Postpartum Hemorrhage: What Does The Evidence Show?

MAJ Katrina Walters 4 April 2011

The Impact of PPH

Worldwide a woman dies every 4 minutes from PPH Top 5 reasons for maternal morbidity Affects 1 to 19% of deliveries Incidence is increasing in high resource countries
(BMC Pregnancy & Childbirth 2009; 9:55.)

Complications of PPH
Anemia PP Depression
(J Nutr 2003 DEC; 133(12):4139)

Acute Renal Failure, Myocardial Infarction, ARDS, Shock Transfusions/ Surgery Sheehans Syndrome Death

Outline
Definitions Etiology/ Risk Factors Prevention through Active Management Initial Management Advanced Techniques Blood Product Utilization Summary

Definitions (1 of 2)
Multiple and problematic Traditional > 500ml for Vaginal Delivery > 1000ml EBL Cesarean section Excess bleeding + s/sx hypovolemia

Gabbe, CH 18

Definitions (2 of 2)
Drop in Hct of 10% after delivery Hct not a clear indicator of acute status Primary vs. Secondary Early vs. Late Severe PPH Recognition may be hampered by occult bleeding

Etiology
Bleeding from Placental Implantation Site Trauma to Genital Tract Coagulation Defects

The 4 Ts of PPH
CAUSE TONE TRAUMA Atony Lacerations, hematoma, inversion, rupture Retained placenta, invasive placenta Coagulopathies INCIDENCE (APPROX) 70% 20%

TISSUE THROMBIN

10% 1%

Am Fam Physician 2007; 75:875.

Bleeding from Placentation Site (Risk Factors)

Uterine Atony Halogenated hydrocarbon GETA Hypotension Overdistended uterus Exhausted myometrium Prior Uterine atony Retained Placental Tissue Abnormal placentation Succenturiate (Extra) Lobe

Trauma to Genital Tract (Risk Factors)

Episiotomy/ Lacerations Instrumented Delivery Compound Fetal Presentation Surgical Delivery Hematomas Uterine Inversion Uterine Rupture Prior uterine scar High parity Hyperstimulation Obstructed labor Midforceps rotation Intrauterine manipulation

Coagulation Defects (Risk Factors)

Abruption Prolonged retention of dead fetus Amniotic fluid embolism Massive transfusions Severe Pre-eclampsia/ Eclampsia Congenital Coagulopathies Anticoagulant Rx Sepsis Saline Induced Abortions Placental Abruption

Other Risk Factors (1 of 2)

Previous PPH 14.8% with 2nd Pregnancy 21.7% with 3rd Pregnancy 10.2% with 3rd if PPH in 1st but not 2nd pregnancy
(Med J Aust 2007 Oct 1; 187(7):391)

Prolonged 3rd Stage

Other Risk Factors (2 of 2)

Small Maternal Blood Volume Small Stature Hypervolemic constricted states (Preeclampsia) Obesity Native Americans, Hispanics, Asians Epidural Anesthesia Nulliparity Women with female genital mutilation
(Lancet 2006JUN3; 367 (9525):1835)

Risk Factor Identification

Small proportion with RF develop PPH and many women without RF have PPH Consider early Type and Screen/Cross for RF

Prevention through Active Management of Third Stage (1 of 3)

SOR B Shifting Definition/ Components Uterotonics + Early Cord Clamp + Cord Traction (NNT = 12)
(Cochrane Database Sys Rev 2010;7:CD007412)

Uterotonics + Cord Traction + Fundal Massage

Prevention through Active Management of Third Stage (2 of 3)

Prophylactic Pitocin (SOR A)
(Cochrane Database Sys Rev 2001; 4: CD001808)

Does timing matter?

(Cochrane Database Sys Rev 2010; 8: CD006173)

Are other uterotonics as effective? (SOR B)

(Cochrane Database Sys Rev 2007; 2:CD005456.)

Cord Traction
(Am J Obstet Gynecol 1997 Oct;177(4):770, Repro Health 2009; 6:2)

Uterine Massage after Placenta Delivery

(Cochrane Database Syst Rev 2008 Jul16; 3:CD006431)

Prevention through Active Management of Third Stage (3 of 3)

Early Cord Clamping
(Pediatrics 2006 APR; 117(4):e779)

Cord Drainage
(Cochrane Database Sys Rev 2005; 4: CD004665.)

Fundal Pressure vs. Cord Traction

(Cochrane Database Sys Rev 2007; 4: CD005462)

Other Prevention Stategies

Tranexamic Acid
(Cochrane Database Sys Rev 2010 JUL7; 7: CD007872)

Avoid Routine Episiotomy (SOR A)

(Cochrane Database Sys Rev 1999;3:CD000081)

Continuous Presence of Midwives Xuesaitong

(Zhongguo Zhong Xi Yi Jie He Za Zhi 2002 MAR; 22(3):182 [Chinese])

Initial Management of PPH (1 of 2)

Recognize PPH Delay in initial care increases risk of severe PPH
(Obstet Gynecol 2011 JAN;117(1):21)

Fundal Massage Intravenous Access Follow local protocols if available (SOR B)

(BJOG 2004 May; 111:495, BJOG 2010; 117:1278)

Initial Management of PPH (2 of 2)

Treat Uterine Atony since this is most common cause for PPH Uterotonics (SOR C) Pitocin Ergot Alkaloids Prostaglandins

Uterotonics
Pitocin
(Obstet Gynecol 2001; 98:386)

Methergine Hemabate
(AM J Obstet Gynecol 1990 JAN;162(1):205)

Misoprostol (SOR B) Route?

