Obstetric hemorrhage

Obstetric hemorrhage
• Hemorrhage is the #1 cause of maternal death
• Accounts for 50% of maternal deaths globally:
• Approximately 250,000 deaths from hemorrhage per year
• US ranks 47th in the world for maternal deaths:
• Maternal mortality doubled in the US between 1990 to
2008 and continues to climb
• Hemorrhage is the leading cause of death in the US; up to
90% are preventable
• In contrast, there were only 9 direct deaths in UK
between 2006 and 2008
• 8th leading cause of direct maternal deaths in the UK
 CMACE: Substandard care
• ‘Substandard care’ in over 50% of women who died:
• Lack of early senior multi-professional involvement
• Lack of close postoperative monitoring
• Failure to act on signs and symptoms
• Inadequate use and interpretation of maternal obstetric
early warning score charts
• The incidence of major obstetric hemorrhage is
increasing in many countries possibly due to the
increasing rate of cesarean delivery
 Definition of hemorrhage
• Antepartum hemorrhage (APH)
– Genital tract bleeding > 24 weeks of gestation until labor
• Intrapartum hemorrhage
– Genital tract bleeding during labor
• Primary postpartum hemorrhage (PPH)
– Blood loss of 500 ml or more within 24 hours of birth
• Major PPH = blood loss greater than 1000 ml

• Secondary PPH
– Blood loss of 500 ml or more from 24 hours to 12 weeks
postpartum
 Key messages
• Primary prevention of hemorrhage
• Preparation to manage hemorrhage
• Early recognition and effective treatment of
hemorrhage
 Prevention- 1
• Identify high-risk women
– Previous postpartum hemorrhage
– Placenta previa and accreta
– Fibroids/multiple pregnancy /polyhydramnios
– Anemia
– Hemorrhagic disorders
– Women who decline blood products
 Prevention- 2
• Active management of third stage of labor
– Delayed cord clamping > 30 seconds recommended
for infants in good condition at birth:
• Reduction in neonatal anemia
• No increase in polycythemia/jaundice
• No increase in maternal PPH

– The omission of controlled cord traction has very little

effect on the risk of severe hemorrhage
– Scaling up hemorrhage prevention programs can
safely focus on the use of oxytocin primarily
 Ecbolics for active 3rd /4th stage
• Oxytocin- primary, routine
– Slightly less effective at reducing initial blood loss
– But not associated with postpartum hypertension
– Consider possible cardiac effects

• Methergine- secondary
– Reduces the risk of PPH by 60%
– Adverse effects: nausea and vomiting
– Associated with increased risk of cerebral hemorrhage,
particularly with history of hypertension
 Ecbolics for active 3 /4 stage rd th

• Misoprostol- secondary
– Given alone, is not as effective as oxytocin or methergine
for prevention of PPH
– High safety profile
• Anticipate uterine atony in high-risk cases
– Consider administering a longer-acting ecbolic (e.g.
methergine or carboprost) with:
Previous atonic PPH Fibroid uterus
Prolonged labor Second stage
Cesarean section
Multiple pregnancy
 Preparation
• High-risk cases
– IV access- 2 IVs
– Group and save/cross-match
• Very high-risk OR cases
– Cell salvage
– Placenta accreta checklist
– ? Interventional radiology
 Early recognition
• Remember:
– Blood loss can be difficult to estimate
– Bleeding can be concealed within the uterus,
broad ligament or abdominal cavity
– Pregnancy masks the maternal response to loss
• Vital to monitor heart rate, BP and RR
• Act on signs and symptoms
• Monitor fundal height postnatally
 Early recognition
Blood loss Signs

500–1000 ml

1000–1500 ml

1500–2000 ml

2000–3000 ml
 Early recognition
Blood loss Signs
Normal BP, tachycardia
500–1000 ml
Palpitations, dizziness

1000–1500 ml

1500–2000 ml

2000–3000 ml
 Early recognition
Blood loss Signs
Normal BP, tachycardia
500–1000 ml
Palpitations, dizziness

Hypotension (systolic 90–80), tachycardia

1000–1500 ml Tachypnea (21–30 breaths/minute)
Pallor, sweating
Weakness, faintness, thirst

1500–2000 ml

2000–3000 ml
 Early recognition
Blood loss Signs
Normal BP, tachycardia
500 – 1000 ml
Palpitations, dizziness

