Dept. Of Obstetrics & Gynaecology PPH Drill Dr. Monika Madaan Specialist Dept. Of Obstetrics & Gynaecology ESI Hospital Manesar

PPH Single most important cause of maternal mortality worldwide. Accounts for 34% of maternal deaths in developing countries.

Definition Any blood loss than has potential to produce or produces hemodynamic instability

Definition Blood loss > 500 ml after delivery Primary : Loss within 1st 24 hours after delivery Secondary : 24 hours till 12 weeks postnatally Minor : 500-1000 ml Moderate : 1000-2000 ml Severe : > 2000 ml

PREDICTION AND PREVENTION - Pl previa/accreta Anticoagulation Rx Coagulopathy Overdistended uterus Grand multiparity Abn labor pattern Chorioamnionitis Large myomas Previous history of PPH Identify pt. at risk

PREDICTION AND PREVENTION Active Management Of Third Stage Of Labor (AMTSL): Should be offered routinely and includes: Administration of uterotonics soon after birth. Delayed cord clamping. Delivery of placenta by controlled cord traction followed by uterine massage.

PPH Drill Clear and logical sequence of steps essential in the management of PPH.

CALL FOR HELP

Skilled Obstetric Team Trained Anaesthesiologist Clinical hematologist Team Effort Skilled Obstetric Team Trained Anaesthesiologist Clinical hematologist Supporting staff

Resuscitation Assess A : Airway B : Breathing C : Circulation Secure 2 wide bore i.v. lines:- 14-16 gauge Draw blood for grouping & cross matching, CBC, LFT/KFT, SE & Coagulogram.

Position flat Keep the patient warm Administer oxygen by mask ( @ 10-15 litres/ min) Catheterize the patient for emptying bladder & monitoring output

Fluid Replacement RAPID WARMED infusion of fluids Crystalloids : Fluids of choice until compatible blood is arranged 1 ml of blood loss= 3 ml of crystalloids Total volume of 3.5 litres of clear fluids (upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood.

If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given

FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1 FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal (ie 12-15 ml/kg or total of 1 litres.) Platelet Concentrate: if Platelet count< 50,000/ microlitre. Cryoprecipitate: if fibrinogen < 1 g/ l.

Continuous vital monitoring. Monitor adequacy of replacement with urine output (0.5 ml/kg/hr) and CVP (4-8 cm water) Main therapeutic goals are to maintain: Haemoglobin > 8gm/dl Platelet count > 75 × 109 / l Prothrombin < 1.5 × mean control APTT < 1.5 × mean control Fibrinogen > 1 gm/ l

Establish Etiology Simultaneously 4 T’s Tone (abnormalities of uterine contraction) : 70 – 80% Trauma (of the genital tract) : 20 % Tissue (retained products of conception) : 10 % Thrombin (abnormalities of coagulation) : 1 %

Explore cervix and vagina Contd… Check tone of uterus well contracted Suspect trauma Explore cervix and vagina

Bimanual Compression If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions

Administer Uterotonic Drugs FIRST LINE Oxytocin: Start with 5 units slow iv or im. Infusion of 20 units in 1 L@ 60 dr/min. Continue same dose @ 40 dr/min until bleeding stops. Maximum upto 3 L. SECOND LINE Ergometrine/ methyl ergometrine: Dose: 0.2 mg im or slow iv Repeat 0.2 mg after 15 min. Maximum 5 doses (1 mg) Syntometrine im

Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. THIRD LINE PGF 2α: Dose: 0.25 mg im. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. Misoprostol: 200-800 µg sublingually. Do not exceed 800 µg WHO GUIDELINES FOR MANAGEMENT OF PPH 2009

Uterine Tamponade Sengstaken Blakemore oesophageal catheter Bakri balloon Sengstaken Blakemore oesophageal catheter Condom catheter Urological Rusch balloon Success depends upon Positive Tamponade test

Procedure of condom Balloon insertion Initial Assembly Condoms-2 Foley’s catheter-no.16 Saline with iv set Speculum Sponge holding forceps

Procedure Lithotomy position Indwelling Foley’s catheter. Explore uterus, cervix and vagina. Inflate balloon with 100-300 ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test).

Compression sutures B Lynch Suture Fundal compression suture Apposes anterior & posterior wall

Contd… Parallel Vertical compression sutures for placenta praevia

Stepwise Uterine Devascularization Uterine arteries Tubal branch of ovarian artery Internal iliac artery

Uterine Artery Embolization Possible only if internal artery ligation has not been done and facility for interventional radiology available

Hysterectomy Resort to hysterectomy “SOONER RATHER THAN LATER” High maternal morbidity Timing and adequate replacement is of utmost importance

Documentation and Debriefing Important to record: Sequence of events Time and sequence of admn of pharmacological agents, fluids, blood products The time of surgical intervention The condition of mother throughout .

Newer Developments Tranexamic acid : 1 gm i.v slow. Can be repeated after 30 min if bleeding continues./ Recombinant activated factor VII (Novoseven): 90 µg/ kg . May be repeated within 15-30 minutes. No clear consensus on efficacy. Carbetocin (oxytocin agonist) : 100 µg i.v or i.m. Produces tetanic uterine contractions.

HAEMOSTASIS ALGORITHM H – Ask for help A – Assess and resuscitate E – Establish etiology M – Massage the uterus O – Oxytocic administration S – Shift to OT T – Tissue n trauma to be excluded and proceed to tamponade A – Apply compression sutures S – Systematic pelvic devascularisation I – Interventional radiology S – Subtotal or total hysterectomy

To Conclude, Management of PPH Has Evolved From: Panic Hysterectomy Pitocin Prostaglandins Happiness

THANK YOU