Medical Management of Postpartum Haemorrhage

MEDICAL MANAGEMENT OF POSTPARTUM HAEMORRHAGE

INTRODUCTION

Primary PPH is the most common form of major obstetrichaemorrhage.

It is the leading cause of maternal morbidity and mortality.

This is one of the major cause of maternal death.

According to Indian guidelines, third direct cause of maternal death.

Incidence (0.5 to 18%-50 countries data)

•4-6% of all pregnancies.

•3.9% -vaginal deliveries.

•6.4%- cesarean deliveries.

-Recurrence risk : 23-25%.

Primary PPH

Loss of 500ml or more of blood from genital tract within 24 hours of birth of baby. (RCOG)

It is of 2 types-minor & major

Minor PPH-500-1000ml of blood loss

Major PPH- >1000ml blood loss. It is of 2 types-Moderate & Severe PPH

Moderate PPH- 1000-2000ml blood loss

Severe PPH- >2000ml blood loss

Drop in hematocrit of 10%

Any amount of blood loss causing hemodynamic instability

A bloodloss of more than 40% of total blood volume (approx 2800 ml) is generally regarded as ‘life-threatening’

Secondary PPH

Abnormal or excessive bleeding from birth canal between 24 hours and 12 weeks postnatally.

CAUSES OF PPH

Primary (< 24 hrs) Secondary ( >24hrs)

Tone - Uterine infection
Trauma - Retained placental fragments
Tissue
Thrombin

PREVENTION OF PPH

Active management of third stage of labour

Itlowers maternal blood loss and reduces the risk of PPH.

Steps of active management of third stage of labour:

1.Administer prophylactic oxytocics: Palpate the abdomen to rule out the presence of an additional baby(s) and give oxytocin 10 units intramuscularly(within 1 minute of birth of baby). Prophylactic oxytocics reduce the risk of PPH by about 60%.

For women without risk factors for PPH delivering vaginally, oxytocin (5 iu or 10 iu by intramuscularinjection).
For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) should be usedto encourage contraction of the uterus and to decrease blood loss.

2. Delayed clamping of the cord is recommended if fetus is healthy. Clamp cord early when indicated.

3.Deliver the placenta by controlled cord traction

Do not wait for signs of placental separation. Deliver by controlled cord traction. If the placenta does not descend during 30-40 sec of controlled cord traction ( It indicates no signs of placental separation), do not continue to pull on the cord

With the next contraction, repeat controlled cord traction with counter traction.

“Never pull on the cord without pushing the uterus up with the other hand”

3.Massage the uterus:.

Repeat the uterine massage every 15 min for the first two hours. Ensure that the uterus remains hard after you stop uterine massage.

Risk factors for PPH:

DETERMINE THE AMOUNT OF BLOOD LOSS:

Visual assessment is inaccurate, hence measure the amount of blood loss with pre weighed sponges or pads

Emergency measures should be initiated if more than 1/3rd of women’s blood volume (blood volume=body weight x 80) is lost.
“Rule of 30”-indicates 30% loss in blood volume and is in moderate shock leading to severe shock and the need for acute management of PPH. Fall in systolic BP by 30mmHg, rise in heart rate by 30 beats/min, rise in respiratory rate by 30breaths/min, drop in hemoglobin or hematocrit by 30%, urine output <30ml/hr.

30 ml

60 ml

350 ml

500 ml

1000 ml

1500 ml

Best method to assess blood loss- Blood collection drape

MANAGEMENT OF MINOR PPH:

Primary PPH involving an estimated blood loss of 500–1000 ml (and in the absence of clinical signs ofshock)

Alert the nurse in charge

Alert the obstetric and anaesthetic staff.

Intravenous access (14-gauge cannula x 1)

Consider venepuncture (20 ml) for:
- group and screen
- full blood count
- coagulation screen including fibrinogen

Commence crystalloid infusion

Monitor pulse and blood pressure every 15 minutes.

MANAGEMENT OF MAJOR PPH:

If a woman with primary PPH is continuing to bleed after an estimated blood loss of 1000 ml (or hasclinical signs of shock or tachycardia associated with a smaller estimated loss),

Full protocol of measures to achieve resuscitation and haemostasis.

MANAGEMENT:

1)COMMUNICATION

2)RESUSCITATION

3)MONITORING & INVESTIGATIONS

4)ARRESTING OF BLEEDING

These components must be initiated and progressed simultaneously for optimal patient care.

Make initial assessment and start basic treatment

Call for help (integrated team approach)
Call the senior sister.
Call senior obstetrician .
Call senior anaesthesiologist.
Alert the blood transfusion laboratory.
Call assistants for delivery of specimens
Alert one member of team to record blood and blood products, fluids, drugs and vital signs

-COMMUNICATION:

Communication and Counselling the patient & relatives .

