2. Management of Post Partum Haemorrhage DR HUSSEINH AKL O&G SPECIALIST HOSPITAL SEGAMAT 17 NOV.2012

4. The confidential enquiry into maternal death (CEMACH) Why CEMACH is important? 200 million global pregnancies 30 million globally experiences ill health due to pregnancy 8 millions have life threatened condition Over half million women dies as result of pregnancy & delivery 88-98% of MMR in the world are avoidable with timely and effective care. In UK, MMR 14 per 100.000 (2003-2005) live birth In Malaysia half million deliveries per year. MMR in Malaysia in 1947 - 700 per 100.000 deliveries in 1999 – 30 per 100.000 live birth MMR now 27.4 per 100.000 live birth target according To MDG5 EXPECTED TO BE 14/100.000 BY 2015 AND FURTHER DECLINE TO 10/100.000 IN 2020 PPH COMPLICATES 2-4% of births

5. Successes in Maternal Mortality Reduction China Malaysia USA England & Wales Sweden Source: England, Wales, Sweden, USA: VanLerberghe and DeBrouwere, Safe Motherhood Strategies, A Review of the Evidence, 2001 Malaysia, China: Koblinsky, Et al., Issues in Programming for Safe Motherhood, 2000

6. Causes of Maternal Deaths Malaysia 1991-1996

7. What we can do? Explain to parents Be vigilant & aggressive management of massive obstetric haemorrhage Don’t promise perfect outcome for mother & the baby We can identify and treat problems that arises but we cannot prevent all complications

8. PPH PPH is a major cause of maternal morbidity & mortality world wide accounting for at least 25% of maternal deaths accounting 30% of MMR in Malaysia Globally > 125.000 women die of PPH each year Major cause of maternal deaths in the UK (often after CS) Incidence is 2-11% in the UK With a low BMI or low Hb, <500ml loss may cause heamodynamic disturbances requiring prompt and appropriate management

9. PPH is the 2 nd leading cause of pregnancy-related death in USA accounting 17% of MMR. WHO shows PPH occurs in 10-15% of births in developing countries. 14 millions cases of PPH occurs per year globally with case fatality 1-2%. PPH creates a great morbidity causing physical/ psychological/ social/ economic impacts on the society.

11. PPH - definitions Primary PPH – is defined as blood loss of ≥ 500ml for vaginal delivery and ≥ 1000ml for caesarean delivery from the genital tract occurring within 24H of delivery. Secondary PPH – is defined as excessive loss occurring between 24H and 6-12 weeks after delivery. 10% change of haematocrite between admission and post partum period. Excessive bleeding producing symptoms and requiring blood tx.

12. Causes of primary PPH Uterine atony Genital tract trauma Coagulation disorders Large placenta Abnormal placental site Retained placenta Uterine inversion Uterine rupture

13. Uterine Atony ( 90%) Caused by failure of uterus to contract after delivery Predisposing factors;  over distended uterus with twins or polyhydramnios, big babies,  prolonged labour  infections  retained tissue  failure to actively managed 3 rd stage of labour  or rarely due to placenta abruption (diffuse bleeding into the uterine muscle that prevents contractions)

14. Genital Tract Trauma (7%) Vulva, vaginal tears episiotomy lacerations of cervix Rupture of the uterus.

16. Coagulation Disorders Severe PET, placenta abruption and sepsis may contribute to PPH. Autoimmune disease, liver disease, inherited or acquired coagulation disorders are rare causes. Sometimes the patient on heparin can lead to excessive bleeding.

17. Abnormal Placental Site Placenta previa, placenta accreta and percreta. Appropriate preplanning is needed to avoid morbidity &mortality. Uterine inversion & rupture are rare causes of excessive bleeding.

18. Causes of secondary PPH Infection - endometritis Retained placenta parts & membranes Subinvolution of the placenta site Rarely trophoblastic disease Pre-existing uterine lesion like submucous uterine fibroid Very rarely uterine Arterial Venous Malformation Inherited coagulation defect

19. Antenatal Risk Factors for PPH Previous PPH Previous retained placenta Maternal Hb ≤ 8.5g/dl at onset of labour. ↑ BMI Para 4 or more Antepartum haemorrhage Overdistention of uterus Uterine abnormities Low-lying placenta Maternal age > 35 years The presence of any risk factors for PPH should lead to the woman being advised to deliver in an obstetric unit (facilities for blood transfusion & surgical management of PPH)

20. Intrapartum Risk Factors for PPH Induction of labour Prolonged 1 st, 2 nd or 3 rd stage Use of oxytocin Precipitate labour Vaginal operative delivery CS

22. Massive Obstetric Haemorrhage 2 nd to PPH This is an important cause of maternal morbidity & mortality Identification of the risk factors, institution of preventive measures and prompt & appropriate management of the blood loss is likely to improve the outcome. Massive PPH loss of 30-40% of the pt’s blood volume (about 2L).

