Obstetric emergency which can kill instantly !! - PPH presenting to ED, so what is the role of Emergency Dept ? The most basic presentation of Obstetric emergency and how to tackle it? Being an emergency physician, obstetrics is always challenging! Keep yourself updated with Obstetric emergency.
3. Definitions
Quantitative :
– >= 500ml for vaginal delivery
– >= 750ml for LSCS
Significant Obstetric Hemorrhage (UK)
– >= 1500ml
Clinical :
– Bleeding in excess of physiological reserve
capacity of woman, evidenced by Tachycardia &
Hypotension
4. Incidence
6% of all live births in the world (WHO)
Responsible for up to 4% of maternal deaths
Worldwide >1.4 Lac women die every year
= 1 death every 4 min !!!
Associated mortality : Death due to PPH occurs
within 2 hours if no active intervention taken, as
compared to APH – 12 hours, Obstructed Labour –
2 days, Infection – 6 days !!!!!
5. Types of PPH
Primary PPH :
o Bleeding during the 3rd
stage labour or within 24 hrs after
childbirth.
More common
Atonic 90%
Traumatic 6%
Mixed
Coagulopathies (Von Willebrand’s disease)
Miscellaneous : anti-coagulant therapy
6. Types of PPH
Secondary PPH : (Delayed/ Late)
– Excessive bleeding from birth canal between 24 hours and
6 weeks after birth.
Retained product of conception
Puerperial sepsis
o Subinvolution of placental bed
o Puerperial inversion of uterus
o Placental polyp
o Ca.Cervix
o Rupture of vulval hematoma
o Uterine AV malformation
o Chorionic epithelioma
7. Risk factors (RCOG Guidelines)
Pre Conception
– Age >40, not multiparous
– Asian ethnicity
– BMI > 35 kg/m2
During pregnancy
– Anaemia (<9g/dl)
– Known placenta previa
– Suspected / proven placental abruption
– Multiple pregnancy
– Pre-eclampsia/ Gestational HT
– Induction of labour
8. Risk factors (RCOG Guidelines)
At delivery
– Caeserean section (elective/ emergency)
– Operative vaginal delivery
– Prolonged labour (>12hours)
– Birth weight > 4kg
– Medio-lateral episiotomy
– Retained placenta
– Pyrexia in labour
9. Clinical features
Signs of shock depend on :
-Amount of bleeding
-Pre delivery hemoglobin levels
Hypotension, tachycardia, cold clammy extremities
Clinical picture can change so rapidly from initial reversible
stage to later irreversible stage that unless timely action is
taken maternal death occurs within a short time.
10. Clinical features
Abdominal Examination :
Atonic PPH: Uterus is flabby & soft, may be overdistended
with clots
Full bladder may obscure finding
Uterus is larger than expected, squeezing it leads to gush
of clotted blood P/V.
Traumatic PPH: Uterus is contracted
Mixed
11. Vaginal examination
Atony :
Bleeding starts few minutes after delivery of fetus
Dark red in colour
Trauma :
Bleeding starts immediately after delivery of fetus
Is bright red in colour
12. Assessment of blood loss
Clinical :
‘The Golden Hour’ is the time at which resuscitation must
begin to achieve max survival before Metabolic Acidosis
sets in.
Rule of 30 :
30% blood loss – SBP fall by 30% - HR to increase by
30/min – RR > 30/min – Hb/HCT to drop by 30% - Urine
output fall < 30ml/hour
13. Assessment of blood loss
Visual Methods :
BRASSS-V method
Soaked pads
Gravimetric method : weighing sponges before & after
Acid-Hematin method (not done routinely)
Measurement of Isotope Cr51 tagged erythrocytes (for
research purpose)
Plasma volume changes – radioactive tracer
16. Prophylaxis
Ante-natal
– Improvement of health status (Rx of anemia and
malnutrition)
– Early detection of risk factors and regular ANC f/up
– Encouragement of institutional delivery
– Blood grouping and Rh typing
– Women with morbid adherent placenta (accreta) : Plan
elective CS with senior Obstetrician
17. Prophylaxis
Intra-natal
– Judicious use of sedatives and anesthetic agents
– Vigilant labour monitoring
– Prompt intervention in Prolonged labour, Obstructed labour
and Uterine inertia
– Active management of 3rd
stage Labour
Post-natal
– Close observation in 4th
stage of labour
– Examination of palcenta and membranes
– Exploration of genital tract for trauma
18. Management of
3rd
stage bleeding
Control the fundus, massage and make it hard
Inj Methergin 0.2mg IV
NS with Oxytocin 20 Units
Arrange for blood transfusion
Catheterise bladder
Placenta
Not Separated
Manual removal under GA
Placenta
Separated
Express Placenta out by CCT
Traumatic to be tackled by exploartion of genital tract
and sutures
19. Manual removal of placenta
Vaginal exploration under GA / Procedural sedation
to evaluate uterine cavity to remove placenta manually,
20. FLUID RESUSCITATION
2006 Guidelines from British Committee for
Standards in Haematology summarises main
therapeutic goals for Mx of massive blood loss is to
maintain:
– Hb > 8g/dl
– Platelet count > 75000/Cu.mm
– PT < 1.5 x mean control
– aPTT < 1.5 x mean control
– Fibrinogen > 1.0 gm/L
21. Transfusion Strategies
Initial resuscitation by IV fluids
It worsens existing coagulopathy and enhances
fibrinolysis !!