- RESUSCITATION:

Assess airway, breathing and circulation (ABC)
Connect pulse oximeter , irrespective of saturation provide supplementary oxygen (10-15 litres by face mask or nasal cannula)
If she is unconscious, call the anaesthetist to intubate.
Monitor PR,BP, SPO2 ,ECG ,Automated BP recording continuosly.
Obtain two intravenous lines [IV Cannula14guage(Red colour) or 16 guage (grey colour)] and draw blood (20ml) for laboratory tests

Complete blood count

Coagulation screen (Platelets, PT, aPTT & Fibrinogen)

Blood group - type and cross matching (4 units)

RFT, LFT & Electrolytes for baseline

Start fluid replacement with intravenous crystalloid fluid ( 3-4 ml of fluid for every 1 ml of blood loss)
Catheterize bladder, monitor fluid intake and urinary output.
Assess need for blood transfusion
Patient should lie flatand she should be kept warm.
Get the blood as soon as possible.
Infuse 3.5litreswarm crystalloid (2 lt RL), and/or colloid(1-2lt) irrespective of blood loss),be given before the blood comes.
If blood is not available, start colloid as soon as possible.
“ BLOOD SHOULD BE STARTED AS SOON AS POSSIBLE AND AS EARLY AS POSSIBLE”
Start blood, but dont use blood filter.
Normal IV set should be used.

Fluid therapy and blood product transfusion:
Crystalloid: Up to 2 litres Hartmann’s solution
Colloid : Up to 1–2 litres colloid until blood arrives
Blood: Crossmatched, If crossmatched blood is still unavailable, give

Uncrossmatchedgroup-specific blood or give ‘O RhD

negative’ blood

Fresh frozen plasma: 4 units for every 6 units of red cells or prothrombin

time/activatedpartial thromboplastin time > 1.5 x normal

(12–15 ml/kg or total 1litres)

Platelets concentrates: If PLT count < 50 x 109
Cryoprecipitate: If fibrinogen < 1 g/l

When the blood loss reaches about 4.5 litres (80% of blood volume), up to 1 litre of fresh frozen plasma (FFP) and 10units of cryoprecipitate (two packs) may be given empirically in the face of relentless bleeding,while awaitingthe results of coagulation studies

Threapeutic goal in the management of massive blood loss:

Hb > 8g/dl

Platelet > 75,000/mm3

APTT< 1 1/2 times the normal.

Fibrinogen>1g/lt

Recombinant factor VIIa therapy should be based on the results of coagulation.If needed Factor VIIa can be given,90ug/kg body weight. Should be repeated if there is no clinical response within 15-30 min.

Maximum of two doses can be given.

-It is used only in life threatening PPH, Only as an adjuvant to standard treatment.

rFVIIa will not work if thereis no fibrinogen and effectiveness may also be suboptimal with severe thrombocytopenia. Hence before giving Factor VIIa we have to make sure that fibrinogen> 1g/l Platelets > 20,000 /mm3.

MONITORING AND INVESTIGATIONS:

Continuous PR,BP, SPO2, ECG monitoring
Temperature every 15 min
Catheterise the bladder ,to monitor the urine output.
Arterial line should be considered.
Consider transfer to intensive therapy unit once the bleeding is controlled or monitoring at highdependency unit on delivery suite, if appropriate.
Use the MEOWS chart
Document the fluid balance, blood, blood products and procedures

Anaesthesia management:

Regional anaesthesia – relative contraindication due to cardiovascular instability

The blockage ofthe sympathetic system can potentially lead to worsening hypotension due to haemorrhage.If cardiovascular stability is achieved and there is no evidence of coagulation failure, regional anaesthesia can be used.

Continuousepidural block is preferred over spinal, as it allows better blood pressure control and for prolonged surgery.When there is continuing bleeding and the cardiovascular stability is compromised, general anaesthesia ismore appropriate.Rapid sequence induction is the gold standard to reduce the risk of aspiration.

ARREST OF BLEEDING:

Causes :Tone, Tissue ,Trauma, Thrombin.

Most common cause is uterine atony.
Exclude traumatic cause, by clinical examination.
Examine the placenta for completeness.
Explore the genital tract, for any vaginal /cervical laceration (or) haematoma.
Broad ligament haematoma and rupture uterus should be excluded.
Rule out extragenital bleeding (for example, subcapsular liver rupture)and uterine inversion.

Bimanual uterine compression and massaging the uterus to stimulate the uterine contractions. Ensure bladder is empty

Syntocinon 5 units by slow intravenous injection (may have repeat dose)

Methyl ergometrine 0.2mg slow IVor IM if she is normotensive.

Syntocinon infusion 40U oxytocin in 500ml of fluid and give it at the rate of 125ml/hr.

