Post Partum Hemorrhage in ED

Obstetric emergency which can kill instantly !! - PPH presenting to ED, so what is the role of Emergency Dept ? The most basic presentation of Obstetric emergency and how to tackle it? Being an emergency physician, obstetrics is always challenging! Keep yourself updated with Obstetric emergency.

1. Post Partum Haemorrhage
Runal Shah
2
nd
year Resident
MEM
KDAH

3. Definitions
Quantitative :
–>= 500ml for vaginal delivery
–>= 750ml for LSCS
Significant Obstetric Hemorrhage (UK)
–>= 1500ml
Clinical :
–Bleeding in excess of physiological reserve
capacity of woman, evidenced by Tachycardia &
Hypotension

4. Incidence
6% of all live births in the world (WHO)
Responsible for up to 4% of maternal deaths
Worldwide >1.4 Lac women die every year
= 1 death every 4 min !!!
Associated mortality : Death due to PPH occurs
within 2 hours if no active intervention taken, as
compared to APH – 12 hours, Obstructed Labour –
2 days, Infection – 6 days !!!!!

5. Types of PPH
Primary PPH :
oBleeding during the 3
rd
stage labour or within 24 hrs after
childbirth.
More common
Atonic 90%
Traumatic 6%
Mixed
Coagulopathies (Von Willebrand’s disease)
Miscellaneous : anti-coagulant therapy

6. Types of PPH
Secondary PPH : (Delayed/ Late)
–Excessive bleeding from birth canal between 24 hours and
6 weeks after birth.
Retained product of conception
Puerperial sepsis
oSubinvolution of placental bed
oPuerperial inversion of uterus
oPlacental polyp
oCa.Cervix
oRupture of vulval hematoma
oUterine AV malformation
oChorionic epithelioma

7. Risk factors (RCOG Guidelines)
Pre Conception
–Age >40, not multiparous
–Asian ethnicity
–BMI > 35 kg/m2
During pregnancy
–Anaemia (<9g/dl)
–Known placenta previa
–Suspected / proven placental abruption
–Multiple pregnancy
–Pre-eclampsia/ Gestational HT
–Induction of labour

8. Risk factors (RCOG Guidelines)
At delivery
–Caeserean section (elective/ emergency)
–Operative vaginal delivery
–Prolonged labour (>12hours)
–Birth weight > 4kg
–Medio-lateral episiotomy
–Retained placenta
–Pyrexia in labour

9. Clinical features
Signs of shock depend on :
-Amount of bleeding
-Pre delivery hemoglobin levels
Hypotension, tachycardia, cold clammy extremities
Clinical picture can change so rapidly from initial reversible
stage to later irreversible stage that unless timely action is
taken maternal death occurs within a short time.

10. Clinical features
Abdominal Examination :
Atonic PPH: Uterus is flabby & soft, may be overdistended
with clots
Full bladder may obscure finding
Uterus is larger than expected, squeezing it leads to gush
of clotted blood P/V.
Traumatic PPH: Uterus is contracted
Mixed

11. Vaginal examination
Atony :
Bleeding starts few minutes after delivery of fetus
Dark red in colour
Trauma :
Bleeding starts immediately after delivery of fetus
Is bright red in colour

12. Assessment of blood loss
Clinical :
‘The Golden Hour’ is the time at which resuscitation must
begin to achieve max survival before Metabolic Acidosis
sets in.
Rule of 30 :
30% blood loss – SBP fall by 30% - HR to increase by
30/min – RR > 30/min – Hb/HCT to drop by 30% - Urine
output fall < 30ml/hour

13. Assessment of blood loss
Visual Methods :
BRASSS-V method
Soaked pads
Gravimetric method : weighing sponges before & after
Acid-Hematin method (not done routinely)
Measurement of Isotope Cr51 tagged erythrocytes (for
research purpose)
Plasma volume changes – radioactive tracer

14. Measuring blood loss in PPH –
BRASSS-V drapes

15. Assessment of blood loss

16. Prophylaxis
Ante-natal
–Improvement of health status (Rx of anemia and
malnutrition)
–Early detection of risk factors and regular ANC f/up
–Encouragement of institutional delivery
–Blood grouping and Rh typing
–Women with morbid adherent placenta (accreta) : Plan
elective CS with senior Obstetrician

17. Prophylaxis
Intra-natal
–Judicious use of sedatives and anesthetic agents
–Vigilant labour monitoring
–Prompt intervention in Prolonged labour, Obstructed labour
and Uterine inertia
–Active management of 3
rd
stage Labour
Post-natal
–Close observation in 4
th
stage of labour
–Examination of palcenta and membranes
–Exploration of genital tract for trauma

18. Management of
3
rd
stage bleeding
Control the fundus, massage and make it hard
Inj Methergin 0.2mg IV
NS with Oxytocin 20 Units
Arrange for blood transfusion
Catheterise bladder
Placenta
Not Separated
Manual removal under GA
Placenta
Separated
Express Placenta out by CCT
Traumatic to be tackled by exploartion of genital tract
and sutures

19. Manual removal of placenta
 Vaginal exploration under GA / Procedural sedation
to evaluate uterine cavity to remove placenta manually,

