MEDICAL MANAGEMENT OF POST PARTUM HAEMORRHAGE

DR VIDYA THOBBI PROFESSOR OF OBG

AL AMEEN MEDICAL COLLEGEBIJAPUR

Magnitude of the Problem

WHO estimates 529,000 maternal deaths occur from complications of

pregnancy and childbirth every year. 99% of maternal deaths occur in the III world countries; More than 60 % of maternal deaths occur in the postpartum

period, when prevention strategies are often lacking. PPH is 50 times commoner in these countries.

•World Health Organization. Global estimates of maternal mortality for 1995: results of an in-depth review, & .analysis and estimation strategy Statement . Geneva: World Health Organization, 1995:2001.•Network: Summer 1997, Vol. 17, No. 4

14 million cases of PPH per year

Definition

Any blood losss from genital tract during delivery > 500ml. (WHO)

ACOG- decline in haematocrit by 10% or need of RBC transfusion.

PRIMARY PPH- Within 24 hours

SECONDARY PPH- upto 12 weeks . is more likely due to infection and retained placental tissue

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Every woman in labor is at risk of PPH.

2/3 of those with PPH –have no identifiable risk factors.

Active management of third stage of labor should be practiced on ALL women in labor.

All post partum women must be closely monitored for PPH.

REMEMBER

Be prepared in all labors

It prevents 60% of atonic PPH

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Assess risk factorsAssess risk factorsAnte partumAnte partum IntrapartumIntrapartum Post PartumPost Partum

APH/ Previous APH/ Previous PPH / MRPPPH / MRP

Operative delivery,Operative delivery,ManipulationsManipulations

Genital tract injuryGenital tract injury

Over distended Over distended uterusuterus

Prolonged laborProlonged labor Retained placentaRetained placenta

Adherent Adherent placentaplacenta

InfectionInfection Uterine inversionUterine inversion

Congenital or Acquired CoagulopathyCongenital or Acquired Coagulopathy

Etiology Atonic Traumatic Coagulation disorders

Atonic! Atonic !! Atonic !!!

Easy to miss

Physicians underestimate blood loss by 50%

Slow steady bleeding can be fatal Most deaths from hemorrhage seen after 5h Abdominal or pelvic bleeding can be

hidden

ACTIVE MANAGEMENT OF THIRD STAGELABOUR(AMTSL)

Adminstration of uterotonic drugs within 1min of delivery of baby OXYTOCIN10 units IM

Controlled cord traction

PREVENTION

Uterine massage after

delivery of placenta

Proposed classification. Adapted for Benedetti Hemorrhage class

Estimated blood loss(ml)

Blood vol loss(%)

Clinical signs & symptoms Treatment

0(normal loss) < 500 <10 None

ALERT LINE

1 500-1000 15 Minimal Observation ± replacement therapy

ACTION LINE

2 1200-1500 20-25 ↓ urine output↑ pulse rate↑ respiratory ratePostural hypotensionNarrow pulse pressure

Replacement and oxyticics

3 1800-2100 30-35 Hypotension TachycardiaCold clammy extremitiesTachypnea

Urgent active management

4 >2400 >40 Profound shock Critical active management

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Assessment of Assessment of ShockShock

CompensatioCompensationn

MildMild ModerateModerate SevereSevere

SymptoSymptoms & ms & signssigns

Palpitation, Palpitation, dizziness, dizziness, tachycardiatachycardia

Weakness, Weakness, sweating, sweating, tachycardiatachycardia

RestlessnesRestlessness, pallor, s, pallor, oliguriaoliguria

Collapse, Collapse, air-hunger, air-hunger, anuriaanuria

BP BP (Systoli(Systolic)c)

