Postpartum Hemorrhage (PPH)

Prakash Thakulla
Intern
 Contents
• Definition
• Etiology
• Prevention
• Initial Management
• Severe PPH management
• Patient safety bundle
 Revised Definition (ACOG-2017)
• It is defined as cumulative blood loss of ≥1000 ml or
blood loss accompanied by symptoms and sign of
hypovolemia within 24 hours of the birth process
(includes the intrapartum loss) regardless of route of
delivery.
 Clinical Features
• Symptoms: • Signs:
– Pallor – Hypotension
– Lightheadedness – Tachycardia
– Weakness – Oliguria
– Palpitation – Low SpO2 (<95%)
– Diaphoresis
– Restlessness
– Confusion
– Air Hunger
– Syncope
 Types
• Primary PPH:
– Within 24 hours of delivery
– Aka Early hemorrhage
• Secondary PPH:
– Occurs after 24 hours and within 12 weeks after
delivery
– Aka late hemorrhage
 Etiology
PRIMARY SECONDARY
• Uterine atony • Sub-involution of placental
• Lacerations site
• Retained placenta • RPOC
• Abnormally adherent • Infection
placenta (accreta) • Inherited coagulation defect
• Coagulation defect (eg. vW factor deficiency)
• Uterine inversion
Etiologies Primary problem Risk factor, signs

Atonic uterus Prolonged use of oxytocin

High parity
Chorioamnionitis
General anesthesia

Over Distended uterus Twin/multiple gestation

Polyhydramnios
aTony Macrosomia

Fibroid uterus Multiple uterine fibroid

Uterine inversion Excessive cord traction
Short cord
Fundal placental implantation

Episiotomy Operative vaginal delivery

Cervical, perineal and vaginal Precipitous delivery
Trauma lacerations
Uterine rupture
Etiologies Primary problem Risk factors, Signs
Retained Placental Retained placenta Succenturiate placenta
Tissue Placenta accreta Previous uterine surgery
Incomplete placenta at
delivery

Abnormalities of Preeclampsia Abnormal bruising

coagulation Inherited clotting factor Petechia
(Thrombin) deficiency (vW, Hemophilia) Fetal death
Severe infection Placenta abruption
Amniotic fluid infusion Fever, Sepsis
Excessive crystalloid replacement Hemorrhage
Therapeutic anticoagulation Current thromboembolism
treatment
 Complications
• Death
• Hypovolemic shock
• Multiple organ system failure
• Anemia
• Fluid overload
• Transfusion related complications
• Anesthesia related complications
 Prevention
• Identify patient with high risk of PPH
– Anemia
– Obesity
– Previous PPH
– Invasive placenta
– Marginal previa
– Fetal macrosomia
– Antenatal hemorrhage
• Tailor the labor management for high risk patients
(IV line, ABO and Rh grouping, Cross match, CBC)
• Active Management of Third Stage of Labor (AMTSL)
in every delivery
 AMTSL
• Oxytocin 10 Units IM or in IV solution
– With, or soon after delivery
• Continuous, CCT
– Use Modified Brandt- Andrew maneuver
• Transabdominal uterine massage after
placenta delivers
 HS Carbetocin Vs Oxytocin
• Carbetocin Haemorrhage Prevention
(CHAMPION) trial, during the third stage of
labor in women giving birth vaginally at 23
hospitals (sites) in 10 countries between July
7, 2015 and January 30, 2018
• Result: Heat-stable carbetocin was noninferior
to oxytocin for the prevention of blood loss of
at least 500 ml or the use of additional
uterotonic agents.
 Initial Management
• Ask for help: assemble team and notify
appropriate department
• Administer 100% O2 at 10L/min via non-
rebreathing face mask
• Maintain patent airway
• Establish large bore (two 16 or 18-G; ideally 14
G) IV access and obtain labs
• Have blood products on standby
• Begin bimanual uterine compression and
massage
 Initial Management
• Start Oxytocin IV
– 20 Units in 1 L fluid
– Infuse 500 ml in initial 10 minute then 250 ml/hr
• Monitor BP, Pulse and Urine output
– Target SBP ≥90 mmHg
– Target urine output ≥0.5 ml/kg/hr
• Antifibrinolytic agent
– Tranexamic acid IV or PO (WOMAN trial, 1 gm IV)
– Earlier use (within 3 hour from time of delivery) is
effective in reducing mortality and severity
• Consider 4Ts to determine the etiology of blood loss
 Uterine Atony
• Most common cause
• Uterus: soft, boggy on bimanual examination and
expression of clots and hemorrhage on fundal
massage
• Bladder empty Bimanual pelvic exam
Intrauterine clot removal uterine massage
• If severe bleding: Bimanual compression
• Start Uterotonics: Oxytocin, Methylergonovine
and PG
• Refractory atony: Uterine tamponade
 Uterotonic agents
Drug Dose and Route Frequency C/I ADR
Oxytocin IV: 20 U/L NS Continuous Rare •Usually none
•500 ml in first 10 (Hypersensitivit •N/V and
minutes, then 250 y) Hyponatremia
ml/hr if prolonged
•Can increase rate of use
infusion or •Hypotension
concentration (40-80 and arrhythmia
U/L NS) if needed if IV push
IM: 10-20 U

