![• Early use of IV TXA as soon as PPH is diagnosed but NOT after 3 hours
of birth is recommended
• Give 1g TXA IV at 1 ml/min, over 10 min. If bleeding continues after
30 mins or restarts 24 hours after 1st
dose, give second dose of 1g IV
• N:B – Latest evidence indicates that I.M TXA equally effective [BJOG.
2023;00:1-10]](https://image.slidesharecdn.com/bleedinginpregnancy-250312105507-6872d01b/85/bleeding-in-pregnancy-post-partum-pptx-28-320.jpg)
bleeding in pregnancy (post partum).pptx
- 1. POSTPARTUM HAEMORRHAGE DR. JUDITH DEPARTMENT OF FAMILY MEDICINE
- 2. OUTLINE • INTRODUCTION/OVERVIEW • DEFINITIONS & CATEGORIES • RISK FACTORS FOR PPH • CAUSES OF PRIMARY & SECONDARY PPH • ASSESSMENT OF BLOOD LOSS AT DELIVERY • MANAGEMENT • TREATMENT • FEW COMPLICATIONS • PREVENTIVE MEASURES • CONCLUSION & TAKE HOME
- 3. INTRODUCTION • Obstetric Haemorrhage ranks as the a leading cause of maternal mortality accounting for approx. 25% of maternal deaths • The term obstetric hemorrhage covers hemorrhage incurred ante- partum, intrapartum, and post-partum, but post-partum hemorrhage is estimated to account for 60% of all. • Although post-partum hemorrhage (PPH) is one of the most preventable obstetric disorders, recent population based studies reveal that it is still the leading cause of maternal mortality in developing countries and severe maternal morbidity in advanced countries.
- 4. DEFINITION • QUANTITAIVE DEFINITION- • Blood loss of more than or equal 500ml following delivery (both spontaneous vaginal delivery or caesarean section(1000mls)). • CLINICAL DEFINTION • Post- partum haemorrhage refers to any amount of bleeding from or into the genital tract following birth of a baby up to the end of puerperium which adversely affect the general condition of the patient evidence by- • rise in pulse rate • Falling blood pressure • or a decrease of 10% or more in haematocrit between admission and postpartum period or any loss enough to cause cardiovascular instability
- 5. EPIDEMIOLOGY • The loss of blood in excess of 500mls has been estimated to complicate 2% of all child birth involving about 13.8 million parturient and recent reviews suggests its occurrence is on the increase in sub Sahara Africa. • Each year 14 million women experience PPH resulting in about 70,000 maternal deaths globally. • Even when women survive, they often need urgent surgical interventions to control the bleeding and may be left with life-long disability.
- 6. TYPES • Essentially 2 Categories of PPH • PRIMARY PPH • Occurs within the first 24 hours of delivery • Most common • SECONDARY PPH • Occurs after 24 hours to the end of 6 weeks after delivery
- 7. RISK FACTORS • Prolonged third stage of labor • Multiple delivery • Episiotomy • Fetal macrosomia • Previous history • Grandmultiparity • Placenta previa • Placenta abruption • Infection
- 8. CAUSES OF PPH ‘The Four T’s” • Tone – uterine atony • Tissues –retained placenta, invasive placenta. • Trauma – of any part of the genital tract, inverted uterus • Thrombin – coagulopathy, DIC
- 9. 1-TONE- • 70% • This is a failure of the myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by a living ligature action. • Failure of uterus to contract and retract effectively after delivery of placenta
- 10. • Risk factors include- • Polyhydramnios, Foetal macrosomia, Multiple gestation, Co-existing Uterine mass, Previous hx of uterine atony, Grandmultiparity, Prolonged/Precipitate labour, oxytocin driven labour, Halogenated Anaesthetic agents,, Tocolytics use, Hx of APH, Full bladder et • Common presentation include- • Excessive bright red bleeding • Boggy uterus • High fundus with non- contracting uterus • Abnormal clots
- 11. 2- TRAUMA • 20% • Usually occurs following operative delivery. • Common sites include- • Vulva, vagina, cervix, perineum, paraurethral region • Rupture uterus
- 12. 3-TISSUE- • Retained products • Abnormal placenta • Placenta praevia /abruptio placenta • Blood clot • 4- THROMBIN • Congenital or acquired • Maybe due to diminished pro coagulants(washed out effect) or increased fibrinolytic activity. • common cause include- placental abruption, jaundice in pregnancy, dead fetus, HELLP syndrome
