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Medical management of postpartum hemorrhage pph lecture

Lecture regarding risk factors, causes, and medical management of postpartum hemorrhage

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Medical management of postpartum hemorrhage pph lecture

  1. 1. THE MEDICAL MANAGEMENT OF POSTPARTUM HEMORRHAGE Chukwuma I. Onyeije, M.D., Atlanta Perinatal Associates
  2. 2. <ul><li>Provide a definition of PPH </li></ul><ul><li>Review the risk factors for PPH </li></ul><ul><li>Understand the nature and importance of rapid diagnosis and treatment </li></ul>OBJECTIVES
  3. 3. For your convenience, A digital copy of this lecture is also located at:
  4. 4. Mary 24 year old G2P2 Underwent a routine cesarean section at 7.30 pm Pre-operative Hb was 13 g/dl. Blood loss of 500cc.
  5. 5. Mary 4 hours post-partum Pulse at 100-120 otherwise stable. BP: 70-90 / 50-60 Analgesia and Hydration provided. 5 hours postpartum: Seizure with obtundation. Hemoglobin: 7 g/dl,
  6. 6. 6 Hours post partum: Elevated cardiac enzymes DIC Myocardial Infarction & Liver failure 9 Hours postpartum: Failed arterial embolization 10 Hours postpartum Uterine packing done. 11 Hours Postpartum: Hysterectomy 2 Days Postpartum: Flatline EKG
  7. 7. ‘‘ She died in childbirth’’
  8. 8. Hemorrhage has probably killed more women than any other complication of pregnancy in the history of mankind.
  9. 9. An estimated 150,000 maternal deaths worldwide result from obstetric hemorrhage each year
  10. 10. 90% of deaths from Postpartum hemorrhage are preventable.
  12. 12. Those caring for pregnant women must be prepared to aggressively treat this complication when it occurs.
  13. 13. What can be done?
  15. 15. THE STEPS TO PPH: P OST P ARTUM H EMORRHAGE: P REDICT H ANDLE P REPARE Identify patients at risk Use a multi-disciplinary Approach Optimize clinical management
  16. 16. Uterine Blood Flow
  17. 17. Large amounts of blood can be lost rapidly following delivery.
  18. 18. Uterine contraction is more important than clot formation or platelet aggregation as a mechanism of hemostasis
  20. 20. Can we Predict PPH? Who is at risk?
  21. 21. Risk Factors for Postpartum Hemorrhage What Should we do with a list like this? Prior postpartum hemorrhage Advanced maternal age Multifetal gestations Prolonged labor Polyhydramnios Instrumental delivery Fetal demise Placental abruption Anticoagulation therapy Multiparity Fibroids Prolonged use of oxytocin Macrosomia Cesarean delivery Placenta previa and accreta Chorioamnionitis General anesthesia
  22. 22. Clinically Important Risk Factors for Postpartum Hemorrhage Prior postpartum hemorrhage Abnormal placentation Operative delivery
  23. 23. Risk Factors for Postpartum Hemorrhage under Clinical Control Prolonged labor Instrumental delivery Anticoagulation therapy Prolonged use of oxytocin Cesarean delivery General anesthesia
  24. 24. Causes of Postpartum Hemorrhage (another busy slide) Primary causes Uterine atony Genital tract lacerations Retained products Abnormal placentation Coagulopathies and anticoagulation Uterine inversion Amniotic fluid embolism Secondary causes Retained products Uterine infection Subinvolution Anticoagulation
  26. 26. What about DIC? Coagulopathy is a relatively uncommon cause of primary PPH Coagulopathy most commonly occurs when another cause of PPH already has produced significant blood loss.
  27. 27. RDFS RDFS is retained dead fetus syndrome Well described in most obstetrics texts Clinically manifested at about 6 weeks after fetal death Rarely seen in modern obstetrics.
  28. 28. Congenital coagulation disorders <ul><li>Uncommon individually </li></ul><ul><li>As a class are present more frequently than commonly thought </li></ul><ul><li>Examples: </li></ul><ul><ul><li>VonWillebrand’s disease </li></ul></ul><ul><ul><li>Specific factor deficiencies (factors II, VII, VIII, IX, X, and XI) </li></ul></ul>
  30. 30. Question: What causes uterine atony and is there anything we can do to prevent uterine atony induced postpartum hemorrhage?
