Post-partum haemorrhage Obstetrics and Gynecology.ppt

PPH

1. MANAGEMENT OF POST MANAGEMENT OF POST
PARTUM HAEMORRHAGEPARTUM HAEMORRHAGE

2. •PPH is a nightmare
•Expert judgement, cool organized thinking and
action
•Challenging situation

3. •Marked improvement in management
•Availability of banked blood
antibiotics
safe cardiac stimulants
sophisticated monitoring
•Still a common cause of maternal mortalitymaternal mortality
•A short but critical window is available for
management of the patient

5. 7%
25%
20%
15%
13%
12%
8%
OTHER DIRECT
CAUSES
HAEMORRAGE
INDIRECT CAUSES
SEPSIS
UNSAFE ABORTION
ECLAMPSIA
OBSTRUCTED
LABOUR
INDIAN SCENARIO: MATERNAL INDIAN SCENARIO: MATERNAL
MORTALITYMORTALITY

6. DEFINITIONDEFINITION
•Blood loss > 500 ml in vaginal delivery
> 1000 ml in caesarean section
•Exact blood loss difficult to measure
•Variable effects of same blood loss in different women
hence
•ACOG - 10% fall in hematocrit and/or need for blood
transfusion
•Any loss which affects the hemodynamic stability

7. TypesTypes
•Primary
•Hemorrhage with in 24 hr (including 3
rd
stage
haemorrhage)
Atonic
Traumatic
Retained tissues
Blood coagulapathy
•Secondary
Beyond 24 hrs and 6 weeks postpatum

8. INCIDENCEINCIDENCE
•Difficult to determine
•1 – 7% of total deliveries
•Atonic PPH – 70% to 80%
•Traumatic PPH – 20%
•PPH in vaginal deliveries – 3.9%
•PPH in caesarean section – 6.4%
•Recurrence of PPH – 20%
•Incidence of PPH in KNH - 1.89 % (last 3 months)
• Atonic PPH – 62.85 % of PPH

9. PREVENTION OF PPHPREVENTION OF PPH
Prevention
•Adolescent care-anemia
•AN care
I F A prophylaxis
Detection & correction of anemia
Identification of high risk women
prone to PPH
•Intrapartum
•Review and identification of HRP for PPH

10. PREVENTION OF PPH (Contd.)PREVENTION OF PPH (Contd.)
ACTIVE MANAGEMENT OF THIRD STAGE (WHO 2012)
• PROPHYLACTIC UTEROTONIC: Oxytocin 10 IU IM
•CONTROL CORD TRACTION BOTH VAGINALLY AND IN CAESAREAN
SECTION
•POSTPARTUM ABDOMINAL UTERINE TONUS ASSESSMENT FOR
EARLY DETECTION OF ATONY
•Inspection of placenta
•Inspection of lower genital tract
•Prophylactic uterine massage is not recommended.

14. METHODS
•Visual estimation
•Standardized visual estimation
•Clinical assessment
•Direct estimation
•Gravimetric estimation
•Photometry

15. Guidelines for standard visual estimation of
blood loss
•Small 10*10 cm swab maximum saturation-60ml
•Medium 30*30 cm max saturation-140ml
•Large 45*45cm max saturation-350 ml
•50cm dia spill-500ml
•75 cm dia floor spill-1000ml
•100cm dia floor spill-1500ml
•Bleed limited to bed only-unlikely to exceed 1000ml
•Bleed spilling over from bed to floor-likely to exceed
1000ml

16. CLINICAL ASSESSMENT
Class 1 Class 2 Class 3 Class 4
% blood loss<15
<750ml
15-30
750-1500ml
30-40
1500-2000ml
>40
>2000ml
Heart rate normal 100 tachycardia120 mod
tachycardia
Marked
tachycardia
BP normal normal decreased decreased
Mean arterial
pressure
Normal Mildly
decreased
<60mmHg decreased
RespirationNormal tachypnea tachypnea Marked
tachypnea
Urine output
(ml/hr)
>30 20-30 5-15 anuric
Mental statusNormal anxious confused obtunded

