Lecture regarding risk factors, causes, and medical management of postpartum hemorrhage

1. THE MEDICAL MANAGEMENT OF POSTPARTUM HEMORRHAGE Chukwuma I. Onyeije, M.D., Atlanta Perinatal Associates

3. For your convenience, A digital copy of this lecture is also located at: http://onyeije.net/present

4. Mary 24 year old G2P2 Underwent a routine cesarean section at 7.30 pm Pre-operative Hb was 13 g/dl. Blood loss of 500cc.

5. Mary 4 hours post-partum Pulse at 100-120 otherwise stable. BP: 70-90 / 50-60 Analgesia and Hydration provided. 5 hours postpartum: Seizure with obtundation. Hemoglobin: 7 g/dl,

6. 6 Hours post partum: Elevated cardiac enzymes DIC Myocardial Infarction & Liver failure 9 Hours postpartum: Failed arterial embolization 10 Hours postpartum Uterine packing done. 11 Hours Postpartum: Hysterectomy 2 Days Postpartum: Flatline EKG

7. ‘‘ She died in childbirth’’

8. Hemorrhage has probably killed more women than any other complication of pregnancy in the history of mankind.

9. An estimated 150,000 maternal deaths worldwide result from obstetric hemorrhage each year

10. 90% of deaths from Postpartum hemorrhage are preventable.

11. WE HAVE THE TOOLS GOOD NEWS

12. Those caring for pregnant women must be prepared to aggressively treat this complication when it occurs.

13. What can be done?

14. THE STEPS TO PPH: P OST P ARTUM H EMORRHAGE: P REDICT H ANDLE P REPARE

15. THE STEPS TO PPH: P OST P ARTUM H EMORRHAGE: P REDICT H ANDLE P REPARE Identify patients at risk Use a multi-disciplinary Approach Optimize clinical management

16. Uterine Blood Flow

17. Large amounts of blood can be lost rapidly following delivery.

18. Uterine contraction is more important than clot formation or platelet aggregation as a mechanism of hemostasis

19. 1. PREDICT: THE STEPS TO PPH: P OST P ARTUM H EMORRHAGE:

20. Can we Predict PPH? Who is at risk?

21. Risk Factors for Postpartum Hemorrhage What Should we do with a list like this? Prior postpartum hemorrhage Advanced maternal age Multifetal gestations Prolonged labor Polyhydramnios Instrumental delivery Fetal demise Placental abruption Anticoagulation therapy Multiparity Fibroids Prolonged use of oxytocin Macrosomia Cesarean delivery Placenta previa and accreta Chorioamnionitis General anesthesia

22. Clinically Important Risk Factors for Postpartum Hemorrhage Prior postpartum hemorrhage Abnormal placentation Operative delivery

23. Risk Factors for Postpartum Hemorrhage under Clinical Control Prolonged labor Instrumental delivery Anticoagulation therapy Prolonged use of oxytocin Cesarean delivery General anesthesia

24. Causes of Postpartum Hemorrhage (another busy slide) Primary causes Uterine atony Genital tract lacerations Retained products Abnormal placentation Coagulopathies and anticoagulation Uterine inversion Amniotic fluid embolism Secondary causes Retained products Uterine infection Subinvolution Anticoagulation

25. 80% OF CASES OF POSTPARTUM HEMORRHAGE ARE DUE TO UTERINE ATONY (a less busy slide)

26. What about DIC? Coagulopathy is a relatively uncommon cause of primary PPH Coagulopathy most commonly occurs when another cause of PPH already has produced significant blood loss.

27. RDFS RDFS is retained dead fetus syndrome Well described in most obstetrics texts Clinically manifested at about 6 weeks after fetal death Rarely seen in modern obstetrics.

29. 80% OF CASES OF POSTPARTUM HEMORRHAGE ARE DUE TO UTERINE ATONY (Did I mention that…)

30. Question: What causes uterine atony and is there anything we can do to prevent uterine atony induced postpartum hemorrhage?

32. Trends in postpartum hemorrhage: United States, 1994–2006 Source: American Journal of Obstetrics & Gynecology 2010; 202:353.e1-353.e6 (DOI:10.1016/j.ajog.2010.01.011 ) Copyright © 2010 Terms and Conditions William M. Callaghan, MD, MPH, Elena V. Kuklina, MD, PhD and Cynthia J. Berg, MD, MPH American Journal of Obstetrics & Gynecology Volume 202, Issue 4, Pages 353.e1-353.e6 (April 2010) DOI: 10.1016/j.ajog.2010.01.011

33. Upper Genital Tract Trauma Most often is the result of uterine rupture Bleeding from direct uterine injury during cesarean Injury of associated vascular structures (uterine, artery or broad ligament varicosities) during cesarean

34. Lower Genital Tract Trauma May occur spontaneously or result from episiotomy, obstetric maneuvers, or operative instrumented deliveries. Involve perineum, cervix and vagina.