  31. 31. <ul><li>Causes of Uterine Atony: </li></ul><ul><li>Overdistension of the uterus </li></ul><ul><li>Myometrial laxity as seen in: </li></ul><ul><ul><li>Multiparity, </li></ul></ul><ul><ul><li>Prolonged labor, </li></ul></ul><ul><ul><li>Use of large quantities of oxytocin, </li></ul></ul><ul><ul><li>Tocolytic therapy, </li></ul></ul><ul><ul><li>General anesthesia. </li></ul></ul>
  32. 32. Trends in postpartum hemorrhage: United States, 1994–2006 Source: American Journal of Obstetrics & Gynecology 2010; 202:353.e1-353.e6 (DOI:10.1016/j.ajog.2010.01.011 ) Copyright © 2010 Terms and Conditions William M. Callaghan, MD, MPH, Elena V. Kuklina, MD, PhD and Cynthia J. Berg, MD, MPH American Journal of Obstetrics & Gynecology Volume 202, Issue 4, Pages 353.e1-353.e6 (April 2010) DOI: 10.1016/j.ajog.2010.01.011
  33. 33. Upper Genital Tract Trauma Most often is the result of uterine rupture Bleeding from direct uterine injury during cesarean Injury of associated vascular structures (uterine, artery or broad ligament varicosities) during cesarean
  34. 34. Lower Genital Tract Trauma May occur spontaneously or result from episiotomy, obstetric maneuvers, or operative instrumented deliveries. Involve perineum, cervix and vagina.
  36. 37. 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5.- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management
  37. 38. Preparation for Postpartum Hemorrhage
  38. 39. “ Perhaps the most important aspect in the management of PPH is the attitude of the attendant in charge. It is critical to maintain equanimity in what can be a chaotic and stressful environment ” . Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441
  39. 40. Analysis Paralysis An excessive number of well-meaning individuals increases the ambient noise, adds to confusion, and opens the door to communication errors. Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441
  40. 42. 1.- Prepare for PPH -Nursing -Anesthesia - Surgical assistance - Others (I.R.) Drugs/Equipment -Methergine -Hemabate -Cytotec -Colloids -Blood/Bl.products -Surg. Instruments -Hemostatic ballons Personnel
  41. 43. Anesthesia / I.V. Access <ul><li>Obtain Anesthesia consultation </li></ul><ul><li>Type of anesthesia </li></ul><ul><li>Need for invasive monitoring </li></ul><ul><ul><li>(A line, Swan-Ganz, etc) </li></ul></ul>
  42. 44. <ul><li>Physicians underestimate blood loss by 50% </li></ul><ul><li>Slow steady bleeding can be fatal </li></ul><ul><li>Most deaths from hemorrhage seen after 5h </li></ul><ul><li>Abdominal or pelvic bleeding can be hidden </li></ul>Postpartum Hemorrhage is Easy to miss
  43. 45. <ul><li>Estimate blood loss accurately. </li></ul><ul><li>Evaluate all bleeding, including slow bleeds. </li></ul><ul><li>If mother develops hypotension, tachycardia or pain…rule out intra-abdominal blood loss. </li></ul>Always look for signs of bleeding
  44. 46. Identify possible post partum hemorrhage. Simultaneous evaluation and treatment. Remember ABCs. Use O2 4L/min. If bleeding does not readily resolve, call for help. Start two 16g or 18g IVs. Initial Assessment
  45. 47. Initial Steps for PPH Bimanual compression Manual exploration of the uterus Empty the bladder Administer uterotonic agents Examine lower genital tract for lacerations.