17. RULE OF 30
•Fall in systolic BP by 30mmHg
•Increase in heart rate by 30 bpm
•Respiratory rate by >30 per min
•Urine output <30ml/hr
•The above indicate30% loss of blood volume
(class 3)

18. DIRECT MEASUREMENT-
•Bed pan
•Bucket
•Brass v drape
•Disposable PPH bags
GRAVIMETRY-
•Material soaked in blood weighed
•Subtract original weight of materials
•Difference gives rough blood loss
PHOTOMETRY-
•Most accurate method –gold standard but not practical

19. Brass V Drape

20. Medical Management

27. MEASURES FOR MINOR PPH (500-1000ML)
WITHOUT CLINICAL SHOCK(RC0G Dec2016)
•IV access(14 gauge canula)
•Urgent venopuncture(20ml) for:
1.Group and screen
2.Full blood count
3.Coagulation screen, including fibrinogen
•Pulse, RR, and BP recording every 15 min
•Start warmed crystalloids infusions.

28. MEASURES FOR MAJOR PPH(>1000ml)AND MEASURES FOR MAJOR PPH(>1000ml)AND
CONTINUE BLEEDING OR CLINICAL SHOCKCONTINUE BLEEDING OR CLINICAL SHOCK
(RCOG Dec 2016)(RCOG Dec 2016)
•A and B- assess airway and breathing
•C- evaluate circulation
•Position the patient flat
•Keep the woman warm
•Two peripheral cannulae, 14 gauze
•Immediate venopuncture(20ml) for:
1.Group and cross match (4 units)
2.Full blood count
3.Coagulation screen, includung fibrinogen
4.Renal and liver functions and serum electrolytes for
baseline

29. •Monitor temperature every 15 min.
•Continuous Pulse, RR, and BP recording(monitor).
•Foley catheter to monitor urine output.
•A high conc of oxygen 10-15L/min via face mask
should be administered.
•Tranfuse blood as soon if clinically required.
•Until blood is available, infuse upto 3.5 L of
warmed clear fluids , initially 2 L of warmed
isotonic crystalloids.
•Documentation of fluid balance, blood , blood
products and procedures.

30. •If no hemostatic test results are available and
bleeding is continuing then after 4 units of red
blood cells ,FFP should be infused at dose 12-
15ml/kg.
•If PT and ApTT is more than 1.5 times normal
and haemorrhage is ongoing, vol of FFP
15ml/kg are needed to correct coagulopathy.
•A plasma fibrinogen level >2g/l should be
maintained during ongoing bleeding.
Cryoprecipitate should be used for fibrinogen
replacement.
•Platelet count <75000/uL : platelets should be
transfused.

31. AC0G Oct 2017
The recommended initial transfusion ratio for
PRBC:FFP:Platelets has been 1:1:1
Designed to mimic replacement of whole blood
Other Related Therapies-
Recombinant Factor VII- Approved by FDA for Hemophilia A and B.
Role in PPH is controversial.Significantly improve hemostasis
but may result in life threatening thrombosis.
Prothrombin complex and Fibrinogen concentrates-approved for
acute bleeding episodes in congenital fibrinogen
deficiency.Data related to PPH and DIC limited.
Cell Salvage- k/a autologous blood transfusion shown to effective
and safe .Limitations are primararily related to availability of
appropriate staff and equipment.

34. Bimanual uterine compression

36. Non Pneumatic antishock garment

37. If pharmacological measures fail to control haemorrhage
surgical interventions should be initiated sooner
rather than later.
Intrauterine balloon tamponade is an appropriate first
line surgical intervention for most women where
uterine atony is the only or main cause of hmg.(RCOG
2016)
Effective 75-86%
If balloon tamponade system is not available the uterus
may be packed with gauze(ACOG 2017)

38. ATONIC PPH (Contd.)ATONIC PPH (Contd.)
 Sengastaken Blakemore Tube

39. Bakri baloon

40. ATONIC PPH (Contd.)ATONIC PPH (Contd.)
 Multiple Folleys catheter for packing uterus
Pressure balloon therapy with condom

