Postpartum Haemorrhage

Definitions

• Primary PPH – blood loss of 500ml or more within 24hours of delivery.

• Secondary PPH – significant blood loss between 24 hours and 6 weeks after birth.

Why do we care?

Major obstetric haemorrhage – more than 1000ml

Very rapidly lead to maternal death

• 3rd highest cause of direct maternal death in the UK and Ireland (2003-2005)

• 58% of these cases care was “seriously substandard”

• Major cause of severe maternal morbidity in “near-miss audits”

Risk FactorsMost cases have no risk factors

• Previous PPH• Antepartum haemorrhage• Grand multiparity• Multiple pregnancy• Polyhydramnios• Fibroids• Placenta praevia• Prolonged labour (&oxytocin)

Prevention

• Be aware of risk factors – may present antenatally or intrapartum

• Treat anaemia antenatally• Active management of the 3rd stage• Prophylactic oxytocics reduce the risk of PPH by

60% (oxytocin or oxytocin & ergometrine)• 5IU IM for vaginal delivery• 5IU IV for LSCS• Consider oxytocin infusions

4 T’s

Tone

Tissue

Thrombin

Trauma

Causes

TonePrevious PPHProlonged labourAge > 40 yearsBig babyMultiple pregnancyPlacenta praeviaObesityAsian ethnicity

TissueRetained placenta/membrane/clot

ThrombinAbruptionPETPyrexiaIntrauterine deathAmniotic fluid embolism

DIC

TraumaCaesarean section(emergency > elective)Perineal traumaOperative deliveryVaginal and cervical tearsUterine rupture

• Blood loss is commonly underestimated

• Loss may be well-tolerated

• Beware the “trickle” and the “moderate lochia”

• Minor PPH can easily progress to major PPH.

Management

• Has the placenta been delivered and is it complete?

• Is the uterus well-contracted?

• Is the bleeding due to trauma?

Resuscitation

A & B – 10 -15l/min O2 by facemaskC - 2 14 gauge cannulae

blood for Hb, U&E, LFTs, clotting crossmatch 4 units 2 litres of crystalloid rapidly

transfuse as soon as possible – consider O – ve blood if any delays.

Uterine Contraction-First Line Drugs

• Oxytocin 5IU• Oxtocin infusion – 40IU in 500mls • Ergometrine 0.5mg• Carboprost (Haemabate©) 0.25mg IM every

15 minutes x 8 doses• Misoprostol 600 mcg sublingually

Uterine Contraction – non-pharm• Empty uterus• Foley catheter• Rub up a contraction• Bimanual compression• Balloon tamponade• Brace suture• Uterine artery ligation• Internal iliac artery ligation• Interventional radiology

• Hysterectomy – before it’s too late

B-Lynch Suture

Balloon Tamponade

Haematological Management

DIC• Transfuse without delay• Involve haematology service at an early stage• Correct coagulopathy• Liase with consultant haematologist re use of

recombinant Factor V11 (Novoseven©) and Fibrinogen.

• Traumatic for patient, family and staff.• Debriefing for patient and staff.• Case analysed to ensure care was of good

standard and any substandard care can be improved.

Secondary PPH

• Infection• Retained placenta• Trophoblastic disease• Antibiotics• Evacuation of retained products if bleeding

persistent or significant amount of tissue retained.