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Postpartum Hemorrhage Xiong yu Obstetric & Gynecology Hospital, Fudan University Blood loss in excess of 500 ml following birth within the first 24 hours of delivery ◦ Serious intrapartum complication ◦ The most significant cause of maternal death worldwide, mortality : 140 000 per year (1 maternal death every 4 minutes) ◦ Incidence: 4–6% of pregnancies ◦ Actual incidence: more high because of inaccurate, significant underreporting Primary PPH ◦ Occurring within the first 24 hours of delivery ◦ 4–6% of pregnancies ◦ Caused by uterine atony in 80% or more of cases Secondary PPH ◦ Occurring between 24 hours and 6–12 weeks postpartum ◦ 1% of pregnancies 4“T” ◦ Tone: uterine atony ◦ Tissue: retained placenta ◦ Trauma: vaginal, cervical, or uterine injury ◦ Thrombin: coagulopathy (pre-existing or acquired) ——SOGC guideline (number 235, October 2009): Active Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage The most common and important cause of PPH The primary protective mechanism for immediate hemostasis after delivery: ◦ Myometrial contraction causing occlusion of uterine blood vessels ——living ligatures of the uterus ◦ Blood flow from the vascular space to the uterine cavity via the myometrium is impeded Etiologic category and process Clinical risk factors Overdistension of uterus Polyhydramnios, Multiple gestation, Macrosomia Uterine muscle exhaustion Rapid labor, Prolonged labor, High parity, Oxytocin use Intra-amniotic infection Fever, Prolonged rupture of membranes Functional/anatomic distortion of uterus Fibroids, Placenta previa, Uterine anomalies Uterine-relaxing medications Halogenated anesthetics, Nitroglycerin Bladder distension Placenta previa Placenta abruption 胎儿 子宫内膜 出血 脐带 胎盘 宫颈 Twin pregnancy fibroid 胎盘 脐带 脐带 胎儿 胎儿 宫颈 肌壁间肌 瘤 带蒂 浆膜下肌 瘤 阴道 Uterine anomalies 带蒂 内膜下肌 瘤 浆膜下肌 瘤 内膜下肌 瘤 Etiologic category and process Avulsed lobule, Succenturiate lobe Abnormally adhered: Accreta, Increta, Percreta Clinical risk factors Incomplete placenta at delivery Placenta previa with or without previous uterine surgery, Prior myomectomy, Prior cesarean delivery, Asherman’s syndrome, Submucous leiomyomata, Maternal age older than 35 years Succenturiate lobe Accreta Placenta villi attach to the myometrium Increta Percreta Placenta villi invade Placenta villi penetrate into the myometrium through the myometrium Etioiogic category and process Lacerations of the cervix, vaginal, or perineum Puerperal Hematomas Clinical risk factors Precipitous delivery Operative delivery Nulliparity, episiotomy, and forceps delivery I Laceration of cervix III Lacerations of perineum II Etioiogic category and process Clinical risk factors Pre-existing states Primary thrombocytopenia Aplastic anemia Acquired in pregnancy HELLP syndrome Abruption placenta Prolonged intrauterine fetal demise Sepsis Amniotic fluid embolism Significant hemorrhage Elevated blood pressure Antepartum hemorrhage Fetal demise Fever Sudden collapse Vaginal bleeding ◦ Bleeding with characteristic soft, poorly contracted (“boggy”) uterus on bimanual pelvic examination ——uterine atony ◦ Bleeding while the uterus is firmly contracted —— retained placenta ——genital tract laceration ◦ Bleeding without clot ——coagulopathy ◦ Pelvic or rectal pressure and pain ——genital tract hematomas Hypovolemic shock Irritable,pallor and clamminess of skin, tachycardia, narrow pulse pressure ——mild degree of shock Weight method： ◦ Blood loss(ml)＝（dressing wet weight after birth－dressing dry weight before birth）/1.05(specific gravity of blood) Volume method: ◦ Collect blood using a container Area method： ◦ 10cm*10cm gause soak blood = 10ml blood Shock index =heart rate/systolic pressure（mmHg） （normal <0.5） shock index 0.6~0.9 =1.0 =1.5 ≥2.0 estimate