20. FLUID RESUSCITATION
2006 Guidelines from British Committee for
Standards in Haematology summarises main
therapeutic goals for Mx of massive blood loss is to
maintain:
–Hb > 8g/dl
–Platelet count > 75000/Cu.mm
–PT < 1.5 x mean control
–aPTT < 1.5 x mean control
–Fibrinogen > 1.0 gm/L

21. Transfusion Strategies
Initial resuscitation by IV fluids
It worsens existing coagulopathy and enhances
fibrinolysis !!
Role of TEG (Thromboelastography) and ROTEM
(Rotational Thromboelastometry) :
–To examine clot formation and dissolution in whole blood &
identify reduction in clot strength in 5-10 min
–To predict need of massive transfusion with accuracy of
71%

22. FFP :Platelets :PRBC = 1 :1 :1
PRBC
–When blood loss exceeds > 30% of blood volume
–Post partum Hb to maintain > 8 gm/dl
–HCT can be normal/high in PPH as resulting plasma loss,
clinical evaluation is must
Platelet Transfusion
–May be required in Thrombocytopenia or paltelet
dysfunction
–Plt > 50,000 is usually adequate for Vaginal delivery, C-
section or epidural anaesthesia
–Prophylactic Platelet transfusion if <20,000 before vaginal
delivery or <50,000 before C-section

23. Fresh Frozen Plasma (FFP)
–Only to be used in massive hemorrhage or to replace
single inherited clotting factor deficiency (mostly factor V)
–FFP + Platelets to be used for multifactor deficiency
associated with severe bleeding and/or DIC
–Indication : aPTT & PT > 1.5 x of reference value,
Fibrinogen < 0.8 gm/L
–Each FFP unit is ~ 200ml, contains 0.4 gm Fibrinogen and
all clotting factors
–Therapeutic dose : 10-15 ml/kg body weight
–ABO compatible to be used

24. Role of Tranexemic Acid
•Role in Obstetrical hemorrhage is still under
evaluation.
•A French Study* reported that use of TXA
–Decreased median blood loss (173 vs. 221 ml)
–Decreased likelihood of stopping bleeding within 30 min
(63% vs. 46%)
–Less chances of progressing to severe PPH (27 vs. 37
women)
–In women undergoing Vaginal Delivery, similar results
found with C-Section also but used along with Oxytocin

25. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219400/

27. Ref :
D.C.DUTTA'S
TEXTBOOK OF OBSTETRICS
6th Edition
Scheme of
Management of
True PPH

28. Management – Uterotonic Rx
Oxytocin
–MoA : myometrial contraction through Oxytocin receptors
and voltage gated Ca++ channel
–Duration : 20 min
–Onset : 3-4 min
–Dose : 20 units in 500ml NS iv rapid infusion / 10 units im
–S/E : Uterine rupture, Hypotension, Water retention –
Hyponatremia, confusion, coma, convulsion, CCF, Death !!
–Strict I/O charting required

29. Ergot derivatives – Methergin
–MoA : Direct action on myometrium to contract
–Onset : 1.5 min (iv), 7 min (im), 10 min (oral)
–Duration : 3 hours
–Dose : 0.2 mg iv/ im
–If bleeding is not controlled, dose can be repeated after 2-
4 hours, but not more than total 4 dose to be given.
–S/E : N&V, Hypertension
–C/I : IHD, HT (Pre-eclampsia)

30. Prostaglandins (Life saving drug to arrest PPH)
PG E1 – Misoprostol
–1
ST
line PR, 2
nd
line SL
–200 mcg tab, max 1000 mcg
–S/E : Fever, Tachycardia
15 Methyl PG F2alpha – Carboprost
–1
st
line im, 2
nd
line Intra-myometrial
–Dose : 0.25 mg, can be repeated every 15-90 min
–Max 8 doses can be given
–S/E : N&V&D, chills
–C/I : Asthma, Active cardiac, renal, liver disease

31. Atonic uterus management
1)Explore uterus for
retained placental bits
2)Uterine massage
3)Firm bimanual
compression
4)Uterine packing or
Balloon catheter
Temponade

32. Atonic uterus management

33. Secondary PPH
1
st
and foremost USG
Principles
–Assess amount of blood loss and REPLACE
–To find out cause and rectify it
–Supportive therapy :
•Blood transfusion, if necessary
•Inj Methergin 0.2 mg iv / im
•Antibiotics
–Conservative therapy : admit and observe x 24 hours

34. Secondary PPH
Active treatment
–Explore the Uterus under GA
–Gentle Curettage (!!Perforation!!)
–Inj Methergin 0.2 mg iv/im
–Send curettings for HPE
–LAPAROTOMY

35. Thank you …
Ref :
Current progress in Obstetrics & Gynaecology
Modern Obstetrics by Ajit Virkud 2/e
Williams Obstetrics 24/e
Practical Guide to High-Risk Pregnancy and Delivery by Fernando Arias 3/e
Practical Obstetrics Problems by Ian Donald 6/e
Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7/e
D.C.DUTTA'S TEXTBOOK OF OBSTETRICS 6/e