1. STEPS FOR THE MANAGEMENT PPH
SEQUENCING THE SERVICE

2. OBJECTIVES Discuss the importance of the Golden Hour
Present a follow-up sequence for PPH
Discuss the importance of the Golden Hour Present a follow-up sequence at HPP

3. STEPS FOR THE MANAGEMENT OF PPH
Early control of the bleeding is the most effective measure for the treatment of PPH
Early control of the bleeding site is the most effective measure in the treatment of PPH
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4. STEPS FOR THE MANAGEMENT OF PPH & THE GOLDEN HOUR
There is a relationship between the time elapsed to control the bleeding and the chance of death
Agressive and rapid interventions
Avoid the lethal triad of PPH: Acidosis, hypothermia and coagulopathy
Golden hour: Some have come to use the term to refer to the core principle of rapid intervention in trauma cases, rather than the narrow meaning of a critical one-hour time period.
Avoid the lethal triad of PPH: Acidosis, hypothermia and coagulopathy. Aggressive and early interventions
There is a relationship, in obstetric hemorrhage, between the unfavorable outcome and the time elapsed to control the bleeding focus
 A Lalonde et al. Int J Gynaecol Obstet Sep;94(3):243
Protocolo HPP SES-MG, Protocolo HPP BH 2016

5. REMEMBER... RED CODE AND TEAMWORK... TEAM LEADERSHIP COMUNICATION
MONITORING
MUTUAL SUPPORT

6. STEPS FOR THE MANAGEMENT OF PPH
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7. STEPS FOR THE MANAGEMENT OF PPH
CALL FOR HELP
Communicate Clearly the diagnosis of PPH
Call Interdisciplinary Team
Communicate patient
Clear diagnosis verification Call Interdisciplinary Team Communicate patient

8. STEPS FOR THE MANAGEMENT OF PPH
ESTIMATE INICIAL BLOOD LOSS
Clinical evaluation - vital Signs
Shock index (> 0.9: transfusion risk)
Visual estimation, weighing of compresses, collecting devices
Clinical evaluation - vital data Shock index (> 0.9: transfusion risk) Visual estimation, weighing of compresses, collecting devices

9. Systolic Blood Pressure SI ≥ 0,9 RELATED TO MASSIVE TRANSFUSION
SHOCK INDEX
Maternal Heart Rate
>
0,9
Systolic Blood Pressure
Lembrar que algumas morbidades de pacientes podem interferir na frequencia cardíaca e pressão arterial ex: arritmia.
METODOS CLÍNICOS DE DIAGNÓSTICO/ESTIMATIVA DE SANGRAMENTO VANTAGENS:
Essencial na estimativa da perda volêmica
Orienta o tratamento da paciente
Avalia resposta do tratamento
Útil em todos os cenários de HPP
Pode ser feito em qualquer maternidade
Baixo custo
DESVANTAGENS:
Diagnóstico tardio
(ainda assim são bastante úteis)
Exige monitoramento rigoroso das puérperas (o que é desejável!)
SI ≥ 0,9 RELATED TO MASSIVE TRANSFUSION

10. STEPS FOR THE MANAGEMENT OF PPH
RAPID ASSESSMENT OF HEMORRHAGE CAUSES (4T)
TONE - abnormalities of uterine contraction: 70%
TRAUMA - genital tract injury: 19%
TISSUE - retained products of conception: 10%
TROMBIN - abnormalities of coagulation: 1%

11. STEPS FOR THE MANAGEMENT OF PPH
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12. STEPS FOR THE MANAGEMENT OF PPH
KEEP OXIGENATION AND PERFUSION
Venous access: 02 caliber (J16 or 14)
Rational infusion of heated liquids: re-evaluate every ml
Oxygen: 8 to 10 l / min in face mask.
Elevation of lower limbs
Continuous monitoring (TAX: every 15 minutes)
Delayed bladder catheter: (monitor diuresis)
Venous access: 02 caliber (J16 or 14) Rational infusion of heated liquids: re-evaluate every ml Oxygen: 8 to 10 l / min in face mask. Elevation of lower limbs Continuous monitoring (TAX: every 15 minutes) Delayed bladder catheter: (monitor diuresis)

13. EXCESSIVE INFUSION OF FLUIDS
Dilution of factors of coagulation
Acidosis
Elevation of blood pressure (before surgical control of hemorrhage
Hypothermia
El mecanismo del aumento de sangrado associado a la infusion excessiva de cristaloides
Quando se hace una grand cantidad de volume, tenemos dilucion de los factores de la coagulacion, acidosis, Elevacion de la presion arterial, e hipotermia.
Mecanismos de aumento do sangramento relacionado a infusão de grandes volumes de cristalóides:
Duschesne JC et al. J Trauma 2010; 69(4):976, Spinella PC & Holcomb JB. Blood Reviews,2009; 23: 231
Maegele et al. Injury 2007;38(3):298 

14. STEPS FOR THE MANAGEMENT OF PPH
REQUEST EXAMS
Collect already in the 1st access puncture
Hemogram, coagulogram, ionogram, cross-test, fibrinogen
Severe cases: lactate and gasometry
EVALUATE ANTIBIOTICS
Bimanual uterine massage
Intrauterine Ballon Tamponade
Surgeries
Collect already in the 1st access puncture Hemogram, coagulogram, ionogram, cross-test, fibrigonene Severe cases: lactate and gasometry

