Postpartum Hemorrhage

1. Postpartum Hemorrhage דר' ישי לוין בי"ח ליס ליולדות המרכז הרפואי תל-אביב

2. Defenitions • Average blood loss at delivery: • Vaginal delivery = 500ml • Cesarean delivery = 1000ml • Repeat cesarean plus hysterectomy = 1500ml • Excessive postpartum blood loss (hemorrhage): • 10% change of hematocrit between admission and the postpartum period • Need for erythrocyte transfusion. ACOG bulletin, Int J Gynecol obstet 1998;61:79-86

3. Defenitions • Severe obstetrical hemorrhage: • Estimated blood loss greater than 1500ml or peripartum fall of Hb concentration > 4g/dL or acute transfusion of > 4U of blood. Shevell and Fergal, Semin in Perinatol 2003;27:86-104

4. Incidence • 3.9% of vaginal deliveries • 6.4% of cesarean deliveries • 11% of all maternal deaths (1980-1985)

5. Predictors and causes of PPH ACOG bulletin, Int J Gynecol obstet 1998;61:79-86

6. Coagulopathies • Acquired • Anticoagulant administration • Severe infections • Gram Negative bacteria • Gram Negative anaerobes • Gram positive bacteria • Viruses • Fungal infections • DIC in abruption, retained dead fetus, amniotic fluid embolism

7. Chorioamnionitis and PPH Mark et al., Obstet Gynecol 2000;95:909-12

8. Management ACOG bulletin, Int J Gynecol obstet 1998;61:79-86

9. Oxytocin Management Massage • Uterine massage • Emptying bladder • Drug therapy • Oxytocine • Methylergonovine • PGF2α • PGE2 • Surgical therapy Revision Bladder emptying Further drugs Surgical therapy Shevell and Fergal, Semin in Perinatol 2003;27:86-104 ACOG bulletin, Int J Gynecol obstet 1998;61:79-86

10. Drug therapy for uterine atony ACOG bulletin, Int J Gynecol obstet 1998;61:79-86

11. Surgical therapy • Uterine artery ligation • Ascending branches are identified at level of vesicouterine peritoneal reflection. (3 cm below a well placed low-transverse incision) • Further reduction in perfusion may be done by ligating uteroovarian and infundibulopelvic vessels. • Good rates of success reported Shevell and Fergal, Semin in Perinatol 2003;27:86-104

12. Surgical therapy • Hypogastric artery ligation • Significantly reduces pulse pressure to uterus • Success in < 50% of cases • In general, use of the procedure should be reserved for hemodynamically stable patients • This technique may lead to increased blood loss and operative time • The time spent in attempting to perform the procedure successfully may delay hysterectomy, thereby increasing blood loss, chance of coagulopathy and possible overall morbidity

13. Pelvic vessel embolization • Success rates as high as 90% in the setting of normal coagulation status • When bleeding is not immediately life-threatening • At present, this technique seems best suited when placed in controlled settings and not in acute, extreme situations

14. Hysterectomy When ?

15. Hysterectomy • Definitive treatment for obstetric hemorrhage • “A reluctance to proceed with hysterectomy for obstetric hemorrhage may be a more likely cause of preventable death in obstetrics than a lack of surgical or medical skills” • Uterine atony will respond to medical therapy in the majority of cases, but hysterectomy may be required in recalcitrant (Intractable) situations. GA dildy, Clin obstet gynecol 2002; 45:330-344. Shevell and Fergal, Semin in Perinatol 2003;27:86-104

16. Hysterectomy • “It is very difficult to obtain experience in ligation of the internal iliac and uterine arteries and to make the decision whether to try preoperative initiatives or directly resort to hysterectomy when the patient is unstable…however, in the end peripartum hysterectomy remains a potentially life-saving procedure which every obstetrician must be familiar.” Acta Obstet Gynecol Scand 2001;80:409-12