DR. FIROUZABADI

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Primary Postpartum haemorrhage

• DR. FIROUZABADI

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Postpartum Hemorrhage

• EBL gt 500 cc
• 10 of deliveries
• If within 24 hrs. pp 1? pp hemorrhage
• If 24 hrs. - 6 wks. pp 2? pp hemorrhage

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Postpartum Hemorrhage

• Incidence
• 3 of all births
• 6.4 of cesarean deliveries
• 3rd most common cause of maternal mortality

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Postpartum Hemorrhage

• Definition
• greater than 500cc blood loss (vaginal delivery)
  or 1000cc blood loss (cesarean)
• decrease in HCT of 10 or greater
• obstetrical emergency that can follow vaginal or
  cesarean delivery with clinical instability
  leading to transfusion, shock, renal failure,
  acute respiratory distress, and coagulopathy

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• Hemorrhage is the underlying causative factor in
  at least 25 of maternal deaths in industrialized
  and underdeveloped countries

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Peripartum Hemorrhage

• Causes of maternal death in US (9.1/100,000)
• hemorrhage 28.7 (?)
• embolism 19.7 (?)
• PIH 17.6 (?)
• infection 13.1 (?)
• anesthesia 2.5 (?)

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• Hospitalization for delivery and Availability of
  blood for transfusion have reduced the maternal
  mortality rate death from hemorrhage .
• It remains a cause of maternal mortality.

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• Hemorrhage is a reason for admission of pregnant
  women to intensive care units.
• Hemorrhage has been identified as the single
  most important cause of maternal death,
  accounting for almost half of all post partum
  death in developing countries.

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• Incidence of obstetrical hemorrhage can not be
  determined precisely
• Defined by a post partum HCT drop of 10 volumes
  percent or need for transfusion.
• 3.9 NVD
• 6-8 C/S

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• Maternal physiology is well prepared for
  hemorrhage
• increase in blood volume .
• hypercoagulable state.
• the tourniquet effect of uterine contractions.

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• vital signs may remain near normal until more
  than 30 of blood volume is lost .
• tachycardia can be attributed to pregnancy,
  stress, pain, and delivery.

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• 5 of women delivering vaginally last more than
  1000 ml of blood. Estimated blood loss is
  commonly only about half the actual loss. The
  effect of hemorrhage depend to a degree on the
  non pregnant blood volume, magnitude of PIH,
  degree of anemia at the time of delivery.

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blood supply to the pelvis
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blood supply to the pelvis

• internal iliac (hypogastric) a.
• ovarian arteries .

Are The main vascular supply to the pelvis .
connected in a continuous arcade on the lateral
borders of the vagina, uterus, and adnexa.
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blood supply to the pelvis

• /The ovarian arteries
• are direct branches of the aorta beneath the
  renal arteries. They traverse bilaterally and
  retroperitoneally to enter the infundibulopelvic
  ligaments.

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blood supply to the pelvis

• /The hypogastric artery
• retroperitoneally posterior to the ureter it
  divides into an anterior and posterior divisions.

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The hypogastric artery
anterior division
5 visceral branches

• Uterine
• superior vesical
• middle hemorrhoidal
• inferior hemorrhoidal
• vaginal

3 parietal branches

• Obturator
• inferior gluteal
• internal pudendal

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The hypogastric artery
posterior division

• important collateral to the pelvis.
• Iliolumbar
• lateral sacral
• superior gluteal

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PHYSIOLOGY OF COAGULATION
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PHYSIOLOGY OF COAGULATION

• The four components of coagulation that
  continuously interrelate are

(1) the vasculature, (2) platelets, (3)
plasma-clotting proteins, (4) fibrinolysis.
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the vasculature

• A disruption in the vessel wall removes the
  protective covering of the endothelial cells and
  releases tissue thromboplastin, which activates
  the clotting mechanism.

