PPH.pptx

All about postpartum hemorrhage and its management.

1. PPH Dr P K Maharana

2. Definition Postpartum haemorrhage (PPH) is defined as a blood loss of 500 ml or more within 24 hours after birth.

3. Introduction Postpartum hemorrhage (PPH) is an obstetric emergency. It is one of the top five causes of maternal mortality in both high and low per capita income countries, although the absolute risk of death from PPH is much lower in high-income countries . Timely diagnosis, appropriate resources, and appropriate management are critical for preventing death.

4. Epidemiology 1.   PPH is the leading cause of maternal mortality in low-income countries, Primary cause of nearly one quarter of all maternal deaths globally .( E stimated 303 000 maternal deaths that occurred globally in 2015.) The reported incidence of PPH in the UK varies from 4% to 11%. 4. Most deaths resulting from PPH occur during the first 24 hours after birth; 5. Majority of these could be avoided through the use of prophylactic uterotonics during the third stage of labour and by timely and appropriate management .

5. Types Primary: Excessive or abnormal bleeding within 1 st 24 hours’ Secondary:  abnormal or excessive bleeding from the birth canal occurring between 24 hours and 12 weeks postnatally is regarded as secondary PPH.

6. Aetiology Uterine atony ; is the most common cause of PPH , but it can also be caused by Trauma ,( Genital tract trauma) Retained placental tissue or Coagulopathy.

7. Risk Factors (High Risk) Placenta previa /low lying Suspected accreta / percreta Platelet count < 70000 Known Coagulopathy. Active Bleeding .

8. Risk Factors( Medium) Prior cesarean , Uterine surgery, Multiple laparotomies Multiple gestation Multi Gravida(> 4 prior births) Prior obstetric hemorrhage Large myomas EFW >4000 gm Obesity (BMI >40) Hematocrit < 30%

9. The management of the third stage of labour in at-risk women should be active with: 1. Intravenous access 2. Cross matched blood available for transfusion 3.Ecbolic at delivery (Syntocinon 10 IU or Syntometrine 1 ampoule) 4. Placental extraction (controlled cord traction). Active management with informed consent should be routine practice.

10. Uterotonics 1.Oxytocin receptor agonists (oxytocin and carbetocin), 2. Prostaglandin analogues ( misoprostol , sulprostone , carboprost ), 3. Ergot alkaloids (such as ergometrine / methylergometrine ) and 4. Combinations of these ( oxytocin plus ergometrine , or oxytocin plus misoprostol

11. Storage of Drugs Oxytocin, ergometrine and the fixed-dose combination of oxytocin and ergometrine are heat-sensitive, requiring transport and storage at 2°C–8°C. I To prevent its degradation and to safeguard its quality, oxytocin should always be stored in refrigeration, regardless of labeling .

12. First-line Treatment Includes: uterotonics, uterine massage, bimanual compression, manual placenta and clot removal, and laceration repair.

13. Second- line Treatment More invasive procedures: (e.g., uterine balloon tamponade and uterine artery embolization) and Surgical techniques: are generally used after “first-line” conservative management failed.

14. Compression techniques Eexternal utérine massage, Bimanual compression, Aorti compression.

15. Medications All the medications: Oxytocin [Pitocin ], Misoprostol [ Cytotec ], Methylergonovine maleate [Methergine], Carboprost tromethamine [ Hemabate ], dinoprostone [ Prostin E2], Recombinant activated factor VIIa [ NovoSeven ], Tranexamic acid [ Cyklokapron ])

16. Procedures Procedures Include : Manual removal of placenta, Manual evacuation of clot, Uterine balloon tamponade, Uterine artery embolization, Laceration & trauma repair.

17. Devices Devices for Uterine Balloon Tamponade. Bakri postpartum balloon, Foley catheter, Sengstaken -Blakemore tube, Rusch balloon

18.   Surgical interventions in the treatment of PPH A wide range of surgical interventions have been reported to control postpartum haemorrhage if patient is unresponsive to medical or mechanical interventions. They include : Curettage Ligation of the uterine, ovarian or internal iliac artery, Uterine Compression Sutures Subtotal or Total hysterectomy.

