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Post-Partum Hemorrhage:

Management and
Complications

Max Mongelli
Clinical Associate Professor
Western Clinical School
University of Sydney
Nepean Hospital
Third stage of labour

 From delivery of the baby to delivery of the


placenta < 20minutes.
 Cessation of umbilical artery pulsation,
placenta separates from uterine wall through
the decidua spongiosa and is delivered
 Capillary haemorrhage and shearing effect
of uterine muscle.
Amount of blood loss depends on:

 How quickly the placenta separates from


uterine wall.
 How effectively the uterine muscle
contracts around the placental bed during
and after separation.
 Intact coagulation system.
Active management
 “Standard practice”
 Administration of an oxytocic at the
delivery of the anterior shoulder/after the
baby has been delivered.
 Early cord clamping and cutting
 Controlled cord traction of the umbilical
cord
Expectant management
 “Conservative” “Physiological”
 Waiting for the umbilical cord to cease
pulsation
 Waiting for signs of placental separation
 Allowing placenta to deliver spontaneously
 Aided by gravity/nipple stimulation/breast
feeding
Active vs Expectant
Management
 Reduced maternal blood loss
 Reduced PPH rates (0.38, CI 0.32 to 0.46)
 Shortening of 3rd stage of labour
(-9.77, CI –10.0 to –9.53)
 Increased maternal nausea
(1.83, CI 1.51 to 2.23)
 Increased vomiting and raised BP
(probably due to use of ergometrine)

Cochrane Database of Systematic Reviews 2000


PPH
 Definition –
primary >500ml
secondary
 PPH rates
 Maternal risks
 mortality

 morbidity

 Risk factors
 Prevention
 Management
Definition
 Blood loss from the genital tract >500ml in
the first 24 hours following delivery
 “normal blood loss” (Bonnar 2000)
- at vaginal delivery: 600ml
- at Caesarean section: 1000ml
PPH
 Haemorrhage is the main cause of death in a
number of countries
 At least 25% of maternal deaths worldwide
due to haemorrhage – the majority
postpartum haemorrhage
 Vast majority in the developing world
 Most important complication of the 3rd stage
of labour
Massive haemorrhage
 >1500ml
 Blood loss requiring replacement of the
patient’s total blood volume
 Transfusion >10 units blood within 24 hours
 Replacement of 50% circulating blood
volume in <3hours
 Loss of >150ml/minute
PPH rates

 Depend on the definition used


 KEMH >500ml 12%, >600ml 9.45%, >1000ml
5.5%
 Similar rates in Australasian tertiary institutions
 Most of Australasia:
 >500ml 8%,

 >1000ml 4.27%,

 >1500ml 1.83%,

 >2000ml 0.6%
Maternal risks
 Mortality
 Triennial reports from UK 1985-96 show no
significant reduction in the number of deaths from
haemorrhage (30 each triennia)
 Majority due to substandard care
 DELAY in - correction of hypovolaemia,
- diagnosis and treatment of defective
coagulation
- surgical control of bleeding
 “TOO LITTLE TOO LATE”
Mortality
 Developing countries PPH 125,000 deaths/yr
 28% of maternal deaths
 Risk 1 in 1000
 Australia 1 in 100,000 deliveries die of PPH
 Life threatening haemorrhage 1 in 1000 deliveries
 Risk increases with increasing maternal age
especially >35 years
Morbidity

 Coagulopathy (DIC)
 Fluid overload/Pulmonary edema
 Left ventricular failure
Morbidity

 Injury to ureter and bladder from surgical


intervention
 Sheehans syndrome
 permanent hypopituitarism caused by
avascular necrosis of the anterior
pituitary gland,
 failure of lactation, amenorrhoea,
hypothyroidism and adrenocortical
insufficiency
Blood Changes in Pregnancy
 Normal adult blood volume 70ml/kg
eg 50kg 3.5L
60kg 4.2L
70kg 5.0L,
etc
 The healthy pregnant woman has a blood
volume of 6-7L in late pregnancy
Blood Changes in Pregnancy

