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

2. 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.

3. 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 ml
Moderate ml
Severe > 2000 ml
WHO : ≥ 500 ml within 24h ; severe if ≥ 1 L

4. 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

5. 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

6. 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

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%)

8. 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 

9. 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
>2000
Systolic BP
Unchanged
Normal
Reduced
Very low
Diastolic BP
Raised
Unrecordable
Pulse (bpm)
Slightly tachycardic
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

10. 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

11. 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

12. Haemorrhage Kit

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

14. 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

15. 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

16. 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

17. 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

18. Uterotonics Tranexamic acid Recombinant VIIa
Other Adjuncts
Uterotonics
Tranexamic acid
Recombinant VIIa

19. 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

20. 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

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

22. 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

23. 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 > )
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):

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

25. 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

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

27. 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

28. “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):
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