NormalNormalSlight fallSlight fall80-80-100mmHg100mmHg

Marked fallMarked fall70-80mmHg70-80mmHg

Profound Profound fallfall50-70mmHg50-70mmHg

Blood Blood losslossBlood Blood volumevolume

500-1000ml500-1000ml10-15%10-15%

1000-1500ml1000-1500ml15-25%15-25%

1500-2000ml1500-2000ml25-35%25-35%

2000-3000ml2000-3000ml35-45%35-45%

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General ManagementGeneral Management Shout for help.Shout for help. Rapid evaluation of vitals.Rapid evaluation of vitals. Oxygen by mask.Oxygen by mask. Uterine massage.Uterine massage. Oxytocin Oxytocin Site 2 large bore (16G-gray color) IV cannula, Site 2 large bore (16G-gray color) IV cannula, Infuse IV fluid – NS / RL- run it fast.Infuse IV fluid – NS / RL- run it fast. Catheterize bladder.Catheterize bladder. Check the placenta –Check the placenta – If it has been expelled If it has been expelled If it is expelled , re examine & make sure it is If it is expelled , re examine & make sure it is

complete. complete. Examine vagina, perineum and cervix for tears.Examine vagina, perineum and cervix for tears.

Save blood for lab test

Draw & Send The blood for lab test

FLUID RESUCITATATION

Maintanance of tissue perfusion. Multiple large bore IV access. Crystalloids[1:3] Colloids & Blood products to maintain Hb near

10gm% during active bleeding.. >80% volume replacement causes dilutional

coagulopathy Coagulopathy&thrombocytopenia-PLT&FFP.

Bimanual Uterine massage

MEDICATIONS FOR PPH

Other drugs used

Tranexamic Acid Recombinant Factor VII a

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OXYTOCIN 1. Oxytocin promotes rhythmic contractions of

upper uterine segment. Short plasma half life-3 min. Continuos I.V.infusion required. Dose 20 units in 500 ml crystalloid(250ml/hr) Give IM or IU, not IV. (Can cause BP) Max dose 40 units

Important side effects of oxytocin

Sudden hypotension Antidiuresis with hyponatremia, > 100

miu/min Neonatal jaundice

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The Uniject device Single dose—to minimize wastage

Prefilled—ensuring correct dose

Nonreusable—to minimize patient-to-patient transmission of blood borne pathogens

Easy to use—to allow use by health workers who do not normally give injections

Compact size—for easy transport and disposal

Carbetocin- what is it? And what are the advantages Long acting ,synthetic octapeptide analogue of

oxytocin

100 mcg of single carbetocin V/s 10 u oxytocin infusion

-faster involution -lesser blood loss - fewer additional oxytocics - lesser need for uterine massage

Obst & gynae survey, 2010, vol 65:3, 148-149

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Given as IVbolus 100ug Acts within 2 min

Peak concentration within 30min

Longer half life 80-90 min

80% Bioavailability

IM effect lasts twice as long as IV

Contraindicated in hepatic and renal dis

Carbetocin

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Methergine

Sustained tonic uterine contraction. I.M. 0.25 Mg. Onset of action-2 to 5 min. Mean plasma half life 30 min. Clinical effect persists 3 hrs. Can cause Hypertension, especially IV. Precautions-in hypertensive,preeclampsia. Refrigeration storage 2-8c

CARBOPROST

0.25mg IM or Intramyometrium. PGF2 Controls hemorrhage in 86% when used

alone, and 95% in combination with others Can repeat up to eight times. Contraindicated in active Br.Asthma Can cause nausea/vomiting/diarrhea, BP.

MISOPROST

PGE1 Prompt uterine contraction. Routes-

oral/sublingual/rectal/vg/intrauterine. Stable at room temp.Long shelf life Easy to administer. Cheap.

MISOPROSTOL

Routes of administration

OralRectalSublingual

Onset of action Duration

Fastest shortest

Slow prolonged

Rapid prolonged

MISOPROST

Dose-600 to 800 micrograms. S/E- minor, dose related.

fever,shivering,diarrhea.

Rectal –longer onset of action.

lower peak levels,

more favourable side effect profile.

FIGO 600mcg orally after delivery of baby if oxytocin is not available

WHO RECOMMONDATIONS MISOPROSTOLAbsence of skilled caregivers to offer controlled cord

traction Non availability of injectablesDifficulties in ensuring safe injection practicesDifficulties in refrigeration preventing the use of

oxytocin SBA should not offer sublingual or rectal misoprostol

for prevention of PPH in preference to oxytocin

(WHO recommendation 2012)

Pharmacokinetic

Oral misoprostol reaches its peak at 20 minutes. Its action is slow in comparison to intra muscular oxytocin.