 During pregnancy:
 40% increase in blood vol
-increase in red cell mass
 Lowering of haematocrit by 10%
 Marked increase in fibrinogen
and factors VII,
VIII and X
Adaptation to blood loss
 Blood loss <1000ml induces little or no
change in pulse or BP
 Catecholamine – induced vasoconstriction
maintains perfusion of the maternal heart
and brain at the expense of diminished
utero-placental blood flow
 Tachycardia may be absent in up to 25% of
cases with severe blood loss.
Haemorrhagic shock
and blood loss
Blood volume BP Symptoms and Degree of
loss signs shock
10-15% Normal Palpitations, Compensated
(500-1000ml) dizziness, HR incr

15-25% Slight fall Weakness, sweating, Mild


(1000-1500ml) tachycardia

25-35% 70-80mmHg Pallor Moderate


(1500-2000ml)
35-45% 60-70mmHg Collapse, air hunger, Severe
(2000-3000ml) anuria
Disseminated Intravascular Coagulation

 Depletion of fibrinogen, coagulation factors and


circulating platelets
 Haemostatic failure
 Microvascular bleeding
 Increased blood loss
 Unlikely if platelet count is normal
Risk Factors for PPH (1)

 Placenta praevia, especially if associated with


accreta/percreta/increta
 Previous history of PPH
 Previous history of retained placenta, Ashermans
syndrome, endometrial ablation
 Hypertensive disorders
 Manual removal of retained placenta
 Refusal of blood transfusion
Risk Factors for PPH (2)

 Maternal obesity
 Large baby
 APH/abruption
 Multiple pregnancy
 Previous PPH (recurrence rate 8-10%)
 Operative delivery – Emergency CS
substantially increases the risk
Risk Factors for PPH (3)

 Anaemia
 Induction/augmentation of labour
 Instrumental delivery
 Prolonged labour (1st or 2nd stage)
 Grand multiparity (>5)
 Bleeding disorder (eg Von Willebrandt’s)
 Use of anti-epileptic medications
Prevention of PPH:
Antenatal period

 Identification and correction of anemia in


pregnancy
 Detection of sub-clinical bleeding disorders
 Detection of placenta accreta/percreta
 Care plan for management of third stage if
risk factors detected
Prevention of PPH (2)
 Oxytocic policy
 Venous access, G+H, active management of
third stage, oxytocin infusion in those
identified as at risk
 Senior obstetrician/anaesthetist at placenta
praevia CS
 +/-gynae oncologist at placenta accreta CS
Management of PPH

 Call for help


 Resuscitate
 Restore circulating blood volume
 Identify and treat the cause
Resuscitation
 Massage fundus
 Venous access, 16 gauge cannula, x2
 Tilt head down, O2 by face mask
 Bloods:FBC, Coags, X-match
 IDC
 Monitoring
Volume replacement
 Crystalloids
 80% infused fluid leave the intravascular space

 AVOID DEXTROSE
 O negative blood if torrential loss
 Packed cells
 4 units FFP for every 6 packed cells
 Platelets/cryoprecipitate
 Involve haematologist early on
 Avoid colloids
Monitoring

 Pulse, BP
 Respiratory rate
 Temperature
 Urine output 0.5 ml/kg/hour (30ml/hour)
 Pulse oximetry
 HDU: Arterial catheterisation
Identify and treat the cause
 Tone  Bimanual compression,
oxytocics
 Tissue  Remove retained
placenta/membranes

 Trauma  Repair genital tract tears

 Thrombin  Correct/prevent
coagulopathy
Uterine atony

 Most common cause of PPH


 Oxytocin infusion (as per local protocol)
 Ergometrine IM
 Rectal misoprostol (up to 800mcg)
 Rectal PGE2 (20 mg)
 Intra-myometrial PG F2 alpha (250 mcg)
Examination under anaesthetic
 Remove retained placental tissue ensuring
the uterus is empty
 Detailed examination of cervix and vagina
to exclude and repair any lacerations
 More oxytocics
 Antibiotic cover
 Medical – PgF2alpha
Case Scenario
 You are the SR/consultant called to theatre.
 Junior registar has a patient who has lost
1500ml has done EUA, given oxytocics
including PgF2alpha and the patient is
continuing to bleed.
 What are you going to do?
Continued bleeding
 Uterine tamponade
 Foley catheter

 Double balloon catheter

 Uterine packing

 Sengstaken-Blakemore tube

 Consider calling gynae oncologist


 Consider arterial embolisation – interventional
radiologist
Laparotomy
 Uterine haemostatic suture
 B Lynch suture