- 13. UTERINE INVERSION • Mostly iatrogenic resulting from mismanagement of 3rd stage - strong traction on the cord with a relaxed uterus/adherent placenta • The uterine fundus falls into the endometrial cavity and may descend to the cervix (Incomplete Inversion- Fundus felt through the Cx) or beyond the cervix (Complete inversion) • Four Degrees
- 14. COMMON CAUSES OF SECONDARY PPH • Retention of placenta tissue • Endometritis • Delayed placental bed involution • Other less common aetiologies: • Congenital coagulopathies • Sub-mucous fibroids, • Adherent Placenta • Caesarean scar dehiscence • Ruptured uterine pseudo-aneurysm • Uterine rupture
- 15. ASSESSMENT OF BLOOD LOSS AFTER DELIVERY • Difficult • Mostly Visual estimation (Subjective & Inaccurate) • Under-estimation very much likely • Clinical picture – Often manifest late & can be misleading • Our Mothers - Malnourished, Anaemic, Small built, Less blood volume
- 16. Table showing the staging scheme for Assessment of Obstetric hemorrhage. Severity of shock Findings % Blood loss None • None < 15- 20% Mild • Pulse rate <100bpm • Mild hypotension • Peripheral vasoconstriction 20-25% Moderate • Pulse rate 100 – 120bpm • Hypotension systolic bp 80- 100mmhg • Restlessness • Oliguria 25-35% Severe • Pulse rate >120bpm • Hypotension (systolic bp <60bpm) • Altered consciousness >35%
- 17. PRINCIPLE OF MANAGEMENT OF PPH 1. MULTIDISCIPLINARY TEAM WORK 2. PROMPT & EFFECTIVE RESUSCITATION 3. PURPOSEFUL INVESTIGATION & ONGOING MONITORING 4. MITIGATION & TREATMENT OF COMPLICATION
- 18. 1. MULTIDISCIPLINARY TEAM WORK • Call for HELP • Multidisciplinary approach • Alert Midwife, Senior Obstetrician, Anaesthetist & Theatre • Alert Blood transfusion service & Haematologist • Alert paramedical services - Porters for transport of blood samples & collection of blood products • Allocate distinct roles to team members.
- 19. 2. PROMPT & EFFECTIVE RESUSCITATION • Assess Airway, Breathing and Circulation • Remove obstructions and suction secretions • Head down tilt and to increase venous return to the heart help preserve cardiac output • Give supplemental oxygen by face mask at 10–15L/min • Secure IV access with 2 large bore cannulae • Obtain blood for haematological investigations & GXM Blood • Catheterisation to empty bladder & monitor urine output
- 20. PROMPT & EFFECTIVE RESUSCITATION (Contd) • Commence fluid resuscitation using 2 – 3L of IV fluids (warm crystalloids (RL) - 3ml/ml of blood loss, Haemacel can also be helpful, if available) • After 3L of IV fluids, further resuscitation should be with cross matched fresh whole blood or O Rh -ve blood • FFP may be necessary if clotting derangement suspected (12–15 ml/kg, after 4 units of blood) • IV Calcium gluconate after 5 units of blood transfusion to counter anticoagulant in blood transfused • Thrombocytopenia - Platelets concentrates • Hypofibrinogenemia - Cryoprecipitate
- 21. 3. PURPOSEFUL INVESTIGATION & ONGOING MONITORING • FBC, Coagulation screen, baseline E & U + Cr and LFT • Cross-match at least 4 units of blood minimum • Continuous monitoring of pulse, blood pressure, respiratory rate oxygen saturation (>95%) and urine output (> 30ml/hr) • Temperature monitoring every 15 minutes (Avoid cold transfusions) • Consider arterial line monitoring and HDU/ICU transfer
- 22. 4. MITIGATION & TREATMENT OF COMPLICATIONS • Interventions are physical, pharmacological, surgical & radiological • Ensure the bladder is empty • Check for completeness of placenta delivery • Uterine massage and Bimanual uterine compression • Oxytocin 10 units bolus, followed by high dose oxytocin infusion to maintain contraction (safe with empty uterus), as first-line treatment
- 24. TREATMENT OF PRIMARY PPH • Multidisciplinary - Obstetrician, Anaesthetist, Haematologist and Blood Bank • Correction of hypovolaemia • Ascertain origin of bleeding • Ensure uterine contraction • Surgical management • Management of special situation
- 25. MANAGEMENT OF UTERINE ATONY • Examine the vulva/ vagina for any trauma. • Palpate fundus • Uterine massage • Bimanual compression • Pneumatic Anti-Shock Garment (PASG)
- 27. TREATMENT OF PRIMARY PPH (Cont.) • Oxytocin: Bolus of 10 units IV followed by Continuous Infusion 100 Miu/min • Ergometrine given parenterally (0.25mg IV is an alternative if oxytocin is unavailable & not a known Htn dx), or if the bleeding does not respond to oxytocin OTHERS • Oxytocin–ergometrine fixed dose (syntometrine) • Prostaglandin drug (e.g. Oral misoprostol 600- 800μg or Carboprost I.M 0.25mg stat, Rpt 15-30 min, Maximum 2.0mg, Routes- IM/Intra-myometrial)