  46. 49. <ul><li>Tone (Uterine tone) </li></ul><ul><li>Tissue (Retained tissue--placenta) </li></ul><ul><li>Trauma (Lacerations and uterine rupture) </li></ul><ul><li>Thrombin (Bleeding disorders) </li></ul>The 4 Ts
  47. 50. <ul><li>Uterine atony causes 80% of hemorrhage </li></ul><ul><li>Assess and treat with uterine massage </li></ul><ul><li>Use medication early </li></ul><ul><li>Consider prophylactic medication... </li></ul>T # 1: Tone: Think of Uterine Atony
  48. 51. <ul><li>Confirms diagnosis of uterine atony. </li></ul><ul><li>Massage is often adequate for stimulating uterine involution. </li></ul>Bimanual Uterine Exam
  49. 52. Medical Treatment of Postpartum Hemorrhage Medications that cause uterine contractions Medications that promote coagulation
  50. 53. METHERGINE “ Speedy” OXYTOCIN “ The Champ” Cytotec Inexpensive (?) Effective Medications for Uterine Atony
  51. 54. OXYTOCIN <ul><li>The common medication used to achieve uterine contraction </li></ul><ul><li>First-line agent to prevent and treat PPH </li></ul><ul><li>Given IV or IM. </li></ul><ul><li>May cause hypotension. </li></ul>OXYTOCIN “ The Champ”
  52. 55. <ul><li>Causes rapid tetanic uterine contraction. </li></ul><ul><li>May trap placenta. </li></ul><ul><li>Can cause Hypertension </li></ul><ul><li>Contraindicated in hypertensive patients and those with pre-eclampsia. </li></ul>METHERGINE METHERGINE “ Speedy”
  53. 56. <ul><li>Hemabate 0.25mg IM or IU. </li></ul><ul><li>Previously known as Prostin. </li></ul><ul><li>Controls hemorrhage in 86% when used alone, and 95% in combination with above. </li></ul><ul><li>Can repeat up to eight times. </li></ul><ul><li>Contraindicated in asthma and (?) hypertension. </li></ul><ul><li>Can cause nausea/vomiting/diarrhea </li></ul>Prostaglandin F2 15-methyl
  54. 57. <ul><li>OXYTOCIN : promotes rhythmic contractions. </li></ul><ul><ul><li>Give 10 mg IM or IV, not IU. </li></ul></ul><ul><li>METHERGINE : promotes rapid tetanic contractions </li></ul><ul><ul><li>0.2mg (1 amp) IM </li></ul></ul><ul><li>HEMABATE : promotes long lasting contractions </li></ul><ul><ul><li>0.25 mg IM q 15min (max X8). </li></ul></ul><ul><li>CYTOTEC : less effective than methergine </li></ul><ul><ul><li>400 to 1000  g (oral, vaginal or rectal) </li></ul></ul>Summary of Medications for Uterine Atony
  55. 58. Fluid Management of Postpartum Hemorrhage
  56. 59. - Balanced * ( 0.9% NaCl, lactated Ringers -Hypertonic (3.5,5, 7.5% NaCl) -Hypotonic (0.45% NaCl) * Same electrolyte concentration as the extracellular compartnt -Albumin (5%, 25%) -Dextran, glucose polymers (40, 70) -Hydroxyethyl starch (Hespan ) Crystalloid Colloid Blood/Blood Products Fluid Management of Postpartum Hemorrhage
  57. 60. Acute Postpartum Blood Loss PROBLEMS : Loss of circulatory Volume Loss of O 2 carrying capacity Restore volume 1 - Crystalloid 2 - Colloid  SaO 2  O 2 carrying capacity Supplemental O 2 Transfusion
  58. 61. 25-30%(15-1800cc) Healthy ?  Crystalloid/Colloid Medical complications ?  Consider transfusion 30-50%(18-3000cc) Crystalloid/Colloid Consider transfusion > 50% ( > 3000cc) Crystalloid/Colloid Blood transfusion Clotting factors (FFP, Cryo) Blood Loss Hemorrhagic Shock - Fluid Management -
  59. 62. Managing blood loss by hemorrhage classification Class Blood Loss Volume Deficit Spx Rx I < 1000 cc 15% Orthostatic tachycardia Crystalloid II 1001-1500 15-25% Incr. HR, orthostasis, mental Decr cap refill Crystalloid, III 1501-2500 25-40% Incr HR, RR Decr BP, Oliguria Crystalloid Colloid, RBCs IV > 2500 > 40% Obtunded Oliguria/anuria CV collapse RBC, Crystalloid, Colloid
  60. 63. Ways to Optimize hemodynamic status <ul><li>Acute isovolemic hemodilution </li></ul><ul><li>Acute hypervolemic hemodilution </li></ul><ul><li>Autologous donation </li></ul><ul><li>Preoperative transfusion </li></ul>
  61. 64. Acute isovolemic hemodilution Withdraw 2-4 u. of Blood  Replace the volume with crystalloid  Lower the pre-op Hct  Replace the blood at end of surgery Acute hypervolemic hemodilution Admin 1500-2000cc Crystalloid  Hemodilution (Lowers pre-op Hct) Ways to optimize hemodynamic status
