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Postpartum Hemorrhage: What Does The Evidence Show?

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Postpartum Hemorrhage: What Does The Evidence Show? MAJ Katrina Walters 4 April 2011 * Pitocin can be given IM vs IV, gold standard Methergine/ Hemabate ... – PowerPoint PPT presentation

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Title: Postpartum Hemorrhage: What Does The Evidence Show?


1
Postpartum Hemorrhage What Does The Evidence
Show?
  • MAJ Katrina Walters
  • 4 April 2011

2
The Impact of PPH
  • Worldwide a woman dies every 4 minutes from PPH
  • Top 5 reasons for maternal morbidity
  • Affects 1 to 19 of deliveries
  • Incidence is increasing in high resource
    countries
  • (BMC Pregnancy Childbirth 2009 955.)

3
(No Transcript)
4
Complications of PPH
  • Anemia
  • PP Depression
  • (J Nutr 2003 DEC 133(12)4139)
  • Acute Renal Failure, Myocardial Infarction, ARDS,
    Shock
  • Transfusions/ Surgery
  • Sheehans Syndrome
  • Death

5
Outline
  • Definitions
  • Etiology/ Risk Factors
  • Prevention through Active Management
  • Initial Management
  • Advanced Techniques
  • Blood Product Utilization
  • Summary

6
Definitions (1 of 2)
  • Multiple and problematic
  • Traditional
  • gt 500ml for Vaginal Delivery
  • gt 1000ml EBL Cesarean section
  • Excess bleeding s/sx hypovolemia

Gabbe, CH 18
7
Definitions (2 of 2)
  • Drop in Hct of 10 after delivery
  • Hct not a clear indicator of acute status
  • Primary vs. Secondary
  • Early vs. Late
  • Severe PPH
  • Recognition may be hampered by occult bleeding

8
Etiology
  • Bleeding from Placental Implantation Site
  • Trauma to Genital Tract
  • Coagulation Defects

9
The 4 Ts of PPH
CAUSE INCIDENCE (APPROX)
TONE Atony 70
TRAUMA Lacerations, hematoma, inversion, rupture 20
TISSUE Retained placenta, invasive placenta 10
THROMBIN Coagulopathies 1
Am Fam Physician 2007 75875.
10
Bleeding from Placentation Site (Risk Factors)
  • Uterine Atony
  • Halogenated hydrocarbon GETA
  • Hypotension
  • Overdistended uterus
  • Exhausted myometrium
  • Prior Uterine atony
  • Retained Placental Tissue
  • Abnormal placentation
  • Succenturiate (Extra) Lobe

11
Trauma to Genital Tract (Risk Factors)
  • Episiotomy/ Lacerations
  • Instrumented Delivery
  • Compound Fetal Presentation
  • Surgical Delivery
  • Hematomas
  • Uterine Inversion
  • Uterine Rupture
  • Prior uterine scar
  • High parity
  • Hyperstimulation
  • Obstructed labor
  • Midforceps rotation
  • Intrauterine manipulation

12
Coagulation Defects (Risk Factors)
  • Abruption
  • Prolonged retention of dead fetus
  • Amniotic fluid embolism
  • Massive transfusions
  • Severe Pre-eclampsia/ Eclampsia
  • Congenital Coagulopathies
  • Anticoagulant Rx
  • Sepsis
  • Saline Induced Abortions
  • Placental Abruption

13
Other Risk Factors (1 of 2)
  • Previous PPH
  • 14.8 with 2nd Pregnancy
  • 21.7 with 3rd Pregnancy
  • 10.2 with 3rd if PPH in 1st but not 2nd
    pregnancy
  • (Med J Aust 2007 Oct 1 187(7)391)
  • Prolonged 3rd Stage

14
Other Risk Factors (2 of 2)
  • Small Maternal Blood Volume
  • Small Stature
  • Hypervolemic constricted states (Pre-eclampsia)
  • Obesity
  • Native Americans, Hispanics, Asians
  • Epidural Anesthesia
  • Nulliparity
  • Women with female genital mutilation
  • (Lancet 2006JUN3 367 (9525)1835)

