Post Partum Hemorrhage

1. Post Partum Hemorrhage District I ACOG Medical Student Teaching Module 2010

2. Post Partum Hemorrhage - Definition • Commonly defined as…. SVD > 500cc blood loss C/S > 1000cc blood loss *PPH generally refers to GA >20wks

3. Other Definitions • Hematocrit Change – defined as change > 10% but not useful in acute setting • Need for Transfusion – variable practice • Hemodynamic stability • Timing – early or late • Symptomatic

4. Relevance • One of top five causes of maternal mortality anywhere • #1 cause maternal mortality worldwide • Developed countries 1/100 000 births compared to 1/1000 births in developing countries • Incidence 5% - 10% deliveries (depends on defn)

5. Physiologic Adaptations of Pregnancy •  plasma volume 40-50% •  RBC 20-30% *in severe PIH - hemoconcentration

6. Normal Mechanism of Hemostasis • ‘Living ligatures’ – Baskett 2000 • Intrinsic vasospasm • Local decidual hemostatic factors including tissue factor & type 1 plasminogen activator inhibitor •  clotting factors (except I and XI)

9. Blood Loss Estimation • All studies show gross underestimation of blood loss at delivery • Visual estimation especially unreliable for small and large amounts of blood loss • Prasertcheroensuk et al (2000) - 228 women in 3rd stage - >500cc : visual (5.7%) actual (27.63%) - >1000cc: visual (.44%) actual (3.51%) ***Incidence underestimated 90%

10. Primary, Early or Acute PPH • Delivery - < 24h PP • 90% PPH cases • Associated with more bleeding

11. Secondary or Late PPH • 24h – 12 weeks postpartum • Affects 1-3% of all deliveries • Common causes include: - infection - RPOC - Abnormal uterine involution

12. Etiology 4 T’s -Tone -Tissue -Trauma -Thrombin

13. Uterine Atony • 75-90% PPH • Mostly associated with 10 PPH • 6% after c/s • Risk factors after c/s incl multiples, Hispanic ethnicity, induced/augmented labor, macrosomia, and chorioamnionitis

14. Tissue • Retained placenta 10% PPH cases • 10% placenta’s have fundal implantation • Placenta accreta 0.005% of all deliveries • 90% of accreta’s have PPH and 50% of these have hyst

15. Trauma • 10 cause PPH in 20% cases • Injury to genital tract during delv OR 1.7 • 65% uterine inversions have PPH • 48% uterine inversions have bld transfusion

16. Thrombin • 1% cases of PPH • Known association with coagulation failure - abruption - PIH - sepsis - IUFD - incompatible blood - abortion

17. Risk Factors in PPH

18. Factors Associated With PPH • Retained Placenta (OR 3.5) • Failure to Progress 2nd Stage (OR 3.4) • Placenta Accreta (OR 3.3) • Lacerations (OR 2.4) • Instrumental Delivery (OR 2.3) • Large For GA Newborn (OR 1.9) • Hypertensive Disorders (OR 1.7) • Induction of Labor (OR 1.4) • Augmentation of Labor With Oxytocin (OR 1.4)

19. Factors Associated With PPH • DM – 30-35% compared to 5-10% • Inherited coagulopathies – most common is VWB (1-3% prevalence) - 70% have type 1 (↓ factor VIII, ↓ vW Ag, ↓ vW factor activity) - risk PPH 22% with vWD & 18% hemophilia

20. Additional Risk Factors • Age > 35y • Asian or Hispanic ethnicity • Obesity • Post dates > 42 wks • Previous PPH • Placenta Previa

21. Key Management Issues • Prevention • Early Recognition • Immediate Appropriate Intervention

22. Blood Loss Signs & Symptoms >2500cc blood loss – 50% mortality if not managed urgently & appropriately

23. Initial Management • ABC’s • Call for help • Mobilize team (staff, anesthesia, blood bank etc) • IV access • Fluid resuscitation • Examine patient including fundal massage, dx trauma/ inversion/ other etiologies, and fundal massage • Foley catheter • Blood work (CBC, coag profile, cross match) • Reverse coagulation abnormality

24. Uterotonic Medications • Oxytocin • Ergot • Hemabate • Misoprostol • Vasopressin

25. Drug Therapy For PPH

26. Surgical Management • Curettage • Embolization • Tamponade (Balloon, packing etc…) • Compression sutures • Vessel ligation • Hysterectomy

27. Tamponade • Bakri Balloon - Silicone balloon - 500cc capacity • Foley catheter with 30cc balloon • Sengstaken-Blakemore Balloon • Vaginal packing • Saline filled glove

28. B-Lynch Suture

29. Vessel Ligation

30. Vessel Ligation • Uterine - O’Leary Stitch - Chromic 0 passed through lateral aspect of lower segment as close to cervix as possible and then through broad ligament lateral to vessels • Ovarian - distal to cornua by passing suture through myometrium medial to vessels

31. Recombinant Activated Factor VIIa • Tx of bleeding disorders • Dose up to 120mcg/kg q2h until hemostasis • Promising but needs more studies • $10,000/mg • Risk thromboembolism

32. Step 1 – Initial Assessment Dx Etiology -explore uterus (tone/tissue) -explore genital tract (trauma) -review history (thrombin) -observe clots • Resuscitation • Large bore iv’s • O2 • Vitals • ±foley catheter Labs -CBC -coag profile -cross match Step 2 – Directed Therapy Tone -massage -compress -drugs Tissue -manual removal -curettage Trauma -correct inversion -repair laceration -identify rupture Thrombin -reverse anticoagulation -replace factors Step 3 – Intractable PPH Get Help -OB/Surgery -Anesthesia -Lab/Blood Bank -ICU Local Control -manual compression -±pack uterus -±vasopressin -±embolization BP and Coagulation -crystalloids -blood products Step 4 - Surgery Repair Lacerations Ligate Vessels -uterines -ovarian -internal iliac Hysterectomy Step 5 – Post Hysterectomy Bleeding Abdominal Packing Embolization

33. Secondary PPH • Generally less bleeding • Mostly related to infection or RPOC • No RCT’s • Abx/uterotonics as appropriate • Evacuation