Overview and medical management of PPH

Dr. Suhas OtivConsultant, KEM Hospital, Pune

Lancet 2006; l368:1189-200

Mortality from PPH

• Half of 500,000 maternal deaths globally

• 28 % of maternal deaths in developing countries

• Risk of death from PPH 1 in 1000 deliveries - developing countries1 in 100,000 deliveries – developed countries

Lancet 2006; l367:1066-72

Incidence of PPH

PPH 5 – 17 % of all deliveries> 500ml

Major PPH 1.3 – 2.5 % of all deliveries> 1000 ml

ACOG 3.9 % of all deliveries

Definition of PPH

Primary PPH: 0 – 24 hours; Secondary PPH: 1 - 84 days

Blood loss > 500 ml at vaginal delivery> 750 - 1000 ml at Cesarean

Severe PPH > 1000 ml loss at vaginal delivery

ACOG: - Fall in hematocrit 10% - Need for PRBC transfusion

Rate of blood loss: > 150ml/min or sudden loss > 1.5 – 2 l

PPH can occur with minimal vaginal bleeding !!!!

Accuracy of visual estimation of blood loss

Blood collection method

Modified –WHO

Modified –WHO

Weighing Blood loss

Modified –WHO

Measuring volume of blood loss

-Transfer of blood-Mops squeezed

BRASSS-V®

Blood Collection Drape with Calibrated Receptacle

Etiology of PPH• Uterine Atony > 80 %

• Lacerations of vagina, cervix • Uterine rupture 10%• Uterine inversion

• Retained placental fragments• Placental accreta / increta / percreta 5%

• Coagulopathy 1%

Risk factors for PPH

• Nulliparity• Obesity• Large baby• Prolonged labor• APH• Multiple pregnancy• Cesarean delivery

• Advanced maternal age• PIH• PPH in previous delivery• Augmented labor• Forceps delivery• Use of tocolyticsх Grand multiparity

65 % cases of PPH occur with no risk factors

PPH at Cesarean delivery: Risk Factors

• General anesthesia• Chorio-Amnionitis• Pre-eclampsia• Protracted active phase of labor• Second-stage arrest• Classic uterine incision

Obstet Gynecol 1991 Jan;77(1):77-82

Risk factors for PPH: a case control studycomparing 666 cases with controls in 154311 deliveries• Retained placenta (OR 3.5, 95% CI 2.1-5.8)

• Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)

• Placenta accreta (OR 3.3, 95% CI 1.7-6.4)

• Lacerations (OR 2.4, 95% CI 2.0-2.8)

• Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)

• Large for gestational age new born (eg, >4000 g) (OR 1.9, 95% CI 1.6-2.4)

• Hypertensive disorders (OR 1.7, 95% CI 1.2-2.1)

• Induction of labor (OR 1.4, 95% CI 1.1-1.7)

• Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7)

J Matern Fetal Neonatal Med. 2005;18(3):149

Management of PPH

• Scenarios – labor room, OR, wards, peripheral hospital

• Effective management– Prompt response– Organized team work – Clear priorities, decisive

• Help: communication, monitoring, assistance, documentation

Being prepared for PPH

• Team: Nursing, doctors, surgical expertise, critical care physician / anesthesiologist

• Drugs: Oxytocin, Methergin, Carboprost, volume expanders, resuscitation

• Equipment: Monitoring, resuscitation, Blood bank, Lab, ICU, OR

Management of PPH at vaginal delivery

First line Management• Call for help• Uterine massage• IV access: X-match, labs• Infuse NS rapidly, • BP, Foley catheter, pulse oximeter, • Prompt Uterotonic drugs

Carboprost 250 mcg, 2 doses 15 minutes apart Oxytocin infusion 40 units / 500 ml in 30 – 60 min Methylergometrine 0.2mg i.m. one dose Misoprostol 400 - 800mcg

• Rapidly evaluate for vaginal / cervical lacerations• Warmth, oxygen

Oxytocic drugs

• Oxytocin• Methyl ergometrine• Misoprostol• Carboprost

Oxytocin

• Storage: Between 2-8 *C, avoid freezing

• Adverse effects: anti-diuretic effect, hypotension, arrhythmias

• Incompatible with noradrenaline, warfarin

• 10 – 40 IU / L of infusate

Ergometrine

• Storage: Refrigerate, protect from light, stable for 60-90 days, discoloration – discard

