PPH Bundle.pptx

I am sharing this as per ALSO 2020 guidelines

1. POSTPARTUM HEAMORRHAGE DR. BASMA ZIA ASSISTANT PROFESSOR OBGYN DEPARTMENT SZWH, CMC, SMBBMU, LARKANA

2. Postpartum Bleeding Definitions Increased Bleeding – 500 to 999 mL – Increase observation, can initiate postpartum hemorrhage (PPH) interventions • PPH – Blood loss ≥1,000 mL, or bleeding accompanied by signs and symptoms of hypovolemia • Decreased blood pressure (BP) and urine output • Increased pulse and respiratory rate • Pallor, dizziness, or altered mental status Menard MK , Main EK, Currigan SM. Executive summary of the reVITALize initiative: standardizing obstetric data definitions. Obstet Gynecol. 2014;124(1):150–153

3. Prevention and Early Recognition Identify patients at increased risk of PPH ─ Previous PPH ─ Invasive placenta ─ Anemia ─ Obesity ─ Placenta P revia ─ Fetal macrosomia ─ Antenatal hemorrhage • Tailor the labor management for high-risk patients (IV, type and cross, complete blood count [CBC]) • Reduce uterine atony with active management of third stage of labor (AMTSL) at every delivery, even if low risk of PPH • Calculate quantified blood loss (QBL) at every delivery

4. Active Management of the Third Stage of Labor Oxytocin 10 IU IM or 10 IU IV bolus over 1-2 minutes – With or soon after delivery of the infant – Misoprostol 600 mcg PO if oxytocin is not available • Continuous, gentle cord traction • Brandt maneuver • Delayed cord clamping for 1 to 3 minutes • Transabdominal uterine massage after the placenta delivers

5. Brandt Maneuver

6. Initial Management of Postpartum Hemorrhage AMTSL does not always prevent PPH – Atony may still occur – Bleeding may be from other causes • Quick response to excessive bleeding, obtaining vital sign measurements, and accurate quantitative assessment of bleeding is critical • Respond to every case of PPH by: – Asking for help – Administering 100% oxygen at 10 L via non-rebreather face mask – Starting two 16- to 18-gauge IVs and obtaining laboratory tests – Having blood products on standby – Starting bimanual uterine compression and massage

7. Bimanual Uterine Compression and Massage

8. Initial Management of Postpartum Hemorrhage (Continued) Start oxytocin IV – If concentration is 20 IU/L, infuse 500 mL bolus over 10 minutes – Infuse maintenance rate at 250 mL/hour – Can increase up to 80 IU/L if needed • Monitor blood pressure and heart rate, empty bladder and measure urine output, obtain laboratory tests (CBC, type and cross) • Consider the Four Ts to determine etiology of blood loss – Tone – Trauma – Tissue – Thrombin

9. Determining the Cause of Postpartum Hemorrhage

10. The Four Ts : Tone • Uterine atony is the most common cause of PPH (70%) • Initial step – Transabdominal uterine massage – Bimanual uterine massage for severe hemorrhage • Uterotonic agents – Oxytocin – Methylergonovine – Prostaglandins • Consider placing uterine balloon tamponade

11. Oxytocin for Treatment of Postpartum Hemorrhage Dose – IV: 20 IU/L normal saline (NS) • 500 mL over 10 minutes, then 250 mL/hour maintenance • Can increase concentration up to 80 IU/L if needed – IM: 20 IU • Contraindications – None • Caution – Overdose or prolonged use can cause water intoxication

12. Carboprost for Treatment of Postpartum Hemorrhage Dose – 0.25 mg IM (can be injected directly into the myometrium) – May be repeated every 15 minutes, if needed – Maximum total dose of 2 mg • Contraindications – Patients with asthma or significant renal, hepatic, or cardiac disease • Adverse effects – Nausea, vomiting – Diarrhea: Consider administration of antidiarrheal drugs

13. Misoprostol for Treatment of Postpartum Hemorrhage Dose – Treatment of acute PPH: 600 mcg SL is most rapidly absorbed and is the preferred route in women with PPH – Other dosing options: 800 mcg PR • Contraindications – Use cautiously in patients with cardiovascular disease • Adverse effects – Pyrexia, shivering, diarrhea, nausea, abdominal pain

