Primary postpartum haemorrage

Primary Postpartum Haemorrhage 2017, Nigeria

1. Presentation on Primary Postpartum Hemorrhage by Dr. Ahmed H. Yakubu (H.O.) DEPARTMENT OF O & G FEDERAL MEDICAL CENTRE, KATSINA presented on 6 TH January, 2018 supervised by Dr. Kundil

2. Outline Introduction Definition Classification Epidemiology Etiology/Risk factors Pathophysiology Prevention Management Conclusion References

3. Introduction Primary PPH is a frequently encountered obstetric emergency. Systemic reviews suggest that the burden of the condition varies from region to region however it is agreed among respected colleges that its attendant mortality and morbidity is significant both in developed and developing countries. WHO statistics suggest that 25 % of maternal deaths in developing countries are d ue to PPH. Unpredictable and relatively common, it is pertinent at the very least identify women at risk and take appropriate measures to limit the prevalence of the emergency.

4. Definition of Primary Postpartum hemorrhage Blood loss in excess of 500mls following vaginal delivery or In excess of 1000mls following caesarean section or in excess of 1500mls following caesarean hysterectomy… Blood loss that is significant enough to cause hemodynamic instability… Decline in hematocrit value by up to 10% or more from the premorbid value… *Any of the above occurring after the age of viability (28weeks) and within the first 24hours after delivery.

5. Classification Minor: Estimated blood loss is 500mls – 1000mls Major: Estimated blood loss is in excess of 1000mls or clinical shock or presence of ongoing or continuous hemorrhage. Moderate: 1000 – 2000mls Severe: >2000mls

6. Epidemiology A systematic review and meta-analysis by Clara Calvert et al in 2012 reported the highest rates of PPH in Africa (27.5%), and the lowest in Oceania (7.2%), with an overall rate globally of 10.8%. Both Europe and North America was around 13%. High rates: Multiple pregnancies (32.4% compared with 10.6% for singletons) The overall rate of major PPH (>1000mls) was much lower at an overall rate of 2.8%, again with highest rate in Africa (5.1%).

7. Etiology/Risk factors (The 4T’s) Tone (Uterine atony ): Over distension: Multifetal Gestation Grandmultiparity Fetal Macrosomia Fetal Abnormalities Polyhydramnios Retained Placenta Retained blood clots Uterine Structural Abnormalities

8. Etiology/Risk factors (The 5 T’s) Tone (Uterine atony ): Poor m yometrial activity: Prolong labour Precipitous labour Placenta implantation in lower uterine segment Drugs chorioamnionitis Hypoxia Hypothermia Uterine anomalies Uterine inversion

9. Etiology/Risk factors (The 5 T’s) Tissue: Retained placenta Retained blood clots Trauma: Spontaneous or Iatrogenic: Uterine Rupture Cervical, vaginal or perineal lacerations

10. Etiology/Risk factors (The 5 T’s) Thrombi (Coagulopathy): Consumptive coagulopathy DIC Dilutional coagulopathy Thrombocytopenia: ITP, TTP Pharmacological inhibition Warfarin Heparin Dextran infusion Hereditary coagulation Disorders Familial Hypofibroginaemia Von W ille B rand disease

11. Risk assessment: Low risk Moderate risk High risk Singleton pregnancy Prior C/S or uterine surgery Previa , accreta , percreta , increta < 4 previous deliveries > 4 previous deliveries PCV <30% Unscarred uterus Multiple gestation Bleeding at presentation No previous Hx Large uterine fibroids Known Coagulation defects Chorioamnionitis Positive Previous Hx MgSo4 use Abnormal vital signs Prolonged us of oxytocin

12. Pathophysiology Physiological changes during pregnancy: Hematological: Progressive decline in Platelet count, (5 – 10%) 100 – 150 x 10 9 cells/l Cardiovascular: Blood flow to the uterus at term is 500 – 800mls/min (10 – 15% of cardiac output)

13. Pathophysiology Physiological changes after delivery of placenta: Uterine contraction and retraction Activation of coagulation system (Factor) Pathology: Uterine atony (80%) Trauma Retained tissue Coagulopathy (DIC) “Living Ligatures”

14. Estimation of blood loss: Visual inspection Clinical signs Hematocrit Gravimetric method Maximum swab (gauze) capacity: small (10 x 10cm) – 60mls, medium (30 x 30cm) – 140mls, Large (45 x 45cm): 350ml Photometric method

15. Clinical features correlation with estimated blood loss: Symptoms/ Signs Systolic Blood pressure Estimated blood loss Degree of shock Palpitations , tachycardia, dizziness. Normal 500 – 1000mls 10 – 15% Compensated Tachycardia, sweating, weakness. 80 – 100mmhg 1 – 1.5L 15 – 25% Mild Restlessness, Oliguria, pallor. 70 – 80mmhg 1.5 – 2L 25 – 35% Moderate Collapse, Anuria, Air hunger. <70mmhg >2L >35 % Severe

16. Prevention: Pre-pregnancy : Health Education (men & women) Primary Health care Services Women Empowerment Pregnancy: Antenatal care: Clinical Evaluation Investigations

17. Labour : Review patients obstetric history Examine Establish a diagnosis Intravenous cannula Investigations: Urgent Full Blood Count (Hematocrit) GXM 2pints Urinalysis Use of Partograph (Active Phase) Episiotomy???, There must be a clear indication based on the experienced judgment

18. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR: Paramount in preventing primary PPH, it involve: Administration of uterotonics , oxytocin, after delivery of the fetus and exclusion of a 2 nd twin. Cord clamping & cutting after 1 – 3min after delivery of fetus Delivery of the placenta by control cord traction after resumption of uterine contraction (signs of separation) Inspect placenta for completeness Rub-up contraction and monitor uterine state every 15minutes for first 2hours. Prophylactic measures for high risk patients should be ensured . Monitor patient up to 24hours before discharge.

