Postpartum Hemorrhage

1. Postpartum Hemorrhage Obsterics & Gynecology Hospital of Fudan University Weirong Gu

2. Postpartum Hemorrhage(PPH) • Blood loss in excess of 500 mlfollowing birth within the first 24 hours of delivery • Serious intrapartum complication • The most significant cause of maternal death worldwide, mortality : 140 000 per year (1 maternal death every 4 minutes) • Incidence: 4–6% of pregnancies • Actual incidence: more high because of inaccurate, significant underreporting

3. Classification • Primary PPH • Occurring within the first 24 hours of delivery • 4–6% of pregnancies • Caused by uterine atony in 80% or more of cases • Secondary PPH • Occurring between 24 hours and 6–12 weeks postpartum • 1% of pregnancies

4. Etiology • 4 “ T ” • Tone: uterine atony • Tissue: retained placenta • Trauma: vaginal, cervical, or uterine injury • Thrombin: coagulopathy (pre-existing or acquired) ——SOGC guideline (number 235, October 2009): Active Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage

5. 1st “T”——uterine atony • The most common and important cause of PPH • The primary protective mechanism for immediate hemostasis after delivery: • Myometrial contraction causing occlusion of uterine blood vessels ——living ligatures of the uterus • Blood flow from the vascular space to the uterine cavity via the myometrium is impeded

6. Uterine atony

7. Placenta previa Placenta abruption 胎儿 子宫内膜 出血 脐带 胎盘 宫颈

8. Uterine anomalies Twin pregnancy fibroid 带蒂 内膜下肌瘤 胎盘 肌壁间肌瘤 脐带 脐带 浆膜下肌瘤 内膜下肌瘤 胎儿 胎儿 带蒂 浆膜下肌瘤 宫颈 阴道

9. 2nd “T”——Tissue retained

10. Succenturiate lobe

11. Placenta accreta Placenta villi attach Placenta villi invade Placenta villi penetrate to the myometrium into the myometrium through the myometrium Accreta Increta Percreta

13. 3rd “T”——Trauma of the genital tract

14. II I Laceration of cervix III Lacerations of perineum

15. 4th “T”——trauma of Thrombin (coagulopathy)

16. Clinical manifestation • Vaginal bleeding • Bleeding with characteristic soft, poorly contracted (“boggy”) uterus on bimanual pelvic examination ——uterine atony • Bleeding while the uterus is firmly contracted —— retained placenta ——genital tract laceration • Bleeding without clot ——coagulopathy • Pelvic or rectal pressure and pain ——genital tract hematomas

17. Clinical manifestation • Hypovolemic shock • Irritable,pallor and clamminess of skin,tachycardia, narrow pulse pressure ——mild degree of shock

18. Diagnosis（ estimates of blood loss ） • Weight method： • Blood loss(ml)＝（dressing wet weight after birth－dressing dry weight before birth）/1.05(specific gravity of blood) • Volume method: • Collect blood using a container • Area method： • 10cm*10cm gause soak blood = 10ml blood

19. Weight method

20. Volume method

21. Shock index • Shock index =heart rate/systolic pressure（mmHg） （normal <0.5） shock index estimate loss of blood（ml） loss of blood volume 0.6~0.9 <500~750 <20% =1.0 1000~1500 20~30% =1.5 1500~2500 30~50% ≥2.0 2500~3500 ≥50~70%

22. Management of PPH • The initial goal • Identifying and treating the cause of blood loss • Instituting resuscitative measures to maintain hemodynamic stability and oxygen perfusion of the tissues

23. Initial assessment and treatment for PPH • Call for help • Resuscitation • Assess the “ABC” • Monitor BP, P, R • Empty bladder, monitor urine output • IV line • Crystalloid, isotonic fluid replacement • Oxygen by mask • Laboratory tests • Complete blood count • Coagulation screen • Blood grouping and cross ——SOGC 2009

24. 1st “T”——Uterine atony • Uterine massage • Diminish bleeding, expel blood and clots, and allow time for other measures to be implemented • Uterotonic drugs • Ongoing blood loss in the setting of decreased uterine tone requires the administration of additional uterotonics as the first-line treatment for hemorrhage

