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Post Partum Hemorrhage-DefinitionlCommonly defined as.SVD 500cc blood lossC/S 1000cc blood loss*PPH generally refers to GA 20wks 1Post Partum Hemorrhage-DefinOther DefinitionslHematocrit Change defined as change 10%but not useful in acute settinglNeed for Transfusion variable practicelHemodynamic stabilitylTiming early or latelSymptomatic2Other Definitions2RelevancelOne of top five causes of maternal mortality anywherel#1 cause maternal mortality worldwidelDeveloped countries 1/100 000 births compared to 1/1000 births in developing countrieslIncidence 5%-10%deliveries(depends on defn)3RelevanceOne of top five causePhysiologic Adaptations of Pregnancyl plasma volume 40-50%l RBC 20-30%*in severe PIH-hemoconcentration4Physiologic Adaptations of PreNormal Mechanism of HemostasislLiving ligatures Baskett 2000lIntrinsic vasospasmlLocal decidual hemostatic factors including tissue factor&type 1 plasminogen activator inhibitorl clotting factors(except I and XI)5Normal Mechanism of Hemostasis66Zymogens of Serine ProteasesActivitiesFactor XIIbinds to exposed collagen at site of vessel wall injury,activated by high-MW kininogen and kallikreinFactor XIactivated by factor XIIaFactor IXactivated by factor XIa in presence of Ca2+Factor VIIactivated by thrombin in presence of Ca2+Factor Xactivated on surface of activated platelets by tenase complex and by factor VIIa in presence of tissue factor and Ca2+Factor IIactivated on surface of activated platelets by prothrombinase complexCofactorsActivitiesFactor VIIIactivated by thrombin;factor VIIIa is a cofactor in the activation of factor X by factor IXaFactor Vactivated by thrombin;factor Va is a cofactor in the activation of prothrombin by factor XaFactor III(tissue factor)a subendothelial cell-surface glycoprotein that acts as a cofactor for factor VIIFibrinogenActivityFactor Icleaved by thrombin to form fibrin clotTransglutaminaseActivityFactor XIIIactivated by thrombin in presence of Ca2+;stabilizes fibrin clot by covalent cross-linkingRegulatory and other proteinsActivitiesvon Willebrand factorassociated with subendothelial connective tissue;serves as a brigde between platelet glycoprotein GPIb/IX and collagenProtein Cactivated to protein Ca by thrombin bound to thrombomodulin;then degrades factors VIIIa and VaProtein Sacts as a cofactor of protein C;both proteins contain gla residuesThrombomodulinprotein on the surface of endothelial cells;binds thrombin,which then activates protein CAntithrombin IIImost important coagulation inhibitor,controls activities of thrombin,and factors IXa,Xa,XIa and XIIa7Zymogens of Serine ProteasesAcBlood Loss EstimationlAll studies show gross underestimation of blood loss at deliverylVisual estimation especially unreliable for small and large amounts of blood losslPrasertcheroensuk et al(2000)-228 women in 3rd stage -500cc:visual(5.7%)actual(27.63%)-1000cc:visual(.44%)actual(3.51%)*Incidence underestimated 90%8Blood Loss EstimationAll studiPrimary,Early or Acute PPHlDelivery-35ylAsian or Hispanic ethnicitylObesitylPost dates 42 wkslPrevious PPHlPlacenta Previa19Additional Risk FactorsAge 3Key Management IssueslPreventionlEarly RecognitionlImmediate Appropriate Intervention20Key Management IssuesPreventioBlood Loss Signs&SymptomsBlood Loss(%)Blood PressureSigns&Symptoms500-1000ml(10-15)normalPalpitations,dizziness,tachycardia1000-1500ml(15-25)Slightly lowWeakness,sweating,tachycardia1500-2000ml(25-35)70-80Restlessness,pallor,oliguria2000-3000ml(35-45)50-70Collapse,air hunger,anuria 2500cc blood loss 50%mortality if not managed urgently&appropriately21Blood Loss Signs&SymptomsBloInitial ManagementlABCslCall for helplMobilize team(staff,anesthesia,blood bank etc)lIV accesslFluid resuscitationlExamine patient including fundal massage,dx trauma/inversion/other etiologies,and fundal massagelFoley catheterlBlood work(CBC,coag profile,cross match)lReverse coagulation abnormality22Initial ManagementABCs22Uterotonic MedicationslOxytocinlErgotlHemabatelMisoprostollVasopressin23Uterotonic MedicationsOxytocinDrug Therapy For PPHDrugDoseSide EffectsContraindicationsOxytocin10 IU IM/IMM5 IU iv bolus10-40 IU/L-Usually none-ctx-N&V-water intoxication-hypersensitivityErgot0.25mg IM0.125 mg IVQ5mins X 5 doses-peripheral vasospasm-HTN-N&V-HTN-peripheral disease-Raynaulds-hypersensitivityHemabate(PGF2)0.25 mg IM/IMMQ15mins X 8 doses-flushing-diarrhea/N&V-O2 desats-bronchospasm-restlessness-hypersensitivity-asthma-active cardiac,pulmonary,renal,or hepatic diseaseMisoprostol(PGE1)400-1000mcg PR/PV/PO X 1 dose-pyrexia/flushing-N&V/diarrhea-abd pain-HA-hypersensitivity-pregnancyVasopressin20U/100ml salineInject 1ml at bleeding site-acute HTN-bronchospasm-N&V/cramps-HA,vertigo-angina-death if iv-coronary artery disease-hypersensitivity24Drug Therapy For PPHDrugDoseSiSurgical ManagementlCurettagelEmbolizationlTamponade(Balloon,packing etc)lCompression sutureslVessel ligationlHysterectomy25Surgical ManagementCurettage25TamponadelBakri Balloon -Silicone balloon-500cc capacitylFoley catheter with 30cc balloonlSengstaken-Blakemore BalloonlVaginal packinglSaline filled glove26TamponadeBakri Balloon 26B-Lynch Suture27B-Lynch Suture27Vessel Ligation28Vessel Ligation28Vessel LigationlUterine -OLeary Stitch -Chromic 0 passed through lateral aspect of lower segment as close to cervix as possible and then through broad ligament lateral to vesselslOvarian -distal to cornua by passing suture through myometrium medial to vessels29Vessel LigationUterine29Recombinant Activated Factor VIIalTx of bleeding disorderslDose up to 120mcg/kg q2h until hemostasislPromising but needs more studiesl$10,000/mglRisk thromboembolism30Recombinant Activated Factor VStep 1 Initial AssessmentResuscitation-Large bore ivs-O2-Vitals-foley catheterDx Etiology-explore uterus(tone/tissue)-explore genital tract(trauma)-review history(thrombin)-observe clotsLabs-CBC-coag profile-cross matchStep 2 Directed TherapyTone-massage-compress-drugsTissue-manual removal-curettageTrauma-correct inversion-repair laceration-identify ruptureThrombin-reverse anticoagulation-replace factorsStep 3 Intractable PPHGet Help-OB/Surgery-Anesthesia-Lab/Blood Bank-ICULocal Control-manual compression-pack uterus-vasopressin-embolizationBP and Coagulation-crystalloids-blood productsStep 4-SurgeryRepair LacerationsLigate Vessels-uterines-ovarian-internal iliacHysterectomyStep 5 Post Hysterectomy BleedingAbdominal PackingEmbolization31Step 1 Initial AssessmentRes
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