4. Mortality from PPH
• Half of 500,000 maternal deaths globally
• 28 % of maternal deaths in developing countries
• Risk of death from PPH
1 in 1000 deliveries - developing countries
1 in 100,000 deliveries – developed countries
6. Incidence of PPH
PPH 5 – 17 % of all deliveries
> 500ml
Major PPH 1.3 – 2.5 % of all deliveries
> 1000 ml
ACOG 3.9 % of all deliveries
7. Definition of PPH
Primary PPH: 0 – 24 hours; Secondary PPH: 1 - 84 days
Blood loss > 500 ml at vaginal delivery
> 750 - 1000 ml at Cesarean
Severe PPH > 1000 ml loss at vaginal delivery
ACOG: - Fall in hematocrit 10%
- Need for PRBC transfusion
Rate of blood loss: > 150ml/min or sudden loss > 1.5 – 2 l
16. Risk factors for PPH
• Nulliparity • Advanced maternal age
• Obesity • PIH
• Large baby • PPH in previous delivery
• Prolonged labor • Augmented labor
• APH • Forceps delivery
• Multiple pregnancy • Use of tocolytics
• Cesarean delivery х Grand multiparity
65 % cases of PPH occur with no risk factors
17. PPH at Cesarean delivery: Risk Factors
• General anesthesia
• Chorio-Amnionitis
• Pre-eclampsia
• Protracted active phase of labor
• Second-stage arrest
• Classic uterine incision
Obstet Gynecol 1991 Jan;77(1):77-82
18. Risk factors for PPH: a case control study
comparing 666 cases with controls in 154311 deliveries
• Retained placenta (OR 3.5, 95% CI 2.1-5.8)
• Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)
• Placenta accreta (OR 3.3, 95% CI 1.7-6.4)
• Lacerations (OR 2.4, 95% CI 2.0-2.8)
• Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)
• Large for gestational age new born (eg, >4000 g) (OR 1.9, 95% CI 1.6-2.4)
• Hypertensive disorders (OR 1.7, 95% CI 1.2-2.1)
• Induction of labor (OR 1.4, 95% CI 1.1-1.7)
• Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7)
J Matern Fetal Neonatal Med. 2005;18(3):149
23. Oxytocin
• Storage: Between 2-8 *C, avoid freezing
• Adverse effects: anti-diuretic effect,
hypotension, arrhythmias
• Incompatible with noradrenaline, warfarin
• 10 – 40 IU / L of infusate
24. Ergometrine
• Storage: Refrigerate, protect from light, stable for 60-90
days, discoloration – discard
• Avoid : heart disease, hypertension, peripheral vascular
disease, hepatic or renal impairment; with antiretroviral
and macrolide antibiotics
• Adverse : Vomiting, nausea, HT, CVA
• Route: IM preferred, IV dilute in 5 ml NS
25. Carboprost – PGF2 alpha
• Caution : Asthma, cardiac disease, epilepsy, liver
disease
• Storage: Refrigerate
• Adverse: Vomiting, diarrhea, flushing,
• Dosage: 250 mcg IM, repeat every 15 - 90
minutes, maximum 8 doses = 2 mg.
• IV injection - bronchospasm, hypertension,
vomiting, and anaphylaxis
26. Misoprostol
• PGE1 analogue
• Adverse effects – vomiting, shivering at higher
doses. No broncho-constriction.
• Storage: Stable at or below 25*C
• Route: Oral, buccal, rectal, vaginal
• Rapid onset of action lasting 4-6 h
27. Misoprostol as an adjunct to standard
uterotonics for treatment of PPH
Lancet. 2010;375(9728):1808
1422 women with atonic PPH treated with routine
uterotonic agents randomized to
600 mcg misoprostol sublingually
Placebo sublingually
Found no difference in blood loss > 500 ml in next 1
hour
28. Treatment of PPH with sublingual misoprostol versus
oxytocin in women receiving prophylactic oxytocin
Lancet. 2010;375(9710):217
31055 women delivered with prophylactic oxytocin in III stage,
809 (3%) who had atonic PPH were randomized to
Misoprostol 800mcg sl
Oxytocin 40 u infusion in 15 minutes
Similar outcomes in both groups
90% women had bleeding controlled in 20 minutes;
30% women had additional blood loss of > 300 ml after Rx
29. After initial treatment
• Evaluate for
retained placental fragment
uterine inversion
lacerations
coagulopathy
• Check urine output,
response to resuscitation, time
volume of blood lost
30. Volume replacement
• Crystalloid: Ringer Lactate, Hartmann, NS
RL similar to plasma
only 20% retained in circulation
Dextrose: only 10% retained, interferes with X matching
NS avoid in pre-eclamptic patient
• Blood volume changes last for 40 minutes only
• Infuse 3 L for each 1 L of estimated blood loss
• Target 90mm systolic pressure, UOP 30ml/hr
• Give colloids after 2 L of crystalloids given
31. Colloids
• Gelatin polymers - Hemaccel
rapid urinary excretion
anaphylaxis
• Hydroxyethyl starch – Hetastarch, Pentastarch
increases plasma volume by 70 – 230%
dose 20 ml/kg = 1 to 1.5 L
no anaphylactic reactions
well tolerated
lasts for 4 hours in circulation
32. Blood transfusion
• No universally accepted guidelines for trigger
• PRBC x 2 if no improvement after 2-3 L of crystalloids or if
ongoing blood loss likely
• Warm carefully. > 40 *C – severe transfusion reactions
• Admin 1 FFP for every 1-2 units of PRBC, at 12-15ml/kg
• No drugs / injections with blood
34. Massive hemorrhage
• Defined as > 10 units of BT required / 24 h
• Likely when persistent SBP < 90,
Loss more than 1500ml
• Cryoprecipitate if no response to FFP or Fibrogen
level < 100
• Expect platelet count < 50,000 after > 2 L blood loss.
Platelets to maintain counts 25-50,000, 1:1
35. Secondary interventions
• Repeated doses of Carboprost max 8 doses
• Intramyometrial Carboprost - off label
• Carboprost uterine irrigation
• Rectal Misoprostol - high doses >800mcg
• Intra-uterine Misoprostol
• Tamponade – Sengstaken tube,
• Uterine Packing
36. Indications for laparotomy
• Unabated blood loss
• Atony unresponsive to Rx
• Vital signs out of proportion to blood loss
• Vaginal laceration extending above fornix
37.
38.
39.
40.
41.
42.
43.
44.
45. Summary
• Symptoms and vital signs of blood loss are more important
than visual assessment of blood loss
• Team approach with protocols and regular drills
• Prompt, sequential use of utero-tonic agents and
replacement of volume are mainstay of Rx
• Low Fibrinogen, abn PT, tachycardia and abnormalities of
placental implantation and detectable troponin are predictors
of increased morbidity