25. Uterine massage

26. Uterotonic drugs

27. Uterotonic drugs (prostaglandin preparation)

28. If bleeding continues • Uterine tamponade • Exploratory laparotomy • Uterine artery embolization

29. Uterine tamponade • Indication：uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after vaginal delivery

30. Packing Bakri Balloon tamponade

31. Exploratory laparotomy • Indication：When uterotonic agents with or without tamponade measures fail to control bleeding in a patient who has given birth vaginally • Techniques • Compression sutures • Artery ligation • Hysterectomy

32. Compression sutures • B-Lynch technique • First reported by B-lynch in 1993 • Compress the uterine corpus and decrease bleeding • Rare Complication：uterine ischemic necrosis with peritonitis

33. Modified B-Lynch • e.g. Hemostatic multiple square suturing • For postpartum hemorrhage caused by uterine atony, placenta previa, or placenta accreta • Eliminateing space in the uterine cavity by suturing both anterior and posterior uterine walls

34. Artery ligation • Bilateral uterine arteries ligation • Bilateral internal iliac arteries ligation • Bilateral ovarian arteries ligation

35. Uterine arteries ligation Internal iliac arteries ligation

36. Artery ligation • Diminish the pulse pressure of blood flowing to the uterus • The timing of this intervention is important: it must be done without delay, before excessive blood loss has occurred • Surgical skill is required to avoid failure and complications such as damage to other vascular structures and the ureters

37. Hysterectomy • Indication: massive hemorrhage has not responded to previous interventions • Notice: If hysterectomy is performed for uterine atony, there should be documentation of other therapy attempts

38. Hysterectomy cavity cavity uterus salpinx endometrium overy myometrium subtotal cervix bladder total vagina

39. Arterial embolization • Indication: stable vital signs , persistent bleeding, especially if the rate of loss is not excessive • Used for bleeding that continues after hysterectomy • Used as an alternative to hysterectomy to preserve fertility

40. Radiographic identification of bleeding vessels • Embolization with gelfoam, coils, or glue, or balloon occlusion

41. An algorithm suggested for the management of atonic PPH H.A.E.M.O.S.T.A.S.I.S. • H: Ask for help • A: Assess (vital parameters, blood loss) and resuscitate • E: Establish etiology and check medication supply (oxytosin, ergometrine) and availability of blood • M: Massage uterus • O: Oxytocin infusion, prostaglandins (intravenous, rectal, intramuscular, intra- myometrial)

42. S: Shift to operating room, exclude retained products and trauma, bimanual compression • T: Tamponade balloon, uterine packing • A: Apply compression sutures • S: Systematic pelvic devascularization (uterine, ovarian, internal iliac) • I: Intervention radiologist, uterine artery embolization if appropriate • S: Subtotal or total abdominal hysterectomy ——ICM/FIGO guideline 2006: Postpartum hemorrhage today: initiative 2004—2006

43. 2nd “T”——Tissue retained • Diagnosis: detection of an echogenic mass in the uterus by ultrasonography • Directed therapy • Whole placenta in uterus：manual removal • Incomplete separation （avulsed lobule, succenturiate lobe）：gentle curettage • Placenta accreta • curettage • wedge resection • medical management • hysterectomy

44. Manual removal of placenta

45. 3rd “T”——Trauma to the Genital Tract • Lacerations of perineum, vagina, or cervix • Genital tract hematomas

46. Lacerations of perineum, vagina, or cervix • Identification and proper repair of lacerations • Transfer to a well-equipped operating room • Proper patient positioning • Adequate operative assistance • Good lighting • Appropriate instrumentation (eg, Simpson or Heaney retractors) • Adequate anesthesia

48. Genital tract hematomas • May not be recognized until hours after the delivery • Sometimes occur in the absence of vaginal or perineal lacerations • The main symptoms are pelvic or rectal pressure and pain

49. Directed therapy • Draining the blood within the hematoma (sometimes placing a drain in situ) • Suturing the incision • Packing the vagina • Interventional radiology

50. 4th “T”——Coagulation Defects • Directed therapy • Appropriate testing • Blood products infused as indicated • Simultaneous surgery if the coagulopathy caused or perpetuated by the hemorrhage