19. Choice of Treatment First line : Oxytocin should be preferred  over ergometrine alone, a fixed-dose combination of ergometrine and oxytocin, carbetocin, and prostaglandins.  ( Quality of evidence: very low to low. Strength of recommendation: strong .) Second Line:  Ergometrine or Oxytocin-ergometrine fixed-dose combination should be offered   ( Quality of evidence: very low to low. Strength of recommendation: strong .) If oxytocin is not available, or if the bleeding does not respond to oxytocin: Third Line: A prostaglandin should be offered as the third line of treatment   ( Quality of evidence: very low to low. Strength of recommendation: strong.) If the above second-line treatments are not available, or if the bleeding does not respond to the second-line treatment, . Misoprostol may be considered as a third line of treatment for the management of PPH, because of its ease of administration and low cost compared with injectable prostaglandins .

20. Commonly Used Drugs Oxytocin ( Pitocin ) 10-40 units per 500-1000mL solution Methylergonovine ( Methergine ):  0.2 milligrams IM (may repeat) 15-methyl PGF2 α ( Hemabate , Carboprost ):  250 micrograms IM (may repeat in q15 minutes, maximum 8 doses ) Misoprostol ( Cytotec ):  800-1000 micrograms PR 600 micrograms PO or 800 micrograms PL

21. Commonly Used Uterotonic Agents with Doses & Mode of Administration . Oxytocin Methyl- ergometrine Prostaglandin F2alpha Route IV IV/IM IM 20 units in 1 liter 60 drops per minute 0.2mg Slow IV or IM 0.25mg IM Continuing Dose 20 units in 1 Liter 40 drops per minute If required, give 0.2 mg IM or IV (slowly every 4 hours Repeat Every 15 minutes Maximum Dose Not more than 3 l of IV fluids containing oxytocin 5 doses (1mg) 8doses (2mg) Precaution Do not give IV Bolus Pre- eclampsia , hypertension, heart disease Asthma

22. In women who have not received oxytocin as a prophylactic during the third stage of labour, oxytocin alone should be offered as the drug of choice for the treatment of PPH.   (Quality of evidence: moderate to high. Strength of recommendation: strong.)

23. The incidence of adverse side-effects was: Significantly ↓ lower in women receiving oxytocin than those given ergometrine ;

24. Factor VIIa & Recombinant factor VIIa. The Consultation agreed that there was not enough evidence to make any recommendation regarding the use of recombinant factor VIIa for the treatment of PPH. Recombinant factor VIIa for the treatment of PPH should be limited to women with specific haematological indications .

25. Tranexamic Acid Administer Tranexamic Acid 1gm intravenously . WHO 2012 guidelines do not specify about Tranexamic Acid due to poor evidences. The World Maternal Antifibrinolytic (WOMAN) Trial : in April 2017 Published in Lancet, The trial authors concluded  that tranexamic acid reduces death due to bleeding in women with clinically diagnosed PPH, and that early treatment appears to optimize benefit.

26.   Non-medical interventions for management of PPH a : Should uterine massage be offered in the treatment of PPH? Yes , once PPH diagnosed . ( Quality of evidence: very low. Strength of recommendation: strong. ) b. Should bimanual uterine compression be offered in the treatment of PPH? Yes , in the treatment of PPH due to uterine atony after vaginal delivery.   (Quality of evidence: very low. Strength of recommendation: weak.) c. Should uterine packing be offered in the treatment of PPH? Not recommended for the treatment of PPH due to uterine atony after vaginal delivery.   (Quality of evidence: very low. Strength of recommendation: weak.) d . Should intrauterine balloon or condom tamponade be offered in the treatment of PPH? Yes, if not responded to treatment with uterotonics, or uterotonics are not available, intrauterine balloon or condom tamponade may be offered in the treatment of PPH due to uterine atony.   (Quality of evidence: low. Strength of recommendation: weak.)

27. Non-medical interventions for management of PPH ( Conti-) e. Should external aortic compression be offered in the treatment of PPH? Yes, external aortic compression for the treatment of PPH due to uterine atony after vaginal delivery may be offered as a temporizing measure until appropriate care is available .   (Quality of evidence: very low. Strength of recommendation: weak.) f. Should nonpneumatic antishock garments be offered in the treatment of PPH? The Consultation decided not to make a recommendation on this question. g. Should uterine artery embolization be offered in the treatment of PPH? If other measures have failed and resources are available, uterine artery embolization may be offered as a treatment for PPH due to uterine atony .   (Quality of evidence: very low. Strength of recommendation: weak.)

