Postpartum Hemorrhage: a practical guide - M. El Sherbiny, MD

August 17, 2011

DEFINITIONExcessive blood loss sufficient to affect the general condition of the mother.INCIDENCELow parity 0.3%Para 4 or > 2%Babiszki et al, 1999

Postpartum Hemorrhage: A Practical Guide - Dr. Mohamed El Sherbiny, MD
Obstetrics & Gynecology
Senior Consultant, Damietta General Hospital
Damietta Egypt

DEFINITION
Excessive blood loss sufficient to affect the general condition of the mother.

INCIDENCE
Low parity 0.3%
Para 4 or > 2%

Babiszki et al, 1999

POSTPARTUM HEMORRHAGE

Primary  within 24 hours
Secondary ( After 24 hours *42 D


Postpartum Hemorrhage
Account 30% of M. mortality worldwide

Uterine Atony  90%
Retained Placenta  3-4%
Genital Tract Trauma  6%
Uterine inversion 
Coagulation Disorders 


Genital Tract TraumaUterine rupture
Episiotomy
Cervical Tear
Vaginal Tear
Vulval & perineal Tear

Broad Ligament Hematoma
Vulvovaginal Hematoma

Prevention
Identification of risk factors
Proper management of 3rd stage

Risk Factors
•Age >35 y & High parity.
•Previous repeated CS.
Previous postpartum hemorrhage.
Anemia or Coagulation disorders.
•Uterine overdistension & fibroids.
Antepartum hemorrhage.

Risk Factors
Certain drugs e.g., halothane, tocolytics
• Prolonged labor
• Traumatic delivery
• Complications of 3rd stage labor

Patient with predisposing risk factors:
1 - They should be monitored closely.
2 - Blood should be available at delivery

MANAGEMENT OF THIRD STAGE

Routine 'active management' is superior to 'expectant management'.
Active management is, however, associated with an increased risk of unpleasant side effects and hypertension, where ergometrine is used.
Prendiville et mal, (Cochrane 2000 Review). In: The Cochrane Library. 3, 2002. Oxford: Update Software.

Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital.

Prostaglandins & 3rd Stage
• Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the active management of the third stage of labour especially for low-risk women.
Glmezoglu et al., 2002 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.

Misoprostol & 3rd Stage
For the prevention of postpartum hemorrhage Oral Misoprostol Alone is:
• 1-As effective as oxytocin alone.
• 2-Less effective than oxytocin + methylergonovine maleate
• 3-Less effective than oral misoprostol + oxytocin.
Caliskan et al, Obstet Gynecol. May 2003; 101(5 Pt 1):921-8. RCT1574

Misoprostol & 3rd Stage
Misoprostol administered rectally is associated with lower peak levels and a reduction in adverse effects (Shivering) compared with the oral route. Increasing rectal doses may achieve higher efficacy without reducing the acceptability of the treatment.
Khan & El Refay Obstet Gynecol. May 2003;101(5 Pt 1):968-74

Misoprostol + Oxytocin
Rectal Misoprostol + Oxytocin
Are going to be the line of choice for management of third stage

POSTPARTUM HEMORRHAGE
MANAGEMENT

Management of Hemorrhagic Shock
Physical examination and resuscitation must be done simultaneously

Management of Hemorrhagic Shock: 2 Basic Goals
1-Restoration of blood volume with adequate oxygen-carrying capacity. (Hemodynamic Resuscitation)
2-Definitive treatment of the underlying disorder (Medical & Surgical)

1-Restoration of blood volume with adequate oxygen-carrying capacityACUTE CARE
-Large 2 gauge IV
-Lab studies
-Airway assessment
-Aspiration prophylaxis
-Supplemental O2Hemodynamic assessment
-Urinary catheter
-CVP catheter & Arterial cath.
-Arterial blood gases

Hemodynamic resuscitation
-Crystalloid
-Colloid (Hetastarch)
-Blood transfusion
Treatment of coagulopathy & Complications

Hemodynamic Assessment
• Urine output maintained greater than 30 ml/hr.
• If urine output is not maintained, CVP is placed.
• If left ventricular function is questioned, or urine output is inadequate despite adequate CVP pressure, a Swan-Ganz catheter should be placed.

The priorities in hemodynamic resuscitation include:
1-Restoring blood volume.
2-Restoring hemoglobin concentration.
3-Restoring coagulation.

ESTIMATION OF BLOOD LOSSVisual Inspection: The most often used but is inaccurate. It is about 50% of the true loss.
Hematocrit: It needs 4 h for significant changes and 48 h for complete compensation.
Urine output: It is one of the most important parameters. Renal blood flow is especially sensitive to blood volume changes.