Hypotension (systolic 90–80), tachycardia

1000 – 1500 ml Tachypnoea (21–30 breaths/minute)
Pallor, sweating
Weakness, faintness, thirst
Hypotension (systolic 80–60), rapid weak pulse (> 110 bpm)
Tachypnea (> 30 breaths/minute)
1500 – 2000 ml
Pallor, cold clammy skin
Poor urinary output (< 30 ml/hr)
Restlessness, anxiety, confusion

2000 – 3000 ml
 Early recognition
Blood loss Signs
Normal BP, tachycardia
500–1000 ml
Palpitations, dizziness

Hypotension (systolic 90–80), tachycardia

1000–1500 ml Tachypnea (21–30 breaths/minute)
Pallor, sweating
Weakness, faintness, thirst
Hypotension (systolic 80–60), rapid weak pulse (> 110 bpm)
Tachypnea (> 30 breaths/minute)
1500–2000 ml
Pallor, cold clammy skin
Poor urinary output (< 30 ml/hr)
Restlessness, anxiety, confusion
Severe hypotension (systolic <50), rapid weak pulse (> 130 bpm)
Air hunger
2000–3000 ml Pallor, cold clammy skin, peripheral cyanosis
Anuria
Confused, drowsy or unconscious
Antepartum and intrapartum
hemorrhage
 Placenta previa Placental abruption
Signs of hypovolemia Signs of hypovolemia

Usually painless bleeding Concealed or revealed bleeding

No significant pain Severe, constant abdominal pain

Soft uterus Tender, rigid (woody) uterus

Often no fetal compromise Fetal compromise

Significant risk of DIC

 Uterine rupture Vasa previa
Vaginal bleeding after rupture
Previous uterine surgery
of the membranes
Signs of hypovolemia Acute fetal compromise

Sudden onset of constant pain Sinusoidal trace

Very high presenting part Fetal bradycardia

Contractions may cease No change in maternal condition

Bleeding (may be concealed) No signs of hypovolemia

Hematuria

Pathological heart rate tracing

Initial
management
of major
antepartum
hemorrhage
 Management of APH
• Similar to PPH
• Need to monitor fetal condition
• Delivery required? If so, how quickly?
– Stabilize mother prior to birth
– Ensure neonatal support present
• Anticipate and prepare for PPH
 Rapid evaluation of maternal and fetal
condition
Ascertain obstetric and clinical history:
• Gestational age
• Previous uterine surgery/cesarean section
• Position of placenta (refer to any antenatal scans)
• Abdominal pain

Examination:
• Estimate blood loss
• Uterine palpation for tone and tenderness
• Abdominal palpation-peritoneal signs or ex utero parts
• Assess placental site using ultrasound scan
• Exclude placenta previa and then perform a VE
Postpartum hemorrhage
 Causes of PPH
• Tone
– Uterine muscle contracts to prevent bleeding
– Atony causes bleeding and predisposes to uterine
inversion
• Tissue
– Retained placenta or membranes or blood clots
within the uterus prevents good contraction
• Trauma
– Vaginal/cervical lacerations
• Coagulation defects (thrombin)
Call for help and state the problem
• Call for help
• Declare the emergency – ‘This is a PPH’
• ‘Code red’
• Senior resident, experienced
obstetrician/faculty, anesthesiologist, OR
team
• Alert dedicated surgical team if you have one
 ABC
• Airway
• Breathing
– High-flow oxygen

• Circulation
– IV access and fluids
– Head down/elevate legs
 Fluid resuscitation
• A priority in any major obstetric hemorrhage
• Aim to restore the circulating volume
– Two large intravenous cannula (at least 16 gauge)
– Send blood for FBC, clotting and cross-match
– Immediately give 2 liters of IV crystalloid
(e.g. Ringer’s or normal saline)
– Use pressure bags
 Routine tranexamic acid (TXA)
(WOMAN Trial)
• World Maternal Antifibrinolytic (WOMAN) Trial
showed a reduction in hemorrhage-related maternal
mortality with TXA (1000mg iv)
• TXA is cost-saving across a wide range of plausible
scenarios as long as the reduction in hemorrhage-
related mortality is > 4.7% (19% in the WOMAN trial)
• TXA is likely cost-saving if used routinely for post-
partum hemorrhage in the US
Treat the cause – low threshold for OR transfer
• Uterine atony
– Uterine massage/bimanual compression
– Catheterize bladder
– Give uterotonics
– Have a Bakri balloon available
• Inverted uterus
– Manually replace as soon as possible
– Remove adherent placenta after uterus replaced
Treat the cause – low threshold for OR transfer