(BJOG 2004;112:547)

Is it effective?
(Cochrane Database Syst Rev 2007;1:CD003249)

Does the order matter?

Pitocin
Dose/ Route Cost Mechanism ContraIndications Onset Duration

10U IM 10-40U in 1L NS over 10min

$85

Increased contractions by increasing intracellular Calcium

3-5 min IM IV Immediate

2-3 hours 1 hour

Methergine
Dose/ Route 0.2mg IM Q24 hours Oral 0.2mg Cost Mechanism Contraindications Hypertension Scleroderma, Raynauds Oral5-10 min Onset Duration

$11 per Uterine ampule Smooth muscle contraction > Vasoconstrict $1.60 per tab

IM2-5 min

3 hours

Hemabate
Dose/ Route 0.25 mg IM Q15min to max dose of 2mg Cost Mechanism ContraIndications Onset Duration

$49 per dose

Prostaglandin Asthma affect on myometrium, also affects arterioles and bronchioles

2-5 min

2 hours

Cytotec
Dose/ Route Cost Mechanism ContraIndications Onset Duration

200 1000 mcg

$0.60 per tab

Prostaglandin affects in myometrium

SL > Oral > Vaginal / Rectal

Vaginal/ Rectal > SL/Oral

Oral SL PR Vaginal

3-6 hours

Unresponsive to Uterotonics
Bimanual Uterine compression HELP! (OB, Anesthesia, Nursing, OR) 2nd Large Bore IV Fluids + Blood Products

Anderson JM, AFP 2007

Unresponsive to Uterotonics
Look for other causes! (SOR C) Explore uterus for retained products Inspect cervix and vagina Incise and Evacuate Large Hematomas (SOR B)
(South Med J 1987 AUG;80(8):991)

Consider Type and Cross Place a Foley catheter to monitor Is/ Os Labs for coagulopathy

Uterine Tamponade
Bakri Balloon Foley, BT-Cath, SengstakenBlakemore Tube Gauze Packing
(Obstet Gynecol Survey 2007; 62(8): 540)

Jacobs AJ, Up to Date 2009

External Aortic Compression Device

Shorter time to bleeding stopped Decreased units of blood transfused Decreased need for additional uterotonics No increased morbidity or mortality
(J Obstet Gynaecol Res 2009 JUN;35(3):453)

Uterine Artery Embolization

Requires available facilities/ personnel Hemodynamically Stable Patient Temporizing measure en route to OR Fertility Effects
(Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992)

Surgical Intervention (1 of 4)

Gabbe, Ch 18

Surgical Intervention (2 of 4)

Gabbe, Ch 18

Surgical Intervention (3 of 4)

Surgical Intervention (4 of 4)

Recombinant Activated Factor VII

Initiates coagulation at site of tissue injury via tissue factor Used for massive hemorrhage $$$ Observational reports of 80% success rate but only used when all other measures short of hysterectomy failed
(Obstet Gynecol 2007; 110:1270)

SOR C

Blood Product Utilization

Local protocols are helpful Dont wait for lab abnormalities if actively bleeding! Massive hemorrhage without replacement of coagulation factors (FFP) will result in coagulation abnormalities

Blood Product Utilization

Product Contents Volume Effect

Whole Blood
PRBCs Platelets

500ml
RBCs, WBCs, few 300ml plasma proteins Pooled concentrate 1 unit = 6 pack Fibrinogen, ATIII, clotting factors, plasma Fibrinogen, Factor VIII, XIII, vWF 50ml

Hct 3%
Hct 3%, less fever PLT 5-10K

FFP

250ml

fibrinogen 510mg/dl fibrinogen 510mg/dl

Cryoprecipitate

40ml

Blood Product Utilization

Active Bleeding and Hct < 25 = PRBCs PLT < 100K or massive transfusion = Platelets Fibrinogen < 125 = cryoprecipitate/ FFP Massive bleeding or INR > 1.5 = Fresh frozen plasma No consensus on ratio of RBC:FFP:PLT
(J Trauma 2007; 62:307, J Trauma 2006; 60:S51)

Refusal of Blood Products

Jehovahs Witnesses 44-fold increased risk of death
(Am J Obstet Gynecol 2001 Oct;185(4):893)

Intraoperative Blood Salvage and Autotransfusion Optimize pre-delivery Hgb Gluten as volume expander Hyperbaric Oxygen

Summary
Active Management of Third Stage of Labor is imperative Always be prepared for PPH, risk factors are not always present and prevention doesnt always work Focus on the basics, dont forget fluid/ blood product replacement Bakri Balloon and Uterine Artery Embolization may be temporizing measures available on the way to the OR