Carboprost 0.25 mg IM every 15 min for maximum 8 doses,provided that she is not asthmatic.

Direct intramyometrial injection of 0.5mg carboprost , can be given.

Misoprostol 1000 microgm per rectally

If medical method fails, initiate surgical haemostasis.Intrauterine Balloon tamponade is an appropriate first line surgical intervention for atonic PPH.

balloon tamponade
haemostatic brace suturing (such as using procedures described by B-Lynch or modifiedcompression sutures)
bilateral ligation of uterine arteries
bilateral ligation of internal iliac (hypogastric) arteries
selective arterial embolisation.

Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterinerupture).

A second consultant clinician should be involved in the decision for hysterectomy

A non-pneumatic antishock garment may be useful inwhere women with PPH require transfer from the peripheral centre to a tertiary care hospital.

ALGORITHM FOR MANAGEMENT OF PPH- “HAEMO-STAISIS”

GENERAL MEDICAL MANAGEMENT- ‘HAEMO’

H / Ask for Help
A / Assess (vital parameters, blood loss) and resuscitate
E / Establish etiology, ecbolics, ensure availability of blood
-Etiology: 4Ts- Tone, Tissue, Trauma, Thrombin
-Ecbolics (syntometrine, ergometrine, bolus syntocinon
-Ensure availability of blood and blood products
M / Massage the uterus
O / Oxytocin infusion, prostaglandins (intravenous,intramuscular,intramyometrial, rectal)

SPECIFIC SURGICAL MANAGEMENT- ‘STASIS’

S / Shift to operating theatre
- Bimanual compression
- Anti shock garment, especially if transfer is required
T / Tissue and trauma to be excluded and proceed to Tamponade balloon, uterine packing
A / Apply compression sutures
S / Systematic pelvic devascularisation (uterine, ovarian, quadruple, internal iliac)
I / Interventional radiology ,Uterine artery embolization
S / Subtotal or Total abdominal hysterectomy
Management of Atonic PPH:
Stimulate uterine contractions by uterine massage
Oxytocics
Oxytocics / Dose and route / Maintenance
Dose / Max dose / Frequency / Side effects / Contra
indications
Oxytocin / IV Infusion 10-40U in 500ml crystalloid at 60 drops/min
(125ml/hr) / IV Infusion 10U/500ml at 40 drops per min
(max.100U) / Not more than 3 litres / Hypotension,
Water intoxication / None
Methyl Ergometrine / 0.2 mg IM/ Slow IV / 0.2 mg after 15min
(max.1gm) / 5 doses / 4th hourly / Nausea, vomiting, hypertension / Hypertension,
Heart disease,
Rh negative,
Severe anemia
15 Methyl PGF 2α / 250 µg / 250µg after 15 min
(max.2 mg) / 8 doses / 15 min / Nausea, vomiting, diarrohea, pyrexia, bronchoconstriction / Asthma, heart disease
Misoprostol / 1000 µg, rectal or
600 µg sublingual / Shivering, fever, tachycardia, / None

BIMANUAL UTERINE COMPRESSION:

Is indicated when uterine massage is not successful in arresting bleeding.
Wear sterile gloves, insert a hand into the vagina and remove any blood clots from the lower part of the uterus or cervix.
Keep the fist into the anterior fornix and apply pressure against the anterior wall of the uterus .
With the other hand, try to antevert the uterus to compress the uterine vessels.
Maintain compression until bleeding is controlled and the uterus contracts.

Internal Bimanual compression of the uterus

COMPRESSION OF AORTA:

Apply downward pressure with a closed fist over the abdominal aorta directly through the abdominal wall.
The point of compression is just above the umbilicus and slightly to the left.
Aortic pulsations can be felt easily through the anterior abdominal wall in the immediate postpartum period.
With the other hand, palpate the femoral pulse to check the adequacy of compression.
If the pulse is palpable during compression, the pressure exerted by the fist is inadequate.
If the femoral pulse is not palpable, the pressure exerted is adequate.
Maintain compression until bleeding is controlled.

Uncontrolled bleeding even after 30 min of oxytocics (oxytocin, methergin, PGF2α and Misoprostol) and uterine compression:-maintain intravenous oxytocin infusion and consider uterine tamponade.

UTERINE TAMPONADE

Can use Condom catheter or Foley’s catheter or Sengstaken Blakemore catheter
Rusch urological balloon or Bakri balloon can also be used if available
Tamponade Test- The concept of this test is to affirm its place as first line of ‘surgical management’.

Positive test-control of PPH following inflation of balloon (indicates that laparotomy is not required)

Negative test-continued PPH following inflation of balloon (indication to proceed with laparotomy)

However, there is no clear evidence how long the tamponade should be left in place. But, in most cases,4-6 hours of tamponade is adequate to achieve hemostasis.