23. Consequences of Massive PPH Acute hypovolemia Sudden and rapid cardiovascular decompensation DIC Iatrogenic complications associated with massive blood transfusion Pulmonary oedema Transfusion reaction ARDS Sheehan’s syndrome (hypopituitarism)

24. Pathophysiology of Massive Obstetric haemorrhage Blood volume increased during pregnancy. Blood flow to pregnant uterus at term 500- 800ml/min Placenta circulation accounting for 400ml/min. Loss of 500-1000ml (10-15% of blood volume) is usually well tolerated by a fit, healthy young woman as she is able to maintain her cardiovascular parameters by effective compensatory mechanism until 30-40% of the blood volume is loss.

25. Blood Loss & cardiovascular Parameters Blood lossHRSystolic BP Tissue perfusion 10-15%increasednormalPostural hypotension 15-30%Increased+NormalPeripheral vasoconstric 30-40%Increased++70-80 mmHg Pallor, oliguria, confusion, restless 40%+Increased+++<60 mmHG Collapse, anuria, dyspnoea

27. PPH / Massive Obstetric Heamorrhage Resuscitation Life-threatening emergency requiring swift & appropriate treatment. Most units have local guidelines for management such as local hosp geography, staff availability, who to contact & agreed timescales for laboratory results Activate Red Alert Management consist of immediate resuscitation, restore blood volume & rapid treatment of the underlying cause to stop ongoing blood loss.

28. Initial measures for Resuscitation Call for help – senior obstetrician, anaesthetists, haematologist, midwife, hospital porter, blood bank & OT staff High flow facial Oxygen even if the SPO 2 is normal. Assess airway & respiration – intubate to protect the airway if decreased level of consciousness secondary to hypotension. 2 large bore IV cannulla (14G) Take blood for FBC, cross match, U&Es, liver functions, coagulation screen Start IV cystalloids to correct hypovolemia Catheterize & measure hourly urine output.

29. Blood Tx – O-ve blood can be given immediately until cross matched blood is available. Replace clotting factors – FFP (4 units every 6 units of blood), cryoprecipatate, recombinant activated factor VII As soon as appropriate in the resuscitation process, transfer the woman to place where there is adequate place, light & equipment to continue treatment (OT) Assess for CVP line V/S, urine output, type & quantity of fluids replaced, drugs given & timelines of events should be recorded by the staff Once bleeding has been stopped & pt stable, pt should be managed in HDU or ICU

30. Principles For Stopping the Bleeding Empty uterus (remove the placental / membranes) Treat uterine atony ( physically, medically & surgically) Repair genital tract trauma in OT

32. Medical Mx of uterine atony Accompanied by physical attempts to contract uterus – rubbing up the uterus & bimanual compression 500 micrograms of ergometrine IV/ can be given IM if difficulty in IV access Start oxytocin infusion 40IU If bleeding doesn't stop, give oxytocin 10IU IV slowly, not bolus

33. If atony continues, carboprost 250 micrograms IM given in the thigh or directly to myometrium & repeated at 15 min interval up to total 4 doses. If bleeding persist or ergometrine contraindicated then 800 micrograms of misoprostol (tables) is given rectally. Recent data shows misoprostol can be use as the 1 st line drug to control PPH. If all measures failed, retained tissue must be considered & the EUA with possible further surgical management is indicated without delay.

34. Surgical Management of PPH Tamponade test A Rusch balloon catheter, Sengstaken-Blakemore tube or Cooke’s balloon inserted into the uterine cavity & fill with 100-500ml warm N/S. If bleeding is controlled and the balloon is left for 24H and removed. Tamponade may be particularly useful to control PPH secondary to Placenta previa & accreta. If conservative intervention for uterine tamponade like uterine packing or balloon tamponade failed then consideration must be given to perform an exploratory laparotomy via vertical midline incision

35. Several procedures may be performed the choice depends on pt’s desire for future child bearing/ extent of the haemorrhage/ experience of the surgeon.

