Transcript Primary Postpartum Haemorrhage

Obstetric
Haemorrhage in a
Resource-poor
Setting
Max Brinsmead PhD FRANZCOG
July 2010
Obstetric haemorrhage is...
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The major cause of maternal death in
resource-poor countries
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The risk is increased by:
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Severe anaemia
Other medical & obstetric conditions
Poverty
Transport problems
Cultural & religious practices
Although the average gravida’s blood
volume is expanded by 1.5L and all clotting
factors are increased...
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Blood loss of 10% or >500ml →Tachycardia
Loss of 25% or 1250ml→Vasoconstriction
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Loss of 33% or 2000ml →Hypotension
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Sweating, pallor, thirst & oliguria
Greater blood loss → Risk of organ damage
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Pale & cold extremities
Weak, thready pulse
But systolic BP may be maintained
Air hunger, restlessness & confusion
DIC and ARDS
>50% loss of blood volume → Cardiorespiratory
arrest
Beware of the patient who survives large PPH
elsewhere and arrives 24 – 48 hours later
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May have a Hyperkinetic Circulation…
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Rapid, full volume pulse
Normal BP
However JVP is raised and there are basal lung creps
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This is anaemic Congestive Cardiac
Failure…
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And requires careful transfusion with IV
Frusemide
After major obstetric haemorrhage the first priority
is adequate IV access
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14G peripheral line
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Use hot towels to vasodilate
Ideally one in each arm
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Femoral vein puncture next best option
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Jugular vein line with CVP is even better
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Long saphenous cutdown next option
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Femoral Artery catheterisation may be
required
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Pressure suit may be a first aid
alternative
Jugular Vein Catheterisation
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Position supine with 15 degree head-down tilt, head
to the left
Skin asepsis, Lignocaine 1%
Identify the two heads of the sternomastoid muscle
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Incise the skin at the apex of these muscles
The vein is deep to the clavicular head of this
muscle and lateral to the carotid artery at the level
of the cricoid cartilage
Use 16G cannula attached to 5 ml syringe
Advance subcutaneously at 30-degree angle
towards the nipple
Aspirate until the vein is reached
Attach manometer which should oscillate with resps.
Complications:
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Pneumothorax
Air embolism
Arterial puncture
Haematoma
Sepsis & thrombosis
Femoral Vein Catheter
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Supine position, inguinal region exposed
Skin antisepsis and drape
Identify the inguinal ligament and femoral vein pulsations
Mark a point 1 cm above the ligament & 0.5-1.0 cm
medial to the arterial pulsations
Infiltrate with 1% Lignocaine
With a 26G finder needle and 5 ml syringe
Advance cephalically at an angle of 45 degrees
When the vein is identified by the flash of blood use a
22G needle with catheter immediately above or below the
finder needle
Advance the catheter when the vein is reached
Secure
OR
Omit the finder needle and proceed with the larger
Intracath on a 10 ml syringe
Complications:
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Arterial puncture
Haematoma
Femoral Nerve Damage
Femoral Vein Catheterisation
Saphenous vein cut down
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Position supine, leg restraint, tourniquet desirable
Skin asepsis, Lignocaine 1%
The vein is 2 cm above and 2 cm anterior to the
medial malleolus
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Incise the skin transversely
Identify the vein by dissection with fine arterial
forceps, separate from adjacent nerve and strip
clean for 2 cm
Place two loops of silk behind the vein
Tie off the distal end and loose tie the proximal
Open the vein with iris scissors or scalpel, using
traction on the distal suture
Tourniquet release
Introduce a blunt plastic cannula, advance and allow
blood to backflow, tighten the upper silk ligature
Suture secure and close the skin
Complications:
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Infection
Delayed healing & keloid scar
Saphenous vein cut down
It is desirable to...
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Check that your cannula is in a vein before
commencing infusion
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The zero mark of a CVP is aligned with the
level of the R. atrium
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5 – 8 cm of H20 is normal
Begin infusion with Hartmanns
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Check by blood aspiration
X-ray for CVP placement
But only 700 ml of each litre remains
intravascular
Albumin is the best colloid but Gel-fusion is
a good substitute
Blood is best
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May require delivery pressure
Fluid warming desirable
Your patient is stabilised when...