28. Management of Shock Blood and fluid products Antishock garment

29. D. Choice of fluid for replacement or resuscitation Intravenous fluid replacement with isotonic crystalloids should be used in preference to colloids for resuscitation of women with PPH.   (Quality of evidence: low. Strength of recommendation: strong . )

30. MASSIVE TRANSFUSION PROTOCOL In order to provide safe obstetric care institutions must have: • Have a functioning Massive Transfusion Protocol (MTP) & • Have a functioning Emergency Release Protocol (A minimum of 4 units of O-negative/ uncrossmatched RBCs)* Have the ability to obtain 6 units PRBCs and 4 units FFP (compatible or type specific) for a bleeding patient Have a mechanism in place to obtain platelets and additional products in a timely fashion

31. MASSIVE TRANSFUSION PROTOCOL for BLOOD BANK: PROTOCOL Important items to be determined at each institution are: 1. How to activate MTP 2. Blood bank number & location; notify as soon as possible. 3. Emergency release protocol that both blood bank staff and ordering parties (MD/RN/CNM) understand 4 . How will blood be brought to L&D? 5. How will additional blood products/platelets be obtained? 6. Mechanism for obtaining serial labs, such as with each transfusion pack, to ensure transfusion targets achieved

32. BLOOD BANK: MASSIVE TRANSFUSION PROTOCOL III. ANTICIPATE ONGOING MASSIVE BLOOD NEEDS OBTAIN MASSIVE TRANSFUSION PACK ; Administer as needed in the following ratio 6:4:1) ( 6 units PRBCs, 4 units FFP, 1 Apheresis pack of platelets)

33. Blood transfusion or crossmatching should not be used as a negative quality marker and is warranted for certain obstetric events. In cases of severe obstetric hemorrhage, ≥4 units of blood products may be necessary to save the life of a maternity patient

34. Lab Facilities Hemoglobin and Platelet count, PT(INR)/PTT, Fibrinogen, and ABG (as needed)

35. RISK ASSESSMENT: PRENATAL • Suspected previa / accreta / increta / percreta * • Pre-pregnancy BMI >50 • Clinically significant bleeding disorder • Other significant medical/surgical risk (consider patients who decline transfusion)

36. Retained Placenta The WHO guide, Managing complications in pregnancy and childbirth , states that if the placenta is not expelled within 30 minutes after delivery of the baby, the woman should be diagnosed as having retained placenta. Since there is no evidence for or against this definition, the delay used to diagnose this condition is left to the judgment of the clinician.

37. Management of retained placenta Recommendations If the placenta is not expelled spontaneously, clinicians may offer Oxytocin 10 IU in combination with controlled cord traction.  ( No formal scientific evidence of benefit or harm. Strength of recommendation: weak.) Ergometrine is not recommended , as it may cause tetanic uterine contractions, which may delay expulsion of the placenta.  (Quality of evidence: very low. Strength of recommendation: weak.) The use of prostaglandin E2 ( dinoprostone or sulprostone ) is not recommended .  (Quality of evidence: very low. Strength of recommendation: strong.)

38. Intraumbilical vein injection of oxytocin Intraumbilical vein injection of oxytocin with saline may be offered for the management of retained placenta.  (Quality of evidence: moderate. Strength of recommendation: weak.)

39. Manual extraction of the placenta If, in spite of controlled cord traction, administration of uterotonics and intraumbilical vein injection of oxytocin+saline , the placenta is not delivered, manual extraction of the placenta should be offered as the definitive treatment .  (No formal assessment of quality of evdence . Strength of recommendation: strong.)

40. WHO-led, multicountry PPH prevention trial in June 2018.   This trial randomized nearly 30 000 women in 10 countries to either oxytocin (the recommended standard of care) or a heat-stable formulation of carbetocin, and found that heat-stable carbetocin was non-inferior to oxytocin for the prevention of PPH (defined as blood loss of at least 500 mL), and the use of additional uterotonic agents.  

41. Key Questions KQ1. What is the evidence for the comparative effectiveness of interventions for management of postpartum hemorrhage? 1. What is the effectiveness of interventions intended to treat postpartum hemorrhage likely due to atony? 2. What is the effectiveness of interventions intended to treat postpartum hemorrhage likely due to retained placenta? 3. What is the effectiveness of interventions intended to treat postpartum hemorrhage likely due to genital tract trauma? 4. What is the effectiveness of interventions intended to treat postpartum hemorrhage likely due to uncommon causes (e.g., coagulopathies , uterine inversion, subinvolution , abnormal placentation )?

42. CONCLUSION • Early opportunities exist of an obstetric hemorrhage. to assess risk , anticipate , and plan in advance. • Multidisciplinary coordination and preparation , ( particularly with the blood bank), is critical in order to provide safe obstetrical care . • A standardized approach to obstetric hemorrhage includes: a clearly defined, staged checklist of appropriate actions to be taken , in an emergency situation and can help to improve patient outcomes