- 28. • Early use of IV TXA as soon as PPH is diagnosed but NOT after 3 hours of birth is recommended • Give 1g TXA IV at 1 ml/min, over 10 min. If bleeding continues after 30 mins or restarts 24 hours after 1st dose, give second dose of 1g IV • N:B – Latest evidence indicates that I.M TXA equally effective [BJOG. 2023;00:1-10]
- 30. • Use of the Non-pneumatic Anti-shock Garment is recommended as a temporizing measure until appropriate care is available
- 32. TRAUMA • LACERATION AND HAEMATOMA- resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. • UTERINE RUPTURE- symptomatic uterine rupture requires surgical repair of defect or hysterectomy • UTERINE INVERSION- rare
- 33. TREATMENT OF PPH UTERINE INVERSION • Manual replacement - - Under GA/Uterine relaxant – Tocolytics (terbutaline, nitro-glycerine, MgSO4) - Oxytocin infusion post-replacement Placenta adherent, LEAVE IN SITU, attempt to deliver may cause MASSIVE HAEMORRHAGE and/or shock. Prompt manually replace the inverted uterus to its normal position. A hand inside the vagina and pushing the fundus along the long axis of the vagina toward the umbilicus (Johnson’s Manoeuvres). • Hydrostatic method. • Surgical method (delayed procedure) Huntington & Haultain procedures
- 35. TISSUE • Failure of expulsion of the placenta and membrane. • Classic signs of placental separation include small gush of blood with lengthening of the umbilical cord and slight rise of the uterus in the pelvis. • Placental delivery can be achieved by the use of the Brandt-Andrews maneuver, which involves applying firm traction on the umbilical cord with one hand while the other applies suprapubic counter- pressure. • At term 90% of placenta will be delivered within 15minutes if it exceeds 30mins= retained placenta
- 36. Management of retained placenta • Placenta not separated at all- • Give oxytocic drugs • Deliver the placenta by Brandt’s Andrew method. • Uterotonic agents down the umbilical cord by PIPING’S method • If not successful MANUAL REMOVAL UNDER GA after urinary catheterization. • Placenta partially separated- • A whole placenta is retained • Resuscitation and manual removal under GA after urinary catheterization and antibiotics
- 37. • If there are retained fragments • Curettage with blunt instruments under GA under antibiotics cover • 3- trapped placenta- • Trapped cervix (closed cervix) • Give uterine relaxants, IV glyceryl trinitrate and controlled cord traction. • If unsuccessful, then manual removal under Ga
- 39. THROMBIN • Coagulation disorders , a rare cause of post-partum hemorrhage are unlikely to respond to the measures described above. • Most coagulopathies are identified before delivery allowing for advance planning preventing PPH
- 41. SURGICAL TREATMENT OF PPH Surgical approach to treatment options are considered when conservative treatments fails Depends on: • Extent & cause of haemorrhage • General condition of patient • Future reproduction desire • Experience & skill of Surgeon
- 42. SURGICAL TREATMENT OF PPH (Contd) • Repair of trauma (if any) • Intrauterine balloon tamponade (Foleys catheters) • Pneumatic Anti-Shock Garment (PASG • Uterine Artery ligation • Utero ovarian Artery Ligation • Internal Iliac Artery Ligation • Brace suturing of Uterus (B-Lynch) • Hysterectomy • Angiographic embolisation
- 43. TREATMENT OF PRIMARY PPH (Contd) • Intrauterine Balloon tamponade include: SOS Bakri, Sengstaken blakemore, Rusch balloon, Foley’s catheter and Condom catheter • It is an effective first line surgical measure in cases of uterine atony, after exclusion of retained product. An USS guided insertion of the balloon maybe performed to ensure correct position, followed by filling it with 200-600mls of warm water or saline depending on the size of the uterine cavity. • The reported success rates are between 70% and 100%. • It is reported that 80-85% of patients will avoid the need for laparotomy. • Different types of balloons have been used, including Segstaken Blakemore tube, Rusch urological balloon and Barki balloon have been used.
