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POSTPARTUM

HEMORRHAGELaura Noble B.A., RRT, AA

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Postpartum Hemorrhage

Case Presentation Definition Epidemiology

Preventative Measures Etiology Management Replacement Therapy

What Can We Do As AnesthesiaAssistants? Case summary

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Case Review

Healthy 32 yr old G3P2

22 weeks pregnant for induction of labourof fetus with a fetal anomaly

Mallampati IV Vaginal delivery with retained placenta

Heavy bleeding

Systolic BP ~60mmHg

Transferred to OR

Dx: Postpartum Hemorrhage

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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 andmortality

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PHYSIOLOGICAL CHANGESIN 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%

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EPIDEMIOLOGY

Major cause of maternal death worldwide

PPH can occur in 10-18% of all births

3% of vaginal deliveries will result insevere PPH

25% of all maternal deaths are caused by

severe hemorrhage

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PREVENTATIVE MEASURES

Active management of the third stage oflabour

Oxytocin with delivery of baby

Prophylactic oxytocin decreases PPH by 40%

Deliver placenta with controlled cord tractionand inspect for completeness

Palpate uterus and inspect lower genital tract

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ETIOLOGY

Remember the 4 Ts:

1. Tone

2. Tissue3. Trauma

4. Thrombin

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1. TONE

Uterine Atony

Boggy uterus

Most common cause of PPH

70% of all PPH

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Risk Factors for Uterine Atony

Uterine over distension(polyhydramnious,large baby, multiples)

Uterine exhaustion(precipitous labour,

prolonged/augmented labour, high parity)

Infection(prolonged rupture of membranes,fever)

Anatomical distortion of the uterus

(uterine abnormality, fibroids, placenta previa)

Exposure to specific drugs (NTG, Volatileagents, Beta agonists)

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2. TISSUE Retained products Abnormal placenta (placenta accreta, increta or

percreta)

Previous uterine surgery

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3. TRAUMA

Lacerations of cervix, vagina,perineum or C/S incision site

Hematomas

Uterine rupture

Uterine inversion

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Risk Factors for Trauma

Precipitous delivery

Operative delivery

Assisted delivery (forceps, vacuum)

Previous uterine surgery

Fundal placenta

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4. THROMBIN

Abnormal coagulation

Very rare

Usually identified before delivery

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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

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MANAGEMENT OF PPH

Communication!!!!

Call for HELP!!

Determine etiology (four Ts)

Vital signs

Large bore I.Vs

Blood work

Oxygen

OR

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Dont Panic!

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Management for Tone

1. Multidisciplinary team work

2.

Uterine massage

3. Pharmacological management

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2. Uterine Massage

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3. Pharmacologic Managementof Atony

Oxytocin

Egonovine Maleate (Ergot)

Hemabate (15-Methyl prostaglandinF2 alpha)

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Management for Tissue

Inspect placenta for completeness

Manually remove remainder ofplacenta

Abnormal placenta

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Management for Trauma

Suture any lacerations

Inspect uterus for inversion

Correction of uterine inversion- doneunder GA

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Management for Thrombin

Fresh frozen plasma

Platelet transfusion

Cryoprecipitate

Hematology consult

Replace specific coagulation factors

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Surgical Intervention Uterine artery ligation

Uterine balloon inflation

Hysterectomy

Pack uterus

8

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Interventional Radiology

Uterine artery embolization

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REPLACEMENT THERAPY

Volume replacement options

Blood loss is usually underestimated

May be asymptomatic until blood lossreaches 25-35%

Any patient who is at risk for PPH should

be cross-matched upon arrival to hospital

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WHAT CAN WE DO ASANESTHESIA 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)

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WHAT CAN WE DO ASANESTHESIA 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!

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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)

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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)

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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)

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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)

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Case Review

Transferred out of ICU

Minimal pain medication required

Discharged home 3 days later

Patient awareness?

(contd)

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What caused this PPH?

Tissue retained placenta

undiagnosed accreta

Trauma Ruptured uterus

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Questions?

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References

1. Chestnut D. Obstetric Anesthesia. 3rd edition. Philadelphia: Elsevier Mosby; 2004.

1. University of Toronto Department of Anesthesia. CME Module 8: ClinicalManagement of Post Partum Hemorrhage. [online]. 2008 [cited April 5, 2009];[16screens]. Available from URL:http://www.anesthesia.utoronto.ca/edu/cme/courses/m08/m08p04.htm

2. 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

3. Schurmans N, MacKinnon C, Lane C, Etches D. Prevention and Management ofPostpartum Haemorrhage. SOGC Clinical Practice Guidelines [serial online] 2000April [cited April 19, 2009]; 88:[11 screens]. Available from: URL:http://www.sogc.org/guidelines/public/88E-CPG-April2000.pdf

4. World Health Organization. Prevention of Postpartum Haemorrhage by Activemanagement of Third Stage of Labour: MPS Technical Update. Geneva: WorldHealth Oraganization, 2006.

http://www.anesthesia.utoronto.ca/edu/cme/courses/m08/m08p04.htmhttp://www.anesthesia.utoronto.ca/edu/cme/courses/m08/m08p04.htmhttp://www.aafp.org/afp/20070315/875.htmlhttp://www.aafp.org/afp/20070315/875.htmlhttp://www.sogc.org/guidelines/public/88E-CPG-April2000.pdfhttp://www.sogc.org/guidelines/public/88E-CPG-April2000.pdfhttp://www.sogc.org/guidelines/public/88E-CPG-April2000.pdfhttp://www.sogc.org/guidelines/public/88E-CPG-April2000.pdfhttp://www.sogc.org/guidelines/public/88E-CPG-April2000.pdfhttp://www.sogc.org/guidelines/public/88E-CPG-April2000.pdfhttp://www.sogc.org/guidelines/public/88E-CPG-April2000.pdfhttp://www.aafp.org/afp/20070315/875.htmlhttp://www.anesthesia.utoronto.ca/edu/cme/courses/m08/m08p04.htm

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