Transcript Primary Postpartum Haemorrhage

Primary Postpartum
Haemorrhage
Max Brinsmead MB BS PhD
May 2015
Introduction
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The average gravida carries 1 - 1.5 l of
“extra blood” in pregnancy as prophylaxis
against PPH but…
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PPH is still the major cause of obstetric
death especially in developing countries
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10 - 15% of women lose >600 ml of blood at
delivery and…
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For 1 - 2% the blood loss can be life
threatening
This presentation will address…
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Current guidelines for the management of
the third stage of labour and their evidence
base
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Emergency (First aid) and
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Advanced Measures for the management of
excessive blood loss in the first 24 hours
after birth
From the Cochrane
Database
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Active vs Expectant Management of the 3rd
stage of labour
• Now withdrawn as out of date
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Oxytocin vs Ergometrine
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Oxytocin vs Prostaglandins
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Uterine massage in preventing PPH
Active vs Expectant Management
of 3rd Stage Labour
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4 studies - all in the UK
Active management associated with:
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Reduced blood loss (-79 ml, CI 64-94 mls less)
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Fewer PPH >500 ml (OR=0.34, CI 0.28-0.41)
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Shorter 3rd stage (-3.4 min, CI 4.66-2.13 min
less)
Active vs Expectant Management
of 3rd Stage Labour
For the individual patient this may mean:
If she declines the administration of an oxytocic
drug she has a 1:6 chance of losing >500 ml
blood
If she has an oxytocic drug this is reduced to a
1:20 chance of losing >500 ml blood
Active vs Expectant Management
of 3rd Stage Labour
Active management is associated with:
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Increased rate of maternal nausea &
vomiting (OR 1.95, CI 1.58 - 2.42)
Increased rate of maternal hypertension
Delayed vs Early (within 60
sec) Cord Clamping
Is associated with:
 No difference in the rate of PPH (RR 1.22 CI
0.96–1.55)
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Increased rates of jaundice requiring
phototherapy
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Neonatal advantages in terms of Hb levels
and Ferritin up to 6 months of age
NICE Guidelines (2007) for
management of the 3rd Stage
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Active management is recommended i.e.
• IM Oxytocin 10 IU
• Early cord clamping
• Cord traction
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Women at low risk of PPH who elect to have physiological
management should have their choice respected
Active management is required if
• There is PPH
• The placenta is not delivered within 60 min
• Patient requests earlier intervention
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Cord traction and uterine palpation should only be used after an
oxytocic has been given
Syntometrine vs Syntocinon
for 3rd Stage Labour
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Use of Syntometrine results in:
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Fewer PPHs (OR 0.74, CI 0.65-0.85)
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BUT
More vomiting
 Greater risk maternal hypertension
 And greater risk of retained placenta
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Prostaglandins for the
Prevention of PPH
Injected PG s resulted in:
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Reduced mean blood loss
Shorter 3rd stage
Non sigificant reduction in rate PPH but…
Shivering (almost 20%)
Diarrhoea
Abdominal pain
Increased cost
Rectal Misoprostol
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PPH rate reduced from 7.0% to 4.8% (not
significant in the study reported) but
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Fewer side effects than after IM or oral use
of PG’s
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This drug is cheap and stable and could
have an enormous impact on maternal
mortality in developing countries
Carbetocin
Danseraua et al Am J Obstet Gynecol March 99
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694 women in a Canadian multicentre trial
One dose Carbetocin 100 ug cf 8 hour
Oxytocin infusion
Outcome studied “additional oxytocic
required”
Fewer patients requiring additional oxytocic
after Carbetocin (OR = 2.03, CI 1.1 - 2.8)
Uterine massage after
delivery of the placenta…
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Only one study of 200 patients and that was with
active management of 3rd stage:
The rate of PPH was halved but not statistically
significant
BUT
Mean blood loss reduced by massage (-42 ml CI -8
to -75)
Reduced need for extra oxytocic (RR 0.20 CI 0.080.50)
2 transfusions required in the no massage group
Also from the Cochrane
Database
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No benefit from cord drainage
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No benefit from umbilical vein injection of
oxytocic
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No benefit from early suckling
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Chinese traditional medicine report pending
Risk factors for Primary PPH
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Prolonged labour
APH
Pre eclampsia
Maternal obesity
Multiple pregnancy
Birth weight >4000g
Advanced maternal age
Previous PPH
Assisted delivery
Low lying placenta
But >50% occur in women without identified risk
factors and…
90% are associated with uterine atony
And all studies of massive PPH fail to identify
consistent risk factors
Patient Assessment
Objective measure of blood loss is desirable
 Postural hypotension the earliest sign
 Tachycardia is usual
 Air hunger and loss of consciousness is
serious
 Urine output a good measure of treatment
 CVP sometimes
 A bedside test of blood clotting desirable
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Emergency Measures
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Rub up a contraction
Deliver the placenta
• If you can
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Gain IV access (large bore cannula)
Additional oxytocic
• IV Ergometrine 0.25 mg
• Syntocinon infusion
• Rectal Cervagem or Misoprostol
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(Empty the bladder)
Bimanual uterine compression
Aortic compression
Advanced Measures 1
Get help
 Check coagulation - use
cryoprecipitate etc.
 EUA is mandatory
 Myometrial PG F2 alpha
 Uterine Packing
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• Intrauterine balloon catheter
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Consider activated Factor VII
Intrauterine Balloon Tamponade
BJOG Review May 2009
 Was effective in 91.5% of cases
• Combined retrospective and prospective studies
• But only a total of 106 patients
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Types of balloons
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Sengstaken Blakemore (GI use)
Rusch (Urological)
Foley (often multiple)
Bakri (Specifically designed for obstetrics)
Condom (+/- Foley)
But there remain many unanswered
questions
Questions concerning intrauterine balloon
tamponade
BJOG Review May 2009
 Is it effective
• There are no RCTs
Risks and contraindications
 Which balloon to use, how to insert it
and what volume to inflate it
 Is a vaginal pack required
 Is an oxytocin infusion required
 Antibioitics and analgesia
 When to deflate and or remove it
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Advanced Measures 2
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Get more help
• Medical – haematologist
• Surgical colleague
• Radiologist for…
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Uterine artery embolisation
Laparotomy and…
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B-Lynch suture
Internal iliac artery ligation
Aortic clamping
Hysterectomy
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