  62. 65. <ul><li>Delay of placental delivery > 30 minutes seen in ~ 6% of deliveries. </li></ul><ul><li>Prior retained placenta increases risk. </li></ul><ul><li>Risk increased with: prior C/S, curettage p-pregnancy, uterine infection, AMA or increased parity. </li></ul><ul><li>Prior C/S scar & previa increases risk (25%) </li></ul><ul><li>Most patients have no risk factors. </li></ul><ul><li>Occasionally succenturiate lobe left behind. </li></ul>T # 2: TISSUE
  63. 67. Oxytocin 10U in 20cc of NS placed in clamped umbilical vein. If this fails, get OB assistance. Check Hct, type & cross 2-4 u. Two large bore IVs. Anesthesia and OR support. Removal of Abnormal Placenta
  64. 68. <ul><li>Relax uterus with halothane general anesthetic and subcutaneous terbutaline. </li></ul><ul><li>Bleeding will increase dramatically. </li></ul><ul><li>With fingertips, identify cleavage plane between placenta and uterus. </li></ul><ul><li>Keep placenta intact. </li></ul><ul><li>Remove all of the placenta. </li></ul>Removal of Abnormal Placenta
  65. 70. <ul><li>If successful, reverse uterine atony with oxytocin, Methergine, Hemabate. </li></ul><ul><li>Consider surgical set-up prior to separation. </li></ul><ul><li>If manual removal not successful, large blunt curettage or suction catheter, with high risk of perforation. </li></ul><ul><li>Consider prophylactic antibiotics. </li></ul>Removal of Abnormal Placenta
  66. 72. Episiotomy Hematoma Uterine inversion Uterine rupture T # 3: Trauma
  67. 73. Rare: ~1/2000 deliveries. Causes include: Excessive traction on cord. Fundal pressure. Uterine atony. Uterine Inversion
  68. 74. <ul><li>Blue-gray mass protruding from vagina. </li></ul><ul><li>Copious bleeding. </li></ul><ul><li>Hypotension worsened by vaso-vagal reaction. Consider atropine 0.5mg IV if bradycardia is severe. </li></ul><ul><li>High morbidity and some mortality seen: get help and act rapidly. </li></ul>Uterine Inversion
  69. 75. <ul><li>Push center of uterus with three fingers into abdominal cavity. </li></ul><ul><li>Need to replace the uterus before cervical contraction ring develops. </li></ul><ul><li>Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage. </li></ul><ul><li>When completed, treat uterine atony. </li></ul>Uterine Inversion
  70. 77. <ul><li>Rare: 0.04% of deliveries. </li></ul><ul><li>Risk factors include: </li></ul><ul><li>Prior C/S: up to 1.7% of these deliveries. </li></ul><ul><li>Prior uterine surgery. </li></ul><ul><li>Hyperstimulation with oxytocin. </li></ul><ul><li>Trauma. </li></ul><ul><li>Parity > 4. </li></ul>Uterine Rupture
  71. 78. <ul><li>Risk factors include: </li></ul><ul><li>Epidural. </li></ul><ul><li>Placental abruption. </li></ul><ul><li>Forceps delivery (especially mid forceps). </li></ul><ul><li>Breech version or extraction. </li></ul>Uterine Rupture
  72. 79. Sometimes found incidentally. During routine exam of uterus. Small dehiscence, less than 2cm. Not bleeding. Not painful. Can be followed expectantly. Uterine Rupture
  73. 80. Vaginal bleeding. Abdominal tenderness. Maternal tachycardia. Abnormal fetal heart rate tracing. Cessation of uterine contractions. Uterine Rupture before delivery
  74. 81. May be found on routine exam. Hypotension more than expected with apparent blood loss. Increased abdominal girth. Uterine Rupture after delivery
  75. 82. Risk factors include: Instrumented deliveries. Primiparity. Pre-eclampsia. Multiple gestation. Vulvovaginal varicosities. Prolonged second stage. Clotting abnormalities. Birth Trauma
  76. 83. Repair of cervical laceration
  77. 84. <ul><li>Hematomas less than 3cm in diameter can be observed expectantly. </li></ul><ul><li>If larger, incision and evacuation of clot is necessary. </li></ul><ul><li>Irrigate and ligate bleeding vessels. </li></ul><ul><li>With diffuse oozing, perform layered closure to eliminate dead space. </li></ul><ul><li>Consider prophylactic antibiotics. </li></ul>Birth Trauma: Hematomas
  78. 85. Pelvic Hematoma
  79. 86. The 4 “Ts” Recalled “ THROMBIN” Check labs if suspicious.