Postpartum Hemorrhage JEFF YAO ALI SHAHBAZ

“ ” Investing in maternal health is a wise health and economic policy decision. Women are the sole income-earners in nearly one third of all households globally. There are spill-over macro-economic benefits from the women whose lives are improved by maternal health interventions. Many maternal- care interventions are proven to be both effective in reducing maternal death and cost-effective, especially for high-risk groups. - WHO M ATERNAL H EALTH

In one study, 73% of such deaths in the US were determined to have been preventable. Underestimation of blood loss contributes greatly to this figure.

Case  A 29 yo G5P4 woman at 39 weeks gestation with preeclampsia delivers vaginally. Her prenatal course has been uncomplicated except for asymptomatic bacteriuria caused by E. coli in the first trimester treated with oral cephalexin. She denies a family history of bleeding diathesis. After the placenta is delivered, there is appreciable vaginal bleeding estimated at 1 L

Define: PPH  Postpartum Hemmorage (PPH)  Blood loss >500mL following vaginal delivery OR >1000mL with C/S  Often underestimated and inaccurate  Clinically: ANY blood loss that can cause hemodynamic instability  If it has the potential to result in hemodynamic instability – TREAT IT!

Case  A 29 yo G5P4 woman at 39 weeks gestation with preeclampsia delivers vaginally. Her prenatal course has been uncomplicated except for asymptomatic bacteriuria caused by E. coli in the first trimester treated with oral cephalexin. She denies a family history of bleeding diathesis. After the placenta is delivered, there is appreciable vaginal bleeding estimated at 1 L

Classification of PPH  Early (primary) PPH  Occurs within 24 hours of delivery (most common)  Late (secondary) PPH  24 hours to 6 weeks after delivery (peak incidence at 1-2 weeks postpartum)

Signs and Symptoms of Postpartum Hemorrhage

Risk Factors for PPH  Retained Placenta/membranes  Failure to progress during second stage of labour (prolonged labour)  Morbidly adherent placenta  Lacerations  Instrument Delivery  Large for GA newborn  Hypertension and Preeclampsia  Previous PPH

Case  A 29 yo G5P4 woman at 39 weeks gestation with preeclampsia delivers vaginally. Her prenatal course has been uncomplicated except for asymptomatic bacteriuria caused by E. coli in the first trimester treated with oral cephalexin. She denies a family history of bleeding diathesis. After the placenta is delivered, there is appreciable vaginal bleeding estimated at 1 L

Causes of PPH Uterine atony, Distended bladder Coagulopathy (pre-existing or acquired) Vaginal, cervical, or uterine injury Retained placenta, Clots

TONE : Abnormalities of Uterine Contraction  Over distention of Uterus  Uterine muscle exhaustion  Intra-amniotic infection  Distortion of uterus  Uterine-relaxing medications  Bladder Distention  May prevent uterine contraction

Tissue: Retained  Retained products  Abnormal placentation  Retained Blood Clots

Trauma of the genital tract  Laceration of cervix, vagina, or perineum  Lacerations from C/S  Uterine Rupture  Uterine inversion

Thrombin: Coagulopathies  Pre-existing States of Coagulopathy  Hemophilia A  Von Willebrand’s Disease  Hx of PPH  Acquired in pregnancy  Idiopathic thrombocytopenic purpura  Thrombocytopenia with preeclampsia  Disseminated intravascular coagulation

The appropriate response to a soft, “boggy” uterus and brisk flow of blood from the vagina after delivery of the placenta is bimanual uterine massage.

Uterine Inversion - Johnson Method of Reduction - Grasp the fundus with palm of hands with fingers pointed to posterior fornix - Continue applying pressure towards the umbilicus as you move the uterus into the abdomen

Brandt-Andrews Maneuver for Cord Traction - Apply gentle traction on the umbilical cord while simultaneously applying suprapubic compression - Avg time from delivery to placental expulsion is 8-9 minutes

Transcervical Placement of Bakri Balloon Catheter for Tamponade of Uterine Hemorrhage

B-Lynch Suture of Uterus for Severe Hemorrhage

SOGC Guideline Recommendations  Active Management of Third Stage of Labour – should be offered and recommended to all women  Oxytocin IM is the preferred medication for prevention of PPH in low-risk vaginal deliveries  An IV bolus of oxytocin can be used for PPH prevention after vaginal birth but not recommended at this time for an elective C/S  Carbetocin can be used for elective C/S and for women delivering vaginally with 1 risk factor to help prevent PPH  Delayed cord clamping by at least 60 seconds is preferred to earlier clamping in premature newborns  Blood loss estimation should be done using clinical markers (signs and symptoms) rather than a visual estimation  Uterine tamponade is effective to temporarily control active PPH from uterine atony not responding to medical therapy  Surgical techniques should be used for intractable PPH unresponsive to medical therapy

SUMMARY [ALMOST DONE!]

 Postpartum hemorrhage is unpredictable and can occur in women with no risk factors.  AMTSL includes oxytocin after delivery of the fetal anterior shoulder and controlled cord traction with the Brandt maneuver.  Uterine massage after delivery of the placenta is a reasonable approach and is included in some AMTSL protocols  Delayed cord clamping (one to three minutes after delivery) may be considered