Post Partum Haemorrhage seminar. 10 th October HoSHAS

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1 Post Partum Haemorrhage seminar 10 th October 2015 HoSHAS

2 Definition and Causes of PPH Dr Riduan bin Mohd Tahar Dept of O&G, HoSHAS

3 Introduc*on There has been a significant decline in maternal mortality from 540 per 100,000 live births in I957 to 28 per 100,000 in 2012 PPH used to be the 1 st leading cause of death in Malaysia Now PPH is the 3 rd leading cause of death

4 Definition of PPH

5 Introduc*on Conven*onally, the term postpartum hemorrhage (PPH) is applied to pregnancies beyond 20 weeks gesta*on. There is no single sa*sfactory defini*on of post partum haemorrhage

6 Defini*on in use 1. Timing of the onset of bleeding 2. Amount of blood loss 3. Decline in hematocrit 10% 4. Reduc*on in haemoglobin level 5. Rapidity of the blood loss Severe haemorrhage, 150ml/min, 50% blood loss in 20 minutes 6. Volume deficit 7. Base on clinical sign

7 Defini*on The World Health Organiza*on (WHO) 1990 Any blood loss from the genital tract during delivery above 500 ml 2003 Revise; to include the first 24 hours a\er delivery.

8 Primary PPH Defined as blood loss above 500 ml following vaginal delivery and above 1000 ml a\er abdominal delivery (Caesarean sec*on). Massive PPH is defined as PPH with blood loss in excess of 1500 ml.

9 Secondary PPH Excessive blood loss between 24 hours and 6 weeks post partum

10 Physiological changes Pregnancy induced hypervolaemia Increase by 30 60% ( ml) for an average size women Most average size healthy women can cope with the blood loss of more than 500mls The average blood loss during a normal vaginal delivery ml approximately 5% of women about 1000 ml during a vaginal birth.

11 Co- morbid Anaemia Severe PE, intravascular deple*on BMI Small size women cannot tolerate well with small blood loss

12 This is an arbitrary value Tends to be underes*mate!! Remains a major challenge in management.

13 How to improve Regular training / drill / courses More accurate method es*ma*on Blood collec*on drapes Weighing swabs Pictorial blood loss Associated risk factor

14 A appropriate or more clinical defini*on of PPH is any blood loss sufficient enough to cause haemodynamic instability. Preven*on is becer Reduce morbidity if detected earlier

15 Purpose of defini*on Standardize 500ml blood loss should be consider as an alert line Easily underes*mate It may be dangerous not to ins*tute simple therapeu*c/prophylac*c measures e.g. uterine massage, uterotonic agent and inspec*on of lower genital tract

16 Purpose of defini*on Effec*ve communica*on Ini*al assessment usually done by JM, Staff nurse, H.O Early recogni*on and prompts basic measures To determine the most suitable line of management To guide the degree of aggressiveness of treatment e.g. rapidly bleeding à surgical management

17 Causes of PPH

18 CAUSES OF PPH (the 4 'T's) TONE (70%) (Atonic uterus, distended bladder) TRAUMA (20%) (Uterine, cervical or vaginal injury) TISSUE (10%) (Retained products of conception) THROMBIN (<1%) (Pre-existing or acquired coagulopathy)

19 Tone Uterine atony is the most common cause of PPH 70% of cases Uterine contrac*on à living ligatures

20 Tone Uterine over- distension Mul*ple pregnancy Macrosomic fetus Polyhydramnios Fetal abnormali*es e.g. severe hydrocephalus

21 Tone Uterine muscle fa*que Prolonged labour Precipitate labour Augmented labour with oxytocin High parity (20 fold increased risk) Prolonged 3 rd stage Previous pregnancy with PPH

22 Tone Intra- amnio*c infec*on Prolonged SROM Chorioamnioni*s Uterine distor*on/abnormality Fibroid uterus Uterine anomalies Placenta praevia

23 Placenta praevia Lower segment takes *me to contract Defensive medicineà increase rate of LSCS Increase risk of placenta accreta 2 previous scar 50% of accreta Mul*disciplinary approach Morbidity and mortality

24 Tone Bladder distension Urinary reten*on Uterine relaxing drugs Anaesthe*c drugs, nifedipine, NSAIDs, beta- mime*cs, MgS04

25 Trauma 20% of case Commonly the lower genital tract trauma Obese pa*ent à limited access for repair

26 Trauma Cervical / vagina / perineal tears Precipitous delivery Manipula*ons at delivery Opera*ve delivery Episiotomy especially with varicose vulva

27 Trauma Extended tear at CS Malposi*on Fetal manipula*on e.g. version of second twin Deep engagement Upper segment CS Lower segment not well formed Severe adhesions at lower segment Transverse lie

28 Trauma Uterine rupture Previous uterine surgery Uterine inversion Mismanagement of third stage of labour High parity Fundal placenta

29 Tissue 10% of cases Foreign body Ineffec*ve uterine contrac*on

30 Tissue Retained placenta / membranes Retained placenta 10% Increase the risk up to 20% History of retained placenta Undiagnosed morbidly adhere placenta Incomplete placenta at delivery, especially< 24 weeks

31 Tissue Abnormal placenta succinturiate /accessory lobe Previous uterine surgery Abnormal placenta on ultrasound Undiagnosed incomplete placenta at delivery Systema*c method to check for placenta completeness

32 Thrombin 1% of cases Mul*disciplinary care

33 Thrombin Pre- exis*ng clokng abnormality E.g. haemophilia A / vwd / hypofibrinogenaemia / ITP Family history An*coagulant History of DVT / PE Aspirin Heparin

34 Thrombin Acquired in pregnancy Gesta*onal thrombocytopenia Severe PE with thrombocytopenia (HELLP) DIVC secondary to abrup*on, AFE, severe sepsis Dilu*onal coagulopathy e.g. massive transfusion

35 Antenatal 1. Age 2. Ethnicity 3. BMI 4. Parity Risk factors 5. Medical condi*on e.g. type II DM, hypertension, haematology 6. Prolonged pregnancy

36 Risk factors Antenatal 7. Macrosomic 8. Mul*ple pregnancies 9. Fibroids 10. Antepartum haemorrhage 11. Previous history of PPH 12. Previous caesarean

37 Risk factors Intrapartum 1. First stage 2. Second stage 3. Third stage 4. Analgesia 5. Delivery methods 6. Episiotomy 7. Chorioamnioni*s

38 Secondary PPH Excessive blood loss between 24 hours and 6 weeks post partum The commonest cause is infec*on (endometri*s) O\en secondary to retained product of concep*on Management includes an*bio*c and evacua*on retained product of concep*on

39 Summary Defini*on Primary PPH, >500ml within 24 hours of delivery Secondary PPH a\er 24 hours to 6 weeks post delivery Massive PPH, > 1500ml Underes*mate Risk factor Causes of PPH 4T 1. Tone 70% 2. Trauma 20% 3. Tissue 10% 4. Thrombin - < 1%

40 ANTICIPATION remains the goal of PPH management

41 Thank You

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