loss of blood（ml） loss of blood volume <500~750 1000~1500 1500~2500 2500~3500 <20% 20~30% 30~50% ≥50~70% The initial goal ◦ Identifying and treating the cause of blood loss ◦ Instituting resuscitative measures to maintain hemodynamic stability and oxygen perfusion of the tissues Call for help Resuscitation ◦ ◦ ◦ ◦ ◦ ◦ Assess the “ABC” Monitor BP, P, R Empty bladder, monitor urine output IV line Crystalloid, isotonic fluid replacement Oxygen by mask Laboratory tests ◦ Complete blood count ◦ Coagulation screen ◦ Blood grouping and cross ——SOGC 2009 Uterine massage ◦ Diminish bleeding, expel blood and clots, and allow time for other measures to be implemented Uterotonic drugs ◦ Ongoing blood loss in the setting of decreased uterine tone requires the administration of additional uterotonics as the first-line treatment for hemorrhage Drug Oxytocin Dose/Route IV: 10–40 units in 1 liter normal saline or lactated Ringer’s solution IM: 10 units Carbetocin IV/IM： 100 μg Ergometrine IM: 0.2 mg Frequency Comment Continuous Avoid undiluted rapid IV infusion, which causes hypotension Every 2–4 h Avoid if patient is hypertensive Drug Dose/Route Frequency Comment 15-methyl PGF2α (Hemabate) IM: 0.25 mg Every 15– 90 min, 8 doses maximum Avoid in asthmatic patients Diarrhea, fever, tachycardia can occur Dinoprostone (PGE2) Suppository: vaginal or rectal 20 mg Every 2 h Avoid if patient is hypotensive. Fever is common. Misoprostol (PGE1) 800–1,000 mcg rectally Uterine tamponade Exploratory laparotomy Uterine artery embolization Indication：uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after vaginal delivery Technique Comment —Packing —4-inch gauze; can soak with 5,000 units of thrombin in 5 mL of sterile saline —Foley catheter —Insert one or more bulbs; instill 60–80 mL of saline —Sengstaken–Blakemore tube —SOS Bakri tamponade balloon —Insert balloon; instill 300–500 mL of saline Packing Bakri Balloon tamponade Indication：When uterotonic agents with or without tamponade measures fail to control bleeding in a patient who has given birth vaginally Techniques ◦ Compression sutures ◦ Artery ligation ◦ Hysterectomy B-Lynch technique ◦ First reported by B-lynch in 1993 ◦ Compress the uterine corpus and decrease bleeding ◦ Rare Complication：uterine ischemic necrosis with peritonitis Modified B-Lynch ◦ e.g. Hemostatic multiple square suturing ◦ For postpartum hemorrhage caused by uterine atony, placenta previa, or placenta accreta ◦ Eliminateing space in the uterine cavity by suturing both anterior and posterior uterine walls Bilateral uterine arteries ligation Bilateral internal iliac arteries ligation Bilateral ovarian arteries ligation Uterine arteries ligation Internal iliac arteries ligation Diminish the pulse pressure of blood flowing to the uterus The timing of this intervention is important: it must be done without delay, before excessive blood loss has occurred Surgical skill is required to avoid failure and complications such as damage to other vascular structures and the ureters Indication: massive hemorrhage has not responded to previous interventions Notice: If hysterectomy is performed for uterine atony, there should be documentation of other therapy attempts Hysterectomy cavity cavity uterus salpinx endometrium overy myometrium subtotal cervix bladder vagina total Indication: stable vital signs , persistent bleeding, especially if the rate of loss is not excessive Used for bleeding that continues after hysterectomy Used as an alternative to hysterectomy to preserve fertility Radiographic identification of bleeding vessels Embolization with gelfoam, coils, or glue, or balloon occlusion H.A.E.M.O.S.T.A.S.I.S. H: Ask for help A: Assess (vital parameters, blood loss) and resuscitate E: Establish etiology and check medication supply (oxytosin, ergometrine) and availability of blood M: Massage uterus O: Oxytocin infusion, prostaglandins (intravenous, rectal, intramuscular, intramyometrial) S: Shift to operating room, exclude retained products and trauma, bimanual compression T: Tamponade balloon, uterine packing A: Apply compression sutures S: Systematic pelvic devascularization (uterine, ovarian, internal iliac) I: Intervention radiologist, uterine artery embolization if appropriate S: Subtotal or total abdominal hysterectomy ——ICM/FIGO guideline 2006: Postpartum hemorrhage today: initiative 2004—2006 Diagnosis: detection of an echogenic mass in the uterus by ultrasonography Directed therapy ◦ Whole placenta in uterus：manual removal ◦ Incomplete separation （avulsed lobule, succenturiate lobe）： gentle curettage ◦ Placenta accreta curettage wedge resection medical management hysterectomy Lacerations of perineum, vagina, or cervix Genital tract hematomas Identification and proper repair of lacerations ◦ ◦ ◦ ◦ ◦ Transfer to a well-equipped operating room Proper patient positioning Adequate operative assistance Good lighting Appropriate instrumentation (eg, Simpson or Heaney retractors) ◦ Adequate anesthesia May not be recognized until hours after the delivery Sometimes occur in the absence of vaginal or perineal lacerations The main symptoms are pelvic or rectal pressure and pain Directed therapy ◦ Draining the blood within the hematoma (sometimes placing a drain in situ) ◦ Suturing the incision ◦ Packing the vagina ◦ Interventional radiology Directed therapy ◦ Appropriate testing ◦ Blood products infused as indicated ◦ Simultaneous surgery if the coagulopathy caused or perpetuated by the hemorrhage Baseline studies ◦ ◦ ◦ ◦ ◦ Complete blood count with platelets Prothrombin time Activated partial thromboplastin time Fibrinogen A type and cross order Be ordered when excessive blood loss is suspected and should be repeated periodically as clinical circumstances warrant Response to hemorrhage before laboratory results are known A simple measure of fibrinogen ◦ A volume of 5 mL of the patient’s blood is placed into a clean, red-topped tube and observed frequently. Normally, blood will clot within 8–10 minutes and will remain intact ◦ If the fibrinogen concentration is low, generally less than 150 mg/dL, the blood in the tube will not clot, if it does, it will undergo partial or complete dissolution in 30–60 minutes AMTSL (active management of the third stage of labor) ◦ Routine use of uterotonics ◦ Early cord clamping, controlled cord traction ◦ Appropriate uterine massage after delivery of the placenta Subinvolution of placental site Retained products of conception Infection Inherited coagulation defects The extent of bleeding usually is less than that seen with primary postpartum hemorrhage Ultrasound evaluation can help identify intrauterine tissue or subinvolution of the placental site Treatment may include uterotonic agents, antibiotics, and curettage Management may vary greatly among patients, depending on etiology and available treatment options, and often a multidisciplinary approach is required Balancing the use of conservative management techniques with the need to control the bleeding and achieve hemostasis Uterotonic agents should be the first-line treatment for postpartum hemorrhage due to uterine atony When uterotonics fail following vaginal delivery, exploratory laparotomy is the next step Williams Obstetrics, 23rd Edition ACOG Practice Bulletin No. 76. 2006. Postpartum hemorrhage ICM/FIGO guideline 2006: Postpartum hemorrhage today: initiative 2004—2006 SOGC guideline (number 235, October 2009): Active Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage RCOG Green-top Guideline No. 52 May 2009:Prevention and management of postpartum haemorrhage THANKS!