Methylergon IM: 0.2 mg Every 2-4 hr -HTN N/V

ovine -Pre-eclampsia Severe HTN
-Cardiovascular (particularly
disease when given IV)
-Drug
hypersensitivity
Drug Dose and Frequency C/I ADR
Route
Carboprost (15- IM: 0.25 mg or Every 15-90 Asthma N/V, diarrhea,
methyl PGF2α) Intramyometrial min (maxm. 8 Relative C/I: HTN, transient
0.25 mg doses i.e. 2 active hepatitis, fever,
mg) pulmonary or headache,
cardiac disease chills,
bronchospas
m
Misoprostol Treatment: 600- One time Rare N/V, diarrhea,
(PGE1) 1000 mcg PO, (Hypersensitivity) shivering,
sublingual, PR transient
Prevention: 600 fever,
mcg PO after headache
delivery if
Oxytocin is not
available
 Trauma
• Assess for:
– Laceration
– Hematoma
– Uterine inversion
– Uterine rupture
• Predominantly venous bleeding
 Vulval Hematoma
• Conservative
management with
observation and
supportive care
• Surgical intervention
• Selective arterial
embolization
 Uterine Inversion
• Risk Factors:
– Fundal placental
implantation
– Uterine atony
– Cord traction applied
before placental
separation
– Abnormally adherent
placenta
 Management
• Ask for help
• Treat hypovolemia and shock
– Crystalloid
– Blood
– Sedation
• Reposition
– Manual vs Hydrostatic (O’Sullivian’s method)
– Surgical correction: Haultain procedure and Hungtington
procedure
• Post Procedure care:
– Oxytocin- 20 U in 500 ml NS/RL at 10 drops/min (add ergot
or PG if not sufficient)
– Prophylactic antibiotic
Johnson Maneuver
 Tissue
• Adequate analgesia
• Digital exploration of uterus
• Removal of retained membranes and placental
fragments
• If known placental invasion: deliver in facility
with blood bank and surgical capabilities
 Thrombin
Etiologies Management
• Pre‐eclampsia, HELLP • Treat underlying disease
syndrome pathology
• ITP, TTP, von Willebrand, • Serially evaluate coagulation
hemophilia status
• Drugs (aspirin, heparin) • Replace appropriate blood
components
• DIC
• Support intravascular volume
– Excessive bleeding (consumption)
– Amniotic fluid embolism
– Sepsis
– Placental abruption
– Prolonged retention of fetal demise
 Severe PPH
• Institute ‘Massive Transfusion’ protocol
• Consider surgical intervention and ICU
management
 Massive Transfusion Protocol
• Use if blood loss >1500 ml, ongoing bleeding
and patient is symptomatic
• Protocol:
– Objectively quantify the blood loss
– Notify surgery, anesthesia and ICU team
– RBC: FFP: Platelet at [Link] or [Link] ratio
– Recent ACOG 2017 recommendation
• Packed RBC: FFP: Platelet=[Link]
 Severe PPH Interventions
• Uterine Packing
– 4 inch gauze soaked with 5000 Unit of thrombin in
5 ml of saline
• Balloon tamponade (temporary measure for
<24 hours)
– Bakri balloon
– Condom tamponade
– Foley catheterization
 Contd…
• Vessel embolization/ ligation: B/L Uterine
artery, Hypogastric artery
• Dilation and curettage
• Compression sutures: B-lynch compression
suture and multiple square sutures
• Recombinant factor VIIa
• Management in ICU: Vasopressor
• Hysterectomy
Patient Safety Bundle

• READINESS
• RECOGNITION AND PREVENTION
• RESPONSE
• REPORTING
 Take Home Message
• AMTSL should be used in every delivery
• Every bleed >500 ml should be evaluated
• Initial response to PPH:
– Team approach‐call for help
– Start 2 large bore IV’s and draw labs, monitor vitals and
urine output, administer oxygen and maintain patent
airway
– Bimanual massage and administer oxytocin
• Use 4T mnemonic to find cause
• Use patient safety bundle to reduce PPH
associated morbidity and mortality
 References
• Williams Obstetric. 25th ed.: Mc Graw Hill
Education.
• Advanced Life Saving in Obstetrics (ALSO). 8th ed.
• Heat-Stable Carbetocin versus Oxytocin to Prevent
Hemorrhage after Vaginal Birth. The New England
Journal of Medicine. 2018 August. (
[Link]
805489
)
THANK YOU