OBSTETRICAL HAEMORRAGE

PUJA AGUNG ANTONIUS

OBGYN DEPT
FACULTY OF MEDICINE
ANDALAS UNIVERSITY
Postpartum Hemorrhage

Objectives
Definition
Etiology
Risk Factors
Prevention
Management
 PPH on bed and floor 2000ml
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anaesthetist obstetrician gynae nurse midwife theatre nurse HCA
 PPH on bed only 1000ml

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anaesthetist obstetrician gynae nurse midwife theatre nurse HCA
 100cm clot 1500ml

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anaesthetist obstetrician gynae nurse midwife theatre nurse HCA

Puddles on the floor

Revealed bleeding.
 Postpartum Hemorrhage

Traditional Definition
blood loss of > 500 mL following vaginal delivery
blood loss of > 1000 mL following cesarean delivery
Functional Definition
any blood loss that has the potential to produce or produces
hemodynamic instability
Incidence
about 5% of all deliveries
 Postpartum Hemorrhage

Early less than 24 hours

Late more than 24 hours 1%
 Postpartum Hemorrhage

Etiology of Postpartum Hemorrhage

Tone - uterine atony
Tissue - retained tissue/clots
Trauma - laceration, rupture, inversion
Thrombin - coagulopathy
 Postpartum Hemorrhage

Risk Factors for PPH - Antepartum

previous PPH or manual removal
placental abruption, especially if concealed
intrauterine fetal demise
placenta previa
gestational hypertension with proteinuria
overdistended uterus (e.g. twins, polyhydramnios)
pre-existing maternal bleeding disorder (e.g. ITP)
 Postpartum Hemorrhage
Risk Factors for PPH - Intrapartum
operative delivery - cesarean or assisted vaginal
prolonged labour
rapid labour
induction or augmentation
chorioamnionitis
shoulder dystocia
internal podalic version and extraction of second twin
acquired coagulopathy (e.g. HELLP, DIC)
Postpartum Hemorrhage
Risk Factors for PPH - Postpartum
lacerations or episiotomy
retained placenta/placental abnormalities
uterine rupture
uterine inversion
acquired coagulopathy (e.g. DIC)
UTERINE ATONY

Atony is identified by a boggy, soft uterus during bimanual

examination and by expression of clots and hemorrhage during
uterine massage.
The most frequent cause of obstetrical hemorrhage is failure of the
uterus to contract sufficiently after delivery and to arrest bleeding
from vessels at the placental implantation site
Risk Factors

Up to half of women who had atony after cesarean delivery were

found to have no risk factors (Rouse, 2006)
Primiparity
High parity 0.3 percent in women of low parity to 1.9 percent
with parity of 4 or greater. It was 2.7 percent with parity of 7 or
greater (Babinszki, 1999).
Risk Factors

Overdistended uterus
Labor abnormalities predispose to atony and include hyper or
hypotonic labor.
Labor induction or augmentation with either prostaglandins or
oxytocin
Prior postpartum hemorrhage
Uterine Atony after Placental Delivery

Vigorous fundal massage usually prevents postpartum hemorrhage

from atony (Hofmeyr, 2008)
Simultaneously, 20 units of oxytocin in 1000 mL of crystalloid
solution will often be effective given intravenously at 10 mL/min for a
dose of 200 mU/min.
Uterotonic Agents

Ergot derivativesmethylergonovineMethergineand ergonovine.

These drugs rapidly stimulate tetanic uterine contractions and act for
approximately 45 minutes parenteral
Regimen is 0.2 mg of either drug given intramuscularly.
 Uterotonic Agents
E- and F-series prostaglandins
Carboprost tromethamine Hemabateis the 15-methyl derivative of
pros- taglandin F2 250 g (0.25 mg) given intramuscularly
E-series prostaglandins dinoprostoneprostaglandin E2is given as a
20-mg suppository per rectum or per vaginam every 2 hours
 Uterotonic Agents
MisoprostolCytotecis a synthetic prostaglandin E1 analogue that has
also been evaluated for both prevention and treatment of atony and
postpartum hemorrhage
Bleeding Unresponsive to Uterotonic Agents