15. STEPS FOR THE MANAGEMENT OF PPH
FLUID AND BLOOD THERAPHY
Estimate severity of volume loss (Shock Index)
Crystalloid: rational use.
Reevaluate every ml
Consider blood transfusion after 1500ml of crystalloids with no adequate and sustained maternal response
Tranexamic acid, IV, 1 gram in 10 minutes
Estimate severity of volume loss (Shock Index) Crystalloid: rational use. Reevaluate every ml Consider blood transfusion after 1500ml of crystalloids with no adequate and sustained maternal response Tranexamic acid in important cases

16. STEPS FOR THE MANAGEMENT OF PPH
DETERMINE THE CAUSE OF PPH- 4T
TONE - Is the uterus contracted ?
TRAUMA - IS there any tract trauma – lacerations ?
TISSUE - Is there any tissue left or placenta acreta ?
TROMBIN - Is there any coagulophaty ?
TREAT THE SPECIFIC CAUSE

17. UTERINE ATONY YES YES BIMANUAL UTERINE COMPRESSION OXYTOCIN
ONSET OF ACTION: (IV): 1 min
MAINTANANCE
DOSE
UTERINE ATONY
No response
YES
TRANEXAMIC ACID: 1 g, IV, 10 minutes
ERGOT
ONSET OF ACTION IM: 2-5 min
MAINTANENCE
DOSE, if necessary
No response
MISOPROSTOL
ONSET OF ACTION (OR): 7-11 min \ (R): 15-20min
No response
Oxytocin 5 iu, slow IV (repeat if necessary)
Ergometrine 0.5 mg, slow IV or IM
Oxytocin infusion (40 iu in 500 ml)
Carboprost 0.25 mg IM every 15 minutes up
to 8 times
Carboprost (intramyometrial) 0.5 mg
Misoprostol 800 micrograms sublingually
Consider tranexamic acid 1 g IV
O uso do TAN e do balão deve ser associado a
o uso de uterotônico.
NON PNEUMATIC ANTI-SHOCK GARMENT
Associate with Intrauterine Ballon
INTRAUTERINE BALLON TAMPONADE
If uterotonics fail to stop bleeding
No response
No response
SURGICAL MANAGEMENT
compressive uterine sutures, ligature of vessels, hysterectomy, damage control
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18. TRANEXAMIC ACID = 1 g, IV, SLOW INFUSION (100mg\min)
TRAUMA
TRANEXAMIC ACID = 1 g, IV, SLOW INFUSION (100mg\min)
REPAIR TEARS
Repair tears
Check perineum, cervix and vagina
HAEMATOMA
Explore it in some cases
Check vagina after birth
UTERINE RUPTURE:
Laparotomy
Primary repair or hysterectomy
O uso do TAN e do balão deve ser associado ao uso de uterotônico.
UTERINE INVERSION :
TAXE MANEVEUR
Laparotomy / Intrauterine Balloon
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19. TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100mg\min)
TISSUE
TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100mg\min)
RETAINED PLACENTA
30-45 min after delivery
RETAINED PART
OF PLACENTA
PLACENTA ACCRETA
MANUAL REMOVAL
The lack of cleavage plane:
Risk of Placenta acreta and severe PPH)
CURETTAGE
DO NOT try to remove
The placenta
The lack of a plane of cleavage between the placental basal plate and the uterine wall
Hysterectomy with placenta in situ
Conservative management
CURETTAGE
Imagens:
Imagem:

20. COAGULAPATHY DIAGNOSIS SPECIFIC TREATMENT + TRANSFUSION NASG
TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100mg\min)
DIAGNOSIS
Prior history of specific deficiencies,
(eg. Von Willebrand's disease); Use of
Anticoagulants; intra-operative excessive
bleeding (DIC), thrombocytopenia,
hypofibrinogenemia
SPECIFIC TREATMENT +
TRANSFUSION
RBC, FFP, platelets, cryoprecipitate,
Activated Factor VIIa, desmopressin,
protamine, among others
O uso do TAN e do balão deve ser associado ao uso de uterotônico.
ADJUVANT TREATMENT
NASG
Surgery: be careful with this choice!
Damage Control, if DIC.
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21. STEPS FOR THE MANEGEMENT FOR PPH
EVALUATION AFTER INITIAL APPROACH:
Reassessment of hemorrhage and hemodynamic status
NASG for the patients with hemodynamic instability
Blood transfusion: if necessary ( to be based on patient's clinical evolution)
Avoid hypothermia: Body temperature, heated fluids, thermal blanket.
If conservative treatment fails: evaluate surgical treatment.

22. STEPS FOR THE MANEGEMENT FOR PPH
STRICT MONITORING AFTER HEMORRHAGE
Strict monitoring in the recovery room in the first 24 hours (it can not be in postpartum ward that offers low risk monitoring)
ICU according to the severity of the case

23. MOTIVATION TO 0MMXH
“For each mother who dies, there is a family that suffers, a community that becomes weaker, a country that gets poorer ”
Carissa F Etienne. PAHO/WHO Director
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