Postpartum Haemorrhage (PPH) Prof.Stephan Gatt Prof.Berrin Gunaydin

KEY LEARNING PONITS To understand the main risk factors for and causes of major obstetric haemorrhage. To understand the importance of early recognition of obstetric haemorrhage. To emphasize that circulatory compensation will occur till significant blood loss has occurred. Decompensation will then occur rapidly. To be familiar with the assessment of the woman, mechanical manoeuvres and drugs to stop the bleeding, and effective fluid resuscitation all need to be started promptly. To communicate clearly within the team about the problem and appropriate allocation of tasks. To document details of management accurately, clearly and legibly.

Definitions APH: Prior to delivery Primary PPH: Onset in the first 24h Secondary PPH : >24h to 6 wks postpartum: ACOG (USA) : ≥ 500 ml after vaginal delivery ≥ 1000 ml after Caesarean Section RCOG (UK) : Minor 500 - 1000 ml Moderate 1000 - 2000 ml Severe > 2000 ml WHO : ≥ 500 ml within 24h ; severe if ≥ 1 L

Background PPH is common, with an incidence in Australia of between 5-15% Postpartum haemorrhage (PPH) remains a major cause of both maternal mortality and morbidity within Australia and New Zealand. RANZCOG College Statement C-Obs 43 (March 2011) Life threatening haemorrhage being defined as blood loss 2.5 litres or more or women who received more than 5 units of blood transfusion or women who received treatment for coagulopathy after an acute event

Maternal mortality due to PPH Confidential enquiry into maternal deaths Too Little IV fluids, oxytocics, BLOOD, Clotting factors Too Late PG, resuscitation - blood replacement, decision for surgery and to get senior surgeon & anaesthetist involved

Risk factors for uterine atony Use of uterine relaxants Deep anaesthesia Magnesium sulphate Labour related factors Induction of labour Prolonged labour Precipitate labour Oxytocin augmentation Manual removal of placenta Factors associated with uterine over distension Multiple pregnancy Polyhydramnios Fetal macrosomia Intrinsic factors Previous PPH Antepartum haemorrhage Obesity Age > 35 years However, postpartum haemorrhage also occurs in women with no risk factors, so physicians must be prepared to manage this condition at every delivery. Am Fam Physician 2007;75:875-82 Breathnach F, Geary M. Uterine atony: definition, prevention, nonsurgical management, and uterine tamponade. Semin Perinatol 2009;33(2):82-7

4 T’s Tone (70%) Tissue (20%) Trauma (10%) Thrombin (<1%) Causes of PPH 4 T’s Tone (70%) Tissue (20%) Trauma (10%) Thrombin (<1%)

Sequelae of PPH Short term Long term Massive blood transfusion –transfusion reactions, TRALI Pulmonary edema Acute renal failure Coagulopathy Peripartum hysterectomy ICU management: invasive monitoring and ventilation Long term Fertility issues Sheehan’s syndrome Psychological sequelae – delayed maternal-child bonding, post-traumatic stress disorder 

Classification of hypovolaemic shock according to blood loss Class II Class III Class IV Blood loss (%) <15 15-30 30-40 >40 Blood loss (ml) 750 800-1500 1500-2000 >2000 Systolic BP Unchanged Normal Reduced Very low Diastolic BP Raised Unrecordable Pulse (bpm) Slightly tachycardic 100-120 120 (thready) >120 (very thready) Capillary refill Slow (>2s) Undetectable Respiratory rate Tachypnoea Tachypnoea (>20/min) Urine output (ml/hr) >30 20-30 10-20 0-10 Extremities Pale Pale, cold, clammy Complexion Ashen Mental state Alert Anxious or aggressive Anxious, aggressive/drowsy Drowsy, confused or unconscious

Principles of management of PPH Call for help/MTP/code blue Resuscitation (ABC) Uterine massage Arrest bleeding Replace circulatory volume Medical interventions Oxytocin Carbetocin (Duratocin) Ergometrine Carboprost Misoprostol Reverse coagulopathy Fluid resuscitation Crystalloid Colloid Blood products Surgical interventions EUA Uterine balloon tamponade Uterine compression sutures Uterine artery ligation Internal iliac artery ligation Interventional radiology Peripartum hysterectomy Pack RBC FFP PLT Cryoprecipitate rFVIIa Tranexamic acid Cell salvage

Initiating Resuscitation Airway Breathing Circulation Oxygen supplementation Large-bore IV catheters Blood sampling for cross-match, haematocrit, coagulation profile Monitor BP, HR, SpO2, urine output, uterine tone

Haemorrhage Kit

PPH Box Contents PPH Medication Box Contents (Kept in Treatment Room Fridge)

Goals of Resuscitation Restore circulatory volume Maintain oxygen delivery Treat the underlying cause  Prevent lethal triad hypothermia, acidosis and coagulopathy Initiation of a management protocol Multidisciplinary care

