PPH.pptx post partum haemorrhage Excessive bleeding after childbirth. Causes of postpartum bleeding include loss of tone in the uterine muscles, a bleeding disorder or the placenta failing to come out completely or tearing

Pph..anaesthesia consideration

1. POSTPARTUM HEMORRHAGE

2. The most commonly accepted definition is blood loss more than 500 mL after vaginal delivery or more than 1000 mL after cesarean delivery. The American College of Obstetricians and Gynecologists (ACOG) defines hemorrhage as blood loss greater than or equal to 1000 mL, or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours of birth.

3. TYPES 1] Primary 2] Secondary Primary – bleeding occurs following delivery of the baby up to 24 hours Primary is two types: A] Third Stage hemorrhage B] True Post Partum hemorrhage Secondary or Delayed or Late Postpartum hemorrhage : Bleeding occurs following delivery of the baby after 24 hours up to 6 weeks

4. CAUSES Uterine Atony Genital Trauma Retained Placenta Uterine Inversion Coagulopathy

5. UTERINE ATONY Most common cause In addition to normal hemostatic mechanisms, postpartum hemostasis involves the release of endogenous uterotonic agents— primarily oxytocin and prostaglandins—that contract the uterus and constrict uterine vessels. Uterine atony represents a failure of this process. In addition, parturients with obstetric hemorrhage may have uterine arteries that are relatively unresponsive to vasoconstrictor substances.

6. Obstetric and Anesthetic Management The ACOG recommends active management of the third stage of labor decrease blood loss and transfusion requirements compared with expectant management. Oxytocin is the first-line drug for prophylaxis of uterine atony after delivery Despite preventive measures, postpartum uterine atony may occur. A multidisciplinary response to atony is imperative.

7. General resuscitative measures include (1) Additional large-bore intravenous access, (2) Intravenous administration of crystalloid and colloid solutions and vasopressors, (3) Laboratory determination of hemoglobin concentration or hematocrit and assessment of coagulation status (4) Preparation of blood products for transfusion

8. Carbetocin , an alternative synthetic oxytocin receptor agonist, has longer duration of action than oxytocin, eliminating the need for prolonged infusion. Dose – 100mcg, IM/IV.

9. Bimanual compression and massage of the uterus and continued infusion of oxytocin may help restore uterine tone. Invasive techniques include intrauterine balloon tamponade, uterine compression sutures, embolization of the arteries supplying the uterus, surgical ligation of arteries, and cesarean hysterectomy.

10. INVASIVE TREATMENT FOR OBSTETRIC HAEMORRHAGE Angiographic arterial embolization Balloon occlusion Surgical arterial ligation Hysterectomy Embolization local anaesthesia complications are few preservation of fertility is likely Can be done in presence of a coagulopathy Requires rapid access to angiographic facility Requires skilled radiologist

11. INTRAUTERINE BALLOON TAMPONADE Inserting a rubber or silicone balloon into the uterine cavity and inflating the balloon with normal saline. Mechanism of action 1. Exerting in inward-to-outward pressure > systemic arterial pressure: prevent continual bleeding. 2. Hydrostatic pressure effect of the balloon on the uterine arteries. Types Condom catheter Rusch catheter 3. Balloon tamponade catheter 4. Foley catheter 5. Bakri tamponade balloon 6. Sengstaken -Blakemore tub

12. Bilateral surgical ligation Uterine, ovarian, and internal iliac arteries Preservation of fertility Damage to other pelvic structures (ureter) Vascular anatomy is variable Lower extremity ischemia Postpartum hysterectomy Definitive treatment for postpartum haemorrhage Tissues are oedematous and congested Amount of blood loss is more Multicentre review showed that the average blood loss for emergent cases was 2526 ml, with an average transfusion requirement of 6.6 units of blood

13. Genital Trauma Most common injuries at childbirth are lacerations and hematomas of the perineum, vagina, and cervix Pelvic hematomas are three types: vaginal, vulvar, and retroperitoneal signs and symptoms Restlessness, Lower abdominal pain, A tender mass above the inguinal ligament Vaginal bleeding Abrupt hypotension Ileus Unilateral leg oedema Urinary retentionhaematuria

