secondary postpartum hemorrhage

Prepared by
Dr.Hesham Abd Elaziz

1. SECONDARY PPH Prepared by Dr. Hesham Abd Elaziz Elmahalla gen. hosp. [phone]

2. Fresh or excessive bleeding from the vagina between 24 hours and 12 weeks after giving birth (Alexander et al. 2002) Definition

3. *In the developed world 0.5-1% *85 % r equiring hospital admission *15 % require bl. transfusion *1-3 % Obliges hysterectomy Alexander et al. 2002 Incidence

4. 1- A history of primary PPH 2- M anual removal of placenta 3- PROM 4 - Previous 2ry PPH 5-Other risk factors include : Multiple pregnancy ,threatened miscarriage, precipitate labour , prolonged third stage, CS and not breast feeding . Risk factors

5. 1-Placental causes 2-Infection 3-Trauma 4-Uterine disease 5-Coagulopathies 6-Idiopathic (1/3 rd of cases) Ætiology

6. 1- Placental causes * Subinvolution of the placental site *Retained products of conception * M aladherent placenta 2- Infection : Endo/ myometritis , infected or dehiscent scar 3- Trauma : Missed vaginal lacerations and hæmatomas Alexander et al. 2002 , ACOG 2006 andRepke in James et al 2011 Ætiology

7. 4- Pre-existing uterine disease * Uterine fibroids * Cervical neoplasm * Cervical polyp * Uterine arteriovenous fistulas 5- Coagulopathies * Congenital hæmorrhagic disorders (von Willebrand’s disease, carriers of hæmophilia A or B, factor XI deficiency) * Use of anticoagulants (e.g. warfarin) Alexander et al. 2002, ACOG 2006; Ambrose and Repke in James et al. 2011 Ætiology

8. 1- Small amounts of bleeding may persist for several weeks and therefore some bleeding defined as a secondary PPH may be normal variant in absence of signs and symptoms of endometritis 2- Bleeding may also represent the 1 st menses after childbirth or 3- A side effect of contraceptive method used Remember

9. 4- Suspect endometritis if there is uterine tenderness, fever or foul smelling lochia 5- Secondary PPH in the first week may be related to coagulopathy , especially V on Willebrand’s dis. Assessment

10. 1- D etailed history including parity , mode of delivery, third stage and puerperal complications 2- Check pulse , blood pressure and temperature 3- Assess uterine size & cervical excitation and uterine tenderness Assessment

11. 4- Exclude other sources of infection e.g. mastitis, urinary tract infection or septic pelvic thrombophlebitis 5- Assess clinical signs of blood loss 6 - Speculum examination : Cervical dilatation, tears, infection , blood or remnant of tissues Assessment

12. Investigations 1-U / S and Doppler study 2- CBC, C-RP and ß- hCG 3- Low vaginal , high vaginal , endocervical and r ectal swabs. 4- Coagulation profile 5- Midstream urine specimen 6- Blood cultures if temperature ≥ 38°C King Edward Memorial HospitalClinical Guidelines

13. (a) Longitudinal view of a uterus distended by echogenic material (b) Transverse view of the uterus also showing the echogenic material within the endometrial cavity.

14. (c) Longitudinal view. Closer view of the echogenic material. (d) The above image with colour Doppler showing vascularity of the retained products of conception.

15. (e) Colour Doppler of retained products of conception on transverse view. AUJUM (Australasian Journal of U/S in Medicine) Oine Omakwu , Talat Uppal , Fernando InfanteTorresPublished 20 May 2016

16. P revention 1-At risk women should deliver at hospital 2-Sterilization &antiseptic technique 3-Ensure complete removal of the placenta 4-Patients with history of 1ry PPH or of 2ry PPH should receive a course of ecbolics & antibiotics 5 -Consider prophylactic antibiotics in risky patients 6-Correction of anæmia

17. The initial treatments are * Ecbolics and antibiotics *Surgical intervention if bleeding is heavy and ongoing e.g. urgent ultrasonographic guided E&C T reatment Aiken et al. 2011

18. E ndometritis can be effectively treated with antibiotics If curettage is recommended, aim to give antibiotics for 6-12 hours before the procedure unless bleeding requires earlier intervention (U/S guided E&C and send for histopathology) King et al. 1989; Ambrose and Repke in James et al. 2011 T reatment

19. H æmodinamically stable woman 1-Take history : parity , 3 rd stage complications , birth mode, & any relevant medical or family history & consider obstetric risk factors. 2- Uterine size & tenderness.

20. 3. Investigations: CBC , CRP, coagulation studies , serum ß- hCG Vaginal , cervical and rectal swabs, mid stream urine, & blood culture if temperature ≥ 38°C. 4. U/S & Doppler ? Other imaging as needed . H æmodinamically stable woman

21. *Conservative management 1-Intravenous antibiotics and ecbolics 2-If bleeding has not settled after 24 hours of antibiotic & ecbolics , consider surgical intervention H æmodinamically stable woman

22. A ntibiotics *In endometritis (tender uterus) *Ampicillin or amoxicillin 2gm IV initial dose then 1gm IV /4 hrs plus * Metronidazol 500 mg/12 hrs IV infusion *Gentamycin 5mg/kg/d IV or Ceftriaxone 1gm/24hrs *If allergic to penicillin shift to Clindamycin 300 mg/8h plus Gentamycin or Lincomycin 600 mg IV in 100 ml over 1hr. RCOG Green-top Guidelines no. 52

