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Post Partum hemorrhage

Post Partum hemorrhage. Chanel Pare-Bingley and Maria Merziotis. Objectives:. Identify and assess the risk factors for postpartum hemorrhage. Formulate a differential diagnosis of postpartum hemorrhage.

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Post Partum hemorrhage

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  1. Post Partum hemorrhage Chanel Pare-Bingley and Maria Merziotis

  2. Objectives: • Identify and assess the risk factors for postpartum hemorrhage. • Formulate a differential diagnosis of postpartum hemorrhage. • Propose immediate management of the patient with postpartumhemorrhage including: inspection for lacerations, use of uterinecontractile agents, management of volume loss and management of coagulopathy.

  3. Outline: • Define and classify two types of PPH , List risk factors for PPH. • Differential Diagnosis of PPH • Discuss Immediate Management for this case • Management Principles – discuss medical and surgical treatment options, as relevant to underlying causes of PPH

  4. Case • A 29 yo G5P4 woman at 39 weeks gestation with preeclampsia delivers vaginally. Her prenatal course has been uncomplicated except for asymptomatic bacteriuria caused by E. coli in the first trimester treated with oral cephalexin. She denies a family history of bleeding diathesis. After the placenta is delivered, there is appreciable vaginal bleeding estimated at 1 L.Are you worried?

  5. 1. Define and classify two types of PPH , List risk factors for PPH. • PPH definedas a bloodloss of >500 cc for vaginalydelivery and >1000 cc for C-Section. • NB: anybloodlossthatproduceshemodynamicinstability • 2 types: • Early (primary) within24 hourspost partum (99%) • Late (secondary)  >24h to 6 weeks Risk Factors?

  6. 1. Define and classify two types of PPH , List risk factors for PPH. • Risk Factors (in decreasing order of frequency): • Retained placenta • Failure to progress during the second stage of labor • Placenta accreta • Lacerations • Instrumental delivery • Large for gestational age newborn (eg, >4000 g) • Hypertensive disorders • Induction of labor • Augmentation of labor with oxytocin

  7. Other risk factors: • placenta previa • History of previous PPH • Obesity • high parity • Asian or Hispanic race • precipitous labor ( less than 3 hours) • first stage of labor longer than 24 hours • uterine overdistention • uterine infection • use of some drugs (eg antidepressants)

  8. 2. Differential Diagnosis of PPH • DDx of early PPH (4 T’s) – 99% of cases • Tone • Tissue • Trauma • Thrombin • DDx of late PPH • Retained products, endometritis, sub-involution of uterus

  9. What is the most common cause of PPH?

  10. 2. Differential Diagnosis of PPH • Etiology (4 T’s) • Tone • Uterine atony most common cause of PPH • Occurs within first 24 hours • Due to: • Multiparity, Magnesium sulfate treatment or preeclampsia • Labour prolonged, precipitous (<3hrs), induced or augmented • Uterus overdistended or infected (chorioamnionitis), uterine leiomyomas • Placenta previa or placental abruption • Fetus: polyhydramnios or fetal macrosomnia • Halogen anesthesia

  11. 2. Differential Diagnosis of PPH • Etiology (4 T’s) • Tissue • Retained placental products, blood clots • Trauma • Laceration, episiotomy, uterine rupture or inversion • Thrombin • Coagulopathy (hemophilia, DIC, vWD, ITP, TTP)

  12. 3. Discuss ImmediateManagement for this case • Assemble team and notify appropriate departments (obstetrics, nursing, anesthesiology, blood bank, laboratory) • ABC, establish large bore IV access (two14-18 gauge), maternal and fetal monitors. Send blood for type and cross match, CBC, BUN, Cr, INR, PTT, fibrinogen. • Administer oxygen (10 to 15 liters/minute) by face mask.

  13. 3. Discuss Immediate Management for this case • Fluid resuscitation: • NS or RL to prevent hypotension (target systolic pressure 90 mmHg) • maintain urine output >30 mL/hour • Transfusion: • 2 units of PRBC if 2-3 L of NS or RL not effective • Massive hemorrhage: red blood cells, fresh frozen plasma, and platelets

  14. 3. Discuss Immediate Management for this case • Initiate uterine massage and/or manual compression • bimanual compression: elevate the uterus and massage through patient's abdomen • Administer uterotonic drugs to reverse atony: (see next slides) • Should know within 30 minutes whether uterotonic treatment is effective. • Tamponadebleeding from the uterine cavity.

  15. 3. Discuss Immediate Management for this case • Inspect the vagina and cervix for lacerations; repair as necessary. Evacuate any retained products • Perform transarterial embolization if the woman is stable. • Perform Hysterectomy if above measures fail

  16. 4. Management Principles – discuss medical and surgical treatment options, as relevant to underlying causes of PPH • Medical Therapy ( 1st line = uterotonics) • Oxytocin (1st line) • 20 U/L NS or RL IV continuous infusion • in addition can give 10 U IMM after delivery of the placenta • Ergonovine vasoconstrictor (2nd line) • 0.25 mg IM/IMM q5min (max dose =1.25 mg)  HTN = contraindication • Carboprost(Hemabate)  synthetic PGF-2 alpha analog (2nd line): • 0.25 mg IM/IMM q15min (max 2 mg) • contraindicated in cardiovascular, pulmonary, renal and hepatic dysfunction) • Misoprostol (3rd line)

  17. 4. Management Principles – discuss medical and surgical treatment options, as relevant to underlying causes of PPH • For intractable bleeding unresponsive to uterotonics • Bakri balloon tamponade • Other options for tamponade: Foley 60-80cc, esophageal cathetar, hydrostatic condom catheter, Belfort-DildyTamponade Balloon, and the BT-Cath • Uterine packing (mesh with antibiotic treatment) • Enough to allow time for correction of coagulopathy or for preparation of an OR

  18. 4. Management Principles – discuss medical and surgical treatment options, as relevant to underlying causes of PPH • Surgical Therapy (Intractable PPH) • B-lynch and Cho sutures (uterine compression sutures) • Similar results to manual uterine compression • laparotomy with bilateral uterine artery embolization or internal iliac ligation (UAE preferred, less risk and easier) • Hysterectomy last option

  19. THANK YOU QUESTIONS? Why so important? “Although maternal mortality rates have declined greatly in the developed world, PPH remains a leading cause of maternal mortality elsewhere.” - Medscape

  20. References and Acknowledgments • UpToDate • http://www.uptodate.com/contents/overview-of-postpartum-hemorrhage?source=search_result&search=postpartum+hemorrhage&selectedTitle=1~135#H9 • http://www.uptodate.com/contents/image?imageKey=OBGYN%2F57307&topicKey=OBGYN%2F6710&rank=1~135&source=see_link&search=postpartum+hemorrhage&utdPopup=true • Toronto Notes 2012, Page OB51 • Medscape • http://emedicine.medscape.com/article/275038-overview • Lecture: Complications of Labour and Delivery given by Dr. Jenna Gale, March 10th 2014. • Jeremy Oats, Suzanne Abraham. Fundamentals of Obstetrics and Gynecology 9th Edition. 2010. p.183-185.

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