Dr.

KAVITHA ERINJIPPURATH
 DEFINITION OF PPH

1. BASED ON BLOOD LOSS

 TRADITIONAL- Bld loss > 500 ml after vag birth,>

1000 ml after LSCS

 SEVERE PPH- Bld loss > 1000 ml

 VERY SEVERE PPH (Major)- Bld loss >2500 ml

 
2. BASED ON HAEMODYNAMIC COMPROMISE
Tachycardia, hypotension
Healthy preg show signs of shock if loss > 1L

3. HAEMATOCRIT
10% fall in PCV levels PP.

4. BLOOD TRANSFUSION
BT required after massive bld loss > 1L or PP Hb
>80 g/L
 INCIDENCE

Incidence in AUS & NZ is 5-15%

Most common cause of Obstetric haemorrhage

Leading cause of maternal mortality and morbidity

 COMMON CAUSES OF
PPH

 TONE (70%)  TRAUMA (20%)

Laceration of Cx/ vagina/

perineum
Ext lacerations at LSCS
Uterine rupture/
inversion
Nongenital tract trauma
 COMMON CAUSES
Contd..

 Tissue (10%)  Thrombin (1%)

Retained products/ Coagulation abnormalities

placenta/ membranes/
clots

Abnormal placenta
 RISKS FACTORS FOR
PPH

1. ANTENATAL

 High maternal age

 Asian ethnicity
 Obesity, BMI> 35
 Grand multi
 Uterine abnormalities- fibroids, congenital
 Maternal blood dyscracias
 Overdistended uterus- MP, polyhydrramnios, big baby
 IUD
 Prev PPH/ Retained placenta
 
2. INTRAPARTUM

 Precipitate/ prolonged labour

 Chorioamnionitis
 Amniotic fluid embolism, DIC
 Uterine inversion
 Genital tract trauma
 Assisted vag delivery
 LSCS, Em> Elective
 
3. POSTPARTUM

 Retained products
 AFE/ DIC
 Drug induced hypotonia (anesthesia, Mg)
 Bladder distention preventing uterine contraction
 RESUSCITATION,
ASSESSMENT AND
TREATMENT

 MDT- O&G, Anesthetics, Haematology, Nursing,
Midwifery

 AIM- restore haemodyamic compromise plus

treat the cause of bleeding
 PRIMARY MEASURES

 Keep patient WARM- temp record Q5min

 ASSESS- Rate and volume of bleed, w/f

underestimation

 ADDRESS- concern of patient and relatives

 ADJUST- position patient flat

 DRS ABC
DANGER- Use PPE 
RESPONSE- Check level of conciousness in pt
SEND- For help
AIRWAY- position, open the airway
BREATHING- O2 15L/min via RBM/ BMV if req
BLS if unresponsive & absent normal breathing
CIRCULATION- BP, spo2, HR Q5min
Permissive hypotension till bleed controlled
 
 Iv access- 2 IVC – 14 -16G
 Urgent lab tests- FBC, G&S, Xmatch( 4-6u), coag
profile, U&E, Lactate, Ca
 Fluid & bld replacement- tissue perfusion and
oxygen delivery
 Avoid dilutional coagulopathy, 2-3L crystalloid till
PRBC ready
 Hb not a transfusion trigger
 BLOOD TRANSFUSION EARLY- 2u PRBC
 O Neg bld if no grp sp bld.
 WHAT FOLLOWS……

 Bimanual compression

 IDC- Empty bladder

Aim for urine output> 30ml/hr

 Bleeding continues- Early surgical intervention

Activation of MTP
SECONDARY MEASURES
Uterotonics- Drugs in the
PPH Box
 OXYTOCIN  ERGOMETRINE

5U slow iv in 2-3 min 250 mcg in 5ml saline over 1-

2 min iv
Rpt dose 5U, total 10U
Or 250 mcg im
Infusion- 5-10U/ Hr
Rpt dose after 15 min upto
SE- Tachycardia , 500 mcg total
hypotension, ECG CI- pre ecclampsia,
changes ecclampsia, HTN, sev sepsis,
renal/hepatic/heart d/s
 
 SYNTOMETRINE (5U Oxytocin+ 500 mcg
Ergometrine)
1 amp im , rpt after 2 hrs in req max 3 mls in
24 hours OR Slow iv bolus 0.5- 1 ml

 MISOPROSTOL (PG E)
800-1000 mcg PR
2 ndLINE UTEROTONICS
CARBOPROST (PGF2) DINOPROST (PGF2)