Role of TEG (Thromboelastography) and ROTEM
(Rotational Thromboelastometry) :
– To examine clot formation and dissolution in whole blood &
identify reduction in clot strength in 5-10 min
– To predict need of massive transfusion with accuracy of
71%
22. FFP :Platelets :PRBC = 1 :1 :1
PRBC
– When blood loss exceeds > 30% of blood volume
– Post partum Hb to maintain > 8 gm/dl
– HCT can be normal/high in PPH as resulting plasma loss,
clinical evaluation is must
Platelet Transfusion
– May be required in Thrombocytopenia or paltelet
dysfunction
– Plt > 50,000 is usually adequate for Vaginal delivery, C-
section or epidural anaesthesia
– Prophylactic Platelet transfusion if <20,000 before vaginal
delivery or <50,000 before C-section
23. Fresh Frozen Plasma (FFP)
– Only to be used in massive hemorrhage or to replace
single inherited clotting factor deficiency (mostly factor V)
– FFP + Platelets to be used for multifactor deficiency
associated with severe bleeding and/or DIC
– Indication : aPTT & PT > 1.5 x of reference value,
Fibrinogen < 0.8 gm/L
– Each FFP unit is ~ 200ml, contains 0.4 gm Fibrinogen and
all clotting factors
– Therapeutic dose : 10-15 ml/kg body weight
– ABO compatible to be used
24. Role of Tranexemic Acid
• Role in Obstetrical hemorrhage is still under
evaluation.
• A French Study* reported that use of TXA
– Decreased median blood loss (173 vs. 221 ml)
– Decreased likelihood of stopping bleeding within 30 min
(63% vs. 46%)
– Less chances of progressing to severe PPH (27 vs. 37
women)
– In women undergoing Vaginal Delivery, similar results
found with C-Section also but used along with Oxytocin
28. Management – Uterotonic Rx
Oxytocin
– MoA : myometrial contraction through Oxytocin receptors
and voltage gated Ca++ channel
– Duration : 20 min
– Onset : 3-4 min
– Dose : 20 units in 500ml NS iv rapid infusion / 10 units im
– S/E : Uterine rupture, Hypotension, Water retention –
Hyponatremia, confusion, coma, convulsion, CCF, Death !!
– Strict I/O charting required
29. Ergot derivatives – Methergin
– MoA : Direct action on myometrium to contract
– Onset : 1.5 min (iv), 7 min (im), 10 min (oral)
– Duration : 3 hours
– Dose : 0.2 mg iv/ im
– If bleeding is not controlled, dose can be repeated after 2-
4 hours, but not more than total 4 dose to be given.
– S/E : N&V, Hypertension
– C/I : IHD, HT (Pre-eclampsia)
30. Prostaglandins (Life saving drug to arrest PPH)
PG E1 – Misoprostol
– 1ST
line PR, 2nd
line SL
– 200 mcg tab, max 1000 mcg
– S/E : Fever, Tachycardia
15 Methyl PG F2alpha – Carboprost
– 1st
line im, 2nd
line Intra-myometrial
– Dose : 0.25 mg, can be repeated every 15-90 min
– Max 8 doses can be given
– S/E : N&V&D, chills
– C/I : Asthma, Active cardiac, renal, liver disease
33. Secondary PPH
1st
and foremost USG
Principles
– Assess amount of blood loss and REPLACE
– To find out cause and rectify it
– Supportive therapy :
• Blood transfusion, if necessary
• Inj Methergin 0.2 mg iv / im
• Antibiotics
– Conservative therapy : admit and observe x 24 hours
34. Secondary PPH
Active treatment
– Explore the Uterus under GA
– Gentle Curettage (!!Perforation!!)
– Inj Methergin 0.2 mg iv/im
– Send curettings for HPE
– LAPAROTOMY
35. Thank you …
Ref :
Current progress in Obstetrics & Gynaecology
Modern Obstetrics by Ajit Virkud 2/e
Williams Obstetrics 24/e
Practical Guide to High-Risk Pregnancy and Delivery by Fernando Arias 3/e
Practical Obstetrics Problems by Ian Donald 6/e
Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7/e
D.C.DUTTA'S TEXTBOOK OF OBSTETRICS 6/e