http://www.misoprostol.org/File/news.php

TRANEXAMIC ACID Anti-fibrinolytic agent to reduce blood loss and the

need for blood transfusion. The WHO panel in systematic review of

randomized controlled trials showed that in surgical patients tranexamic acid reduced the risk of blood transfusion by 39% Tranexamic acid may be offered as a treatment for PPH if uterotonic options have failed, or trauma is the cause

Doses of 60-120 ug/kg intravenously were used.

r FVIIa in the management of PPH It has potential to become universal hemostatic

agent It is a safe effective hemostatic measure in

severe obstetric hemorrhage , both as1.adjunctive treatment to surgical hemostasis and2.rescue therapy where PPH is refractory to current medical and uterus sparing surgeries.Dose 40-90mcg/kg i.v.[NOVOSEVEN]

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The WHO has published guidelines for the management of PPH based on a review of the evidence by an expert panel

For prevention of PPH, syntometrine compared with oxytocin isassociated with a trend to reduced blood loss >1000ml (odds ratio (OR) 0.78, 0.58-1.03); no difference in blood transfusion (OR 1.37, 0.89 to 2.10), and less use of additional uterotonics (risk ratio (RR) 0.83, 0.72-0.96), but more side effects, particularly hypertension (RR 2.40, 1.58-3.64).1

Oxytocin compared with ergometrine is associated with no statistically significant difference in blood loss >1000ml (RR 1.09, 0.45-2.66) and use of additional uterotonics (RR 1.02, 0.67-1.55); and fewer adverse side effects: vomiting (RR 0.09, 0.05-0.16); elevated blood pressure (RR 0.01, 0.00-0.15). There were insufficient data to compare the outcome blood transfusion.2,,3

There were no clear benefits for the use of carbetocin4, intramuscular prostaglandins5 or sulprostone6,7 over oxytocin and/or ergometrine.

For prevention of PPH, misoprostol (400 to 800 mcg) compared with injectable uterotonics is associated with increased blood loss of ≥ 1000ml (RR 1.32; 95% CI 1.16-1.51), but no statistical difference in the incidence of severe morbidity, including maternal death (RR 1.00, 95% CI 0.14- 7.10)55

Meta-analysis of trials in the Cochrane database systemic review

Oxytocin alone reduces PPH by 60% ( 7 trials) Syntometrine Vs oxytocin More chances of HTN

with former : otherwise both effective (6 trials) Active Vs Expectant management of 3rd stage clearly

established superiority of AMTSL( 5 trials) Carboprost/ Misoprostol Vs conventional (32trials) -

conventional preferred Carbetocin- not recommended

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Recommendations- Prevention

10 U of Oxytocin IM/ IV infusion I Line WHO doesnot recommend IV bolus RCOG

does Methyl ergometrine 0.2 mg IV/IM II Line

if there are no contra indications Carboprost 250mcg IM III Line Misoprostol 600mcg oral/1000mcg P/R

when other drugs not available04/12/23 33

Recommendations - PPH 40 u oxytocin in 500ml- 125ml/hr ( RCOG) 20u in 1 L - 60 dr/min ( WHO) Methergine 0.2mg repeat 15 mins followed by 4th

hrly 5 doses Carboprost once in 15 Mins Maxm 8 doses Syntometrine more side effects but may be used Misoprostol Not very beneficial ( WHO) Tranexamic acid- May help if trauma is the cause

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WHO 2012 Recommendations

Based on this direct evidences, the WHO strongly recommends

Oxytocin alone should be used for the treatment of PPH in preference to adjunct misoprostol.

Blood/Blood products

Unstable patient Continued bleeding Loss > 30% Severe PPH Coagulopathy

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Choice of Blood /components

O Group Rh –ve in dire emergency Grouped and cross matched Packed cells 6u of packed cells - give 4 u of FFP PT/APTT >1.5 of normal - 12-15ml FFP/KG Platelets if <50,000 or during surgery ,<80000

give 10 units Fibrinogen<100mg - cryoprecipitate upto 10

units

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OXYTOCIN ERGOMETRINE MISOPROSTOL CARBOPROST

Dose 10IU IM. or 10-40U in IV InfusionC.S – 5 IU slow IV followed by infusion Act in 2-3min, specific to uterine smooth muscle

Ergotmetrin 0.5mgMethergin 0.2mg IM Acts in 6-7min, acts systemically on smooth muscle