15
Risk Factor Identification
  • Small proportion with RF develop PPH and many
    women without RF have PPH
  • Consider early Type and Screen/Cross for RF

16
Prevention through Active Management of Third
Stage (1 of 3)
  • SOR B
  • Shifting Definition/ Components
  • Uterotonics Early Cord Clamp Cord Traction
    (NNT 12)
  • (Cochrane Database Sys Rev 20107CD007412)
  • Uterotonics Cord Traction Fundal Massage

17
Prevention through Active Management of Third
Stage (2 of 3)
  • Prophylactic Pitocin (SOR A)
  • (Cochrane Database Sys Rev 2001 4
    CD001808)
  • Does timing matter?
  • (Cochrane Database Sys Rev 2010 8
    CD006173)
  • Are other uterotonics as effective? (SOR B)
    (Cochrane Database Sys Rev 2007 2CD005456.)
  • Cord Traction
  • (Am J Obstet Gynecol 1997 Oct177(4)770,
    Repro Health 2009 62)
  • Uterine Massage after Placenta Delivery (Cochrane
    Database Syst Rev 2008 Jul16 3CD006431)

18
Prevention through Active Management of Third
Stage (3 of 3)
  • Early Cord Clamping
  • (Pediatrics 2006 APR 117(4)e779)
  • Cord Drainage
  • (Cochrane Database Sys Rev 2005 4
    CD004665.)
  • Fundal Pressure vs. Cord Traction
  • (Cochrane Database Sys Rev 2007 4
    CD005462)

19
Other Prevention Stategies
  • Tranexamic Acid
  • (Cochrane Database Sys Rev 2010 JUL7 7
    CD007872)
  • Avoid Routine Episiotomy (SOR A)
  • (Cochrane Database Sys Rev
    19993CD000081)
  • Continuous Presence of Midwives
  • Xuesaitong
  • (Zhongguo Zhong Xi Yi Jie He Za Zhi 2002
    MAR 22(3)182 Chinese)

20
Initial Management of PPH (1 of 2)
  • Recognize PPH
  • Delay in initial care increases risk of severe
    PPH
  • (Obstet Gynecol 2011 JAN117(1)21)
  • Fundal Massage
  • Intravenous Access
  • Follow local protocols if available (SOR B) (BJOG
    2004 May 111495, BJOG 2010 1171278)

21
Initial Management of PPH (2 of 2)
  • Treat Uterine Atony since this is most common
    cause for PPH
  • Uterotonics (SOR C)
  • Pitocin
  • Ergot Alkaloids
  • Prostaglandins

22
Uterotonics
  • Pitocin
  • (Obstet Gynecol 2001 98386)
  • Methergine
  • Hemabate
  • (AM J Obstet Gynecol 1990 JAN162(1)205)
  • Misoprostol (SOR B)
  • Route?
  • (BJOG 2004112547)
  • Is it effective?
  • (Cochrane Database Syst Rev
    20071CD003249)
  • Does the order matter?

23
Pitocin
Dose/ Route Cost Mechanism Contra-Indications Onset Duration
10U IM 10-40U in 1L NS over 10min 85 Increased contractions by increasing intracellular Calcium 3-5 min IM IV Immediate 2-3 hours 1 hour
24
Methergine
Dose/ Route Cost Mechanism Contra-indications Onset Duration
0.2mg IM Q2-4 hours Oral 0.2mg 11 per ampule 1.60 per tab Uterine Smooth muscle contraction gt Vasoconstrict Hypertension Scleroderma, Raynauds IM- 2-5 min Oral- 5-10 min 3 hours
25
Hemabate
Dose/ Route Cost Mechanism Contra- Indications Onset Duration
0.25 mg IM Q15min to max dose of 2mg 49 per dose Prostaglandin affect on myometrium, also affects arterioles and bronchioles Asthma 2-5 min 2 hours
26
Cytotec
Dose/ Route Cost Mechanism Contra-Indications Onset Duration
200 1000 mcg Oral SL PR Vaginal 0.60 per tab Prostaglandin affects in myometrium SL gt Oral gt Vaginal / Rectal Vaginal/ Rectal gt SL/Oral 3-6 hours
27
Unresponsive to Uterotonics
  • Bimanual Uterine compression
  • HELP! (OB, Anesthesia, Nursing, OR)
  • 2nd Large Bore IV
  • Fluids Blood Products