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platelets

• Activation of surface receptors causes
  morphologic changes in the platelets (changing
  first to a sphere and then to a spiderlike
  structure with pseudopods) and the generation of
  thromboxane A2 These lead to platelet aggregation
  and eventual formation of a platelet plug.

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plasma-clotting proteins

• Activation of the clotting system is initiated in
  two ways
• the intrinsic or extrinsic pathway.

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Intrinsic Pathway

• requires no extravascular component for
  initiation and begins with Factor XII, which is
  activated by contact with injured epithelium.

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Extrinsic Pathway

• is activated by the tissue factor
  thromboplastin (which subsequently activates
  Factor VII) when vascular disruption occurs.
  Prothrombin is converted to thrombin, which
  catalyzes the conversion of fibrinogen to fibrin.
  A clot is eventually formed at the site of
  vascular injury.

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fibrinolysis

• plasma substrate plasminogen is activated This
  substrate is converted to the active enzyme
  plasmin, which lyses fibrin clots and destroys
  fibrinogen and Factors XII and VII.

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Etiology of PPH
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Etiology of PPH

• The causes of postpartum hemorrhage can be
  thought of as the four Ts

• tone,
• tissue,
• trauma,
• thrombin

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Etiology of PPH
Uterine atony

• Multiple gestation,
• high parity,
• prolonged labor
• chorioamnionitis,
• augmented labor,
• tocolytic agents

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Etiology of PPH
Retained uterine contents

• Products of conception,
• blood clots

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Etiology of PPH

• Placental abnormalities

Congenital Bicornuate uterus
Location Placenta previa
Attachment
Acquired structural Leiomyoma, previous
surgery
Peripartum Uterine inversion,
uterine rupture, placental abruption
Accreta
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Etiology of PPH
Lacerations and trauma

•  Unplanned
• Vaginal/cervical tear,
• surgical trauma

•  Planned
• Cesarean section,
• episiotomy

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Etiology of PPH

• Coagulation disorders

Acquired DIC, dilutional coagulopathy, heparin
Congenital Von Willebrand's disease
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prevention
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Women in whom these factors have been identified
should be advised to deliver in a specialist
obstetric unit
odds ratio for PPH Risk Factor
13 12 5 4 Proven abruptio placentae Known placenta praevia Multiple pregnancy Pre-eclampsia/gestational hypertension
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The following factors, becoming apparent during
labour and delivery are associated with an
increased risk of PPH.
odds ratio for PPH Risk factor
9 4 5 5 2 2 2 Delivery by emergency Caesarean section Delivery by elective Caesarean section Retained placenta Mediolateral episiotomy Operative vaginal delivery Prolonged labour (gt12 hours) Big baby (gt4 kg)
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• In the event of a woman coming to delivery while
  receiving therapeutic heparin,

the infusion should be stopped. Heparin activity
will fall to safe levels within an hour.
Protamine sulphate will reverse activity more
rapidly, if required.
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Antenatal assessment anemia

• Detection of anemia more than physiologic anemia
  of pregnancy is important, because anemia at
  delivery increases the likelihood of a woman
  requiring blood transfusion.

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management
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Guideline by the RCOG

• COMMUNICATE.
• RESUSCITATE.
• MONITOR / INVESTIGATE.
• STOP THE BLEEDING.

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COMMUNICATEcall 6

• Call experienced midwife
• Call obstetric registrar alert consultant
• Call anaesthetic registrar , alert consultant
• Alert haematologist
• Alert Blood Transfusion Service
• Call porters for delivery of specimens / blood

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RESUSCITATE

• IV access with 14 G cannula X 2
• Head down tilt
• Oxygen by mask, 8 litres / min
• Transfuse

• Crystalloid
• Colloid
• once 3.5 litres infused, GIVE O NEG If no
  cross-matched blood available OR give
  uncross-matched own-group blood, as available

• Give up to 1 liter Fresh Frozen Plasma and 10
  units cryoprecipitate if clinically indicated