Intramyometrial inj
1 ml of 5mg/ml diluted in 9ml
Intramyometrial inj saline= 0.5 mg/ml, discard 4ml.
250 mcg/ml, rpt 15-90 min MAX 6ml or 3 mg given.
prn 21-22G spinal needle, 1-2ml into
either side of the uterine fundus
MAX 2 mg, 8 doses or 2ml into fundus.
Through the anterior abd wall
Tuberculin syringe after vag birth or directly into
SE-Critical HTN, N/V, myometrium in LSCS
CI-Active lung/ heart/ hepatic/
headache fever &chills renal d/s, sev asthma
 INTRACTABLE
BLEEDING

1. TRANSFER TO OT
Review MTP activation, position flat, O2,
bimanual compression, analgesia

2. OT PREPARATION
Invasive monitoring- A line, UO, ? CVC
Warm blood and IVF
Devices to deliver fluid under pressure, level 1
Forced pt warmers
VTE prophylaxis
Personnel- An and O&G consultant inputs, addn staff
 
3. INTERVENTIONS

 Pharmacological- Tranexamic Acid 1 gm in 100 ml saline

over 10 min, ? R factor 7a
 Supportive- Cell salvage
 Interventional- Balloon tamponade/ emb of bleeding
Artery in Radiology suite
 Clinical- Bimanual compression contd, intrauterine Bakri
balloon
 
4. SURGICAL PROCEDURES

 Laparotomy- aortic clamp as temporising measure

 Blynch, figure of 8 uterine sutures
 Bilateral Uterine A/ Internal Iliac A ligation
 Radical hysterectomy
 ANESTHESIA IN PPH

AIM
 Resuscitate and maintain circulatory volume
 Tissue O2 delivery
 Metabolic equilibrium
 Correction of coagulopathy
CHALLENGES-
 Full stomach- Aspiration prophylaxis, RSI
 Coagulopathy- RA may be CI
 Volume depleted- volume resuscitaion, large bore iv access,
invasive monitoring, Anesthetic agents may compund to the
instability, awareness risk under GA
 ALL issues of peripartum anesthesia
 Coagulopathy

 CLINICAL FEATURES
Oozing from puncture sites, inj sites, Sx field
Haematuria
Petechae, subconjunctival/ submucosal bleed
Blood that does NOT clot

 LAB PARAMETERS
Platelet count < 50
PT > 1.5 times N, INR >1.5
APTT > 1.5 times N
Fibrinogen < 2.5g/dl
 
3. CORRECTION OF COAGULOPATHY
Optimise the metabolic state

LETHAL TRIAD - HYPOTHERMIA

ACIDOSIS
COAGULOPATHY
AVOID HYPOTHERMIA AVOID ACIDOSIS

KEEP PT TEMP> 35 DEG


Ph> 7.2, BE >-6

Fluid warmers Maintain oxygenation

Forced air warmers Maintain cardiac output
Decrease exposure of pt Maintain tissue perfusion
Removal of wet linen Monitor ph, BE, ABG
Warm blankets
Measure temp Q15mins
 MTP

 ACTIVATE- Bld loss> ½ BV
2.5L Bld loss
4 U PRBC in 4 hours plus
haemodynamic instability
 PERSON- Lead Clinician

 MONITOR-Q30min/ Q1H
FBC, Coag profile, ABG, Ca, lactate,
fibrinogen
 MTP

 MTP PACK 1- 4 PRBC, 4 FFP, 10 U CRYOPPT
 MTP PACK 2- 4 PRBC, 4 FFP, 1 ADULT DOSE
PLATELET
 Ca gluconate- 10% 10 ml, if Ca >1.1 mmol/L
 Intractable bleed- f7a
 Bleed controlled- Lead clinician deactivates MTP
 MTP

 LAB TARGETS

Ph>7.2
Base excess>-6
Lactate <4 mmo/L
Ca 2+ > 1.1 mmol/L
Platelets >50
Fibrinogen >2.5g/L
PT/APTT <1.5 times N, INR< 1.5
 
 TRANSFER TO ICU
 REFERENCES

 Queensland Clinical Guidelines (Maternity and
Neonatal Clinical Guidelines)

 Policy, Guideline and Procedural Manual on PPH

(Royal Women’s Hospital)

 Management of Obstetric Haemorrhage Anesthesia

Tutorial Of The Week 257
 
 THANK YOU