladin , 800ug SL misoprostol. IV fluids isotonic crystalloids NS is prefered over colloids. Tranexamic acid used if the bleeding doesnot stop with uterotonics or sure of traumatic PPH. Not responding to uterotonic or uterotonic not available then intrauterine balloon tamponed recommended There is no response to uterotonic and tamponed measure then surgical intervention The use of uterine pack not recommended IV /IM oxytocin 10 IU with CCT recommended in retained placenta Ergometrine not recommended in retained placenta Single dose of amphicillin or cephalosporin recommended if MRP is practised

14. Bimanual compression, external aortic compression, non pneumatic anti shock garment, intrauterine balloon tamponed are temporary measures until appropriate surgical treatment , while shifting.

15. Management of obstetric hemorrhage Organisation Call for help (experienced Obstetrician and anesthetists) Alert the blood bank and hematologist Designate a doctor or nurse to record the vitals, UOP , fluids and drug administration OT ready. R esuscitation Administer O2 mask Place 2 large bore (16 G ) IV lines Take blood for crossmatching 4-6 PRBCs, for CBC count, coagulation screen, RFT, and electrolyte status. Rapid fluid replacement with NS or RL 2litres. Blood transfusion PRBCs

16. Uterine contraction – first line drugs Oxytocin 10IU IM/IV Oxytocin 20IU in 500ml NS Methyl ergometrine 0.2mg (max 5 doses 4 th hourly Carboprost 0.25mg IM every 15min to 90min x 8 doses Misoprostol 800mcg SL/PR .

17. Empty the uterus. Foley catheter UOP Uterine massage, bimanual compression Balloon tamponed Brace Sutures Uterine artery ligation, stepwise revascularization Internal iliac artery ligation Interventional radiology Hysterectomy before too late .

18. Secondary PPH Retained placenta Infection endometritis Infection of the cervical and vaginal tears Puerperal uterine inversion Uterine polyp, fibroids Undiagnosed Ca Cx chorioepithelioma

19. Take home message PPH remains the number one killer of women in developing country. Access to well stocked and well staffed facilities capable of rapid response in PPH are lacking in lower resource settings. A formal protocol for the prevention and treatment PPH and also for referral to higher center recommended Frequent use of stimulation and drills in the PPH treatment of the health personal. A prepared mind, a prepared team, a full range of therapy is required to avert maternal death.

20. Thank you