Transcript Primary Postpartum Haemorrhage

Severe Obstetric
Haemorrhage
Max Brinsmead MB BS PhD
May 2015
Introduction
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The average gravida carries 1 - 1.5 l of
“extra blood” in pregnancy as prophylaxis
against PPH but…
PPH is a major cause of obstetric death
especially in 3rd world countries
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10 - 15% of women lose >600 ml of blood at
delivery and…
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For 1 - 2% the blood loss can be life
threatening
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Another 0.5 - 1% have severe antepartum
haemorrhage from abruption or placenta
previa
This presentation will address…
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Emergency (First aid) and
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Diagnosis and management of severe APH
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Advanced Measures for the management of
excessive blood loss in the first 24 hours
after birth
Risk factors for Primary PPH
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Prolonged labour
APH
Pre eclampsia
Maternal obesity
Multiple pregnancy
Birth weight >4000g
Advanced maternal age
Previous PPH
Assisted delivery
Low lying placenta
But >50% occur in women without identified risk
factors and…
90% are associated with uterine atony
And all studies of massive PPH fail to identify
consistent risk factors
Patient Assessment
Objective measure of blood loss is desirable
 Postural hypotension the earliest sign
 Tachycardia is usual
 Air hunger and loss of consciousness is
serious
 Urine output a good measure of treatment
 CVP sometimes
 A bedside test of blood clotting desirable
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Emergency Measures for
PPH
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Rub up a contraction
Deliver the placenta
• If you can
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Gain IV access (large bore cannula)
Additional oxytocic
• IV Ergometrine 0.25 mg
• Syntocinon infusion
• Rectal Cervagem or Misoprostol
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(Empty the bladder)
Bimanual uterine compression
Aortic compression
Advanced Measures 1
Get help
 Check coagulation - use
cryoprecipitate etc.
 EUA is mandatory
 Myometrial PG F2 alpha
 Uterine Packing
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• Intrauterine balloon catheter
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Consider activated Factor VII
Blood replacement products:
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Whole blood
All components (after 48hrs factors low)
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Packed Red cells
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Frozen plasma
All clotting factors except for platelets
Store up to 1 year at -20 to -30 C
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Cryoprecipitate
Fibrinogen, factors VIII, XIII, VWF
lacks antithromin III
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Platelets
Only last 5 days
Red cells only
The Coagulation Mechanism
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Mechanical
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Contraction
Surgical
Coagulation
Cascade
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Platelet plug
Clotting cascade
• Thrombin >
Fibrinogen to
Fibrin
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Termination
Removal
Intrauterine Balloon Tamponade
BJOG Review May 2009
 Was effective in 91.5% of cases
• Combined retrospective and prospective studies
• But only a total of 106 patients
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Types of balloons
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Sengstaken Blakemore (GI use)
Rusch (Urological)
Foley (often multiple)
Bakri (Specifically designed for obstetrics)
Condom (+/- Foley)
But there remain many unanswered
questions
Questions concerning intrauterine balloon
tamponade
BJOG Review May 2009
 Is it effective
• There are no RCTs
Risks and contraindications
 Which balloon to use, how to insert it
and what volume to inflate it
 Is a vaginal pack required
 Is an oxytocin infusion required
 Antibioitics and analgesia
 When to deflate and or remove it
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Advanced Measures 2
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Get more help
• Medical – haematologist
• Surgical colleague
• Radiologist for…
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Uterine artery embolisation
Laparotomy and…
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B-Lynch suture
Internal iliac artery ligation
Aortic clamping
Hysterectomy
When confronted with a pregnant patient
who is bleeding after 20w
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There are five questions that need
urgent answers…
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How much blood has been lost
What is the maternal condition
What is the fetal condition
Is the patient in labour
What is the cause of the bleeding
THINK in terms of aetiology...
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Bleeding from a normally situated
placenta = Abruption
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Bleeding from a low placenta =
Placenta previa
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Cervical bleeding:
• “Show”
• Ectropion or Cancer
ACT in terms of priority...
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Assess maternal wellbeing
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Assess fetal wellbeing
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Resuscitate if required
Anticipate further problems
Is the fetus compromised
Is the fetus salvageable
Then attempt diagnosis
Essential observations
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Maternal vital signs
• General appearance
• Pulse and BP
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Uterus
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Nature and amount of PV loss
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Size
Tone and tenderness
Contractions
You can’t do this with CTG belts in place
Just blood or blood and liquor
Fetus
• Fetal heart present or absent
Essential Investigations
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HB, Blood group and save or Xmatch
• Depends on the amount of blood lost
• And the suspected diagnosis
• Remember that abruption is often associated with
a large concealed loss
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Ultrasound
• Best done “on the ward” if bleeding is substantial
• Requires skill in distinguishing blood clot from
placenta
• Vaginal scan the best way of evaluating degrees
of placenta previa
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Urinalysis for proteinuria
• May require bladder catheterisation
• Abruption may be associated with “acute” pre
eclampsia
• And the blood pressure may not be raised
Immediate management
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Large bore IV line
• If estimated loss is >250 ml
• Or if abruption or placenta previa is diagnosed
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Resuscitate with IV Fluids
• Commence with saline
• Colloids if shocked
• Blood if estimated loss >2 L
Analgesia
 Corticosteroids for gestation <37wks
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Monitoring response
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Maternal PR and BP
• Watch for pre eclampsia
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Indwelling catheter
• Hourly urine output
• Only a few require CVP
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Watch for coagulopathy
• A bedside test of clotting
• Prothrombin time (aPTT) and platelets
• HB takes a while to adjust
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CTG and umbilical Dopplers for the
fetus
Definitive management
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Conservative for placenta previa
• Most will settle
• Deliver when paediatric resources permit
• But must proceed to CS at any gestation if
the blood loss is life threatening for the
mother
 Aggressive
management for
abruption
• CS sooner rather than later for fetal reasons
• But vaginal delivery is usually possible with
IUFD
• Give more blood than you see
• Watch for coagulopathy
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