1. MANAGEMENT OF POST PARTUM HAEMORRHAGE
Dr. KAVITHA ERINJIPPURATH

2. 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

3. 2. BASED ON HAEMODYNAMIC COMPROMISE
Tachycardia, hypotension
Healthy preg show signs of shock if loss > 1L
HAEMATOCRIT
10% fall in PCV levels PP.
BLOOD TRANSFUSION
BT required after massive bld loss > 1L or PP Hb
>80 g/L

4. INCIDENCE
Incidence in AUS & NZ is 5-15% Most common cause of Obstetric haemorrhage Leading cause of maternal mortality and morbidity

5. COMMON CAUSES OF PPH TONE (70%) TRAUMA (20%)
Laceration of Cx/ vagina/ perineum
Ext lacerations at LSCS
Uterine rupture/ inversion
Nongenital tract trauma

6. COMMON CAUSES Contd.. Tissue (10%)
Retained products/ placenta/ membranes/ clots
Abnormal placenta
Thrombin (1%)
Coagulation abnormalities

7. RISKS FACTORS FOR PPH 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

8. 2. INTRAPARTUM
Precipitate/ prolonged labour
Chorioamnionitis
Amniotic fluid embolism, DIC
Uterine inversion
Genital tract trauma
Assisted vag delivery
LSCS, Em> Elective

9. POSTPARTUM
Retained products
AFE/ DIC
Drug induced hypotonia (anesthesia, Mg)
Bladder distention preventing uterine contraction

10. RESUSCITATION, ASSESSMENT AND TREATMENT
MDT- O&G, Anesthetics, Haematology, Nursing, Midwifery
AIM- restore haemodyamic compromise plus
treat the cause of bleeding

11. 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

12. 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

13. Iv access- 2 IVC – G
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.

14. WHAT FOLLOWS…… Bimanual compression IDC- Empty bladder
Aim for urine output> 30ml/hr
Bleeding continues- Early surgical intervention Activation of MTP

15. SECONDARY MEASURES Uterotonics- Drugs in the PPH Box
OXYTOCIN
5U slow iv in 2-3 min
Rpt dose 5U, total 10U
Infusion- 5-10U/ Hr
SE- Tachycardia , hypotension, ECG changes
ERGOMETRINE
250 mcg in 5ml saline over 1-2 min iv
Or 250 mcg im
Rpt dose after 15 min upto 500 mcg total
CI- pre ecclampsia, ecclampsia, HTN, sev sepsis, renal/hepatic/heart d/s

16. 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 ml
MISOPROSTOL (PG E)
mcg PR

17. 2nd LINE UTEROTONICS DINOPROST (PGF2) CARBOPROST (PGF2)
Intramyometrial inj 250 mcg/ml, rpt min prn MAX 2 mg, 8 doses Tuberculin syringe SE-Critical HTN, N/V, headache fever &chills
Intramyometrial inj 1 ml of 5mg/ml diluted in 9ml saline= 0.5 mg/ml, discard 4ml. MAX 6ml or 3 mg given G spinal needle, 1-2ml into either side of the uterine fundus or 2ml into fundus. Through the anterior abd wall after vag birth or directly into myometrium in LSCS CI-Active lung/ heart/ hepatic/ renal d/s, sev asthma

18. INTRACTABLE BLEEDING TRANSFER TO OT
Review MTP activation, position flat, O2,
bimanual compression, analgesia
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

19. 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

20. 4. SURGICAL PROCEDURES
Laparotomy- aortic clamp as temporising measure
Blynch, figure of 8 uterine sutures
Bilateral Uterine A/ Internal Iliac A ligation
Radical hysterectomy

21. 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

22. 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

23. CORRECTION OF COAGULOPATHY
Optimise the metabolic state
LETHAL TRIAD - HYPOTHERMIA
ACIDOSIS
COAGULOPATHY

24. AVOID HYPOTHERMIA KEEP PT TEMP> 35 DEG Fluid warmers Forced air warmers Decrease exposure of pt Removal of wet linen Warm blankets Measure temp Q15mins
AVOID ACIDOSIS Ph> 7.2, BE >-6 Maintain oxygenation Maintain cardiac output Maintain tissue perfusion Monitor ph, BE, ABG

25. 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

26. 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

27. 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

28. TRANSFER TO ICU

29. 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

30. THANK YOU