Overview and medical management of pph
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Transcript of Overview and medical management of pph
Overview and medical management of PPH
Dr. Suhas OtivConsultant, KEM Hospital, Pune
Lancet 2006; l368:1189-200
Mortality from PPH
• Half of 500,000 maternal deaths globally
• 28 % of maternal deaths in developing countries
• Risk of death from PPH 1 in 1000 deliveries - developing countries1 in 100,000 deliveries – developed countries
Lancet 2006; l367:1066-72
Incidence of PPH
PPH 5 – 17 % of all deliveries> 500ml
Major PPH 1.3 – 2.5 % of all deliveries> 1000 ml
ACOG 3.9 % of all deliveries
Definition of PPH
Primary PPH: 0 – 24 hours; Secondary PPH: 1 - 84 days
Blood loss > 500 ml at vaginal delivery> 750 - 1000 ml at Cesarean
Severe PPH > 1000 ml loss at vaginal delivery
ACOG: - Fall in hematocrit 10% - Need for PRBC transfusion
Rate of blood loss: > 150ml/min or sudden loss > 1.5 – 2 l
PPH can occur with minimal vaginal bleeding !!!!
Accuracy of visual estimation of blood loss
Blood collection method
Modified –WHO
Modified –WHO
Weighing Blood loss
Modified –WHO
Measuring volume of blood loss
-Transfer of blood-Mops squeezed
BRASSS-V®
Blood Collection Drape with Calibrated Receptacle
Etiology of PPH• Uterine Atony > 80 %
• Lacerations of vagina, cervix • Uterine rupture 10%• Uterine inversion
• Retained placental fragments• Placental accreta / increta / percreta 5%
• Coagulopathy 1%
Risk factors for PPH
• Nulliparity• Obesity• Large baby• Prolonged labor• APH• Multiple pregnancy• Cesarean delivery
• Advanced maternal age• PIH• PPH in previous delivery• Augmented labor• Forceps delivery• Use of tocolyticsх Grand multiparity
65 % cases of PPH occur with no risk factors
PPH at Cesarean delivery: Risk Factors
• General anesthesia• Chorio-Amnionitis• Pre-eclampsia• Protracted active phase of labor• Second-stage arrest• Classic uterine incision
Obstet Gynecol 1991 Jan;77(1):77-82
Risk factors for PPH: a case control studycomparing 666 cases with controls in 154311 deliveries• Retained placenta (OR 3.5, 95% CI 2.1-5.8)
• Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)
• Placenta accreta (OR 3.3, 95% CI 1.7-6.4)
• Lacerations (OR 2.4, 95% CI 2.0-2.8)
• Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)
• Large for gestational age new born (eg, >4000 g) (OR 1.9, 95% CI 1.6-2.4)
• Hypertensive disorders (OR 1.7, 95% CI 1.2-2.1)
• Induction of labor (OR 1.4, 95% CI 1.1-1.7)
• Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7)
J Matern Fetal Neonatal Med. 2005;18(3):149
Management of PPH
• Scenarios – labor room, OR, wards, peripheral hospital
• Effective management– Prompt response– Organized team work – Clear priorities, decisive
• Help: communication, monitoring, assistance, documentation
Being prepared for PPH
• Team: Nursing, doctors, surgical expertise, critical care physician / anesthesiologist
• Drugs: Oxytocin, Methergin, Carboprost, volume expanders, resuscitation
• Equipment: Monitoring, resuscitation, Blood bank, Lab, ICU, OR
Management of PPH at vaginal delivery
First line Management• Call for help• Uterine massage• IV access: X-match, labs• Infuse NS rapidly, • BP, Foley catheter, pulse oximeter, • Prompt Uterotonic drugs
Carboprost 250 mcg, 2 doses 15 minutes apart Oxytocin infusion 40 units / 500 ml in 30 – 60 min Methylergometrine 0.2mg i.m. one dose Misoprostol 400 - 800mcg
• Rapidly evaluate for vaginal / cervical lacerations• Warmth, oxygen
Oxytocic drugs
• Oxytocin• Methyl ergometrine• Misoprostol• Carboprost
Oxytocin
• Storage: Between 2-8 *C, avoid freezing
• Adverse effects: anti-diuretic effect, hypotension, arrhythmias
• Incompatible with noradrenaline, warfarin
• 10 – 40 IU / L of infusate
Ergometrine
• Storage: Refrigerate, protect from light, stable for 60-90 days, discoloration – discard
