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Post Partum Hemorrhage. District I ACOG Medical Student Teaching Module 2010. Post Partum Hemorrhage - Definition. Commonly defined as…. SVD > 500cc blood loss C/S > 1000cc blood loss *PPH generally refers to GA >20wks. Other Definitions.

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post partum hemorrhage

Post Partum Hemorrhage

District I ACOG Medical Student Teaching Module 2010

post partum hemorrhage definition
Post Partum Hemorrhage - Definition
  • Commonly defined as….

SVD > 500cc blood loss

C/S > 1000cc blood loss

*PPH generally refers to GA >20wks

other definitions
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
relevance
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)
physiologic adaptations of pregnancy
Physiologic Adaptations of Pregnancy
  •  plasma volume 40-50%
  •  RBC 20-30%

*in severe PIH - hemoconcentration

normal mechanism of hemostasis
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)
blood loss estimation
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%

primary early or acute pph
Primary, Early or Acute PPH
  • Delivery - < 24h PP
  • 90% PPH cases
  • Associated with more bleeding
secondary or late pph
Secondary or Late PPH
  • 24h – 12 weeks postpartum
  • Affects 1-3% of all deliveries
  • Common causes include:

- infection

- RPOC

- Abnormal uterine involution

etiology
Etiology

4 T’s

-Tone

-Tissue

-Trauma

-Thrombin

uterine atony
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
tissue
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
trauma
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
thrombin
Thrombin
  • 1% cases of PPH
  • Known association with coagulation failure

- abruption

- PIH

- sepsis

- IUFD

- incompatible blood

- abortion

factors associated with pph
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)
factors associated with pph1
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

additional risk factors
Additional Risk Factors
  • Age > 35y
  • Asian or Hispanic ethnicity
  • Obesity
  • Post dates > 42 wks
  • Previous PPH
  • Placenta Previa
key management issues
Key Management Issues
  • Prevention
  • Early Recognition
  • Immediate Appropriate Intervention
blood loss signs symptoms
Blood Loss Signs & Symptoms

>2500cc blood loss – 50% mortality if not managed urgently & appropriately

initial management
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
uterotonic medications
Uterotonic Medications
  • Oxytocin
  • Ergot
  • Hemabate
  • Misoprostol
  • Vasopressin
surgical management
Surgical Management
  • Curettage
  • Embolization
  • Tamponade (Balloon, packing etc…)
  • Compression sutures
  • Vessel ligation
  • Hysterectomy
tamponade
Tamponade
  • Bakri Balloon

- Silicone balloon - 500cc capacity

  • Foley catheter with 30cc balloon
  • Sengstaken-Blakemore Balloon
  • Vaginal packing
  • Saline filled glove
vessel ligation1
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

recombinant activated factor viia
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
slide32

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

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