2. postpartum hemorrhage
Dr. M.Moshfeghi
OBS&GYN
fellowship of perinatology
Shariati.Hospital ,TUMS
RUYAN INSTITUTE

3. INTRODUCTION major cause of maternal morbidity,
 —  (PPH) is an obstetrical emergency.
major cause of maternal morbidity,
one of the top three causes of maternal mortality,

4. that 46% of these near-miss events , failure to identify high-risk status failure to transfer to a higher level of care or inappropriate care.
were preventable

5. the most preventable cause of maternal mortality
With timely diagnosis,
appropriate resources,
appropriate management,

6. DEFINITIONS
PPH Primary the first 24 h after delivery (early PPH) secondary occurs 24 h to 12 w after delivery (late or delayed PPH).

7. PPH is classically defined
by the volume of blood loss.
estimated blood loss ≥500 mL after NVD
or ≥1000 mL after cesarean .

8. Another classic definition
10-point decline in postpartum hematocrit. not a clinically useful definition: antepartum hemoconcentration , from preeclampsia or dehydration may cause a large fall in hematocrit.

9. RCOG
minor (500 to 1000 mLs) major (>1000 mLs), subdivisions moderate (1000 to 2000 mLs) severe (>2000 mLs) active bleeding >1000 mL within the 24 hours following birth that continues despite the use of initial measures, including first-line uterotonic agents and uterine massage"

10. The diagnosis of heavy bleeding
judgment of care providers
a degree of bleeding that threatens to cause, or
is associated with, hemodynamic instability.

11. 1 to 5 percent of deliveries
INCIDENCE 
1 to 5 percent of deliveries

12. PATHOGENESIS  — 
in late pregnancy uterine artery blood flow is 500 to 700 mL/min
about 15 percent of cardiac output.

13. uterine bleeding is controlled by :
●Contraction of the myometrium, which compresses the blood vessels supplying the placental bed.
●Local decidual hemostatic factors.

14. PPH occurs when disturbance in one or both of these mechanisms.
include
incomplete placental separation,
defective myometrial contraction,
bleeding diatheses.

15. CAUSES
Atony
Trauma
Coagulopathy

16. Atony 1 in 20 births 80 percent of cases of PPH
1 in 20 births
80 percent of cases of PPH
boggy and dilated uterus may contain a significant amount of blood. .
may be diffuse or localized to an area of uterine muscle.
fundal region may be well contracted while the lower uterine segment is dilated and atonic

17. lacerations, surgical incisions, or uterine rupture Trauma
 — Trauma-related bleeding
due to
lacerations,
surgical incisions,
or uterine rupture

18. is both a cause and result of PPH
Coagulopathy
is both a cause and result of PPH
since persistent heavy bleeding,
leads to consumption of clotting factors.

19. RISK FACTORS Retained placenta/membranes
•Failure to progress during the second stage
•Morbidly adherent placenta
•Laceration
Instrumental delivery
•LGA
• preeclampsia,eclampsia,HELLP•

20. Other risk factors
personal or family history of previous PPH, obesity, high parity, Asian or Hispanic race, precipitous labor, uterine overdistention uterine infection, uterine inversion, inherited bleeding diathesis, acquired bleeding diathesis (eg, amniotic fluid embolism, abruptio placenta, sepsis, fetal demise), use of some drugs, such as uterine relaxants and drugs that affect coagulation (possibly including antidepressants)

21. The key to management of PPH
recognize excessive bleeding Before it becomes life-threatening, identify the cause, initiate appropriate intervention.
Before

22. Symptoms related to blood loss with postpartum hemorrhage

23. CONTROL OF V/S Q ¼H Q1/2 H Q1 H THEN UNTILL STABILITY

24. not sufficient to only look for vaginal or incisional bleeding
significant hemorrhage can occur into the retroperitoneum or into a vaginal/vulval hematoma without visible blood loss bleeding from a poorly contracted and dilated lower segment despite adequate upper segment contraction.