14. Tranexamic Acid for Treatment of Postpartum Hemorrhage Dose (consider use within 3 hours of onset of bleeding) – 1 g IV diluted in 100 mL NS over 10 minutes – May repeat in 30 minutes if no response, or if bleeding recurs within 24 hours – Maximum dose of 2 g/24 hours • Contraindications – Impaired renal function – Prior complications with use ( eg , intravascular clot, hypersensitivity, vision changes) • Adverse Effects – May increase risk of thrombosis (DVT, PE, or CVA)

15. The Four Ts : T rauma Assess for: Lacerations Hematomas Uterine inversion Uterine rupture

16. Vulvar Hematoma Note: Hematomas may not be visible on perineum and require vaginal inspection or palpation

17. Uterine Inversion Rare, but important to recognize quickly Suspect if shock is disproportionate to blood loss Replace uterus immediately May require IV nitroglycerin or general anesthesia to relax the contracted lower uterine segment Discontinue oxytocin temporarily After replacement Watch for vasovagal reflex Use uterotonic agents at high normal doses

18. Uterine Inversion: Recognition

19. Uterine Inversion: Replace Uterus Through the Cervix

20. Uterine Inversion: Restitution

21. The Four Ts: T issue Assess for adequate analgesia if uterine exploration is needed Examine the placenta and membranes Tissue is a diagnosis of exclusion after first addressing tone and trauma Placenta may be invasive: Accreta, increta, percreta If known placental invasion, deliver in a facility with a blood bank and advanced surgical capabilities

22. Manual Removal of Tissue Use analgesia Digital exploration of the uterus Remove retained membranes and placental fragments

23. The Four Ts: T hrombin Etiologies Preeclampsia HELLP syndrome Idiopathic thrombocytopenic purpura Thrombotic thrombocytopenic purpura von Willebrand disease Hemophilia Drugs (aspirin, heparin) Disseminated intravascular coagulation (DIC) Consumptive or dilutional coagulopathy Amniotic fluid embolism Sepsis Placental abruption Prolonged retention of a dead fetus

24. Thrombin: Management of Coagulopathy Treat the underlying disease process Serially evaluate coagulation status Replace appropriate blood components Support intravascular volume

25. Management of Severe Postpartum Hemorrhage PPH may continue despite preventive measures and initial management guided by the Four Ts Administer tranexamic acid when standard measures fail to control bleeding within the first 3 hours of hemorrhage Consumption of clotting factors (DIC) may prolong or worsen PPH Consider initiating the massive transfusion protocol, prepare for surgical interventions and possible intensive care management

26. Massive Transfusion Protocol Based on initial research conducted in combat and other massive trauma situations Initiating massive transfusion protocol decreases laboratory test response times and improves proper use of platelets and fresh frozen plasma Use if QBL >1,500 mL May use with lower QBL if bleeding is ongoing and the patient is symptomatic

27. Typical Massive Transfusion Protocol Components Notification of blood bank, surgery, intensive care unit, and anesthesia teams Predetermined release of blood and blood products by the blood bank Blood product ratios - RBCs:fresh frozen plasma:platelets administered at 6:4:1 or 4:4:1 ratio Continue quantitative measurement of ongoing blood loss

28. Severe Postpartum Hemorrhage Interventions Uterine balloon tamponade (first-line) Uterine packing Vessel embolization/ligation Dilation and curettage Compression sutures (B- Lynch) Compression sutures (B- Lynch) Recombinant factor VIIa Management in an intensive care unit – Vasopressors Hysterectomy

29. Uterine Balloon Tamponade Consider use of uterine balloon if ongoing blood loss is unresponsive to uterotonic drugs Temporary measure - typically less than 24 hours – Have a plan to transfer to a higher level of care or consult a surgeon about hysterectomy Requires careful monitoring for blood loss, symptoms of hypovolemia, infection, and urinary compromise All maternity care departments should have tamponade balloons in stock and hold regular training sessions on safe use

30. Uterine Balloon Tamponade