post partum hemorrhage
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Post Partum Hemorrhage
District I ACOG Medical Student Teaching Module 2010
Post Partum Hemorrhage - Definition
Commonly defined as….
SVD > 500cc blood loss
C/S > 1000cc blood loss
*PPH generally refers to GA >20wks
Other Definitions
Hematocrit Change – defined as change > 10% but not useful in acute setting
Need for Transfusion – variable practiceHemodynamic stabilityTiming – early or lateSymptomatic
Relevance
One of top five causes of maternal mortality anywhere
#1 cause maternal mortality worldwideDeveloped countries 1/100 000 births
compared to 1/1000 births in developing countries
Incidence 5% - 10% deliveries (depends on defn)
Physiologic Adaptations of Pregnancy
plasma volume 40-50% RBC 20-30%
*in severe PIH - hemoconcentration
Normal Mechanism of Hemostasis
‘Living ligatures’ – Baskett 2000Intrinsic vasospasmLocal decidual hemostatic factors
including tissue factor & type 1 plasminogen activator inhibitor
clotting factors (except I and XI)
Zymogens of Serine Proteases
Activities
Factor XII binds to exposed collagen at site of vessel wall injury, activated by high-MW kininogen and kallikrein
Factor XI activated by factor XIIa
Factor IX activated by factor XIa in presence of Ca2+
Factor VII activated by thrombin in presence of Ca2+
Factor Xactivated on surface of activated platelets by tenase complex and by factor VIIa in presence of tissue factor and Ca2+
Factor II activated on surface of activated platelets by prothrombinase complex
Cofactors Activities
Factor VIII activated by thrombin; factor VIIIa is a cofactor in the activation of factor X by factor IXa
Factor V activated by thrombin; factor Va is a cofactor in the activation of prothrombin by factor Xa
Factor III (tissue factor) a subendothelial cell-surface glycoprotein that acts as a cofactor for factor VII
Fibrinogen Activity
Factor I cleaved by thrombin to form fibrin clot
Transglutaminase Activity
Factor XIII activated by thrombin in presence of Ca2+; stabilizes fibrin clot by covalent cross-linking
Regulatory and other proteins
Activities
von Willebrand factorassociated with subendothelial connective tissue; serves as a brigde between platelet glycoprotein GPIb/IX and collagen
Protein C activated to protein Ca by thrombin bound to thrombomodulin; then degrades factors VIIIa and Va
Protein S acts as a cofactor of protein C; both proteins contain gla residues
Thrombomodulin protein on the surface of endothelial cells; binds thrombin, which then activates protein C
Antithrombin III most important coagulation inhibitor, controls activities of thrombin, and factors IXa, Xa, XIa and XIIa
Blood Loss Estimation
All studies show gross underestimation of blood loss at delivery
Visual estimation especially unreliable for small and large amounts of blood loss
Prasertcheroensuk et al (2000)
- 228 women in 3rd stage
- >500cc : visual (5.7%) actual (27.63%)
- >1000cc: visual (.44%) actual (3.51%)
***Incidence underestimated 90%
Primary, Early or Acute PPH
Delivery - < 24h PP90% PPH casesAssociated with more bleeding
Secondary or Late PPH
24h – 12 weeks postpartumAffects 1-3% of all deliveriesCommon causes include: - infection
- RPOC
- Abnormal uterine involution
Etiology
4 T’s
-Tone
-Tissue
-Trauma
-Thrombin
Uterine Atony
75-90% PPHMostly associated with 10 PPH6% after c/sRisk factors after c/s incl multiples,
Hispanic ethnicity, induced/augmented labor, macrosomia, and chorioamnionitis
Tissue
Retained placenta 10% PPH cases10% placenta’s have fundal implantationPlacenta accreta 0.005% of all deliveries90% of accreta’s have PPH and 50% of
these have hyst
Trauma
10 cause PPH in 20% casesInjury to genital tract during delv OR 1.765% uterine inversions have PPH48% uterine inversions have bld
transfusion
Thrombin
1% cases of PPHKnown association with coagulation failure - abruption - PIH - sepsis - IUFD - incompatible blood - abortion
Risk Factors in PPHEtiology Process Clinical Risk Factors
Tone Overdistended Uterus Polyhydramnios, Multiple Gestation
Macrosomia
Uterine Muscle Fatigue Rapid Labor, Prolonged Labor
High Parity
Intra Amniotic Infection Fever, Prolonged ROM
Functional/Anatomic Distortion of the Uterus
Fibroid Uterus
Placenta Previa
Uterine Anomalies
Tissue Retained Products
Abnormal Placenta
Incomplete Placenta at Delivery