HYPOVOLEMIC SHOCK
Crystalloid Versus Colloid Solution.
There is a excessive mortality (5%) in patients resuscitated with colloid compared with crystalloid.
Schlerhout and Roberts, The Cochrane injuries Group Albumin Reviewers (1998). ; (1998) Bonnar (2000)

HYPOVOLEMIC SHOCK
During the wait lactated Ringer (3ml for every one ml of blood lost) is given

HYPOVOLEMIC SHOCK
Blood alone Versus Blood + Lactated Ringer
Survival was higher (4-6%) when blood and lactated Ringer solution is administered compared with blood alone (replacement of extracellular fluid) (Barber et al, 1999)

Whole Blood Vs Component therapy
Component therapy provides better treatment because only the specific component needed is given. National Institutes of Health (1993)
Whole blood is needed when acute hemorrhage is catastrophic. (Klein, 1994, Schwartz, 1994).


American association of blood bank 1994

Coagulopathy
• Dilutional coagulopathy (the commonest).
• DIV coagulopathy
Abruptioo placenta. IUFD. Septecemia. A F embolism.

Diagnosis:Clinical: Excessive bleeding at puncture site. Continuous oozing at wound sites.
Laboratory: Fibrogen, Fibrin & FDP, platelet
Prothrombin & Partial TT
Cunningham et al, 2001

Coagulopathy: Treatment
Treatment must be directed to the cause to reverse defibrination.
Component replacement therapy (Fresh frozen plasma and platelets)
Heparin infusion to block DIV clotting is dangerous and should not be given.
• Only indication is IUFD without bleeding just before delivery.
• (Epsilon Aminocaproic Acid or Tranexamic acid their use in most cases of obstetrical coagulopathy is not recommended. Accumulation of fibrin polymer could lead to organ ischemia and infarction.
Cunningham et al, 2001

Definitive treatment of the underlying disorderMEDICAL
Oxytocin, Ergometrine, Prostaglandin, (PGE2, PG 15-methyl F2a, PG F2-a, PGE2(Misopristol))

Surgical
Homeostasis & Repair of GT, Bilateral Uterine artery ligation
Stepwise uterine devascularization, B-Lynch suture, Internal iliac ligation, Hysterectomy, Procedures for L. segment bleeding

Postpartum Hemorrhage
30 u oxytocin in 1000 mL lactated Ringer
Firm fundal massage

Before delivery of the placenta:
Contracted cervix, Partial separation, Placenta Accreta

After delivery of the placenta
Uterine Atony, Genital Tract Trauma, Uterine inversion, Coagulation Disorders

Postpartum Hemorrhage Before delivery of the placenta
Fundal massage & Oxytocin infusion

Manual removal of the placenta

Postpartum Hemorrhage after delivery of the placenta
Firm fundal massage & Oxytocin infusion

Bimanual compression of the uterus


Uterine Ecobolics
In addition to the infused oxytocin
1- Methergine (Methyl Ergometrine): IV or IM 0.2-0-4 mg (hazard of Hypertensive crisis)
2- Prostag. F2 a Enzaprost: 5 mg Infusion or IU.
3- Prostag. E1 analogue: Misoprostol (Cytotic, Mesotac)
1000g (5 Tab) rectally

Rectal Misoprostol
Rectal misoprostol in a dose of 800 micrograms could be a useful 'first line' drug for the treatment of primary postpartum haemorrhage.
Mousa & Alfirevic (Cochrane Review October 2002). In: The Cochrane Library. Issue 3, 2003. Oxford: Update Software.

Rectal Misoprostol
Further randomised controlled trials are required to identify the best drug combinations, route, and dose for the treatment of postpartum haemorrhage.
Mousa & Alfirevic (Cochrane Review October 2002). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.

Surgical Treatment
1- Traumatic hemorrhage.
2- Atonic hemorrhage.
3- Bleeding from Lower U. segment: especially with accreta.

Surgical Treatment1- Traumatic hemorrhage:
•Homeostasis & Repair of the genital tract
•Bilateral Internal iliac ligation for multiple cervical tear or broad ligament hematoma, rupture uterus with inaccessible U. artery.
•Angiographic arterial emobolization

Surgical Treatment cont.2- Atonic hemorrhage:
•Bilateral Uterine artery ligation (85%)
•Stepwise uterine devascularization (almost 100)
•B-Lynch suture (100% ?)
•Bilateral Internal iliac ligation (65%)
•Hysterectomy (subtotal)

Surgical Treatment cont.3- Bleeding from Lower U. segment (especially with accreta):
1- Over sewing of the placental site
2- Low & high bilateral uterine vessels ligation (Stepwise 1-3)
3- Longitudinal lateral mattress sutures at the site of bleeding of both uterine walls
4- Circular interrupted sutures around the bleeding area on the serosal surface
5- Bilateral Internal iliac ligation.
6- Hysterectomy: almost total
7- Tight uterine packing.