Begin bimanual uterine compression

Immediately mobilize the emergent care obstetrical team to the
delivery room and call for whole blood or packed red cells
Request urgent help from the anesthesia team.
Two large-bore intravenous catheters
Indwelling Foley catheter
 Bleeding Unresponsive to Uterotonic Agents
Begin volume resuscitation with rapid intravenous infusion of crystalloid
Manually explore the uterine cavity for retained placental fragments
and for uter ine abnormalities, including lacerations or rupture
Inspect the cervix and vagina again for lacerations
Blood transfusions
Uterine Packing or Balloon Tamponade

24F Foley catheter with a 30-mL balloon is guided into the uterine
cavity and filled with 60 to 80 mL of saline.
Segstaken-Blakemore
Rusch balloons
Condom catheters
Gauze
 Surgical Procedures

Uterine compression sutures

Pelvic vessel ligation
Angiographic embolization
Hysterectomy
 Rupture of the Uterus
Primary occurring in a previously intact or unscarred uterus
Secondary reexisting myometrial inci- sion, injury, or anomaly
Complete when all layers of the uterine wall are separated
Incomplete when the uterine muscle is separated but the visceral
peritoneum is intact
Diagnosis

Hypovolemic shock
Diaphragmatic irritation with pain referred to the chest
Nonreassuring fetal heart rate
Cessation of contractions
Loss of station
Felt alongside the fetus.
Pathogenesis.

Rupture of the previously intact uterus during labor most often

involves the thinned-out lower uterine segment
Inherent weakness in the myometrium in which the rupture takes
place anatomical anomalies, adenomyosis, and connective- tissue
defects such as Ehlers-Danlos syndrome
 Management and Outcomes
Uterine rupture accounted for 14 percent of deaths caused by
hemorrhage
Hysterectomy that may be necessary to control hemorrhage.
Hysteroraphy conservative
 Traumatic Uterine Rupture
Blunt trauma
Internal podalic version extraction
Difficult forceps delivery
Breech extraction
Unusual fetal enlargement such as with hydrocephaly.
 Postpartum Hemorrhage

Prevention
be prepared
active management of the third stage
prophylactic oxytocin with delivery or with delivery of anterior shoulder
10 U IM or 5 U IV bolus
20 U/L N/S IV run rapidly
early cord clamping and cutting
gentle cord traction with suprapubic countertraction
 Postpartum Hemorrhage

Active v.s Expectant Third Stage Management

Outcome (subjects)
PPH > 500 mL (n=4636)
PPH > 1000 mL (n=4636)
Maternal Hb < 91 (n=4256)
Blood transfusion (n=4829)
Therapeutic oxytocin (n=4829)
Nausea (n=3407)
Manual removal (n=4829)
0.1 1 10
Cochrane Library
Issue 1, 2000 Odds Ratio (95% Confidence Interval)
 Postpartum Hemorrhage

Diagnosis - Is this a PPH?

consider risk factors
observe vaginal loss
express blood from vagina following C/S
REMEMBER
blood loss is consistently underestimated
ongoing trickling can lead to significant blood loss
blood loss is generally well tolerated to a point
 Postpartum Hemorrhage

Diagnosis - What is the cause?

assess the fundus
inspect the lower genital tract
explore the uterus
retained placental fragments
uterine rupture
uterine inversion
assess coagulation
PostpartumHemorrhage

A = airway
B = breathing
C = circulation
Postpartum Hemorrhage
Management - ABCs
talk to and observe patient
large bore IV access ( 16 gauge)
crystalloid - lots!
CBC
cross-match and type
get HELP!
 AIRWAY

Eddy Rahardjo
 Estimasi BB : ... 60 kg
Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml
Estimasi Blood Loss : .... % EBV = ..... ml

Tsyst 120 100 < 90 < 60-70

Nadi 80 100 > 120 > 140 - ttb
Perf hangat pucat dingin basah

-- 15% EBV
NORMO -- 30% EBV
VOLEMIA -- 50% EBV

EBL = perdarahan 600 1200 2000 ml

Infus RL 1200-2000 2500-5000 4000-8000 ml
Kristaloid vs Koloid sebagai Cairan Pengganti:
Hasil-hasil
Kristaloid Koloid

