post partum haemorrhage n.
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Post-Partum Haemorrhage
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  1. Post-Partum Haemorrhage Student Conference – Sept 5/14 Hannah Oately and Kimberly Reiter

  2. Objectives: • 10540 - Identify and assess the risk factors for postpartum hemorrhage. • 10541 - Formulate a differential diagnosis of postpartum hemorrhage. • 10542 - Propose immediate management of the patient with postpartumhemorrhage including: inspection for lacerations, use of uterinecontractile agents, management of volume loss and managementof coagulopathy.

  3. Case Example: • 29 y.o. G5P4 woman at 39 weeks GA with pre-eclampsiadelivers vaginally • Her prenatal course has been uncomplicated, except for asymptomatic bacteriuria caused by E. coli in the 1st trimester treated with oral cephalexin • She denies a FHx of bleeding diathesis • After the placenta is delivered, there is appreciable vaginal bleeding of ~ 1 L

  4. What is PPH? • Defined as blood loss of >500 mL following vaginal delivery or >1000 mL following cesarean section • Some women (anemia, cardiac hx, preeclampsia) become hemodynamically unstable with less blood loss • 2 TYPES OF PPH: • Primary PPH: within 24 hours of delivery • Secondary PPH: 24 hours after delivery

  5. (Not so) fun facts… • Estimate blood flow to uterus at term is 500-800ml/minute shock occurs quickly • Blood loss is frequently underestimated • Leading cause of maternal mortality globally • ¼ of maternal deaths (>140,000 annually) • American college of Obstetricians & Gynecologists, 06

  6. Risk Factors: • Etiology: 4 T’s: • Tone  most common (75-80%) • Trauma • Thrombin • Tissue

  7. Labour & Delivery Risk Factors: • Labour • Prolonged • Precipitous (<3 hrs) • Induced • Augmented with oxytocin • Failure to progress during the 2nd stage • Meds inhibiting contractions - halothane anaesthesia, MgSO4 (treatment of pre-eclampsia) • Type of delivery: forceps, vacuum, C-section, breech • Possibility of Lacerations (perineal, vaginal, cervical, uterine) • Incisions – i.e. episiotomy • Possibility of uterus rupture or inversion • Shoulder dystocia • Retained products of conception (POC)

  8. Maternal & FetalRisk Factors: • Infection (chorioamnionitis) • Cephalopelvic disproportion & labour induction • Uterine over-distension • Multi-fetal gestation • Fetalmacrosomia • Polyhydramnios • Fetal abnormality (hydrocephalus) • Abnormal placentation • Placenta accreta • Placental abruption • Placental previa • Bi-lobed • Past medical hx • Previous PPH • Hypertensive disorders • Obesity (espc BMI > 40) • Bleeding disorders (vWD, low platelets)

  9. In short…. • A large number of women have no risk factors • PPH usually has a single cause, but more than one cause is also possible, most likely following a prolonged labour that ultimately ends in an operative vaginal delivery

  10. Back to our Case Example… • 29 y.o. G5P4 woman at 39 weeks GA with pre-eclampsiadelivers vaginally • Her prenatal course has been uncomplicated, except for asymptomatic bacteriuria caused by E. coli in the 1st trimester treated with oral cephalexin • She denies a FHx of bleeding diathesis • After the placenta is delivered, there is appreciable vaginal bleeding of ~ 1 L

  11. Differential Diagnosis: • Tone*** (most common cause) • Uterine atony • Boggy, enlarged, soft uterus • Tissue • Retained clots or placental products • Trauma • Laceration (cervix, vagina, uterus) • Hematoma (injured blood vessel) • Uterus rupture • Abdo pain, popping sensation intra-abdominally • Inversion • Accompanied by vasovagal response • Placenta attached to uterus fundus • Thrombin • DIC, Hemophilia, vWD,ITP, TTP, ASA use

  12. Things to consider… • Placenta delivered and no missing parts? • Amount of blood loss and how it’s progressed? Sx of hypovolemia? • Duration of 3rd stage? Distended uterus? • Push started before cervical dilation, fast dilation? • Personal, family hx of bleeding disorder? • Transfusion history and if any reactions? • Vaginal penetration since delivery

  13. Immediate Management: • General Management: • ABCs + vitals • 2 large bore IVs and crystalloids • Blood work: • CBC, INR, aPTT, fibrinogen, cross and type • Physical exam • Volume status • Basic resp, CVD and abdominal exam • Speculum • Use retraction so can examine behind cervix, deep sulcus • Suction out blood, clots, tissue • Bimanual • Feel for tone and if soft/enlarged/boggy  massage uterus • Examine placenta • Transfusion • 4 units PRBC based on blood work, then add cyro, FFP, platelets • Jehovah’s Witnesses

  14. Immediate Management: • Specific Management based on ddx: • Uterine atony • Uterontonic agents • Lacerations: repair with interrupted or running sutures • Retained POC • Carefully examine placenta and uterus manually if cervix open • Manually extract what you can (D & C if not) • Hematoma: • Large drop in HCT with/without low back or rectal pain • Need US/CT for diagnosis of retroperitoneal • If tense/expanding and HCT keeps falling-ligate vessel • Accreta • Consider if no retained POC, bleeding despite above treatment • MRI • Bedside ultrasound (to r/o rupture, retained POC, hematoma)

  15. Management Principles: • Medical Management: uterotonic agents First line: • Oxytocin 20 U/L NS or RL IV continuous infusion • In addition can give 10 U IMM after delivery of the placenta Second line: • Ergotrate 0.25 mg IM q 5 min up to 1.25 mg; can be given as IV bolus of 0.125 mg ( • HTN is a relative contraindication* • Hemabate 0.25mg IM q 15 min to max 2 mg (major prostaglandin s/e and contraindicated in CV, pulmonary, renal and hepatic dysfunction) • Asthma is a relative contraindication* • Misoprostol 600-800 mcg • Carbetocin 100 mcg IV continuous infusion

  16. Management Principles: • Local Control: Uterine Tamponade • For intractable bleeding unresponsive to uterotonics, consider tamponade • Bi-manual compression: elevate the uterus and massage through the patient’s abdomen • Uterine packing – mesh with antibiotic treatment • Bakri balloon – may slow haemorrhage enough to allow time for correction of coagulopathy or for preparation of an OR • Foley with 60-80 cc • Hydrostatic condom catheter • Esophageal catheter • Urologic balloon

  17. Management Principles: • Surgical Management: • D&C • Fix POC • Beware of vigorous scraping which can lead to Asherman’s syndrome • Embolization • Continuous bleeding or hematoma • Uterine artery or internal iliac artery by interventional radiologist • Laparotomy with bilateral ligation of uterine artery, ovarian artery or hypogastric artery • Hysterectomy last option with angiographic embolization if post-hysterectomy bleeding • B-Lynch and Cho sutures • Specific uterine management for uterine inversion or rupture

  18. Follow-up! • Bleeding due to retained tissue or trauma may present more insidiously • After delivery regularly monitor vitals, blood loss, uterine size/tone • Monitor for fever, wbc, foul smelling discharge, dysuria • Endometritis (especially if C/S)

  19. References: • Toronto Notes • Medscape • Uptodate • Williams Obstetrics and Gynecology (6ed) • Case Files

  20. Questions?