• Empty the uterus

• Repair tears
• Treat coagulopathies
 Uterotonics
Drug Dose Comment
200 micrograms
Contraindicated with
Methergine Active 3rd stage - give 2nd dose IM
hypertension
Physiological 3rd stage – give 1st dose

Alternative to
Oxytocin 10 units IM or 5 units IV
methergine

200 micrograms IM Contraindicated with

Ergotrate
(if methergine has not been given) hypertension

Will not initiate

Oxytocin 40 units in 500 ml normal saline
uterine contraction,
infusion over 4 hours
but may maintain it
 Uterotonics
Drug Dose Comment
Contraindicated in severe
250 micrograms IM
Carboprost/ asthma
At least 15 minutes between doses
Hemobate Side Effects – pyrexia &
To a maximum of 8 doses
diarrhea
Less effective than
Carboprost
Misoprostol 800 micrograms PR Side effects: pyrexia and
diarrhea but uncommon
with rectal administration
 Give blood products early
• To restore oxygen-carrying capacity
– Red blood cells
• O-negative, type-specific, full cross-match, cell salvage

• To correct coagulation defects

– Fresh frozen plasma
– Cryoprecipitate
– Platelets
Immediate management of major postpartum hemorrhage
Call for Help
Senior OB nurses, experienced obstetricians, anesthesiologist.
Contact Blood Bank and Hematology as indicated

Lie flat Massage uterus Intravenous access Rapid fluid Observations Assess cause
Give Expel clots and rub up 2 large bore cannulas replacement Respiratory Atony
high flow contraction Take blood samples: 2L crystalloid – rate, pulse, Trauma
oxygen Bi manual compression CBC, clotting screen, Ringers or 0.9% BP, O2 Retained
group and cross- Saline saturations placental tissue
match TXA 1000mg IV; Coagulation
4 units may repeat

Stop the bleeding

Oxytocin infusion Oxytocin 10 units/ Urinary catheter and Carboprost Misoprostol

40 units oxytocin Methergine 200mcg urine measurement 250 micrograms 800 micrograms
IV infusion via pump IM or slow IV injection Empty bladder, given IM every given per rectum
over 4 hours (Methergine contra- monitor urine output 15 minutes up to
indicated if raised BP) hourly 8 doses

Massage uterus and Bimanual Compression AND Repair Perineal / Vaginal / Cervical Tears

Assessment

Blood Transfusion/Blood products

Monitoring Reassess causes of bleeding
Consider: O negative emergency blood,
Document all observations – Use Modified Atony
(use blood warmer and maintain maternal
Obstetric Early Warning Score Chart Trauma
warmth)
Estimate blood loss / Weigh all swabs Retained placental tissue
FFP, Platelets, Cryoprecipitate, Factor VIIa
Accurate fluid balance Coagulation
 Surgical approaches – low threshold for
transfer to OR
• EUA, manual removal
• Repair of tears – vaginal, cervical, uterine
• Bakri balloon
• B-Lynch suture for uterine atony
• Sutures to placental bed
• Uterine/internal iliac vessel ligation
• Hysterectomy
B-Lynch Suture
Uterine Artery Ligation
 Other approaches
• Uterine packing
• Uterine artery embolization
• Aortic compression
Correction of coagulation defects
• Check clotting (including fibrinogen)
– Don’t wait for results if massive hemorrhage
• Keep the patient warm
– Use blood warmer
– Use forced air warming blanket
• Give FFP, cryoprecipitate (good source of
fibrinogen), platelets
 Uterine
Inversion
 Take-home messages
• Primary prevention of hemorrhage
• Preparation to manage hemorrhage
• Early recognition and effective treatment of
hemorrhage
 Remember
• Close postoperative monitoring
– Fundal height and PV loss

• Act on signs and symptoms

• Early senior multi-professional involvement,
including hematologists if indicated