Manfaat Merembes ke komponen Tetap berada di komponen

ekstraselular intravaskular
Mengurangi peningkatan cairan volume yang diperlukan
paru lebih sedikit
Meningkatkan fungsi organ Meningkatkan transpor
setelah operasi oksigen ke jaringan,
Reaksi anafilaktik minimal kontraktilitas jantung dan
Kemungkinan dapat mengurangi keluarannya
angka kematian
Lebih murah
Predisposisi untuk terjadinya
Resiko Mahal
Choi et al 1999.
edema pulmonal
Kristaloid vs Koloid sebagai Cairan Pengganti:
Kesimpulan
Kristaloid merupakan pilihan pertama untuk digunakan, karena:
Lebih aman
Lebih murah
Lebih mudah didapatkan
 Postpartum Hemorrhage

Management - Assess the fundus

simultaneous with ABC s
atony is the leading cause of PPH
if boggy bimanual massage
rules out uterine inversion
may feel lower tract injury
evacuate clot from vagina and/or cervix
may consider manual exploration at this time
Postpartum Hemorrhage

Management - Bimanual Massage

 Postpartum Hemorrhage

Management - Oxytocin
5 units IV bolus
20 units per L N/S IV wide open
10 units intramyometrial given transabdominally
 Postpartum Hemorrhage

Management -ManualExploration
if no response to bimanual massage and oxytocin then proceed to
exploration
manual exploration will:
rule out uterine inversion
palpate cervical injury
remove retained placenta or clot from uterus
rule out uterine rupture or dehiscence
 Postpartum Hemorrhage

Management - Additional Uterotonics

ergotamine - caution in hypertension
0.25 mg IM or 0.125 mg IV
maximum dose 1.25 mg
Hemabate (carboprost) - asthma is relative contraindication
15 methyl-prostaglandin F2
0.25 mg IM or intramyometrial
Maximum dose 2 mg
Cytotec (misoprostol) - caution in asthma
400 mg pr or po
 Postpartum Hemorrhage

Management - Bleeding with firm uterus

explore the lower genital tract
requirements - appropriate analgesia
- good exposure and lighting
appropriate surgical repair
- may temporize with packing
 Postpartum Hemorrhage

Management - Continued uterine bleeding

possible coagulopathy - INR, PTT, TCT, fibrinogen

if coagulation is abnormal:
correct with clotting factors, platelets
if coagulation is normal:
prepare for O.R. (may consider embolization)
rule out uterine rupture, inadequate incision repair
consider uterine/hypogastric ligation, hysterectomy
 Masase fundus uteri
Segera sesudah plasenta lahir
(maksimal 15 detik)

Uterus kontraksi Ya Evaluasi rutin

?
Tidak

Evaluasi / bersihkan bekuan

darah / selaput ketuban
Kompresi Bimanual Interna
(KBI) maks. 5 menit
Pertahankan KBI selama 1-2 menit
Uterus kontraksi ? Ya Keluarkan tangan secara hati-hati
Lakukan pengawasan kala IV
Tidak

Ajarkan keluarga melakukan Kompresi

Bimanual Eksterna (KBE)
Keluarkan tangan (KBI) secara hati-hati
Suntikan Methyl ergometrin 0,2 mg i.m
Pasang infus RL + 20 IU Oksitosin, guyur
Lakukan lagi KBI
 Pengawasan
Uterus kontraksi Ya
kala IV
?
Tidak RUJUK

siapkan laparotomi
Lanjutkan pemberian infus + 20 IU Oksitosin
minimal 500 cc/jam
Selama menunggu operasi dapat dilakukan
Kompresi Aorta Abdominalis atau pemasangan
balon/ kassa intrauterin

Ligasi arteri uterina dan/atau hipogastrika Perdarahan Pertahankan

B-Lynch method berhenti uterus

Perdarahan
berlanjut

Histerektomi
 Postpartum Hemorrhage

Management - ABC s

ENSURE that you are always ahead

with your resuscitation!!!!
consider need for Foley catheter, CVP, arterial line, etc
consider need for more expert help
B-Lynch
methode
B-Lynch
Medical Anti Schock Trouser & Penekan
Infus
Postpartum Hemorrhage

Conclusions
be prepared
practice prevention
assess the loss
assess maternal status
resuscitate vigorously and appropriately
diagnose the cause
treat the cause
 Postpartum Hemorrhage

Management - Evolution

Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness
Postpartum Hemorrhage

Thank You