POSTPARTUM HEMORRHAGE (PPH) British Columbia Section 2006 OVERVIEW OF PRESENTATION z z z z z Definitions Diagnosis Etiologies Risk Factors Management Options DEFINITION z z z Excessive blood loss that makes the patient symptomatic (ie lightheadedness, vertigo, syncope) +/- signs of hypovolemia (ie hypotension, tachycardia, or oliguria) A subjective assessment Traditionally: (although they underestimate EBL) – – – EBL >=500 cc after vaginal delivery EBL >=1000 cc after a cesarean section Can also use a decline in Hct of 10% to define PPH INCIDENCE z z Affects 5-15% of women giving birth Two categories: – – Early (primary) hemorrhage: occurs within the first 24 hours postpartum Late (secondary) hemorrhage: occurs after 24 hours postpartum PREVENTION z Identifying the risk factors – z Assess every woman’s risk for PPH and make appropriate arrangements for her care Active management of the 3rd stage of labour – Will discuss later ETIOLOGIES: 4 T’s z z z z Tone: uterine atony, ~ 1 in 20 deliveries Tissue: retained placental tissue Trauma: uterine, cervical or vaginal lacerations Thrombin: dilutional coagulopathy, consumptive coagulopathy and coagulation disorders Uterine Atony z z z Most common cause of PPH Accounts for 75-80% of cases of primary PPH Need to be aware of risk factors Risk Factors For Uterine Atony z Over distended uterus – – – z Polyhydramnios Multiple gestation Macrosomia Uterine muscle exhaustion – – – Rapid labour Prolonged labour High parity z Intra amniotic infection – z Fever and/or prolonged labour Functional/anatomical distortion of the uterus – – – Fibroid uterus Placenta previa Uterine anomalies GENITAL TRACT TRAUMA and Risk Factors z z Second most common cause of PPH Lacerations of cervix or vagina: – – z z Precipitous delivery Operative delivery Genital tract hematomas Uterine rupture: – – – spontaneous (1/1900 deliveries) blunt trauma (eg. MVA) previous uterine scar GENITAL TRACT TRAUMA and Risk Factors z Lacerations/extensions at C-section: – – – Prolonged labour Malposition Deep engagement UTERINE INVERSION and Risk Factors z z Iatrogenic During 3rd stage of labour: inversion Æ traction on peritoneal structures Æ vasovagal response Æ vasodilation Æ increased bleeding and risk of hypovolemic shock z Risk factors: – – High parity Fundal placenta Retained Products of Conception and Risk Factors z Retained blood clots: – z Atonic uterus Retained products: – – – – Abnormal Placenta: accreta, percreta, succenturiate lobe Previous uterine surgery (ie: myomectomy) High parity Incomplete placenta at delivery Coagulation Abnormalities and Risk Factors z Pre-existing states: – – Hemophilia A Von Willebrand’s Disease z z z History of hereditary coagulopathies History of liver disease Therapeutic anti-coagulation: – History of blood clots Coagulation Abnormalities and Risk Factors – cont’d z Acquired in pregnancy: – – – ITP Pre-eclampsia and thrombocytopenia DIC z z z z z Pre-eclampsia Dead fetus in utero Severe infection Abruption Amniotic fluid embolism Active Management of the 3rd Stage z Use of uterotonic drugs after the delivery of the anterior shoulder: – z z z Oxytocin 10 U IM, 5 U by IV push or 10-20 U per litre IV drip running at 100-150 cc/hr Early cord clamping and controlled cord traction Ensure continued uterine contraction post delivery of placenta by fundal palpation and massage if necessary Inspect placenta for completeness Approach to Identifying Etiology z z z z Abdominal palpation: boggy vs. firm uterus, ?uterine inversion Careful inspection of cervix, vagina, vulva and perianal area for lacerations and/or hematomas Manual exploration of uterine cavity: remove clots, retained tissue? Consider coagulopathy if no other cause identified PRIMARY MANAGEMENT – “ABC’s” z z z z z z z Notify attending physician and other staff Monitor vital signs, urine output, possible foley 1 large bore IV Type of cross-match 2-4 units of PRBC’s Fluid resuscitation with crystalloids Baseline blood work for Hgb, hematocrit, platelets and coagulation profile Then proceed with directed treatment TREATMENT OF UTERINE ATONY z z Bimanual compression and massage of uterus Drugs: – – – Rapid, continuous infusion of dilute IV oxytocin (40-80 U in 1L NS) Misoprostil (Cytotec, PGE1): 800-1000 mcg rectally Methylergonovine maleate (Methergine): 0.2 mg IM repeat q5mins as needed up to 5 doses: z – Contraindicated in women with hypertension Prostaglandin F2α analogues (Hemabate): 0.25 mg IM repeat q15 mins prn up to 8 doses z Contraindicated in those with asthma/brochospasm TREATMENT OF UTERINE ATONY z Methods to Tamponade the Uterus – Uterine packing z – SOS Bakri Balloon/other brand uterine balloons z z – Pack uterus with gauze layering from one cornua to the other with a sponge stick ending such that the gauze is allowed to extend though the cervical os Insert balloon Instil 300-500cc saline Foley catheter z z Can insert one or more bulbs Instil 60-80cc of saline TREATMENT OF GENITAL TRACT TRAUMA z z Lacerations: identify and repair with continuous interlocking sutures Large expanding hematomas – – Sx: Pelvic or rectal pressure, pain Tx: Drain the blood within the hematoma, can place a drain in situ, suture the incision, vaginal packing or interventional radiology if hematoma expansion cannot be tempered TREATMENT OF GENITAL TRACT TRAUMA z z Uterine rupture: repair small defects, may need total abdominal hysterectomy Uterine inversion – – Can replace manually by placing the palm of the hand against fundus and by exerting upward pressure with the fingertips circumferentially May need to relax uterus with agents such as magnesium sulfate, halothane, terbutaline or nitroglycerin in order to replace uterine corpus TREATMENT OF RETAINED PLACENTAL TISSUE z z z Manual removal Curettage (with a large curette) Extensive placenta accreta may need a hysterectomy TREATMENT OF COAGULOPATHY z z Reverse anticoagulation Von Willebrand’s disease: – z Desmopressin before the surgery and post for severe hemorrhage Replace Factors: – Platelet concentrate, cryoprecipitate, fresh frozen plasma, platelets, packed RBC’s INTRACTABLE PPH z Get help – z Local control – – z Manual compression and packing of uterus Vasopressin at site of bleeding in c-section BP and coagulation – z Notify OB, anesthesia and ICU Crystalloids and blood products to maintain urine output, BP and coagulation Consider angiographic embolization Intractable PPH - Surgical Approach z z Repair of lacerations Surgical uterine compression techniques – z Ligation of vessels – – z z Example: B-Lynch Uterine arteries Internal iliacs Emergency Hysterectomy Uterine artery/internal iliac embolization Delayed (Secondary) PPH z z z z Between 24hrs and 12 weeks postpartum Affects 0.5 – 2 % of women Secondary to atony due to retained products Management: – – – Uterotonic agents Antibiotics Possible D&C COUNSELLING z z z z Women with a prior PPH have ~ 10% risk of recurrence in a subsequent pregnancy Always consider preventative measures Counsel appropriately Take appropriate measures REFERENCES: z z z Prevention and Management of Postpartum Haemorrhage. SOGC clinical guidelines. JOGC, April 2000 Postpartum Hemorrhage. ACOG Practice Bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006: 108:10391047. Jacobs, A. Causes and treatment of postpartum hemorrhage. Uptodate online (14.3)