Primary Postpartum Haemorrhage

Severe Obstetric
Max Brinsmead MB BS PhD
May 2015
The average gravida carries 1 - 1.5 l of
“extra blood” in pregnancy as prophylaxis
against PPH but…
PPH is a major cause of obstetric death
especially in 3rd world countries
10 - 15% of women lose >600 ml of blood at
delivery and…
For 1 - 2% the blood loss can be life
Another 0.5 - 1% have severe antepartum
haemorrhage from abruption or placenta
This presentation will address…
Emergency (First aid) and
Diagnosis and management of severe APH
Advanced Measures for the management of
excessive blood loss in the first 24 hours
after birth
Risk factors for Primary PPH
Prolonged labour
Pre eclampsia
Maternal obesity
Multiple pregnancy
Birth weight >4000g
Advanced maternal age
Previous PPH
Assisted delivery
Low lying placenta
But >50% occur in women without identified risk
factors and…
90% are associated with uterine atony
And all studies of massive PPH fail to identify
consistent risk factors
Patient Assessment
Objective measure of blood loss is desirable
 Postural hypotension the earliest sign
 Tachycardia is usual
 Air hunger and loss of consciousness is
 Urine output a good measure of treatment
 CVP sometimes
 A bedside test of blood clotting desirable
Emergency Measures for
Rub up a contraction
Deliver the placenta
• If you can
Gain IV access (large bore cannula)
Additional oxytocic
• IV Ergometrine 0.25 mg
• Syntocinon infusion
• Rectal Cervagem or Misoprostol
(Empty the bladder)
Bimanual uterine compression
Aortic compression
Advanced Measures 1
Get help
 Check coagulation - use
cryoprecipitate etc.
 EUA is mandatory
 Myometrial PG F2 alpha
 Uterine Packing
• Intrauterine balloon catheter
Consider activated Factor VII
Blood replacement products:
Whole blood
All components (after 48hrs factors low)
Packed Red cells
Frozen plasma
All clotting factors except for platelets
Store up to 1 year at -20 to -30 C
Fibrinogen, factors VIII, XIII, VWF
lacks antithromin III
Only last 5 days
Red cells only
The Coagulation Mechanism
Platelet plug
Clotting cascade
• Thrombin >
Fibrinogen to
Intrauterine Balloon Tamponade
BJOG Review May 2009
 Was effective in 91.5% of cases
• Combined retrospective and prospective studies
• But only a total of 106 patients
Types of balloons
Sengstaken Blakemore (GI use)
Rusch (Urological)
Foley (often multiple)
Bakri (Specifically designed for obstetrics)
Condom (+/- Foley)
But there remain many unanswered
Questions concerning intrauterine balloon
BJOG Review May 2009
 Is it effective
• There are no RCTs
Risks and contraindications
 Which balloon to use, how to insert it
and what volume to inflate it
 Is a vaginal pack required
 Is an oxytocin infusion required
 Antibioitics and analgesia
 When to deflate and or remove it
Advanced Measures 2
Get more help
• Medical – haematologist
• Surgical colleague
• Radiologist for…
Uterine artery embolisation
Laparotomy and…
B-Lynch suture
Internal iliac artery ligation
Aortic clamping
When confronted with a pregnant patient
who is bleeding after 20w
There are five questions that need
urgent answers…
How much blood has been lost
What is the maternal condition
What is the fetal condition
Is the patient in labour
What is the cause of the bleeding
THINK in terms of aetiology...
Bleeding from a normally situated
placenta = Abruption
Bleeding from a low placenta =
Placenta previa
Cervical bleeding:
• “Show”
• Ectropion or Cancer
ACT in terms of priority...
Assess maternal wellbeing
Assess fetal wellbeing
Resuscitate if required
Anticipate further problems
Is the fetus compromised
Is the fetus salvageable
Then attempt diagnosis
Essential observations
Maternal vital signs
• General appearance
• Pulse and BP
Nature and amount of PV loss
Tone and tenderness
You can’t do this with CTG belts in place
Just blood or blood and liquor
• Fetal heart present or absent
Essential Investigations
HB, Blood group and save or Xmatch
• Depends on the amount of blood lost
• And the suspected diagnosis
• Remember that abruption is often associated with
a large concealed loss
• Best done “on the ward” if bleeding is substantial
• Requires skill in distinguishing blood clot from
• Vaginal scan the best way of evaluating degrees
of placenta previa
Urinalysis for proteinuria
• May require bladder catheterisation
• Abruption may be associated with “acute” pre
• And the blood pressure may not be raised
Immediate management
Large bore IV line
• If estimated loss is >250 ml
• Or if abruption or placenta previa is diagnosed
Resuscitate with IV Fluids
• Commence with saline
• Colloids if shocked
• Blood if estimated loss >2 L
 Corticosteroids for gestation <37wks
Monitoring response
Maternal PR and BP
• Watch for pre eclampsia
Indwelling catheter
• Hourly urine output
• Only a few require CVP
Watch for coagulopathy
• A bedside test of clotting
• Prothrombin time (aPTT) and platelets
• HB takes a while to adjust
CTG and umbilical Dopplers for the
Definitive management
Conservative for placenta previa
• Most will settle
• Deliver when paediatric resources permit
• But must proceed to CS at any gestation if
the blood loss is life threatening for the
 Aggressive
management for
• CS sooner rather than later for fetal reasons
• But vaginal delivery is usually possible with
• Give more blood than you see
• Watch for coagulopathy
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