Post Partum Hemorrhage

PPH

Primary PPH

Within 24 hours of birth

>500 mL vaginal birth or >1000 mL C section

** Or any amount that causes symptoms

Secondary PPH

Abnormal or excessive bleeding

24 hrs to 12 weeks postnatal

Often assoc with endometritis

** Can further subdivide PPH as minor (500-1000 mL) or major (>1000 mL)

PPH

One of leading causes of maternal mortality

1-5% of deliveries

#1 cause postpartum women admitted to ICU

Blood flow to uterus at term: >700 mL/min

Blood loss often under-estimated and bleeding not

always obvious… so what signs can we look for?

What are the signs/sympt?

Steps to managing PPH

Predict:

identify patients at risk

Prepare:

Multi-disiplinary approach, PPH protocol

Manage:

Timely, accurate diagnosis and appropriate interventions

Active management of 3rd stage of labour

Causes of PPH

Any deviation from normal

stage 3:

Placenta completely separates

from uterus

Myometrium contracts

Vessles constrict

Coagulation pathways activate

4 T’s of PPH

Tone: Failure of uterus to contract

Tissue: Retained products in uterus

Trauma: Vaginal, perineal, uterine

Thrombin: Coagulation abnormalities

TONE

Atony of uterus

75-90 % of PPH

Causes:

Overdistension of uterus (large baby, multiple gestation)

Uterine muscle exhaustion (prolonged labour)

Uterine infection

Uterine relaxants (general anesthetic)

Retained placental fragments

TISSUE

Retained placental products

#1 cause for massive transfusions (>10 units RBC)

Risks: Placenta previa (above cervix)

Placenta accreta/increta/percreta(invade into uterus)

Prior C-section

Curettage

Uterine infection

TRAUMA

5-10% of PPH

Lacerations, incisions, uterine rupture, hematoma

Risks:

Instrumented deliveries

Primiparity

Pre-eclampsia

Multiple gestation

Prolonged second stage

Vulvovaginal varicosities

Uterine inversion

THROMBIN

Coagulation defects

Risks

Pyrexia in labour, sepsis

Pre-eclampsia, HELLP

Placental abruption

Pre-existing clotting disorder or liver failure

Anti-coagulants

Fetal demise

Review of some risks

Abnormal or retained placenta

Prolonged or precipitous labour

Lacerations or use of instruments

Distended uterus

Hypertensive disorders (Pre-eclampsia)

Induction of labour or oxytocin use

Previous PPH

Fetal demise

Coagulation disorders

….

Case - Mary

25 year old G1P0

Pregnancy complicated by pre-eclampsia

Labour has been prolonged (stage 1/2: >25 hours)

Serial blood work stable: Hb 120, normal CBC and lytes

Vitals stable, but blood pressure has been ~160/90

A Case - Mary

Resistant to assisted delivery, but eventually agrees to use of foreceps

Baby is delivered soon after with 2rd degree tear

Placenta delivered: appears intact with no missing or extra lobes

Bleeding estimated at 400 mL, with a slow trickle from tear

During suturing of her tear you note vitals deteriorating to HR 120, BP 90/60, pallor, feels dizzy

Management

Bedside evaluation, frequent vitals, ABCs

CBC, extended lytes, PT/PTT, screen and x-match

*Hb and Hct may not reflect acute changes

Reverse coagulopathies or electrolyte abnormalities

Active management of 3rd stage

Cord traction, uterine massage, remove retained products

Uterotonics: Oxytocin, carboprost, misoprostol

IV access & fluids, urine output, transfusion as needed

Blood products

Blood should be drawn q30-60 min to guide replacement (CBC, lytes, ionized calcium, PTT/INR)

No hard/fast rules: 2 units pRBC if hemodynamics do not improve after 2-3 liters of NS, EBL > 1500 mLs and continued bleeding expected

Typically FPP:pRBC = 1:2-3 (to stop dilutional coagulapathy)

Goals: HB >75

Platelets > 50 000

PTT and INR > 1.5 control

Fibrinogen > 200 mg/dL

Uterine massage/compression

Balloon tamponade

•Effective mainly in uterine atony

•Need to continue to monitor vitals and blood work closely.

•If fails move on to embolization or surgery

Arterial embolization

Must be stable enough to go to interventional radiology

Aortic compression

Emergency hysterectomy

• Can try suturing techniques first (B-Lynch suture)

• Hysterectomy typically a last resort

• More readily done for uterine perforation, placenta accreta/increta/percreta

Case - Mary

You suspect uterine atony so you give oxytocin (10

units IM) and call the team

Ask nurses to start 2 large bore IVs and fluids, blood

work, foley catheter, give oxygen

Uterine massage followed by compression

Uterus initially feels boggy but after ~1 minute

contracts causing a large gush of pooled blood to

exit the vagina (~800 mL)

Case - Mary

Vitals stabilize after 3 liters of NS and she is weaned off

O2

Vaginal tear repaired

Hb remains stable ~95-100, remaining bloodwork normal

Urine output stays above 40 ml/hr

Mary is closely monitored and recovers well over next

couple of days (her baby is healthy too!)