Condous et al study showed that tamponade test had a positive result of >87% for successful management of PPH.It should be removed during day time in the presenc of senior staff. Balloon should be deflated but left in place to ensure that bleeding donotreccur.

Condom tamponade

Catheterise the bladder prior to the procedure
Under aseptic precautions a size 16 sterile rubber catheter is inserted into sterile condom(dipped in cidex for 20minutes and wash with saline) and tied near the mouth of the condom by a silk thread, inner end of the catheter remaining within the condom
Cervical lips held with sponge holder
Condom tied over the catheter is introduced into the uterine cavity. The outer end of the catheter is connected with a saline set and saline is kept 60 -70 cms above the level of abdomen and the condom is inflated
Inflate the condom with 250-500 ml of Normal saline
Pack the vagina with gauze

Removal of the balloon

After6-8 hours, if the uterine fundus remains at the same level and there is no active bleeding through the cervix or lumen of the catheter, it is safe to remove the balloon provided the woman is stable and adequate blood is replaced.
Deflate the balloon slowly, but do not remove it for 30min.
If there is no bleeding after 30 min & remove the balloon catheter.
If bleeding starts when the balloon is deflated, re-inflate the balloon and prepare for surgical line of management.

Foley’s catheter

A balloon of 30 ml capacity is effective in controlling PPH. But the shape of the balloon may not correspond to the elongated uterine cavity. Hence it is not suitable for large post partum cavities.
Additional Foley catheters can be inserted if necessary to control postpartum hemorrhage resulting from atony , may be useful in cases where cervical lacerations have been repaired and if bleeding persists.
Not recommended for PPH

Bakri balloon

Indications:

The Bakri Postpartum Balloon catheter is intended to provide temporary control or reduction of postpartum uterine bleeding when conservative management is warranted.

Contraindications:

-Arterial bleeding requiring surgical exploration or angiographic embolization

-Cases indicating hysterectomy

-Pregnancy

-Cervical cancer

-Purulent infections of the vagina, cervix or uterus

-Untreated uterine anomaly

-Disseminated intravascular coagulation

-A surgical site that would prohibit the device from effectively controlling bleeding

Insertion:

Vaginal Delivery: Transvaginal Placement

Rule out if the uterus is clear of any retained placental fragments, arterial bleeding or lacerations.

Determine approximate uterine volume by ultrasound or direct examination.

Under ultrasound guidance, insert the balloon portion of the catheter into the uterus, making certain that the entire balloon is inserted past the cervical canal and internal ostium.

Note: Avoid excessive force when inserting the balloon into the uterus.

If not already indwelling, place a Foley catheter in patient bladder to collect and monitor urine output.

To ensure maintenance of correct placement and maximize tamponade effect, the vaginal canal may be packed with iodine- or antibiotic-soaked vaginal gauze at this time.

Cesarean Delivery: Transabdominal Placement

Rule out if the uterus is clear of any retained placental fragments, arterial bleeding or lacerations.

Determine uterine volume by intraoperative direct examination or postoperative ultrasound examination.

From above (via access of the cesarean incision), pass the tamponade balloon, inflation port first, through the uterus and cervix.

Have an assistant pull the shaft of the balloon through the vaginal canal, until the deflated balloon base comes in contact with the internal cervical ostium.

Close the incision per normal procedure, taking care to avoid puncturing the balloon while suturing.

If not already indwelling, place a Foley catheter in patient bladder to collect and monitor urine output.

NOTE: Inflate the balloon after the hysterotomy incision is closed to avoid balloon puncture.

Inflate the balloon with 500ml sterile liquid

Patient monitoring:

Once balloon is placed and inflated, connect the drainage port to a fluid collection bag to monitor hemostasis.

Patient monitoring should include,

Blood pressure, pulse, urine output, cramping, pallor and active bleeding.

Signs of deteriorating or unimproving conditions should indicate more aggressive treatment and management of patient uterine bleeding.

Balloon removal:

Maximum indwell time is 24 hours. Balloon may be removed sooner upon physician determination of hemostasis or the need to apply more aggressive treatment.

Sengstaken-Blakemore catheter (after cutting the distal tube to facilitate insertion and retention in the uterine cavity)

It is predominantly used for tamponade of esophageal varices & introduction of contrast media
Hold the balloon catheter with sponge holding forceps and insert it into the uterine cavity
Fill the balloon with warm sterile water or saline until it becomes visible in the cervical canal.When the pressure exceeds that of patient’s BP , no additional fluid needs to be added and bleeding should stop.
If there is no bleeding through the cervix or through the drainage channel of the balloon catheter, the Tamponade Test result is pronounced successful & no further fluid is added.
If the bleeding does not stop, result is unsuccessful and laparotomy is indicated.