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STEPS FOR THE MANAGEMENT PPH

STEPS FOR THE MANAGEMENT PPH. OBJECTIVES. Discuss the importance of the Golden Hour Present a follow-up sequence for PPH. STEPS FOR THE MANAGEMENT OF PPH. Early control of the bleeding is the most effective measure for the treatment of PPH.

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STEPS FOR THE MANAGEMENT PPH

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  1. STEPS FOR THE MANAGEMENT PPH

  2. OBJECTIVES • Discuss the importance of the Golden Hour • Present a follow-up sequence for PPH

  3. STEPS FOR THE MANAGEMENT OF PPH Early control of the bleeding is the most effective measure for the treatment of PPH Título da apresentação

  4. STEPS FOR THE MANAGEMENT OF PPH & THE GOLDEN HOUR There is a relationship between the time elapsed to control the bleeding and the chance of death • Agressiveandrapidinterventions • Avoid the lethal triad of PPH: Acidosis, hypothermia and coagulopathy  A Lalondeet al. Int J Gynaecol Obstet. 2006 Sep;94(3):243 Protocolo HPP SES-MG, 2016. Protocolo HPP BH 2016

  5. REMEMBER... RED CODE AND TEAMWORK... • TEAM • LEADERSHIP • COMUNICATION • MONITORING • MUTUAL SUPPORT

  6. STEPS FOR THE MANAGEMENT OF PPH Título de la presentación

  7. STEPS FOR THE MANAGEMENT OF PPH CALL FOR HELP Communicate Clearly the diagnosis of PPH Call Interdisciplinary Team Communicate patient

  8. STEPS FOR THE MANAGEMENT OF PPH ESTIMATE INICIAL BLOOD LOSS Clinical evaluation - vital Signs Shock index (> 0.9: transfusion risk) Visual estimation, weighing of compresses, collecting devices

  9. SHOCK INDEX Maternal HeartRate > 0,9 SystolicBloodPressure SI ≥ 0,9 RELATED TO MASSIVE TRANSFUSION

  10. STEPS FOR THE MANAGEMENT OF PPH RAPID ASSESSMENT OF HEMORRHAGE CAUSES (4T)

  11. STEPS FOR THE MANAGEMENT OF PPH Título da apresentação

  12. STEPS FOR THE MANAGEMENT OF PPH KEEP OXIGENATION AND PERFUSION Venousaccess: 02 caliber (J16 or 14) Rationalinfusion of heatedliquids: re-evaluateevery 300-500ml Oxygen: 8 to 10 l / min in face mask. Elevationof lowerlimbs Continuousmonitoring (TAX: every 15 minutes) Delayedbladdercatheter: (monitor diuresis)

  13. EXCESSIVE INFUSION OF FLUIDS Duschesne JC et al. J Trauma 2010; 69(4):976, Spinella PC & Holcomb JB. Blood Reviews,2009; 23: 231 Maegeleet al. Injury 2007;38(3):298 

  14. STEPS FOR THE MANAGEMENT OF PPH http://www.liaccentralsorologica.com.br/site/wp-content/uploads/1.png REQUEST EXAMS Collect already in the 1st access puncture Hemogram, coagulogram, ionogram, cross-test, fibrinogen Severe cases: lactate and gasometry EVALUATE ANTIBIOTICS Bimanual uterinemassage IntrauterineBallonTamponade Surgeries

  15. STEPS FOR THE MANAGEMENT OF PPH FLUID AND BLOOD THERAPHY • Estimate severity of volume loss (Shock Index) • Crystalloid: rational use. • Reevaluate every 300-500 ml • Consider blood transfusion after 1500ml of crystalloids with no adequate and sustained maternal response • Tranexamic acid, IV, 1 gram in 10 minutes

  16. STEPS FOR THE MANAGEMENT OF PPH DETERMINE THE CAUSE OF PPH- 4T • TONE - Istheuteruscontracted ? • TRAUMA - IS thereanytract trauma – lacerations ? • TISSUE - Isthereanytissueleftor placenta acreta ? • TROMBIN - Isthereanycoagulophaty ? TREAT THE SPECIFIC CAUSE

  17. UTERINE ATONY BIMANUAL UTERINE COMPRESSION YES OXYTOCIN ONSET OF ACTION: (IV): 1 min MAINTANANCE DOSE No response YES TRANEXAMIC ACID: 1 g, IV, 10 minutes ERGOT ONSET OF ACTION IM: 2-5 min MAINTANENCE DOSE, ifnecessary No response MISOPROSTOL ONSET OF ACTION (OR): 7-11 min \ (R): 15-20min No response NON PNEUMATIC ANTI-SHOCK GARMENT AssociatewithIntrauterineBallon INTRAUTERINE BALLON TAMPONADE Ifuterotonicsfailto stop bleeding No response No response SURGICAL MANAGEMENT compressiveuterine sutures, ligature of vessels, hysterectomy, damagecontrol Título da apresentação

  18. TRAUMA • TRANEXAMIC ACID = 1 g, IV, SLOW INFUSION (100mg\min) • REPAIR TEARS • Repairtears • Check perineum, cervixand vagina Explore it in some cases Check vagina afterbirth • HAEMATOMA • Laparotomy • Primaryrepairorhysterectomy • UTERINE RUPTURE: • UTERINE INVERSION : • TAXE MANEVEUR • Laparotomy / IntrauterineBalloon Título da apresentação

  19. TISSUE • TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100mg\min) RETAINED PLACENTA 30-45 min after delivery RETAINED PART OF PLACENTA PLACENTA ACCRETA • CURETTAGE DO NOT tryto remove The placenta • MANUAL REMOVAL • The lack of cleavage plane: • Risk of Placenta acreta andsevere PPH) Hysterectomywith placenta in situ Conservative management • CURETTAGE Imagens: https://rphcm.allette.com.au/publication/cpm/Manual_removal_placenta.html Imagem: http://wellroundedmama.blogspot.com.br/2013/09/placenta-accreta-part-four-diagnosis.html

  20. COAGULAPATHY • TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100mg\min) • NASG • Surgery: be careful with this choice! • Damage Control, if DIC. • Prior history of specific deficiencies, • (eg. Von Willebrand's disease); Use of • Anticoagulants; intra-operative excessive • bleeding (DIC), thrombocytopenia, • hypofibrinogenemia • SPECIFIC TREATMENT • + • TRANSFUSION • RBC, FFP, platelets, cryoprecipitate, • Activated Factor VIIa, desmopressin, • protamine, among others • ADJUVANT TREATMENT • DIAGNOSIS • Título da apresentação

  21. STEPS FOR THE MANEGEMENT FORPPH EVALUATION AFTER INITIAL APPROACH: • Reassessment of hemorrhage and hemodynamic status • NASG for the patients with hemodynamic instability • Blood transfusion: if necessary ( to be based on patient's clinical evolution) • Avoid hypothermia: Body temperature, heated fluids, thermal blanket. • If conservative treatment fails: evaluate surgical treatment.

  22. STEPS FOR THE MANEGEMENT FORPPH STRICT MONITORING AFTER HEMORRHAGE • Strict monitoring in the recovery room in the first 24 hours (it can not be in postpartum ward that offers low risk monitoring) • ICU according to the severity of the case

  23. MOTIVATION TO 0MMXH • “For each mother who dies, there is a family that suffers, a community that becomes weaker, a country that gets poorer ” • Carissa F Etienne. PAHO/WHO Director

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