25. G1 25 W ROM MYOMATOUS UT Sudden onset cardiac arrest 4 hr after hysterotomy By vomiting and 2 liter blood in drain bag

26. some drugs can have unanticipated hemodynamic side effects
, beta-blockade may prevent a normal heart rate response in a bleeding patient; histamine release due to an analgesic (morphine) may lead to peripheral vasodilation and destabilized compensated shock with resultant sudden hemodynamic collapse.

27. Management of risk personnel, medication, equipment, blood products.
availability of
personnel,
medication,
equipment,
blood products.

28. PPH protocols
Ideally, each hospital labor and delivery unit should have a PPH protocol for patients with estimated blood loss exceeding a predefined threshold (often 1000 mL)..

30. The protocol should provide
a standardized approach , notifying a multidisciplinary team, and treatment

31. PPH kits
— In addition to a protocol, for labor and delivery units assemble kits including medications and instruments that may be needed to manage PPH

36. Example of instruments, equipment, and medications to assemble for a postpartum hemorrhage emergency cart
Equipment/supplies for starting an intravenous line (14-, 16-, 18-, and 20-gauge peripheral venous catheter, 1 L Lactated Ringer's solution , intravenous tubing, four-way stopcock, tape

37. Urinary catheter kit, urimeter
Lubricating gel
Assorted sizes of sterile gloves, including elbow-length gloves
Vaginal retractors, including a long right-angle retractor
Sterile speculum, long weighted speculum
Sponge forceps

38. Vaginal packs, 2 by 2 and 4 by 4 sponge gauze packs, gauze bandage rolls Balloon catheter kit for intrauterine tamponade Sterile utility bowl, 20 and 60 mL syringes, irrigation water Banjo curettes Long needle holder Appropriate sutures for cervical and vaginal laceration repair and for uterine compression sutures Uterine forceps

39. llustrations showing how to perform
, uterine compression,
uterine artery ligation,
intrauterine balloon placement,
replacement of inverted uterus

43. Equipment/supplies for drawing blood
(eg, syringes; needles; red, green, blue, and tiger top tubes; alcohol prep pads; tourniquet) for laboratory studies with prewritten lab and blood bank requisition orders; instructions on how to order tests and blood and how to activate the massive transfusion protocol Biohazard bag Adult oxygen nonrebreather mask Tubing and filter for blood transfusion

44. Equipment for warming irrigation and intravenous fluids
Pressure infusor bag
Tape, bandages

45. WHERE IS …..?????
EXPIRATIN DATE
WHO IS ……??????
WHEN….??????G

46. Medications
: Kit for transabdominal intramyometrial injection of carboprost under ultrasound guidance: 20 mL syringe, 20 mL sterile saline for injection, 6 inch 20-gauge and 6 inch 22-gauge amniocentesis needles Misoprostol, five 200 mcg tablets Oxytocin, 10 to 40 units per 500 to 1000 mL NS Methylergonovine, 0.2 mg/mL 1 ampule (requires refrigeration) Carboprost, 250 mcg/mL 1 ampule (requires refrigeration)

47. Steps in management of postpartum hemorrhage
Assemble team and notify appropriate departments obstetrics, nursing, anesthesiology, blood bank, laboratory

48. Patients with persistent postpartum vaginal bleeding
should be assessed urgently by a provider who can initiate all necessary urgent care.
Any unstable patient
should be moved to an operating room as soon as practically possible, .

49. General principles maintain adequate circulatory volume
●Restore or maintain adequate tissue oxygenation
●Reverse or prevent coagulopathy
●Eliminate the obstetric cause of PPH

50. dilutional coagulopathy
If an intervention does not succeed, the next must be swiftly instituted.
delays
dilutional coagulopathy
shock, and death

51. in the setting of cardiovascular instability
avoid
if necessary, hysterectomy.
prolonged,
futile attempts

52. Initiate uterine massage establish large-bore (two 16- or 18-gauge, ideally 14-gauge) intravenous access.

53. Administer uterotonic drugs* to reverse atony:
within 30 minutes
whether uterotonic treatment will reverse atony.
If it does not,
invasive intervention
is usually warranted