41. BalIoon temponade
•Inserted transcervicaliy or through cesarean incision ,has an
exit port for blood drainage inflated with 300-500ml of
saline(Bakri baloon and condom catheter).
•Foley catheter-insert one or more bulbsand fill with 60ml of
saline.(ACOG 2017)
•The practice has been to fill the balloon until part of it is
visible by cervix . At this stage there is no bleeding through
cervix and none through drainage channel of cather the test
of temponade is successful and no further fluid fluid is added
•The woman shouid receive broad spectrum antibiotics from
time of insertion for upto 3 days .Infusion of oxytocin 40 units
in 1L NS continued to keep uterus contracted

42. •After 6h if uterine fundus remains at the same level
and there is no active bleeding,provided the woman
is stable and adequate blood replacement is given .
•6h is sufficient for placental bed to clot and stop
bleeding.
•First ballon is deflated but is not removed for 30 min,
no bleeding the oxytocin infusion is stopped for
another 30 min and if there is still no bleeding cather
is removed .
•Different types-Sengstaken-Blakemore tube ,Rusch
urological balloon ,Bakri balloon,condom cather and
foley catheter balloon.

43. ATONIC PPH (Contd.)ATONIC PPH (Contd.)
 Uterine Packing
•Sterile roller gauze
Done in selected cases
No dead space left
Disadvantage
1. Nonpharmacological
2. Masks trauma
3. Infection

44. Uterine Compression Sutures
•Although there are no good quality studies that
provide evidence for success of uterine compression
sutures for Atony.
•Effectiveness reported is 60-75% with none of the
technique shown superior to another.(ACOG2017)
•B-Lynch is most common,other techniques are
modified B-Lynch,vertical uterine sutures and square
compression sutures.

45. Haemostatic sutures
B Lynch suture (1997)

46. ATONIC PPH (Contd.)ATONIC PPH (Contd.)
Haemostatic sutures (Contd.
•Vertical uterine Sutures (Hayman et al 2002)
•Cervico - Isthmic apposition suture

47. ATONIC PPH (Contd.)ATONIC PPH (Contd.)
Haemostatic sutures (Contd.)
•Haemostatic multiple square sutures (Cho 2000)

48. ATONIC PPH (Contd.)ATONIC PPH (Contd.)

No Relief
Step wise Devascularisation procedure(Abd Raboo 1994)
Very effective for PPH control

49. UTERINE ARTERY LIGATION:
Site : 2cm medial to lateral edge of uterus and 2-3cm
below low transverse cs incision.
Suture material : No 0 or 1 absorbale (polyglactin910,
chromic catgut)
Needle : large curved tapered needle.
Procedure: needle is passed through myometrium from
ant to posterior then brought back through an
avascular space in broad ligament and tied.
OVARIAN ARTERY LIGATION:
Site: just below uterine ovarian ligament.
Success rate : 80-95%

50. ATONIC PPH (Contd.)ATONIC PPH (Contd.)
Internal iliac artery ligation
•Unilateral ligation decreases pulse pressure 75%
• B/L ligation decreases pulse pressure 85% and reduce
blood flow by 50%

51. Internal iliac artery ligation
Site :3cm below the birfucation of common iliac artery.
Procedure: uterus elevated out of abdominal incision, fundus
tilted away from site to be ligated and midportion of round
ligament is clamp and divided to permit entery into
retroperitoneal space.
• Avascular post leaf of broad lig is opened with sharp
dissecion.using moistend gauge on sponge forcep
retroperitoneal space is opened with gentle blunt dissection.
• Ureter should be identified and retracted medially with
attached peritoneum. Identify the birfurcation of common iliac
artery and doubly ligate the internal iliac artey (3 cm below
bifurcation)

52. Pelvic vessel embolisation
•Candidates-hemodynamically stable appear to
have persistent slow bleeding and have failed
less invasive therapy .
•UAE Success rate -58-98%(ACOG2017)
•If no discrete bleeding points are found the
anterior division of both internal iliac arteries
are usually embolised.
•Material: gelatin sponge pieces, poly vinyl
alcohol particles.

53. ATONIC PPH (Contd.)ATONIC PPH (Contd.)
Hysterectomy – Final resort