Acute Resuscitation Airway, breathing, circulation take priority: prevent aortocaval compression Administer oxygen : contribution of plasma O2 when Hb < 7 g/dL Establish IV access ( at least two 14-16G) : cross match 4-6 units, Hb, plt, INR/PTT, DIVC screen

Acute Resuscitation Crystalloids preferred over colloids Limited crystalloid infusion Short half-lives, dilutional coagulopathy Via rapid infusor Monitoring : BP, heart rate, SpO2, blood loss, urine output, uterine tone May need inotropes

Massive Transfusion Protocol Benefits: reduces logistical problems associated with the transport of blood from the blood bank to patient sustained administration of blood components in pre-determined ratios to retard onset of DIVC reduces transfusion needs and survival in trauma improves maternal outcome ? Bormanis J. Development of a massive transfusion protocol. Transf Apheresis Science 2008;38:57-63 Cotton BA, Au BK, Nunez TC, Gunter OL, Robertson AM, Young PP. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma. 2009;66:41–49 Gunter OL Jr, Au BK, Isbell JM, et al. Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma. 2008;65:527–534

Uterotonics Tranexamic acid Recombinant VIIa Other Adjuncts Uterotonics Tranexamic acid Recombinant VIIa

Uterotonics Oxytocin: IV 5U slow bolus, followed by infusion of 30U in 500ml DS over 3 hours  Note: may precipitate cardiovascular collapse in severely hypovolaemic patients

Uterotonics Carbetocin (Duratocin): IV slow bolus 100 mcg onset within 2 minutes 1 hour duration of action Ergometrine: IM 500 mcg or IV 250 mcg slow bolus IV 250 mcg infusion Contraindicated in hypertensive (relative), severe pre-eclampsia S/E : increases BP, nausea and vomiting

Uterotonics Carboprost (PGF2α): 250 mcg IM or intrauterine S/E : bronchospasm, hypertension Misoprostol 600 mcg single dose (PR, PV)

Other Adjuncts:TRANEXAMIC ACID (TXA) May be useful although clinical value not proven TXA 1g over 10 min and 1g over 8h if massive transfusion RANZCOG Possible indications: Evidence of hyperfibrinolysis – labs or ROTEM/TEG studies Any patient with increased risk of PPH and undergoing CS RCOG Any patient diagnosed with atonic refractory bleeding WHO

Other Adjuncts: Novoseven Novoseven (recombinant activated factor VII) 70-90ug/kg dose Binds to platelets and activates factor X Induces haemostasis at the site of vascular injury independent of the presence of factors VIII and IX by forming complexes with exposed tissue factor Reduced effect Thrombocytopenia (platelets > 50 000) Low fibrinogen (fibrinogen > 1 g/l) Hypothermia Acidosis (pH < 7.1) D. Karalapillai & P. Popham Recombinant factor VIIa in massive postpartum haemorrhage IJOA 2007;16:29-34 J Ahomen & R Jokela Recombinant factor VIIa for life threatening post-partum haemorrhage BJA 2005;94 (5): 592-595

Obstetric Management of PPH Surgical measures Examination under anaesthesia Repair of genital tract lacerations Exploratory laparotomy Compression sutures (eg. B-lynch) Hysterectomy

Uterine devascularisation Stepwise uterine devascularisation Unilateral uterine vessel ligation Bilateral uterine vessel ligation Low uterine vessel ligation Unilateral ovarian vessel ligation Bilateral ovarian vessel ligation

Hysterectomy A measure of last resort Should be considered sooner than later Subtotal hysterectomy may be simpler and quicker

Interventional Radiology Indications Placenta praevia major and placenta accreta Atonic uterus during caesarean section Uterine tear during caesarean section Bleeding post hysterectomy Success rate of 90% Ideally, bilateral femoral catheters inserted prior to C-section (controlled situation) Occlusion of internal iliacs

“HEMOSTASIS” algorithm H : Help (A: Assess vital parameters, blood loss and resuscitate ) E : Establish etiology & Ensure availability of blood M : Massage the uterus O : Oxytocin infusion and prostaglandins S : Shift to operating theatre T : Tamponade – balloon/uterine packing (Rusch/Bakri balloon) A : Apply compression sutures (B-lynch) S : Systemic pelvic devascularisation (uterine, ovarian, internal iliacs) I : Interventional radiology (pelvic artery embolisation) S : Subtotal/ total hysterectomy Varatharajan, L.; Chandraharan, E.; Sutton, J.; Lowe, V. & Arulkumaran, S. Outcome of the management of massive postpartum hemorrhage using the algorithm "HEMOSTASIS", International journal of gynaecology and obstetrics. 2011;113(2):152-154. Summary Varatharajan et al. evaluated the outcome of management for massive PPH using the algorithm `HAEMOSTASIS’ The algorithm was found to provide a logical management pathway to reduce blood transfusions, hysterectomy, admissions to intensive care units and also maternal deaths