14. ANAESTHETIC MANAGEMENT OF GENITAL TRAUMA For vulval haematomas and small lacerations - Local infiltration and a small dose of intravenous opioid For extensive lacerations and vaginal haematomas Pudendal nerve block - technically may not be feasible Neuraxial blockade - may cause hypotension Sedation -most preferred N20,02 with inhalational agents, low dose ketamine For retroperitoneal haematoma - Laparotomy with general anaesthesia Rapid sequence induction Difficult intubation to be anticipated

15. Retained Placenta Retained placenta is defined as failure to deliver the placenta completely within 30 minutes of delivery of the infant and occurs in approximately 3% of vaginal deliveries Typically results from one of three causes: (1) incarcerated placenta (2) placenta adherens (3) placenta accreta The severity of bleeding ranges from minimal to severe and can be life threatening and require transfusion

16. Risk factors preterm delivery, oxytocin use during labor, preeclampsia, nulliparity OBSTETRIC MANAGEMENT Manual removal and inspection of the placenta After removal of the placenta, uterine tone should be enhanced with oxytocin

17. ANAESTHETIC MANAGEMENT OF RETAINED PLACENTAL PRODUCTS - If epidural catheter is in situ additional local anaesthetic drug can be given Subarachnoid block can be given if patient is haemodynamically stable Nitrous oxide analgesia Low dose ketamine GA can be given with rapid sequence induction Methods to facilitate uterine relaxation Halogenated inhalational agents Nitroglycerin

18. PLACENTA ACCRETA Placenta accreta vera is defined as adherence to the myometrium without invasion of or passage through uterine muscle Placenta increta represents invasion of the myometrium Placenta percreta includes invasion of the uterine serosa or other pelvic structures Risk factors Previous uterine trauma Previous caesarean section Low lying placenta

19. Diagnosis Antepartum diagnosis is rare Difficulty in removal placenta Ultrasonography MRI Transvaginal colour dopler

20. Obstetric management Uterine curettage, followed by over-sewing of the bleeding placental bed. Balloon occlusion Embolization techniques Postpartum hysterectomy – definitive Anaesthetic management Preoperative diagnosis of placental abnormalities Identifying patients with high risk for placenta accreta Preparation for hysterectomy Availability of blood products

21. Uterine Inversion Uterine inversion, or the turning inside-out of all or part of the uterus, is a rare but potentially disastrous event Risk factors Short umbilical cord Uterine anomalies Inappropriate fundal pressure Excessive umbilical cord traction An abnormally implanted placenta ( eg - placenta accreta)

22. Obstetric management Early replacement of the uterus is the best treatment Once the uterus has been replaced Oxytocin (20 U/L) should be infused initially, Additional drugs (15-methyl prostaglandin F2-alpha) may be needed. ANAESTHETIC MANAGEMENT OF UTERINE INVERSION Uterine tone precludes immediate replacement Uterine relaxation is needed before successful replacement can be performed Ideal technique should have - Rapid uterine relaxation - No side effects - Short duration - Restoration of uterine tone after replacement of the uterus

23. GA with inhalational agents most preferred Equipotent doses of all volatile halogenated agents produce a similar degree of uterine relaxation Endotracheal intubation is mandatory Other modes terbutaline, magnesium sulfate , organic nitrates

24. Anesthesia for peripartum hysterectomy Obstetrician requires good skeletal muscle relaxation and a quiet operative field Choice of technique - REGIONAL ANAESTHESIA Risk of hypotension The operative time for caesarean hysterectomy is more Patient may have fatigue and restlessness. Intraperitoneal manipulation, dissection, and traction result in pain, nausea, and vomiting. Hyperemic pelvic viscera with engorged, edematous vasculature require careful dissection facilitated by a quiet operative field If RA is given then - Maintenance of a T-4 sensory level - Prophylaxis against nausea and vomiting - Judicious sedation Most of the cases require GA for emergency obstetric hysterectomy

25. Regardless of the anaesthetic technique used Two large-gauge intravenous catheters At least two units of packed PRBCS should be immediately available Additional units should be available without delay. Vasoactive drugs (e.g., Phenylephrine, dopamine, epinephrine) Establish invasive monitoring Fluid warmer Equipment for rapid infusion of fluids