19. Management: CALL FOR HELP (4 ASSISTANTS) Resuscitation: Airway Breathing Circulation : 2 wide-bore IV cannula in-situ, investigation samples, normal saline. Anti-shock garment Request for 2 – 4 pints of Fresh Whole blood Notify the theater to be on stand-bye and blood bank of the possibility of the need for more blood within a short time. Document critical intervention/information and time, i.e. note vital signs momentarily, drugs, fluids given and volume, SPo2 and c hest auscultation.

20. Management: Tertiary level continue: Examination: Uterine palpation for atony , rupture or inversion Inspect placenta for completeness Inspect Genital tract for laceration Inspect for signs of coagulopathy Review of results

21. Treatment of underlying causes: UTERINE ATONY: Mix 4 0IU Oxytocin + 1L Normal saline to over 4hours + empty urinary bladder. Other uterotonic agents may be used: Misoprostol (800ug – 1000ug), Ergometrine or Carboprost Bimanual compression Uterine tamponade : SOS Bakri tamponade , Ebb uterine tamponade system, Condom or Surgical gloves

22. Improvised condom Tamponade Bakri Uterine Tamponade Baloon

23. UTERINE ATONY: Laparotomy, ongoing hemorrhage 2 o unresponsive-atonic uterus Ancillary measures: Bimanual compression NASG Uterine tamponade External aortic compression Bimanual Uterine Compression

24. OPTIONS INCLUDE: Uterine/Ovarian artery ligation or Selective Arterial Embolization Uterine compression sutures B-lynch, Modified B-lynch, vertical uterine, square compression suture. Hysterectomy OTHER TREATMENT: Use of tranexamic acid Use of antibiotic prophylaxis Further care in the Intensive Care Unit!

25. B lynch sutures Uterine artery ligation

26. Treatment of underlying causes: RETAINED TISSUE: Require performing a manual/digital exploration , Therapeutic indication: Uterine atony despite optimal use of uterotonics Incomplete Placenta Retained placenta due to avulsion of cord Retained blood clots. Diagnostic values: Complete or partial uterine inversion Detects uterine rupture Genital tract lacerations Retained tissue

27. Treatment of underlying causes: RETAINED TISSUE: Require performing a manual/digital exploration … Done under anesthesia or adequate analgesic cover based on the clinical urgency of the situation. Using elbow length surgical gloves* Continue uterotonic infusion during evacuation or delivery of the placenta. Resume bimanual massage/compression after evacuation. Have an assistant examine the placenta for completeness if/when retrieved. Short term broad spectrum antibiotics.

28. Treatment of u nderlying causes: TRAUMA: Uterine Rupture: Absence of contraction with abdominal pain/tenderness. repair of laceration or hysterectomy . Despite well contracted uterus bleeding persists “per vagina “… Consider cervical, vaginal or perineal lacerations or a combination. Repair immediately under Adequate analgesia Excellent lighting Good positioning & exposure: realize the full extent & proper anatomy of the laceration before repair Extensive lacerations (cervical lacerations inclusive) are best repaired in the theatre Observe laceration for bleeding after repair

29. Treatment of underlying causes: COAGULOPATHY: History (risk factors) clinical signs (bleeding from puncture sites, mucous membranes or into the skin, spontaneous bruising) Available Investigation results: Bedside clotting time Clotting profile (PT, aPTT , D-dimer) Platelet count (<50 x 10 9 /L) Transfuse with Fresh whole blood or Transfuse with relevant blood component: FFP: requirement 5 pints of PRBC : 1 pint FFP (10-20ml/kg). Platelet concentrate: 1 pint increase count by 10 x 10 9 /L, maintain count >50 x 10 9 /L. Cryoprecipitate in isolated deficiencies.

30. Treatment of underlying cause: HEMATOMA : An extravascular localized (progressive) collection or accumulation of blood associated with intense pain and localized tender swelling. This may be associated with significant deterioration in the hemodynamic state of the patient. It may occur in relation to laceration or in isolation. Rx: Vulva or vaginal hematoma: for large progressive hematomas + tachycardia, hypotension or anemia. I & D, secure hemostasis, and repair defect in layers Retroperitoneal hematoma requires Laparotomy

31. COMPLICATIONS: EARLY COMPLICATIONS: Postpartum anaemia Infections ATN Pulmonary edema Thromboembolic events Blood transfusion related (massive blood transfusion ) Gastrointestinal ulceration Surgical related Anesthesia related

32. LATE COMPLICATIONS: Sheehans Syndrome Infertility Uterine synechiae Infections Child neglect Maternal depression Rh Isoimmunization

33. CONCLUSION: AMTSL is paramount to preventing primary PPH. It is necessary to have a protocol for its management which should be communicated to medical staffs involved. Conducting periodic reviews and practice drills will enhance the efficiency of its management.

34. REFERENCES: Textbook of Obstetrics and Gynecology for Medical Students, 2 nd Edition, Edited by Akin Agboola , 2006 WHO Recommendation for the prevention and treatment of postpartum hemorrhage, 2012. RCOG Guideline, Prevention and Management of Postpartum Hemorrhage , December 2016. ACOG Practice Bulletin, Postpartum hemorrhage, October 2017 . Medscape, Postpartum Hemorrhage, updated August 03, 2017. Monroe Kerrs , Operative Obstetrics, 11 th Edition.