• Avoid : heart disease, hypertension, peripheral vascular disease, hepatic or renal impairment; with antiretroviral and macrolide antibiotics

• Adverse : Vomiting, nausea, HT, CVA

• Route: IM preferred, IV dilute in 5 ml NS

Carboprost – PGF2 alpha

• Caution : Asthma, cardiac disease, epilepsy, liver disease

• Storage: Refrigerate• Adverse: Vomiting, diarrhea, flushing,• Dosage: 250 mcg IM, repeat every 15 - 90

minutes, maximum 8 doses = 2 mg.• IV injection - bronchospasm, hypertension,

vomiting, and anaphylaxis

Misoprostol

• PGE1 analogue• Adverse effects – vomiting, shivering at higher

doses. No broncho-constriction.• Storage: Stable at or below 25*C• Route: Oral, buccal, rectal, vaginal• Rapid onset of action lasting 4-6 h

Misoprostol as an adjunct to standard uterotonics for treatment of PPHLancet. 2010;375(9728):1808

1422 women with atonic PPH treated with routine uterotonic agents randomized to

600 mcg misoprostol sublinguallyPlacebo sublingually

Found no difference in blood loss > 500 ml in next 1 hour

Treatment of PPH with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocinLancet. 2010;375(9710):217

31055 women delivered with prophylactic oxytocin in III stage, 809 (3%) who had atonic PPH were randomized to

Misoprostol 800mcg slOxytocin 40 u infusion in 15 minutes

Similar outcomes in both groups 90% women had bleeding controlled in 20 minutes; 30% women had additional blood loss of > 300 ml after Rx

After initial treatment

• Evaluate for retained placental fragmentuterine inversionlacerationscoagulopathy

• Check urine output, response to resuscitation, timevolume of blood lost

Volume replacement

• Crystalloid: Ringer Lactate, Hartmann, NSRL similar to plasma

only 20% retained in circulationDextrose: only 10% retained, interferes with X matchingNS avoid in pre-eclamptic patient

• Blood volume changes last for 40 minutes only• Infuse 3 L for each 1 L of estimated blood loss• Target 90mm systolic pressure, UOP 30ml/hr• Give colloids after 2 L of crystalloids given

Colloids• Gelatin polymers - Hemaccel

rapid urinary excretionanaphylaxis

• Hydroxyethyl starch – Hetastarch, Pentastarchincreases plasma volume by 70 – 230%dose 20 ml/kg = 1 to 1.5 Lno anaphylactic reactions well toleratedlasts for 4 hours in circulation

Blood transfusion

• No universally accepted guidelines for trigger

• PRBC x 2 if no improvement after 2-3 L of crystalloids or if

ongoing blood loss likely

• Warm carefully. > 40 *C – severe transfusion reactions

• Admin 1 FFP for every 1-2 units of PRBC, at 12-15ml/kg

• No drugs / injections with blood

Target

• Hb > 7, • Platelets > 50,000 /ml• Fibrogen > 100mg/dl• PT < 1.5 times control

Massive hemorrhage

• Defined as > 10 units of BT required / 24 h

• Likely when persistent SBP < 90, Loss more than 1500ml

• Cryoprecipitate if no response to FFP or Fibrogen level < 100

• Expect platelet count < 50,000 after > 2 L blood loss. Platelets to maintain counts 25-50,000, 1:1

Secondary interventions

• Repeated doses of Carboprost max 8 doses• Intramyometrial Carboprost - off label• Carboprost uterine irrigation• Rectal Misoprostol - high doses >800mcg• Intra-uterine Misoprostol• Tamponade – Sengstaken tube, • Uterine Packing

Indications for laparotomy

• Unabated blood loss

• Atony unresponsive to Rx

• Vital signs out of proportion to blood loss

• Vaginal laceration extending above fornix

Summary

• Symptoms and vital signs of blood loss are more important than visual assessment of blood loss

• Team approach with protocols and regular drills

• Prompt, sequential use of utero-tonic agents and replacement of volume are mainstay of Rx

• Low Fibrinogen, abn PT, tachycardia and abnormalities of placental implantation and detectable troponin are predictors of increased morbidity

Thank you !