400-600μg oral –serum conc in 7.5-30min(mean 18 min) Rectal- serum conc in 15-60min (mean 40min)

125 μg IMActs in <5min,

Short acting Long acting Long acting Long acting

safe Contraindicated in HT

Safe , home delivery and non skilled attendent

Contraindicated in asthma

inexpensive More expensive Inexpensive expensive

Min side effect Nausea, vomiting, HT Shivering, pyrexia Bromchospasm,vomiting diarrhoea, flushing

Cold storage more stable to heat and light

Demands cold storage No cold storage Cold storage

CHOICE OF UTEROTONICS

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OxytocicsOxytocics

Dose & Dose & routeroute

Maintenance Maintenance dosedose

Max Max dosedose

frequencyfrequency Precaution Precaution /CI/CI

OxytocinOxytocin IV infusion IV infusion 10U/500ml 10U/500ml 60dpm 60dpm

IV infuse IV infuse 10U/500ml 10U/500ml 40dpm40dpm

Not Not more more than 3lt than 3lt

-Acts -Acts within 3 within 3 min min

Ergometrine Ergometrine / Methergin/ Methergin

IM /IM /

slow IV of slow IV of 0.2mg0.2mg

0.2mg after 0.2mg after 15 min. 15 min.

5 doses.5 doses.

(1mg)(1mg)

44thth hourly hourly PIH, HT, PIH, HT, Heart Heart disease.disease.

15methyl 15methyl PGF2PGF2αα

IMIM 250 250μμgg

****

250250μμg afterg after

15mnts15mnts

8 doses8 doses

(2mg)(2mg)

15 - 90mnts15 - 90mnts Asthma, Asthma, heart heart disease.disease.

** NEVER GIVE PROSTAGLANDIN INTRAVENOUSLY** NEVER GIVE PROSTAGLANDIN INTRAVENOUSLY

IT MIGHT BE FATALIT MIGHT BE FATAL

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3 3 DsDs causing thecausing the 4th 4th DD(eath)(eath)

1. D1. Delayelay in recognizing & seeking help.in recognizing & seeking help.

2.2. DDelay in transport & reaching medical elay in transport & reaching medical facility.facility.

33.. D Delay in receiving an adequate Rx elay in receiving an adequate Rx comprehensive care upon arrivalcomprehensive care upon arrival

How to diagnose

When to shift?

What & how to give early & appropriate treatment ?

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WHERE TO SHIFT?WHERE TO SHIFT?

DDelay in shifting is an important cause ofelay in shifting is an important cause of DDeatheath

Think of shifting as early as possible.Think of shifting as early as possible.• Shift as quickly as possible.Shift as quickly as possible.

• Communicate- to patient /attendantCommunicate- to patient /attendant

• - to the tertiary care personnel- to the tertiary care personnel

Shift to a tertiary care centre with:Shift to a tertiary care centre with:• OTOT

• ICU ICU

• Blood bankBlood bank

• PersonnelPersonnel

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HOW TO SHIFT?HOW TO SHIFT?

Shift preferably in an ambulance,Shift preferably in an ambulance, With nasal oxygen on flowWith nasal oxygen on flow With 2 IV lines with fluid on flow (With 2 IV lines with fluid on flow (it can be it can be

lifelinelifeline)) Document Document

• The events in sequenceThe events in sequence

• IV fluids givenIV fluids given

• Drugs administeredDrugs administered

Communicate to personnel at tertiary care centre.Communicate to personnel at tertiary care centre.

NASG Non inflatable anti Non inflatable anti shock garmentshock garment

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For handling emergencies one must have a crash kit with the following Brannula (16 ,18 ,20) Bulbs- grouping and

cross matching Venesection Set Syringes/ Gloves Roller gauze / mops /

sticking plaster, scissor Foley’s catheter Drip sets I. V. Fluids- RL, DNS Hemacel, Intubation materialsOxytocin,MisoprostolPGF2alpha,MetherginOxygen with mask

Crash Kit (Emergency Tray)-

Hydrocortisone Calcium Gluconate Deriphylline Atropine Adrenaline Dopamine,

Dobutamine

Intelligent anticipation, skilled supervision, prompt detection

and effective institution of therapy can prevent disastrous consequences of PPH.

THANKYOU

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