Stepwise uterine devascularization for intractable hemorrhage
This technique entails five
successive steps (using chromic catgut 1 with Mayos needle), if bleeding is not controlled by one step the next step is taken until bleeding stops.
The procedure was effective in all 103 (100%) cases.
Abdrabbo, 1994, Am J Obstet Gynecol. 171:694-700

Stepwise uterine devascularization
The steps were
(1) unilateral uterine vessel ligation.
(2) Bilateral uterine vessel ligation.
(3) Low uterine vessel ligation.
(4) Unilateral ovarian vessel ligation.
(5) Bilateral ovarian vessel ligation.

Abdrabbo, 1994, Am J Obstet Gynecol. 171:694-700

Stepwise uterine devascularization
Step (1) Unilateral uterine vessel ligation
Through a vascular area in the broad ligament from anterior to posterior, then forward through myometrium 2cm medial to the uterine border. Performed alone only for CS.

Step (2) Bilateral uterine vessel ligation.
Performed for vaginal delivery or CS not responding to step 1.
Step 1 & 2 are at the level of the upper part of L. Segment (No bladder mobilization) or below the CS incision.

Stepwise uterine devascularization
At the lower part of LS after bladder dissection at this level ligation is done after cervicovaginal branch was turned upward along the uterine margin.
It is reserved for LS bleeding (usually due to P.previa or low P.accreta) and not responding to step 2.
Abdrabbo, 1994, Am J Obstet Gynecol. 171:694-700

Stepwise uterine devascularization
Through a vascular area in the infandibulo-pelvic ligament from anterior to posterior, inferior to and including the ovarian vessels.
Indicated in continued bleeding after step 1 & 2.

Step (5) Bilateral ovarian vessel ligation.
Indicated in continued bleeding after step 4.
Abdrabbo, 1994, Am J Obstet Gynecol, 171:694-700

The B-Lynch technique (brace suture) for intractable hemorrhage.
It may be particulary useful because of its simplicity of application, life saving potential, relative safety, and its capacity for preserving the uterus and thus fertility.
The B-Lynch, 1997 BJ of Obstet and Gynaecol, 104: 372-375

Description of B-Lynch technique
Lloyd Davies position for access to the vagina.
A lower segment incision is made.
Bimanual compression is first tried to assess the potential chance of success if vaginal bleeding is controlled.
No 2 chronic catgut with 70 mm round needle is used.


B-Lynch technique

Description of B-Lynch technique
13- For a major placenta praevia an independent figure of eight suture is placed at the beginning anteriorly or posteriorly or both prior to the application of the B-Lynch suturing technique if necessary.
The B-Lynch, 1997 B J of Obstet and Gynaecol, 104: 372-375

Placenta Previa with Prior Uterine Incisions: Effect on Incidence of Placenta Accreta

Number of Prior Uterine Incisions 
0 5
1 24
2 40
3 47
4 67

Obstet Gynecol 66:89-92, 1985.

Placenta accreta, increta and percreta
A placenta previa with previous CS should be considered of having a morbidly adherent placenta. Particular attention should be focused to confirming or excluding this diagnosis using U/S. When present, senior anaesthetic and obstetric input are vital in planning the delivery.
RCOG guidelines Grade B Evidence base Level III

Placenta previa accreta.
(Increta or Percreta) with severe bleeding
Direct pressure with warm packs and oxytocics
1-Oversewing of the placental site
2-Low & high bilateral uterine vessels ligation (Stepwise 1-3)
3-Longitudinal lateral mattress sutures at the site of bleeding of both uterine walls

Longitudinal lateral mattress sutures at the site of bleeding of both uterine walls

Placenta previa accreta (Increta or Percreta) with severe bleeding
4- Circular interrupted sutures around the bleeding area on the serosal surface
5- Bilateral Internal iliac ligation.
6- Hysterectomy: almost total
7- Tight uterine packing.

Placenta previa & accreta with previous CS
Circular Interrupted suture: An interrupted 2-3-cm sutures (chromic o) at 1-cm intervals
Arranged in a circle around the bleeding area on the serosal surface. They were placed as deeply to reach the endometrium.

Bilateral Internal iliac Artery Ligation.
It is indicated mainly for:
• Large broad ligament or lateral pelvic hematoma
• Multiple cervical tears.
• L. segment bleeding or atonic pp as a last resort.
It is less effective than B uterine artery ligation or for atonic hemorrhage.

Post Hysterectomy Bleeding
• Diffuse post hysterectomy bleeding may be controlled by abdominal packing to allow time for normalization of the woman's haemodynamic and coagulation status.
• Specific vessels which haemorrhage persistently may be controlled with embolization procedures. (II-3)

LATE POSTPARTUM HEMORRHAGE
It is often the result of abnormal involution of placental site rather than retained placental fragment

Treatment
Cochrane Library
• No information is available from RCT to inform the management of women with secondary postpartum haemorrage.
• A well designed RCT comparing the various drug therapies against each other and against placebo or no treatment groups is needed.
Alexander et al., November 2001 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.
 

Treatment of late postpartum hemorrage
30-40 u oxytocin +1000 L.Ringer