Anderson JM, AFP 2007
28
Unresponsive to Uterotonics
  • Look for other causes! (SOR C)
  • Explore uterus for retained products
  • Inspect cervix and vagina
  • Incise and Evacuate Large Hematomas (SOR B)
  • (South Med J 1987 AUG80(8)991)
  • Consider Type and Cross
  • Place a Foley catheter to monitor Is/ Os
  • Labs for coagulopathy

29
Uterine Tamponade
  • Bakri Balloon
  • Foley, BT-Cath, Sengstaken-Blakemore Tube
  • Gauze Packing
  • (Obstet Gynecol Survey 2007 62(8) 540)

Jacobs AJ, Up to Date 2009
30
External Aortic Compression Device
  • Shorter time to bleeding stopped
  • Decreased units of blood transfused
  • Decreased need for additional uterotonics
  • No increased morbidity or mortality
  • (J Obstet Gynaecol Res 2009 JUN35(3)453)

31
Uterine Artery Embolization
  • Requires available facilities/ personnel
  • Hemodynamically Stable Patient
  • Temporizing measure en route to OR
  • Fertility Effects
  • (Obstet Gynecol Survey 2007 62(8) 540,
    Obstet Gynecol 2009MAY113(5)992)

32
Surgical Intervention (1 of 4)

Gabbe, Ch 18
33
Surgical Intervention (2 of 4)
Gabbe, Ch 18
34
Surgical Intervention (3 of 4)
35
Surgical Intervention (4 of 4)
36
Recombinant Activated Factor VII
  • Initiates coagulation at site of tissue injury
    via tissue factor
  • Used for massive hemorrhage
  • Observational reports of 80 success rate but
    only used when all other measures short of
    hysterectomy failed
  • (Obstet Gynecol 2007 1101270)
  • SOR C

37
Blood Product Utilization
  • Local protocols are helpful
  • Dont wait for lab abnormalities if actively
    bleeding!
  • Massive hemorrhage without replacement of
    coagulation factors (FFP) will result in
    coagulation abnormalities

38
Blood Product Utilization
Product Contents Volume Effect
Whole Blood 500ml ? Hct 3
PRBCs RBCs, WBCs, few plasma proteins 300ml ? Hct 3, less fever
Platelets Pooled concentrate 1 unit 6 pack 50ml ? PLT 5-10K
FFP Fibrinogen, ATIII, clotting factors, plasma 250ml ? fibrinogen 5-10mg/dl
Cryoprecipitate Fibrinogen, Factor VIII, XIII, vWF 40ml ? fibrinogen 5-10mg/dl
39
Blood Product Utilization
  • Active Bleeding and Hct lt 25 PRBCs
  • PLT lt 100K or massive transfusion Platelets
  • Fibrinogen lt 125 cryoprecipitate/ FFP
  • Massive bleeding or INR gt 1.5 Fresh frozen
    plasma
  • No consensus on ratio of RBCFFPPLT
  • (J Trauma 2007 62307, J Trauma 2006
    60S51)

40
Refusal of Blood Products
  • Jehovahs Witnesses 44-fold increased risk of
    death
  • (Am J Obstet Gynecol 2001 Oct185(4)893)
  • Intraoperative Blood Salvage and Autotransfusion
  • Optimize pre-delivery Hgb
  • Gluten as volume expander
  • Hyperbaric Oxygen

41
Summary
  • Active Management of Third Stage of Labor is
    imperative
  • Always be prepared for PPH, risk factors are not
    always present and prevention doesnt always work
  • Focus on the basics, dont forget fluid/ blood
    product replacement
  • Bakri Balloon and Uterine Artery Embolization may
    be temporizing measures available on the way to
    the OR
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