POSTPARTUM HEMORRHAGE

Laura Noble B.A., RRT, AA

Postpartum Hemorrhage

Case Presentation Definition Epidemiology Preventative Measures Etiology Management Replacement Therapy What Can We Do As Anesthesia Assistants? Case summary

Case Review

Healthy 32 yr old G3P2 22 weeks pregnant for induction of labour of fetus with a fetal anomaly Mallampati IV Vaginal delivery with retained placenta Heavy bleeding Systolic BP ~60mmHg Transferred to OR Dx: Postpartum Hemorrhage

DEFINITION

Blood loss >500mL for a vaginal delivery Blood loss >1000mL for a caesarian section 10% decrease in hematocrit Requires a blood transfusion Primary PPH is within 24 hours after birth Secondary PPH is 24 hours to 6 weeks after birth Primary PPH involves heavier bleeding and is more likely to result in maternal morbidity and mortality

PHYSIOLOGICAL CHANGES IN PREGNANCY

Blood volume increases by 50% Red blood cells only increase 20-30% Uterine blood flow is 600ml/min Hypercoaguable state Upper airway edema Decrease in FRC Oxygen consumption increase by 20%

EPIDEMIOLOGY

Major cause of maternal death worldwide PPH can occur in 10-18% of all births 3% of vaginal deliveries will result in severe PPH 25% of all maternal deaths are caused by severe hemorrhage

PREVENTATIVE MEASURES

Active management of the third stage of labour Oxytocin with delivery of baby Prophylactic oxytocin decreases PPH by 40% Deliver placenta with controlled cord traction and inspect for completeness Palpate uterus and inspect lower genital tract

ETIOLOGY
Remember the 4 Ts: 1. Tone 2. Tissue 3. Trauma 4. Thrombin

1. TONE

Uterine Atony Boggy uterus Most common cause of PPH 70% of all PPH

Risk Factors for Uterine Atony

large baby, multiples)

Uterine over distension Uterine exhaustion Infection

(polyhydramnious,

(precipitous labour, prolonged/augmented labour, high parity) (prolonged rupture of membranes,

fever)

Anatomical distortion of the uterus

(uterine abnormality, fibroids, placenta previa)

Exposure to specific drugs

agents, Beta agonists)

(NTG, Volatile

2. TISSUE

Retained products Abnormal placenta (placenta accreta, increta or percreta) Previous uterine surgery

3. TRAUMA

Lacerations of cervix, vagina, perineum or C/S incision site Hematomas Uterine rupture Uterine inversion

Risk Factors for Trauma

Precipitous delivery Operative delivery Assisted delivery (forceps, vacuum) Previous uterine surgery Fundal placenta

4. THROMBIN

Abnormal coagulation Very rare Usually identified before delivery

Risk Factors for Thrombin

Pre-existing

Von Willebrands Hemophilia Idiopathic thrombocytopenia (ITP) History of blood clots

Acquired in pregnancy
Pre-eclampsia HELLP Amniotic fluid embolus

Medication (aspirin, heparin) Antepartum hemorrhage

MANAGEMENT OF PPH

Communication!!!! Call for HELP!! Determine etiology (four Ts) Vital signs Large bore I.Vs Blood work Oxygen OR

Dont Panic!

Management for Tone

1. 2. 3.

Multidisciplinary team work Uterine massage Pharmacological management

2. Uterine Massage

3. Pharmacologic Management of Atony

Oxytocin Egonovine Maleate (Ergot) Hemabate (15-Methyl prostaglandin F2 alpha)

Management for Tissue

Inspect placenta for completeness Manually remove remainder of placenta Abnormal placenta

Management for Trauma

Suture any lacerations Inspect uterus for inversion Correction of uterine inversion- done under GA

Management for Thrombin

Fresh frozen plasma Platelet transfusion Cryoprecipitate Hematology consult Replace specific coagulation factors

Surgical Intervention

Uterine artery ligation Uterine balloon inflation Hysterectomy Pack uterus

Interventional Radiology

Uterine artery embolization

REPLACEMENT THERAPY

Volume replacement options Blood loss is usually underestimated May be asymptomatic until blood loss reaches 25-35% Any patient who is at risk for PPH should be cross-matched upon arrival to hospital

WHAT CAN WE DO AS ANESTHESIA ASSISTANTS?

