Postpartum hemorrhage Felipe A. Medeiros Assistant Professor Department of Anesthesiology The University of Texas medical Branch March 14th, 2016

Overview Severe bleeding is the single most significant cause of maternal death worldwide More than half of all maternal deaths occur within 24 hours of delivery In addition to death, serious morbidity may follow postpartum hemorrhage (PPH): Adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis

Definition There is no single, satisfactory definition of postpartum hemorrhage Estimates of blood loss at delivery are notoriously inaccurate Diagnosis usually is based on subjective observations Estimated blood loss in excess of 500 mL following a vaginal birth or a loss of greater than 1,000 mL following cesarean birth A decline in hematocrit levels of 10%

Definition Early or primary PPH Late or Secondary PPH Within the first 24h of delivery More common – occurs in 4-6% of pregnancies Associated with greater degree of blood loss and morbidity Late or Secondary PPH Between 24 hours and 6–12 weeks postpartum Occurs in approximately 1% of pregnancies Often the specific etiology is unknown

Etiology Late PPH: **Early PPH: Uterine atony Lacerations of vagina and cervix Retained placental tissue—especially placenta accreta Coagulopathy Uterine inversion Late PPH: Infection Placental site subinvolution Retained placental fragments

Early PPH – Uterine atony Most common cause of severe PPH - accounts for 80% of cases Risk factors Uterine overdistention (polyhydramnios, multiple gestation, fetal macrosomia) High parity Precipitous or prolonged labor Intraamniotic infection Use of uterine-relaxing agents (terbutaline, magnesium sulfate, halogenated anesthetic agents, and nitroglycerin) Cesarean delivery Induced / augmented labor AMA Hypertensive disease Presentation: Postpartum bleeding Finding of the characteristic soft, poorly contracted uterus

Early PPH – Uterine atony Prophylaxis: ACOG recommends prophylactic administration of uterotonic agents to prevent uterine atony. Active management of the third stage of labor , including uterine massage and oxytocin administration, decreases blood loss and transfusion requirements compared with expectant management Treatment: Bimanual uterine massage Uterotonics Surgical management

Early PPH – Uterine atony / Uterotonics Dose and route Half- life Side effects Contra-indication Oxytocin 0.3-0.6 IU/min IV infusion > 6 min Tachycardia Hypotension Myocardial ischemia Free water retention None Ergonovine/ methylergonovine 0.2 mg IM May be repeated once after 1h 2-4h Nausea and vomiting Arteriolar constriction Hypertension Preeclampsia CAD 15-Methyl prostaglandin F 2α 0.25 mg IM May be repeated every 15 min up to 2 mg Fever, Chills Diarrhea Bronchoconstriction Reactive airway disease Pulmonary HTN Hypoxemia Misoprostol 600-1000 µg per rectum, sublingual, or buccal

Early PPH – Uterine atony Surgical treatment Intrauterine baloon tamponade Hypogastric artery ligation – rarely used Bilateral uterine artery ligation (O’Leary sutures) B-Lynch technique Hemostatic multiple square suturing (suturing both anterior and posterior uterine walls) Hysterectomy B-Lynch sutures

Early PPH – Lower genital tract lacerations Risk factors: Forceps delivery Vacuum extraction Fetal macrosomia Precipitous labor and delivery The use of episiotomy Presentation: Persistent bleeding in the presence of adequate uterine tone Pelvic pain and shock may be the only presenting signs and symptoms A retroperitoneal hemorrhage may occur after laceration of one of the branches of the hypogastric artery (usually following c-section)

Early PPH – Lower genital tract lacerations Treatment Packing the vagina Hemostasis and suture of lacerations Genital tract hematomas may present in the absence of laceration. Progressive enlargement of the mass indicates a need for incision and drainage

Early PPH – Retained placental tissue Risk factors: Previous uterine surgery Non spontaneous expulsion of placenta Presentation: Failure to deliver the placenta completely within 30 minutes after delivery of the infant and occurs in approximately 3% of vaginal deliveries. Non integrity of placenta upon examination Detection of an echogenic mass in the uterus on US Treatment: Ultrasonography can help diagnose a retained placenta Manual removal Curettage

Early PPH – Placenta accreta Placenta that in whole or in part invades the uterine wall and is inseparable from it Risk factors: Prior cesarean delivery is a major risk factor Placenta previa. Other uterine procedures Short cesarean-to-conception interval Advanced maternal age Smoking 20% have no identifiable risk factors

Early PPH – Placenta accreta Treatment Intrauterine baloon tamponade Uterine compression sutures Angiographic arterial embolization Bilateral surgical ligation of the uterine arteries Peripartum hysterectomy

Early PPH – Uterine inversion Definition: Uterine corpus descends to, and sometimes through, the uterine cervix Associated with severe postpartum hemorrhage, and hemodynamic instability may be worsened by concurrent vagal reflex–mediated bradycardia Risk factors: Umbilical cord traction

Early PPH – Uterine inversion Treatment: Replacement of the uterine corpus To restore normal anatomy, relaxation of the uterus may be necessary. Terbutaline, magnesium sulfate, halogenated general anesthetics, and nitroglycerin have been used for uterine relaxation If manual replacement is unsuccessful, laparotomy is required

Early PPH - Coagulopathy Risk factors: HELLP syndrome, Abruptio placentae Prolonged intrauterine fetal demise Sepsis Amniotic fluid embolism Significant hemorrhage may lead to consumption coagulopathy PMH / Family hx of coagulopathy Presentation: Diffuse bleeding Treatment: Appropriate testing should be ordered, with blood products infused as indicated

Management of PPH

Practice points Excessive postpartum bleeding causes severe maternal M&M Be aware of risk factors for PPH and take indicated preventive measures Vigilant postpartum monitoring can allow earlier detection of PPH and treatment Algorithms are available to guide management for the various causes of PPH Management requires team work between surgeons and anesthesiologists Anesthesiologist should be aware of the common causes of PPH and their treatment options

Reference list Scavone, BM . Chestnut's Obstetric Anesthesia: Principles and Practice, Chapter 38, 881-914 ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006 Oct;108(4):1039-47 Rouse DJ. What is new in postpartum hemorrhage? Best articles from the past year. Obstet Gynecol. 2013 Sep;122(3):693-4 Int J Gynaecol Obstet. 2013 Dec;123(3):254-6. doi: 10.1016/j.ijgo.2013.06.024. Epub 2013 Aug 30.