54. Initiate oxytocin , start at 10 to 40 milliunits per minute.
: oxytocin 40 units in 1 liter of normal saline or Ringer's lactate.
, start at 10 to 40 milliunits per minute.
15 units in 250 mL Expect rapid response.
Avoid rapid bolus injection
If no IV access, give 10 units im;
response within three to five minutes.
no absolute contraindications to oxytocin oxytocin is the uterotonic of choice,

55. Carbetocin
(where availableΔ) 100 micrograms slow intravenous injection as single dose. A long-acting analogue of oxytocin, carbetocin is a potential alternative if titrable oxytocin intravenous infusion is not feasibl

56. If oxytocin is not immediately available or does not control PPH
Methylergonovine 200 micrograms im(including intramyometrial) /2-4 Hr
maximum of 1 mg (five doses).
response within two to five min.
Do not give intravenously.
Avoid in hypertension, Raynaud's phenomenon, or scleroderma.
If first dose ineffective, quickly add a different uterotonic agent (eg, carboprost tromethamine).

57. Add Carboprost tromethamine
(PGF2alpha, Hemabate) 250 micrograms im/ 15 to 90 minutes, maximum (eight doses).
Peak 30 minutes.
Do not give intravenously.
Avoid in asthma/bronchospasm or hypertension.
Relatively contraindicated in renal or hepatic insufficiency or reduced cardiac output.
Can cause tachycardia, pyrexia, diarrhea.
If no response after one or two doses, quickly move to a different uterotonic agent.

58. misoprostol (PGE1)
400 micrograms sublingually or rectally as a single dose. Maximum 800 micrograms 30 minutes after sublingual 40 to 60 minutes after rectal can be given to women with hypertension or asthma/bronchospasm. a micro-enema prepared from oral misoprostol tablets dissolved in 5 mL saline

59. Dinoprostone (PGE2)
20 mg vaginal or rectal suppository is an alternative to misoprostol. Its actions and contraindications are similar to misoprostol; it can be repeated at two hours

60. Balloon tamponade should be initiated
early
if bleeding is brisk,
if the patient is not hemodynamically stable,
and blood products are not readily available
in conjunction with,
preparations for laparotomy
or transarterial embolization .

61. early recourse to intrauterine balloon tamponade
allow time for stabilization and institution of resuscitative procedures

62. Administer oxygen
(10 to 15 liters/minute) by face mask. Anesthesia team should evaluate airway and breathing; intubate if indicated.

63. Inspection
the vagina and cervix for lacerations; repair as necessary. Evacuate any retained products of conception. Replace uterus if inverted.

64. Fluid resuscitation:
Infuse isotonic crystalloid to prevent hypotension (target systolic pressure 90 mmHg) maintain urine output at >30 mL/hour.

65. Transfusion
: If hemodynamics do not improve with 2 to 3 liters of crystalloid two units packed red blood cells. massive hemorrhage, red blood cells, FFP, and apheresis platelets are best

66. Choice of the most appropriate combination of fluids
controversial. Crystalloid solutions appear to be as effective as colloid solutions in most settings.

67. packed red blood cells
hematocrit of approximately 80% increases the hemoglobin level by 1 g/dl or a hemoglobin level less than 6 g/dL should be considered a candidate for transfusion

68. Platelet count immediately after completion of the transfusion equilibrate within 10 minutes and can be assessed

69. Cryoprecipitate
is obtained from FFP and contains factor VIII (80 to 120 units), fibrinogen (200 mg), von Willebrand’ factor XIII. One unit of cryoprecipitate and one unit of FFP will have a similar effect on the fibrinogen level (increase of 10 to 15 mg/dL).

70. once a massive transfusion protocol has been initiated
Check ionized calcium and potassium levels every 15 minutes and treat hypocalcemia and hyperkalemia aggressively.

71. Fibrinogen falls before other coagulation factors
For every 500 mL of blood loss, hemoglobin levels will fall by about one gram/dL;

72. Trans arterial embolization
Perform if the woman is stable and there is time for personnel and facilities to mobilize.