26. RECENT ADVANCES Intra operative cell salvage Chance of amniotic fluid embolism Haemolytic disease in future pregnancies Leukocyte depletion filter is useful Separate suction for amniotic fluid advised Thromboelastography Useful guide in massive haemorrhage Provides information regarding coagulation factors, platelet function, fibrinogen levels, fibrinolysis Rapid results Can be done near the patient

27. Role of TRANEXAEMIC ACID Antifibrinolytic 1gm IV stat dose Followed by a second dose after 30 min if bleeding doesn't stop RECOMBINANT FACTOR VIIa useful in unresponsive massive haemorrhage Coagulopathy has to be corrected prior Prerequisites platelet count >50,000 fibrinogen > 0.5gms /L ph. >7.2 Dose-90 mcgs /kg stat dose followed by 120 mcg/kg if bleeding persists Thromboembolic events can occur High cost, lack of availability

28. Massive bleeding is defined as the loss of more than one blood volume within 24 hours (h), 50% of the patient's total blood volume lost in less than 3h or bleeding in excess of 150ml/minute

29. MASSIVE BLOOD TRANSFUSION Definition- Replacement of one entire blood volume within 24 h Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h Transfusion of >20 units of PRBCs in 24 h Transfusion of >4 units of PRBCs in 1 h when on- going need is foreseeable Replacement of 50% of total blood volume (TBV) within 3 h.

30. The resuscitation objectives in the context of massive transfusion include: A mean arterial pressure (MAP) within the range of 60 to 65 mm Hg Hemoglobin level between 7 and 9 g/dL International normalized ratio (INR) below 1.5 Fibrinogen levels within the range of 1.5 to 2 g/L Platelet counts above 50,000 μL pH between 7.35 and 7.45 Core temperature above 35 °C

31. Risks Associated with Transfusion Acute hemolytic transfusion reaction : This reaction is characterized by symptoms such as fever, chills, flank pain, and oozing from IV sites, resulting from acute intravascular hemolysis of transfused red blood cells. The leading cause is typically ABO incompatibility or a reaction to other RBC antigens. Transfusion-associated sepsis : This sepsis occurs when a patient is transfused with blood containing a microorganism, causing symptoms such as fever, chills, and hypotension. Anaphylactic transfusion reaction : This is a severe allergic reaction characterized by angioedema, wheezing, and hypotension. Allergic transfusion reaction : commonly arises from antigen-antibody interactions between the patient and the transfused product, and it typically presents with symptoms limited to hives and itching. Febrile non-hemolytic transfusion reaction (FNHTR) : FNHTR occurs due to the release of cytokines from white blood cells in the transfused product, and fever is the sole symptom. Hypotensive transfusion reaction : These reactions are characterized by a significant drop in systolic blood pressure, typically 30 mm Hg or more. The underlying mechanism is likely related to vasoactive kinins. Patients taking angiotensin receptor inhibitors are at an elevated risk for hypotensive transfusion reactions.

32. Hypothermia due to rapid transfusion of large amounts of cold blood can cause arrhythmias or cardiac arrest. Transfusion-associated circulatory overload (TACO) The high osmotic load of blood products draws volume into the intravascular space over the course. RBCs should be infused slowly Transfusion-related acute lung injury (TRALI) occurs within 6 hours of transfusion in a patient. TRALI results when human leukocyte antigen (HLA) class I and II neutrophil or possibly monocyte antibodies in donor plasma react with recipient white blood cells, leading to increased pulmonary microvascular permeability, interstitial and alveolar edema , and extravasated neutrophils in the alveolar spaces. Multiparous female donors are more likely to carry the offending antibodies

33. Metabolic alkalosis: Because of citrate overload. Monitor acid- base status Hypocalcemia: Because of citrate overload from rapid transfusion of blood products. Transfusion of stored blood may lead to acidosis , hyperkalemia . Stored blood develops low pH caused by the addition of acidic citrate-phosphate-dextrose and the accumulation of lactic and pyruvic acids that result from RBC metabolism and glycolysis.

34. Complications of PPH Anemia Anterior pituitary ischemia with delay or failure of lactation (i.e., Sheehan syndrome or postpartum pituitary necrosis) Blood transfusion Dilutional coagulopathy Fatigue Myocardial ischemia Orthostatic hypotension Postpartum depression Death