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STEPS FOR THE MANAGEMENT PPH
SEQUENCING THE SERVICE
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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
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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 Título da apresentação
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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
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REMEMBER... RED CODE AND TEAMWORK... TEAM LEADERSHIP COMUNICATION
MONITORING MUTUAL SUPPORT
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STEPS FOR THE MANAGEMENT OF PPH
Título de la presentación
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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
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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
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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
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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%
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STEPS FOR THE MANAGEMENT OF PPH
Título da apresentação
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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)
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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
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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
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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
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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
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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 Título da apresentação
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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 Título da apresentação
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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:
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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. Título da apresentação
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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.
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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
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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 Vídeo do urso -
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