1. Primary Postpartum Haemorrhage Max Brinsmead MB BS PhD May 2015

2. 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

3. 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

4. From the Cochrane Database Active vs Expectant Management of the 3rd stage of labour Now withdrawn as out of date Oxytocin vs Ergometrine Oxytocin vs Prostaglandins Uterine massage in preventing PPH

5. 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)

6. 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

7. 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

8. 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

9. NICE Guidelines (2007) for management of the 3 rd 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

10. 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

11. 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

12. 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

13. 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)

14. Uterine massage after delivery of the placenta… Only one study of 200 patients and that was with active management of 3 rd 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Intrauterine Balloon Tamponade BJOG 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

21. Questions concerning intrauterine balloon tamponade BJOG 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

22. 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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