73. arterial embolization
should not be attempted
in unstable patients
should not be considered an emergency procedure for managing uncontrolled PPH of indeterminate cause

74. Perform laparotomy if others fail
Surgical approaches that
are quick,
relatively easy,
and effective should be tried first..

75. Options
uterine artery ligation, a B-Lynch stitch other uterine compression suture. Hysterectomy is the last resort for atony, but should not be delayed in women who have DIC and require prompt control of uterine hemorrhage to prevent death..

76. first-line approach for placenta creta
hysterectomy
Suture deep pelvic bleeders.
Tamponade pelvic bleeding with pelvic packing

77. Key components of evaluation and treatment
Cumulative measurement of blood loss Use visual aids (eg, posters) that correlate the size and appearance of blood on specific surfaces

79. drops in blood pressure
generally not manifested until class III hemorrhage develops,
up to 30 percent loss before this occurs.
Hemoglobin and hematocrit values are poor indicators of acute blood loss

80. no change in, Class I hemorrhage blood loss of up to 15 percent.
heart rate is minimally elevated or normal,
no change in,
pulse pressure,
or respiratory rate
blood pressure.

81. Class II hemorrhage stable systolic blood pressure
a 15 to 30 percent loss
An increasing maternal heart rate
and tachypnea with
stable systolic blood pressure
prompt investigation and institution of a PPH protocol, even if only light vaginal bleeding is observed

82. Class III hemorrhage
30 to 40 percent blood loss, significant drop in blood pressure and changes in mental status. hypotension (systolic <90 mmHg) drop in blood pressure greater than 20 to 30 percent

83. . While diminished anxiety or pain may contribute to such a drop,
the clinician must assume it is due to hemorrhage until proven otherwise.
Heart rate (≥120 and thready) and respiratory rate are markedly elevated,
while urine output is diminished. .

84. emergency hysterectomy
should be avoided in a coagulopathic patient with inadequate intravenous access for massive transfusion/correction of electrolyte imbalances, result of uncontrolled retroperitoneal hemorrhage and myocardial depression.

85. Recombinant factor VIIa NovoSeven
200 μg/kg initial dose; may repeat with 100 μg/kg at 1 and 3 hr after the first dose May increase risk of thromboembolic events

87. Ensure intravenous access.
management of postpartum hemorrhage based on estimated blood loss and hemodynamic stability
Step 1: Before delivery
Screen all women admitted to Labor and Delivery for risk factors for obstetric hemorrhage.
, type and screen, or type and crossmatch, depending on level of hemorrhage risk.
Ensure intravenous access.

88. Step 2:
At delivery Give oxytocin for active management of the third stage.

89. Step 3: After delivery Quantify blood loss.
Initiate additional measures to control bleeding based on severity of obstetric hemorrhage.
Blood loss >500 mL and <1000 mL at vaginal delivery or >1000 mL and <1500 mL at cesarean delivery with ongoing excessive bleeding and/or mild tachycardia and/or hypotension.

90. Get help and notify obstetric hemorrhage team
Get help and notify obstetric hemorrhage team. Continue to monitor vital signs and quantify blood loss. Ensure intravenous access with a large gauge catheter(s). Begin bimanual uterine massage. Increase oxytocin flow rate

91. Volume resuscitation, blood and blood products if bleeding second uterotonic (eg, methylergonovine, carboprost tromethamine). Examine for lacerations, retained products of conception, uterine inversion,.

92. If cesarean delivery: Apply conservative surgical interventions to control bleeding (eg, uterine artery/ovarian artery ligation, uterine compression sutures).

93. ongoing excessive bleeding and/or hemodynamic instability.
Do all of the above.
Draw blood for baseline labs.
Insert intrauterine balloon.
two units packed red cells and one to two units fresh frozen plasma.
Activate a massive transfusion protocol if bleeding is heavy and transfusion of four or more units of blood is likely

94. If vaginal delivery: Move the patient to an operating room to perform conservative surgical interventions to control bleeding.

95. selective arterial embolization
only if patient is hemodynamically stable. in an operating room. Bleeding patients should only be moved to a radiology suite for embolization if they are hemodynamically stable .

96. If conservative surgical interventions are not successful, perform hysterectomy..