 Modified B Lynch

 Arterial ligation
 Bilateral internal artery ligation

 Bilateral uterine/ovarian artery


ligation
 Hysterectomy
 Total

 Subtotal
Technique
 70mm round bodied No.2 CCG
 3cm from the right lower edge and 3cm
from the right lateral border of the incision
 Thread through into the uterine cavity and
emerge the needle 3cm above the incision
 Pass the CCG over the fundus 3-4cm from
the right cornual border
Technique
 Feed CCG posteriorly and vertically.
 Enter uterine cavity posteriorly at same site
as superior anterior entry point
 Pull CCG under moderate tension, assistant
applies manual compression
 Pass suture horizontally to emerge on
posterior wall at the same level but on the
left posterior side of the uterus
Technique

 Suture knot using two or three throws whilst


assistant maintains bimanual compression
 Close the lower transverse incision in the
uterus
B Lynch suture
 Advantages
 Effective control of haemorrhage

 Conservation of the uterus for fertility

 Avoidance of more radical procedure

(hysterectomy) and its potential


morbidity
 Relatively simple

Disadvantage:
-paralytic ileus
Hayman compression sutures

 Does not require a lower uterine incision


 Uses 1-vicryl x 4

 Bladder has to be reflected down

 Simpler than B-Lynch


Balloon Tamponade

Various methods available:


 Sengstaken tube
 SOS-Bakri tamponade balloon
catheter
 Condoms
 Foley’s catheters
 Surgical glove
SOS – Bakri Balloon Tamponade
SOS – Bakri Balloon Tamponade

The indications for use:

 Temporary management of lower uterine


segment bleeding.

 Indicated in about one third of all PPH


cases.
Sengstaken-Blakemore Balloon Tamponade
Sengstaken-Blakemore Balloon Tamponade

 Esophageal balloon inflated to 250 ml with


normal saline
 Prophylactic antibiotics
 Prevented major surgery in more than 70%
of cases
 May help reduce bleeding if transfer is
required.
Balloon Tamponade with Condoms

 The idea was first introduced by Professor Sayeba Akhter


(Dhaka, Bangladesh) to save the life of a woman who had
severe jaundice with intractable PPH.
 Condom is inflated with isotonic saline of 250 – 500 ml
(sometime >500 ml – 1 L)
 When the bleeding is reduced considerably, further
inflation is stopped. then outer end of the catheter is
folded and fixed to the thigh.
 To keep the inflated balloon within the uterus, the post
vagina is packed with sterile pack
Uterine Artery Ligation -
“O’ Leary Stitch”

 Requires downward bladder reflection to reduce


risk of ureteric injury.
 Bilateral ligation effective in 90% of cases
 High ligature may be required.
 Low risk of long-term complications
Interventional Radiology
 Percutaneous transcatheter embolisation
 Must be performed before uterine artery
ligation
 Performed under fluoroscopic guidance
 Gelfoam is the preferred agent
 Angiographic occlusion balloon catheters
 Success rate 95-97%
 Useful for vulvovaginal hematomas
Interventional Radiology:
Disadvantages
 There may be a significant delay before
personnel and equipment are in place
 Not widely available
 Contraindicated if coagulopathy is present
 Minimal data on subsequent pregnancy
outcomes
Interventional Radiology:
Complications

 Procedure related morbidity of 6%


 Post-embolisation fever
 Buttock ischemia
 Vascular perforation
 Infection
Case scenario
 You are a GP obstetrician delivering a low
risk woman in a country hospital.
 You are delivering the placenta and note
that her BP has suddenly fallen to 80/40,
pulse 40. She is bleeding profusely
 What do you do?
 What is your differential diagnosis?
Concealed PPH
 If hypovolaemic……..and no overt bleeding
consider
 Broad ligament haematoma
 Ischiorectal fossa haemorrhage/haematoma
 Paravaginal haematoma
 Intra abdominal bleeding
 Previous uterine scar – uterine rupture

 Rupture of vascular aneurysms

 Liver/spleen rupture
Conclusions

 Relevance of PPH worldwide


 Increasing incidence of PPH
 Prophylaxis
 Don’t forget the basics
 Good luck!