Post Partum Hemorrhage (PPH)

Postpartum hemorrhage for medical student level.

1. Post Partum Hemorrhage

2. PPH Primary PPH W ithin 24 hours of birth >500 mL vaginal birth or >1000 mL C section ** Or any amount that causes symptoms Secondary PPH Abnormal or excessive bleeding 24 hrs to 12 weeks postnatal Often assoc with endometritis ** Can further subdivide PPH as minor (500-1000 mL ) or major (>1000 mL )

3. PPH One of leading causes of maternal mortality 1-5% of deliveries #1 cause postpartum women admitted to ICU Blood flow to uterus at term: > 700 mL /min B lood loss often under-estimated and bleeding not always obvious… so what signs can we look for?

4. What are the signs/ sympt ?

5. Steps to managing PPH Predict : identify patients at risk Prepare : M ulti- disiplinary approach, PPH protocol Manage : Timely, accurate diagnosis and appropriate interventions Active management of 3 rd stage of labour

6. Causes of PPH Any deviation from normal stage 3 : Placenta completely separates from uterus M yometrium contracts Vessles constrict Coagulation pathways activate

7. 4 T’s of PPH Tone : Failure of uterus to contract Tissue : Retained products in uterus Trauma : V aginal, perineal , uterine Thrombin : Coagulation abnormalities

8. TONE Atony of uterus 75-90 % of PPH C auses: Overdistension of uterus (large baby, multiple gestation) Uterine muscle exhaustion (prolonged labour ) Uterine infection Uterine relaxants (general anesthetic) Retained placental fragments

9. TISSUE Retained placental products #1 cause for massive transfusions (>10 units RBC) Risks: Placenta previa (above cervix) Placenta accreta/increta/percreta (invade into uterus) Prior C-section Curettage U terine infection

10. TRAUMA 5-10% of PPH L acerations, incisions, uterine rupture, hematoma Risks: Instrumented deliveries Primiparity Pre- eclampsia Multiple gestation Prolonged second stage Vulvovaginal varicosities Uterine inversion

11. THROMBIN Coagulation defects Risks Pyrexia in labour , sepsis Pre- eclampsia , HELLP Placental abruption Pre-existing clotting disorder or liver failure Anti-coagulants Fetal demise

12. Review of some risks Abnormal or retained placenta Prolonged or precipitous labour Lacerations or use of instruments Distended uterus Hypertensive disorders (Pre- eclampsia ) Induction of labour or oxytocin use Previous PPH Fetal demise Coagulation disorders ….

13. Case - Mary 25 year old G1P0 Pregnancy complicated by pre- eclampsia Labour has been prolonged (stage 1/2: >25 hours) Serial blood work stable: Hb 120, normal CBC and lytes Vitals stable, but blood pressure has been ~160/90

14. A Case - Mary Resistant to assisted delivery, but eventually agrees to use of foreceps Baby is delivered soon after with 2 rd degree tear Placenta delivered: appears intact with no missing or extra lobes B leeding estimated at 400 mL , with a slow trickle from tear During suturing of her tear you note vitals deteriorating to HR 120, BP 90/60, pallor, feels dizzy

15. Management Bedside evaluation, frequent vitals, ABCs CBC, extended lytes , PT/PTT, s creen and x -match * Hb and Hct may not reflect acute changes Reverse coagulopathies or electrolyte abnormalities Active management of 3 rd stage Cord traction, uterine massage, remove retained products Uterotonics : Oxytocin , carboprost , misoprostol IV access & fluids, urine output, transfusion as needed

16. Blood products Blood should be drawn q30-60 min to guide replacement (CBC, lytes , ionized calcium, PTT/INR) No hard/fast rules: 2 units pRBC if hemodynamics do not improve after 2-3 liters of NS, EBL > 1500 mLs and continued bleeding expected Typically FPP:pRBC = 1:2-3 (to stop dilutional coagulapathy ) Goals: HB >75 Platelets > 50 000 PTT and INR > 1.5 control Fibrinogen > 200 mg/ dL

17. Uterine massage/compression

18. Balloon tamponade Effective mainly in uterine atony Need to continue to monitor vitals and blood work closely. If fails move on to embolization or surgery

19. Arterial embolization Must be stable enough to go to interventional radiology

20. Aortic compression

21. Emergency hysterectomy Can try suturing techniques first (B-Lynch suture) Hysterectomy typically a last resort More readily done for uterine perforation, placenta accreta/increta/percreta

22. Case - Mary You suspect uterine atony so you give oxytocin (10 units IM) and call the team Ask nurses to start 2 large bore IVs and fluids, blood work, foley catheter, give oxygen Uterine massage followed by compression Uterus initially feels boggy but after ~1 minute contracts causing a large gush of pooled blood to exit the vagina (~800 mL )

23. Case - Mary Vitals stabilize after 3 liters of NS and she is weaned off O2 Vaginal tear repaired Hb remains stable ~95-100, remaining bloodwork normal Urine output stays above 40 ml/hr Mary is closely monitored and recovers well over next couple of days (her baby is healthy too!)