Primary Postpartum Haemorrhage

Max Brinsmead MB BS PhDMay 2015

Introduction

The average gravida carries 1 - 1.5 l of “extra blood” in pregnancy as prophylaxis against PPH but…

PPH is still the major cause of obstetric death especially in developing countries

10 - 15% of women lose >600 ml of blood at delivery and…

For 1 - 2% the blood loss can be life threatening

This presentation will address…

Current guidelines for the management of the third stage of labour and their evidence base

Emergency (First aid) and

Advanced Measures for the management of excessive blood loss in the first 24 hours after birth

From the Cochrane Database

Active vs Expectant Management of the 3rd stage of labour

• Now withdrawn as out of date

Oxytocin vs Ergometrine

Oxytocin vs Prostaglandins

Uterine massage in preventing PPH

Active vs Expectant Management of 3rd Stage Labour

4 studies - all in the UK

Active management associated with:

Reduced blood loss (-79 ml, CI 64-94 mls less)

Fewer PPH >500 ml (OR=0.34, CI 0.28-0.41)

Shorter 3rd stage (-3.4 min, CI 4.66-2.13 min less)

Active vs Expectant Management of 3rd Stage Labour

For the individual patient this may mean:

If she declines the administration of an oxytocic drug she has a 1:6 chance of losing >500 ml blood

If she has an oxytocic drug this is reduced to a 1:20 chance of losing >500 ml blood

Active vs Expectant Management of 3rd Stage Labour

Active management is associated with:

Increased rate of maternal nausea & vomiting (OR 1.95, CI 1.58 - 2.42)

Increased rate of maternal hypertension

Delayed vs Early (within 60 sec) Cord Clamping

Is associated with: No difference in the rate of PPH (RR 1.22 CI

0.96–1.55)

Increased rates of jaundice requiring phototherapy

Neonatal advantages in terms of Hb levels and Ferritin up to 6 months of age

NICE Guidelines (2007) for management of the 3rd Stage

Active management is recommended i.e.• IM Oxytocin 10 IU• Early cord clamping• Cord traction

Women at low risk of PPH who elect to have physiological management should have their choice respected

Active management is required if• There is PPH• The placenta is not delivered within 60 min• Patient requests earlier intervention

Cord traction and uterine palpation should only be used after an oxytocic has been given

Syntometrine vs Syntocinon for 3rd Stage Labour

Use of Syntometrine results in:

Fewer PPHs (OR 0.74, CI 0.65-0.85)

BUT

More vomiting Greater risk maternal hypertension And greater risk of retained placenta

Prostaglandins for the Prevention of PPH

Injected PG s resulted in:

Reduced mean blood loss Shorter 3rd stage Non sigificant reduction in rate PPH but… Shivering (almost 20%) Diarrhoea Abdominal pain Increased cost

Rectal Misoprostol

PPH rate reduced from 7.0% to 4.8% (not significant in the study reported) but

Fewer side effects than after IM or oral use of PG’s

This drug is cheap and stable and could have an enormous impact on maternal mortality in developing countries

Carbetocin

Danseraua et al Am J Obstet Gynecol March 99

694 women in a Canadian multicentre trial One dose Carbetocin 100 ug cf 8 hour

Oxytocin infusion Outcome studied “additional oxytocic

required” Fewer patients requiring additional oxytocic

after Carbetocin (OR = 2.03, CI 1.1 - 2.8)

Uterine massage after delivery of the placenta…

Only one study of 200 patients and that was with active management of 3rd stage:

The rate of PPH was halved but not statistically significant

BUT Mean blood loss reduced by massage (-42 ml CI -8

to -75) Reduced need for extra oxytocic (RR 0.20 CI 0.08-

0.50) 2 transfusions required in the no massage group

Also from the Cochrane Database

No benefit from cord drainage

No benefit from umbilical vein injection of oxytocic

No benefit from early suckling

Chinese traditional medicine report pending

Risk factors for Primary PPH Prolonged labour APH Pre eclampsia Maternal obesity Multiple pregnancy Birth weight >4000g Advanced maternal age Previous PPH Assisted delivery Low lying placenta But >50% occur in women without identified risk factors

and… 90% are associated with uterine atony And all studies of massive PPH fail to identify consistent risk

factors

Patient Assessment

Objective measure of blood loss is desirable Postural hypotension the earliest sign Tachycardia is usual Air hunger and loss of consciousness is

serious Urine output a good measure of treatment CVP sometimes A bedside test of blood clotting desirable

Emergency Measures

Rub up a contraction Deliver the placenta

• If you can

Gain IV access (large bore cannula) Additional oxytocic

• IV Ergometrine 0.25 mg• Syntocinon infusion• Rectal Cervagem or Misoprostol

(Empty the bladder) Bimanual uterine compression Aortic compression

Advanced Measures 1

Get help Check coagulation - use

cryoprecipitate etc. EUA is mandatory Myometrial PG F2 alpha Uterine Packing

• Intrauterine balloon catheter Consider activated Factor VII

Intrauterine Balloon TamponadeBJOG Review May 2009 Was effective in 91.5% of cases

• Combined retrospective and prospective studies• But only a total of 106 patients

Types of balloons• Sengstaken Blakemore (GI use)• Rusch (Urological)• Foley (often multiple)• Bakri (Specifically designed for obstetrics)• Condom (+/- Foley)

But there remain many unanswered questions

Questions concerning intrauterine balloon tamponadeBJOG Review May 2009 Is it effective

• There are no RCTs Risks and contraindications Which balloon to use, how to insert it

and what volume to inflate it Is a vaginal pack required Is an oxytocin infusion required Antibioitics and analgesia When to deflate and or remove it

Advanced Measures 2

Get more help• Medical – haematologist• Surgical colleague• Radiologist for…

Uterine artery embolisation Laparotomy and…

B-Lynch suture Internal iliac artery ligation Aortic clamping Hysterectomy

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