• Avoid : heart disease, hypertension, peripheral vascular disease, hepatic or renal impairment; with antiretroviral and macrolide antibiotics
• Adverse : Vomiting, nausea, HT, CVA
• Route: IM preferred, IV dilute in 5 ml NS
Carboprost – PGF2 alpha
• Caution : Asthma, cardiac disease, epilepsy, liver disease
• Storage: Refrigerate• Adverse: Vomiting, diarrhea, flushing,• Dosage: 250 mcg IM, repeat every 15 - 90
minutes, maximum 8 doses = 2 mg.• IV injection - bronchospasm, hypertension,
vomiting, and anaphylaxis
Misoprostol
• PGE1 analogue• Adverse effects – vomiting, shivering at higher
doses. No broncho-constriction.• Storage: Stable at or below 25*C• Route: Oral, buccal, rectal, vaginal• Rapid onset of action lasting 4-6 h
Misoprostol as an adjunct to standard uterotonics for treatment of PPHLancet. 2010;375(9728):1808
1422 women with atonic PPH treated with routine uterotonic agents randomized to
600 mcg misoprostol sublinguallyPlacebo sublingually
Found no difference in blood loss > 500 ml in next 1 hour
Treatment of PPH with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocinLancet. 2010;375(9710):217
31055 women delivered with prophylactic oxytocin in III stage, 809 (3%) who had atonic PPH were randomized to
Misoprostol 800mcg slOxytocin 40 u infusion in 15 minutes
Similar outcomes in both groups 90% women had bleeding controlled in 20 minutes; 30% women had additional blood loss of > 300 ml after Rx
After initial treatment
• Evaluate for retained placental fragmentuterine inversionlacerationscoagulopathy
• Check urine output, response to resuscitation, timevolume of blood lost
Volume replacement
• Crystalloid: Ringer Lactate, Hartmann, NSRL similar to plasma
only 20% retained in circulationDextrose: only 10% retained, interferes with X matchingNS avoid in pre-eclamptic patient
• Blood volume changes last for 40 minutes only• Infuse 3 L for each 1 L of estimated blood loss• Target 90mm systolic pressure, UOP 30ml/hr• Give colloids after 2 L of crystalloids given
Colloids• Gelatin polymers - Hemaccel
rapid urinary excretionanaphylaxis
• Hydroxyethyl starch – Hetastarch, Pentastarchincreases plasma volume by 70 – 230%dose 20 ml/kg = 1 to 1.5 Lno anaphylactic reactions well toleratedlasts for 4 hours in circulation
Blood transfusion
• No universally accepted guidelines for trigger
• PRBC x 2 if no improvement after 2-3 L of crystalloids or if
ongoing blood loss likely
• Warm carefully. > 40 *C – severe transfusion reactions
• Admin 1 FFP for every 1-2 units of PRBC, at 12-15ml/kg
• No drugs / injections with blood
Target
• Hb > 7, • Platelets > 50,000 /ml• Fibrogen > 100mg/dl• PT < 1.5 times control
Massive hemorrhage
• Defined as > 10 units of BT required / 24 h
• Likely when persistent SBP < 90, Loss more than 1500ml
• Cryoprecipitate if no response to FFP or Fibrogen level < 100
• Expect platelet count < 50,000 after > 2 L blood loss. Platelets to maintain counts 25-50,000, 1:1
Secondary interventions
• Repeated doses of Carboprost max 8 doses• Intramyometrial Carboprost - off label• Carboprost uterine irrigation• Rectal Misoprostol - high doses >800mcg• Intra-uterine Misoprostol• Tamponade – Sengstaken tube, • Uterine Packing
Indications for laparotomy
• Unabated blood loss
• Atony unresponsive to Rx
• Vital signs out of proportion to blood loss
• Vaginal laceration extending above fornix
Summary
• Symptoms and vital signs of blood loss are more important than visual assessment of blood loss
• Team approach with protocols and regular drills
• Prompt, sequential use of utero-tonic agents and replacement of volume are mainstay of Rx
• Low Fibrinogen, abn PT, tachycardia and abnormalities of placental implantation and detectable troponin are predictors of increased morbidity
Thank you !