Post-Partum Haemorrhage 250mL per slide

Overview Incidence Risk factors Causes Medical Management Surgical Management Use of blood products/MTP

Post-Partum Haemorrhage ≥500mL vaginal birth ≥1000mL caesarean section Major cause of maternal morbidity and mortality 5% of births in Australia affected by significant post-partum haemorhage (>1000mL)

Antenatal Risks: Screen and Address! antepartum haemorrhage (especially placental abruption and placenta praevia) PPH with a previous pregnancy known abnormal placental adherence (e.g. accreta, increta or percreta) multiple pregnancy (e.g. twins and higher order multiples) disorders of haemostasis/inherited bleeding disorders grand multiparity pre-eclampsiamacrosomia maternal obesity elective or previous caesarean section Hb <9g/dL Persons refusing blood products

Prevention - Anaemia Decreases ability to cope with PPH Treat anaemia Hb <10.5 in pregnancy Increased plasma volume expansion relative to red cell mass, therefore physiological dilution with Hb decrease 2-3x iron requirements during pregnancy Increased MCV indicates folate deficiency as opposed to iron deficiency anaemia

Risks during labour and birth Use of oxytocics in labour Prolonged labour Pyrexia Instrumental and surgical delivery Episiotomy Placental retention Physiological third stage Active third stage management reduces PPH risk by 60%

Primary PPH Tone ≈70% Trauma ≈20% Tissue ≈10% Thrombin ≈1%

Secondary PPH From 24 hours post birth to 12 weeks Abnormalities of placentation Infection Pre-existing uterine disease Trauma Disorders of haemostasis The majority of cases of secondary postpartum haemorrhage are due to inadequate involution of the uterus caused by uterine infection and/or retained placental tissue

Recognition Blood Loss Pulse BP Signs 10-15% Increased Normal Postural hypotension 15-30% Increased + Peripheral vasoconstriction 30-40% Increased ++ 70-80mmHg Pallor, oligouria, confusion >40% Increased +++ <60mmHg Dyspnoea, collapse, anuria

H: Ask for HELP and Hands on the uterus (uterine massage) HAEMOSTASIS H: Ask for HELP and Hands on the uterus (uterine massage) A: Assess and resuscitate (vital signs, IV fluids, blood and blood products) E: Establish aetiology, ensure availability of blood and ecbolics (oxytocin) M: Massage uterus O: Oxytocics – Oxytocin infusion/prostaglandins– IV/per rectal/IM/intramyometrial S: Shift to theatre – bimanual compression/anti-shock garment T: Tissue and Trauma (exclude/manage)/proceed to Tamponade balloon/uterine packing A: Apply compression sutures – B-Lynch/modified compression sutures (2–5) S: Systematic pelvic devascularization – uterine/ovarian/quadruple/internal iliac I: Interventional radiology (and if appropriate, uterine artery embolization) S: Subtotal/total abdominal hysterectomy Best Practice & Research Clinical Obstetrics and GynaecologyVol. 22, No. 6, pp. 1089–1102, 2008

COPIOUS Call for help O2 Position head down IV access, fluids, bloods O-Negative blood Uterine massage, Urinary Catheter Syntocinon/ergometrine

Tone (Atony) Overdistension of the uterus Uterine infection Pharmacological agents Uterine inertia after a prolonged or induced labour Uterine inversion Fibroids Full bladder Retained placenta or retained blood clot Hypovolaemia and shock

Atony Tone Rub up contractions Bimanual compression Medication Ergometrine 500 microg IV/IM *HTN, headaches, nausea 10 units syntocinon IV Syntocinon infusion 40 units/4 hours 800microg misoprostol PR (Carboprost 250microg IM, NEVER IV) Aortic Compression

Trauma Tissue Systematic check of cervix, vaginal vault and perineum Repair tears Tissue Ensure adequate checking of placenta and membranes Be wary of placenta accreta

Thrombin Coagulopathies Preeclampsia/PIH HELLP syndrome Amniotic fluid embolism Sepsis Bleeding disorders Drugs (aspirin, heparin) FDIU

DIC Occurs earlier in PPH than other massive haemorrhage situations Widespread activation of clotting cascade leads to thrombosis and consumption of coagulation factors Results in depletion of coagulation factors and platelets Highlights the need for Cryoprecipitate in obstetric haemorrhage

Fluid Resuscitation & Blood Products Up to 3L warm crystalloid Early consideration of blood products 2 units PRCs 2 units PRCs, 2 units FFP 10 units (2.5g) Cryoprecipitate (higher concentration of fibrinogen) Consider platelets if levels<50 Consider 1g tranexamic acid loading dose the g infusion over 8/24

Massive Transfusion Protocol Consultant to contact blood bank directly MTP Pack 2 Units PRCs (O-negative from theatre) 2 Units PRCs (crossmatched) 10 Units Cryoprecipitate 4 Unit Platelets (pooled) Monitor FBE, UEC, CMP Coags, blood gas every hour

Surgical Management Intrauterine balloon tamponade B-Lynch Suture Appropriate first line management in theatre ‘Tamponade Test’ to assess for laparotomy If tamponade effective, remote need for laparotomy If ineffective, further surgical management likely B-Lynch Suture Uterine artery/Internal iliac ligation Subtotal/Total Hysterectomy Embolisation

Blood flow to pregnant term uterus 500-800mL min

Key Problem Areas (PROMPT) Failure to make a clear diagnosis of PPH Delay in commencing fluid resuscitation Delay in decision to transfer to theatre Uncertainty in estimating blood loss Uncertainty in how to access blood products rapidly