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Systolic BP is > 100 mm
AND
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Pulse rate is < 100 / min
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Put in a bladder catheter to monitor urine output
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CVP is better, of course
Placenta Previa
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After appropriate resuscitation delivery is
indicated when…
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Examination under anaethesia → Caesarean if…
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The placenta is palpable through 2 or more fornices
The presenting part cannot be brought into the pelvic brim
During Caesarean Section…
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The fetus is mature
The fetus is dead or severely malformed
Continuing haemorrhage threatens
The patient is unwilling or resources prevent continuing
hospitalisation
Lower segment preferred
Consider ligation of major vessels
Go above the placenta to perform ARM & delivery
Use Green-Armytage to control bleeding after incision
A place for bipolar version and bringing down a leg
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Requires > 4 cm dilation of the cervix
Attach a 1.5 Kg weight to the ankle
The buttock compresses the placenta
While the thigh dilates the cervix
Don’t attempt delivery until fully dilated
Placental Abruption
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If the Uterus is > Dates or…
The fetus is dead then…
Assume major blood loss
As a guide to fluid replacement:
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If the BP is 100 mm give 1,000 ml
If the BP is <80 mm give 2,000 ml
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Plan delivery if >36 weeks
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Examination under anaesthesia may be required
An early recourse to CS maybe life saving for the fetus
But do not begin CS until resuscitation is complete and
coagulation has been checked
A rapid infusion of cryoprecipitate and platelets is
desirable
Aim for vaginal delivery by amniotomy and oxytocin
infusion when there has been fetal death
But monitor coagulation and
Prepare for PPH
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Postpartum Haemorrhage
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Begin aggressisve Rx earlier when there is…
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Severe anaemia (HB <7.0)
 Severe pre eclampsia
 Prolonged labour
Principles:
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Secure adequate IV access ASAP
Empty the uterus
Contract the uterus by oxytocics
• Ergometrine, Syntocinon, Rectal Misoprostol
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Bimanual uterine compression or
Aortic compression
Compress the bleeding site
• Pack the vagina
• Intrauterine balloon tamponade
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Surgical options
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Internal iliac artery ligation
B-Lynch suture
Hysterectomy
Uterine artery embolisation
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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B-Lynch Suture
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Use lithotomy in order to assess vaginal bleeding
Empty the bladder
GA and laparatomy
Expose the lower segment
Exteriose the uterus – open CS incision if present
Tie off any obvious bleeders
Compress the uterus manually to assess likely response
Use 70 mm needle and No. 2 chromic catgut or Vicryl
Go in anteriorly 3 cm above right lower edge and 3 cm towards
midline, through the uterine cavity and up vertically 3 cm
Go through the posterior uterine wall – now 4 cm from the
lateral edge of uterus
Take the suture posteriorly over the top of the uterine fundus
Bring the suture to the same UPPER point anteriorly
B-Lynch Suture (2)
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Re enter the uterine cavity and go laterally then out posteriorly
at a corresponding point on the left side
Go over the top of the uterus on the left side
Re enter the uterine cavity at the corresponding upper anterior
point
Then out at the corresponding lower anterior point.
Tie anteriorly below the CS incision with manual compression of
the uterus
Re suture the CS incision
For bleeding from the lower uterine segment (after placenta
previa) put figure of 8 sutures anteriorly and or posteriorly
BEFORE the B-Lynch suture
B-Lynch Suture Technique
When a patient presents with a retained placenta
of >24 hours...
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First resuscitate, transfuse and give antibiotics
Delay placental removal (for up to 48 hrs if required)
Prepare for morbid adherence of the placenta
During EUA after PPH always consider…
The possibility of uterine rupture
For secondary PPH up to 7 days after birth…
Uterine “curage” with 2 fingers is safer
For secondary PPH more than 7 days after birth…
Suction is safer than traditional curette
And remember to give antibiotics for sufficient time
before EUA to control generalised sepsis
Renal Failure after Obstetric Haemorrhage
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Diagnosis…
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Less than 400 ml urine in 24 hours
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Beware of toxicity from any drugs usually
excreted by the kidneys
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Avoid fluid and sodium overload during the
oliguric phase
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Strict fluid balance
Mannitol or Frusemide
Bicarbonate infusion for acidosis
Ion exchange resin, insulin & glucose or dialysis for
hyperkalaemia
Avoid dehydration in the diuretic phase
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Strict fluid balance
May require up to 10 litres/day
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