35. 2. PREPARE: THE STEPS TO PPH: P OST P ARTUM H EMORRHAGE:

37. 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5.- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management

38. Preparation for Postpartum Hemorrhage

39. “ Perhaps the most important aspect in the management of PPH is the attitude of the attendant in charge. It is critical to maintain equanimity in what can be a chaotic and stressful environment ” . Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441

40. Analysis Paralysis An excessive number of well-meaning individuals increases the ambient noise, adds to confusion, and opens the door to communication errors. Yinka Oyelese, MD, Obstet Gynecol Clin N Am 34 (2007) 421–441

42. 1.- Prepare for PPH -Nursing -Anesthesia - Surgical assistance - Others (I.R.) Drugs/Equipment -Methergine -Hemabate -Cytotec -Colloids -Blood/Bl.products -Surg. Instruments -Hemostatic ballons Personnel

46. Identify possible post partum hemorrhage. Simultaneous evaluation and treatment. Remember ABCs. Use O2 4L/min. If bleeding does not readily resolve, call for help. Start two 16g or 18g IVs. Initial Assessment

47. Initial Steps for PPH Bimanual compression Manual exploration of the uterus Empty the bladder Administer uterotonic agents Examine lower genital tract for lacerations.

52. Medical Treatment of Postpartum Hemorrhage Medications that cause uterine contractions Medications that promote coagulation

53. METHERGINE “ Speedy” OXYTOCIN “ The Champ” Cytotec Inexpensive (?) Effective Medications for Uterine Atony

58. Fluid Management of Postpartum Hemorrhage

59. - Balanced * ( 0.9% NaCl, lactated Ringers -Hypertonic (3.5,5, 7.5% NaCl) -Hypotonic (0.45% NaCl) * Same electrolyte concentration as the extracellular compartnt -Albumin (5%, 25%) -Dextran, glucose polymers (40, 70) -Hydroxyethyl starch (Hespan ) Crystalloid Colloid Blood/Blood Products Fluid Management of Postpartum Hemorrhage

60. Acute Postpartum Blood Loss PROBLEMS : Loss of circulatory Volume Loss of O 2 carrying capacity Restore volume 1 - Crystalloid 2 - Colloid  SaO 2  O 2 carrying capacity Supplemental O 2 Transfusion

61. 25-30%(15-1800cc) Healthy ?  Crystalloid/Colloid Medical complications ?  Consider transfusion 30-50%(18-3000cc) Crystalloid/Colloid Consider transfusion > 50% ( > 3000cc) Crystalloid/Colloid Blood transfusion Clotting factors (FFP, Cryo) Blood Loss Hemorrhagic Shock - Fluid Management -

62. Managing blood loss by hemorrhage classification Class Blood Loss Volume Deficit Spx Rx I < 1000 cc 15% Orthostatic tachycardia Crystalloid II 1001-1500 15-25% Incr. HR, orthostasis, mental Decr cap refill Crystalloid, III 1501-2500 25-40% Incr HR, RR Decr BP, Oliguria Crystalloid Colloid, RBCs IV > 2500 > 40% Obtunded Oliguria/anuria CV collapse RBC, Crystalloid, Colloid

64. Acute isovolemic hemodilution Withdraw 2-4 u. of Blood  Replace the volume with crystalloid  Lower the pre-op Hct  Replace the blood at end of surgery Acute hypervolemic hemodilution Admin 1500-2000cc Crystalloid  Hemodilution (Lowers pre-op Hct) Ways to optimize hemodynamic status

67. Oxytocin 10U in 20cc of NS placed in clamped umbilical vein. If this fails, get OB assistance. Check Hct, type & cross 2-4 u. Two large bore IVs. Anesthesia and OR support. Removal of Abnormal Placenta

72. Episiotomy Hematoma Uterine inversion Uterine rupture T # 3: Trauma

73. Rare: ~1/2000 deliveries. Causes include: Excessive traction on cord. Fundal pressure. Uterine atony. Uterine Inversion

79. Sometimes found incidentally. During routine exam of uterus. Small dehiscence, less than 2cm. Not bleeding. Not painful. Can be followed expectantly. Uterine Rupture

80. Vaginal bleeding. Abdominal tenderness. Maternal tachycardia. Abnormal fetal heart rate tracing. Cessation of uterine contractions. Uterine Rupture before delivery

81. May be found on routine exam. Hypotension more than expected with apparent blood loss. Increased abdominal girth. Uterine Rupture after delivery

82. Risk factors include: Instrumented deliveries. Primiparity. Pre-eclampsia. Multiple gestation. Vulvovaginal varicosities. Prolonged second stage. Clotting abnormalities. Birth Trauma

83. Repair of cervical laceration

85. Pelvic Hematoma

86. The 4 “Ts” Recalled “ THROMBIN” Check labs if suspicious.