- 46. FEW COMPLICATIONS OF PPH • Haemorrhagic shock & DIC • Renal Failure • Puerperal sepsis • Lactation failure • Blood transfusion reaction • Thromboembolism • Sheehan’s syndrome
- 47. PPH PREVENTIVE MEASURES • Regular & Diligent ANC • Antepartum correction of anaemia • Identification of high risk cases • Delivery in hospital with facility for Emergency Obstetric Care. • Availability of functional Ambulances to transfer high risk cases to higher level of care facility • Local/Regional anaesthesia in place of halogenated GA, as appropriate • ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR • 4th Stage of labour - Observation, Oxytocin infusion postpartum (as indicated)
- 48. Conclusion • Post partum hemorrhage , defined as the loss of more than 500mls of blood after delivery. • It occurs in about 25% of child birth. • Uterine atony is responsible for most cases and can be managed with uterine massage in conjunction with oxytocin, prostaglandins and ergot alkaloids. • The best preventive strategy is active management of the third stage of labor • DILIGENT RISK IDENTIFICATION & ANTICIPATION, WITH PROMPT MULTIDISCIPLINARY INTERVENTIONS CAN REDUCE SIGNIFICANTLY the outcomes of PPH.
- 49. THANK YOU FOR LISTENING
- 50. FURTHER READING • Theunissen, F.J., Chinery, L. and Pujar, Y.V. Current research on carbetocin and implications for prevention of postpartum haemorrhage. Reprod Health 2018: 15 (Suppl 1): 94 • FIGO recommendations on the management of postpartum hemorrhage. 2022. Int J Gynecol Obstet. 2022;157(Suppl. 1):3–50 • Gungorduuk K, Asicioglu O, Besimoglu B, Guungorduuk OC, Yildirm G, Ark C, et al. Using intraumbilical v.ein injection of oxytocin in routine practice with active management of the third stage of labor: a randomized controlled trial. Obstet Gynecol. 2010 Sep. 116(3):619-24 • WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017; 389(10084): 2105– 16. • Nguyen Toan Tran, Catrin Schulte-Hillen, Sarah Bar-Zeev, Agnes Chidanyika, Willibald Zeck. How to use heat-stable carbetocin and tranexamic acid for the prevention and treatment of postpartum haemorrhage in low-resource settings. BMJ Global Health 2022;7:e008913 • World Health Organization. Updated WHO Recommendation on Tranexamic Acid for the Treatment of Postpartum Haemorrhage. 2017. • Haleema Shakur-Still, Ian Roberts, Stanislas Grassin-Delyle, Rizwana Chaudhri, Amber Geer, Monica Arribas, Elodie Lamy, Raoul Mansukhani, Mwansa Ketty Lubeya, Kiran Javaid et al. Alternative routes for tranexamic acid treatment in obstetric bleeding (WOMAN-PharmacoTXA trial): a randomised trial and pharmacological study in caesarean section births. BJOG. 2023;00:1-10