23. E cbolics Administer bolus dose then maintenance doses of one of the following : * Oxytocin 10 IU Intramuscular * Syntometrine IM * Ergometrine 500 micrograms IM * Carboprost 250 μ g *Misoprostol 800 μ g rectal and/or intrauterine to help the uterus expel products of conception BJOG: An International Journal of Obstetrics & Gynaecology

24. Indicated if excessive or continuing bleeding irrespective of ultrasonic finding (after excluding coagulopathy) S urgical management RCOG Green-top Guidelines no. 52

25. Uterine massage Aortic compression S urgical management

26. M ay include any of the following: *Examination under anæsthesia *Ultrasonic guided E&C (suction) * Balloon tamponade (? CS scar) *Ligation of internal iliac arteries * Interventional radiology ? * Hysterectomy (1-3%) of cases S urgical management

27. U/S guided E&C *Administer antibiotics for 6 to 12 hours *Suction curettage is expedient *Avoid vigorous curettage (3%) risk of uterine perforation & Asherman’s s yndrome *Send tissue for histopathology to exclude c horiocarcinoma and to confirm diagnosis *If bleeding continues after curettage (suction) consider further intervention King et al. 1989; Ambrose and Repke in James et al. 2011

28. B alloon tamponade Main indication is 2ry PPH with maladherent placenta (Partial or total preservation of the placenta) King et al. 1989; Ambrose and Repke in James et al. 2011

29. Uterine artery ligation Hypogastric artery lig .

30. Selective vascular embolisation Hysterectomy

31. H æmodynamically compromised woman 1- Start resuscitation (ABCD) 2- O2 mask and insert 2 large bore IV lines 3 - CBC , cross match, coagulation studies 4 - Commence fluid replacement until blood arrives and monitor urine output . 5 - IV antibiotics and ecbolics

32. 6 - Examination under anæsthesia to identify cause & treat accordingly 7- Rub up the uterus , evacuate clots . 8- Bimanual compression of the uterus 9- External aortic compression H æmodynamically compromised woman

33. 10-surgical evacuation (E&C) (suction) 11- If bleeding continue other options include *Balloon tamponade *Uterine devascularization *Specific factor transfer *Hysterectomy 12- Specialized treatments as choriocarcinoma and coagulopathies. (consultation or referral) H æmodynamically compromised woman

34. *O2 mask and 2 cannulas 16 gouge *Crystalloids : up to 2 liters Hartman’s solution *Colloids : up to 1-2 liters until blood arrives (?Dextran) *Blood : Cross-matched or O negative blood *Fresh frozen plasma: 4 units for every 6 units RBCs (15 ml/kg or total 1 liter) *Platelet concentrates : If platelet < 50.000 / cc *Cryoprecipitate : If fibrinogen < 100 mg / dl RCOG Green-top Guideline No. 52 Stabilization of marked bleeding

35. up to 1 litre of fresh frozen plasma (FFP) and 10 units of cryoprecipitate may be given empirically in the face of relentless bleeding , while awaiting the results of coagulation studies . * Avoid hypothermia and hypotension * Observations : pulse , BP, RR , O2 saturation, urine output RCOG Green-top Guideline No. 52 Stabilization of marked bleeding

36. Rfactor VIIa suggested dose is 90 ug / kg which may be repeated in the absence of clinical response within 15–30 minutes Before giving rFactor VII be sure that : Fibrinogen > 100 mg / dl * P latelets > 20 .000 / cc to achieve good clinical response Stabilization of marked bleeding

37. O ur aim * Hæmoglobin > 8 gm / dl *Platelets > 75.000 / cc *Fibrinogen >100mg / dl * Prothrombin < 1.5 mean control * A PTT < 1.5 mean control RCOG Green-top Guideline No. 52

38. Significant causes of 2ry PPH 1- Retained product of conception 2- Endometritis 3- Subinvolution 4- Idiopathic Assessment 1- ABC 2-History 3-Pulse, BP, Temp. , RR 4- S&S 5- Uterine size 6- B lood loss Conservative management *Monitor vital signs *IV line *Investigations: U/S & lab. *Antibiotics & ecboliics *Surgical interference w hen indicated Stable condition

39. *ABCD * O2 by mask *2 IV canulas *Monitor vital signs *Crystalloids & colliods o r blood product infusion * Avoid hypothermia Unstable condition *U/S & Doppler *CBC, CRP , - ß HCG *Coagulation profile *Bl. culture *Urinalysis *Antibiotics * Ecbolics * Foly’s catheter *E&C (suction) * Balloon tamponade * Devasculari - zation *Hysterectomy Resuscitation Investigations Treatment

40. References 1. RCOG. Prevention and management of postpartum haemorrhage . Green top guideline No. 52; April 2011 2 . Cochrane Database of Systematic Reviews 2002, Alexander J, Thomas P, Sanghera J. Treatments for secondary haemorrhage . 3 . ACOG. ACOG Practice Bulletin. Postpartum Haemorrhage . Clinical Management Guidelines for ObstetricianGynecologists . Number 76, October 2006. 4 . Ambrose A, Repke JT. Puerperal problemsThird ed. Philadelphia: Elsevier; 2011. 5 . Aiken CEM, Mehasseb MK, Prentice A. Secondary postpartum haemorrhage 2011 6 . Neill A, Thornton S. Secondary postpartum haemorrhage . J Obstet Gynaecol 2002 7-BJOG : An International Journal of Obstetrics & Gynaecology

41. THANKS Prepared by Dr.Hesham Abd Elaziz Elmahalla gen. hosp. [phone]