Be aware Team work Oxygen Help transport to the OR Monitors I.V. access Retrieve Ergot and Hemabate from the fridge Blood work
(contd)

WHAT CAN WE DO AS ANESTHESIA ASSISTANTS?

RSI Difficult airway equipment Prime the Level 1 rapid infuser Check and hang blood Warming mechanisms (Hotline, blankets) Point of care testing Put in/assist with an arterial line, CVP Be prepared for anything!

Case Review

Healthy 32 yr old G3P2 1 CS, 1 SVD 22 weeks pregnant for induction of labour Mallampati IV Retained placenta Heavy bleeding Systolic BP ~60mmHg Transferred to OR
(contd)

Case Review

GA RSI with Glide scope 2 18g I.V.s and arterial line inserted Placenta manually removed Uterotonics given Bakri balloon and vaginal packing inserted
(Contd)

Case Review

Interventional Radiology Surgical Hysterectomy Total EBL 10L Total blood products given: PRBC 21, platelets 6, Cryo 10, FFP 12 N/S 1 litre R/L 4 litres, Voluven 1.5 litres

(Contd)

Case Review

ICU admission PCV 10/5, Fi02 0.40 ABG 7.49/31/193/24/10 HgB 84, platelets 122, INR 1.0 Normal electrolytes Pt extubated the following morning

(contd)

Case Review

Transferred out of ICU Minimal pain medication required Discharged home 3 days later

Patient awareness?
(contd)

Dreams of Walking in the Snow

What caused this PPH?

Tissue

retained placenta undiagnosed accreta Ruptured uterus

Trauma

Questions?

References
1.

Chestnut D. Obstetric Anesthesia. 3rd edition. Philadelphia: Elsevier Mosby; 2004. University of Toronto Department of Anesthesia. CME Module 8: Clinical Management of Post Partum Hemorrhage. [online]. 2008 [cited April 5, 2009];[16 screens]. Available from URL: http://www.anesthesia.utoronto.ca/edu/cme/courses/m08/m08p04.htm Anderson J, Etches D. Prevention and Management of Postpartum Hemorrhage [online]. March 2007 [cited April 19, 2009]; Available from URL: http://www.aafp.org/afp/20070315/875.html Schurmans N, MacKinnon C, Lane C, Etches D. Prevention and Management of Postpartum Haemorrhage. SOGC Clinical Practice Guidelines [serial online] 2000 April [cited April 19, 2009]; 88:[11 screens]. Available from: URL: http://www.sogc.org/guidelines/public/88E-CPG-April2000.pdf World Health Organization. Prevention of Postpartum Haemorrhage by Active management of Third Stage of Labour: MPS Technical Update. Geneva: World Health Oraganization, 2006.

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References (contd)
6.

Garcia J. Postpartum Hemorrhage [online]. December 2001 [cited April 14, 2009]; Available from URL: http://www.fammed.washington.edu/network/sfm/Didactic%20Handout s/Postpartum%20hemorrhage%2012-01.ppt Dunn PF. Clinical Anesthesia Procedures of the Massachusetts General Hospital. 7th Edition. Boston: Lippincott Williams and Wilkind;2007. Up To Date [online] 2009 [cited April 25, 2009]; Available from URL: http://www.uptodate.com/online/content/image.do?imageKey=obst_pix /uterin5.htm&title=Uterine%20artery%20ligation Smith S. Uterine Fibroid Embolization. American Family Physician. [online] 2000 [cited April 24, 2009]; Available from URL: http://www.aafp.org/afp//AFPprinter/20000615/3601.html Ciliberto C. Physiological Changes Associated with Pregnancy [online]. 1998 [cited May 20, 2012]; Available from URL: http://www.nda.ox.ac.uk/wfsa/html/u09/u09_003.htm

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