36. Intervention after laparotomy Make sure uterine cavity is empty as small pieces of tissue can cause atony. If bleeding from large placental sinuses following CS then undersewing the placenta bed ± insertion of Rusch balloon may control bleeding. If bleeding from uterine atony unresponsive to drug treatment but ↓ with manual compression, B-Lynch or vertical compression sutures should be attempted to provide continuous compression & ↓ blood flow to the uterus. Systematic pelvic devascularization by ligation of uterine, tubal branch of ovarian or anterior division of internal iliac arteries.

37. Internal iliac ligation will help in controlling both the uterine & vaginal branch bleeding ( B/L ligation results in 85% reduction of pulse pressure & 50% reduction blood flow & bleeding reduced by 50%). Hysterectomy is the last option. Subtotal hysterectomy is safer & quicker to perform. If the bleeding is from the lower segment ( placenta previa, accreta or tears) then total hysterectomy is carried out The decision for hysterectomy should not be unduely delayed as this can result in the death of the mother.

38. Procedures 1.Compressive suture – B-Lynch suture in 1997 can be effective in uterine atony 2.B/L uterine artery ligation –safe & effective method, identify the ureters then ascending branches of uterine artery are ligated at the level of vesicouterine peritoneal reflection. 3.B/L internal iliac artery ligation 4.Hysterectomy –remain definitive measure for control severe PPH, should not be delayed.Placenta accreta is the most common indication for emergency CS hysterectomy.

40. Arterial Embolization for Massive PPH Advantages  Less invasive than laparotomy  Help to preserve fertility  Quicker recovery than laparotomy Disadvantages  Only available in a few centres  May not be possible to get the required equipment to obstetric OT or transfer a woman to the radiology department  Appropriately trained interventional radiologists must be available

41. Method A catheter is inserted through the femoral artery and advanced above the bifurcation of the aorta and a contrast dye is injected to identify the bleeding vessels. The catheter is then directed to the bleeding vessels and embolized with gelatin sponge which is usually reabsorbed in 10 days.

42. Updates of the surgical Mx of PPH Systematic review of conservative management of PPH what to do when medical Tx fails 48 studies included in the review 2006 The cumulative outcome showed success rates of 90.7% ( confidence interval 95%) for arterial embolization – 84% for ballon tamponade – 91.7% for uterine compression sutures and 84.6% for internal iliac ligation or uterine devascularization.

43. At present there is no evidence to suggest that anyone method is better for the management for severe PPH. RCT of various treatment options may be difficult to perform in practice. Balloon tamponade is the least invasive and the most rapid approach, it would be logical to use this as the 1 st step in the management.

44. Case Illustration 1 27 year old G2 P1, had antenatal follow-up and delivery at private maternity centre. Scanty information as to what happened had ante-natally, but was known to have had a ventouse delivery and subsequently developed uterine atony. Transferred out to a government hospital and arrived 2 ½ hours after delivery. By then, patient was moribund and very pale. Laprotomy decided upon, but patient died before surgery could be performed.  Q1. What is the risk factor to the mother?  Q2. What are the commonest causes of uterine atony?  Q3. Explain the management of uterine atony in hospital.

45. Answers A1. Ventouse delivery and subsequently developed uterine atony. A2. Common causes can be divided into 2 main categories:  Predetermined Risk Factors Uterine over distension Multiparity Anaemia Past obstetric history of PPH Ante-partum haemorrhage Uterine fibroid/retained products of conception  Controllable Risk Factors Operative deliveries Anaesthesia Prolonged labour Mismanagement of 3 rd stage A3. As in lecture.

47. Case Illustration 2 26 years old G2 P1 admitted to GH for post dates. Induced with prostin and subsequently had ventouse extraction. Developed PPH and blood loss underestimated. Uterus was found to be atonic and cervical tear noted. MO attempted to suture cervical tear unsuccessfully. Meanwhile patient continued bleeding. O&G specialist called in as patient collapsed. Resuscitation carried out and hysterectomy performed 1 ¼ hours after delivery. By then, DIVC had set in. Patient died in ICU 8 hours later.  Q1. What are the causes of death for this patient?  Q2. Explain the management of PPH secondary to genital trauma.

48. Answer A1. PPH due to atonic uterus and cervical tear Secondary to DIVC A2. Perform general resuscitative measures Correct hypovolaemia/hypotension Set up a minimum of 2 iv drips for major PPH (>1000cc blood loss) a 3rd iv line or CV should be considered Stabilise the patient with crystalloids (Hartman’s) or colloids (haemacele/gelafusin) Take blood for FBC, GXM, Plt Place the patient in lithotomy position Find bleeding point if visible and clamp it Suture tear immediately Start broad spectrum antibiotics Place continuous bladder drainage Watch out for bleeding

50. THANK YOU For Attending

51. Thank You Egypt