Previous Uterine Scar
High Parity
Retained Blood Clots Atonic Uterus
Trauma Lacerations Precipitous or Operative Delivery
Extensions at C/S Malposition, Deep Engagement
Uterine Rupture Previous Uterine Surgery
Uterine Inversion High Parity, Fundal Placenta
Thrombin Pre-existing Coagulopaties, Liver Disease
Acquired in Pregnancy ITP, DIC
Therapeutic Anti-coag History of clots
Factors Associated With PPH
Retained Placenta (OR 3.5)Failure to Progress 2nd Stage (OR 3.4)Placenta Accreta (OR 3.3)Lacerations (OR 2.4)Instrumental Delivery (OR 2.3)Large For GA Newborn (OR 1.9)Hypertensive Disorders (OR 1.7)Induction of Labor (OR 1.4)Augmentation of Labor With Oxytocin (OR 1.4)
Factors Associated With PPH
DM – 30-35% compared to 5-10%Inherited coagulopathies
– most common is VWB (1-3% prevalence)
- 70% have type 1 (↓ factor VIII, ↓ vW Ag,
↓ vW factor activity)
- risk PPH 22% with vWD & 18% hemophilia
Additional Risk Factors
Age > 35yAsian or Hispanic ethnicityObesityPost dates > 42 wksPrevious PPHPlacenta Previa
Key Management Issues
PreventionEarly RecognitionImmediate Appropriate Intervention
Blood Loss Signs & Symptoms
Blood Loss (%) Blood Pressure
Signs & Symptoms
500-1000ml (10-15) normal Palpitations, dizziness, tachycardia
1000-1500ml (15-25) Slightly low Weakness, sweating, tachycardia
1500-2000ml (25-35) 70-80 Restlessness, pallor, oliguria
2000-3000ml (35-45) 50-70 Collapse, air hunger, anuria
>2500cc blood loss – 50% mortality if not managed urgently & appropriately
Initial Management
ABC’sCall for helpMobilize team (staff, anesthesia, blood bank etc)IV accessFluid resuscitationExamine patient including fundal massage, dx
trauma/ inversion/ other etiologies, and fundal massage
Foley catheterBlood work (CBC, coag profile, cross match)Reverse coagulation abnormality
Uterotonic Medications
OxytocinErgotHemabateMisoprostolVasopressin
Drug Therapy For PPH
Drug Dose Side Effects ContraindicationsOxytocin 10 IU IM/IMM
5 IU iv bolus
10-40 IU/L
-Usually none
-ctx
-N&V
-water intoxication
-hypersensitivity
Ergot 0.25mg IM
0.125 mg IV
Q5mins X 5 doses
-peripheral vasospasm
-HTN
-N&V
-HTN
-peripheral disease
-Raynauld’s
-hypersensitivity
Hemabate
(PGF2α)
0.25 mg IM/IMM
Q15mins X 8 doses
-flushing
-diarrhea/N&V
-O2 desats
-bronchospasm
-restlessness
-hypersensitivity
-asthma
-active cardiac, pulmonary, renal, or hepatic disease
Misoprostol
(PGE1)
400-1000mcg PR/PV/PO X 1 dose
-pyrexia/flushing
-N&V/diarrhea
-abd pain
-HA
-hypersensitivity
-pregnancy
Vasopressin 20U/100ml saline
Inject 1ml at bleeding site
-acute HTN
-bronchospasm
-N&V/cramps
-HA, vertigo
-angina
-death if iv
-coronary artery disease
-hypersensitivity
Surgical Management
CurettageEmbolizationTamponade (Balloon, packing etc…)Compression suturesVessel ligationHysterectomy
Tamponade
Bakri Balloon
- Silicone balloon - 500cc capacityFoley catheter with 30cc balloonSengstaken-Blakemore BalloonVaginal packingSaline filled glove
B-Lynch Suture
Vessel Ligation
Vessel Ligation
Uterine - O’Leary Stitch
- Chromic 0 passed through lateral aspect of lower segment as close to cervix as possible and then through broad ligament lateral to vessels
Ovarian - distal to cornua by passing suture through myometrium medial to
vessels
Recombinant Activated Factor VIIa
Tx of bleeding disordersDose up to 120mcg/kg q2h until
hemostasisPromising but needs more studies$10,000/mgRisk thromboembolism
Step 1 – Initial Assessment
Resuscitation-Large bore iv’s-O2-Vitals-±foley catheter
Dx Etiology-explore uterus (tone/tissue)-explore genital tract (trauma)-review history (thrombin)-observe clots
Labs-CBC-coag profile-cross match
Step 2 – Directed Therapy
Tone-massage-compress-drugs
Tissue-manual removal-curettage
Trauma-correct inversion-repair laceration-identify rupture
Thrombin-reverse anticoagulation-replace factors
Step 3 – Intractable PPH
Get Help-OB/Surgery-Anesthesia-Lab/Blood Bank-ICU
Local Control-manual compression-±pack uterus-±vasopressin-±embolization
BP and Coagulation-crystalloids-blood products
Step 4 - Surgery
Repair Lacerations Ligate Vessels-uterines-ovarian-internal iliac
Hysterectomy
Step 5 – Post Hysterectomy Bleeding
Abdominal Packing Embolization
Secondary PPH
Generally less bleedingMostly related to infection or RPOCNo RCT’sAbx/uterotonics as appropriateEvacuation
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