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MONITOR / INVESTIGATE

• Cross-match 6 units
• Full blood count
• Clotting screen
• Continuous pulse / BP /
• ECG / Oximeter
• Foley catheter urine output
• CVP monitoring

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STOP THE BLEEDING

• Exclude causes of bleeding other than uterine
  atony
• Ensure bladder empty
• Uterine compression
• IV syntocinon 10 units
• IV ergometrine 500 mg
• Syntocinon infusion (30 units in 500 ml)
• prostaglandins
• Surgery earlier rather than late
• Hysterctomy early rather than late

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If conservative measures fail to control
haemorrhage, initiate surgical haemostasis SOONER
RATHER THAN LATER

• laparotomy
• Bilateral ligation of uterine arteries
• Bilateral ligation of internal iliac (hypogastric
  arteries)
• Hysterectomy

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• Resort to hysterectomy SOONER RATHER THAN LATER
  (especially in cases of placenta accreta or
  uterine rupture)

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• Whole blood frequently is used for rapid
  correction of volume loss because of its ready
  availability, but component therapy is ideal. A
  general practice has been to transfuse 1 unit of
  fresh-frozen plasma for every 3 to 4 units of red
  cells given to patients who are bleeding
  profusely

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Genital tract lacerations

• Genital trauma always must be eliminated first if
  the uterus is firm.

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Management of uterine atony

• Explore the uterine cavity.
• Inspect vagina and cervix for lacerations.
• If the cavity is empty, Massage and give
  methylergonovine 0.2 mg, the dose can be repeated
  every 2 to 4 hours.
• Rectal 800mcg. Misoprostol is beneficial.

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Uterine AtonyProstaglandins

• ? myometrial intracellular free Ca, enhance
  action of other oxytocics
• Side effects fever, nausea/vomiting, diarrhea
• 15-methyl PG F2? (Carboprost, Hemabate)
• may cause bronchospasm, altered VQ, ?
  shunt, hypoxemia, HTN
• 250 ?g IM or intramyometrially q 15-30 min, up to
  max 2 mg.
• contraindications asthma, hypoxemia

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Management of uterine atony

• During the administration of uterotonic agents,
  bimanual compression may control hemorrhage. The
  physician places his or her fist in the vagina
  and presses on the anterior surface of the uterus
  while an abdominal hand placed above the fundus
  presses on the posterior wall. This while the
  Blood for transfusion made available.

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Retained placenta

• Retained placental fragments are a leading cause
  of early and delayed postpartum hemorrhage.
  Treatment is manual removal, General anesthesia
  with any volatile agent (1.52 minimum alveolar
  concentration (MAC)) may be necessary for uterine
  relaxation
• On rare occasions, a retained placenta is an
  undiagnosed placenta accreta, and massive
  bleeding may occur during attempted manual
  removal.

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Placenta accreta

• Placenta accreta is defined as an abnormal
  implantation of the placenta in the uterine wall,
  of which there are three types

(1) accreta vera, in which the placenta adheres
to the myometrium without invasion into the
muscle. (2) increta, in which it invades into
the myometrium. (3) percreta, in which it invades
the full thickness of the uterine wall and
possibly other pelvic structures, most frequently
the bladder.
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Placenta accreta

• In a patient with a previous cesarean section and
  a placenta previa

• Previous one has 14 risk of placenta accreta.
• Previous two has 24 risk of placenta accreta.
• Previous three has 44 risk of placenta accreta.

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UTERINE RUPTURE

• Rupture of the uterus is described as complete or
  incomplete and should be differentiated from
  dehiscence of a cesarean section scar.

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UTERINE RUPTURE
The reported incidence
for all pregnancies is 0.05,
After one previous lower segment cesarean section
0.8
After two previous lower segment cesarean section
is 5
all pregnancies following myomectomy may be
complicated by uterine rupture.
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UTERINE RUPTURE

• Complete rupture describes a full-thickness
  defect of the uterine wall and serosa resulting
  in direct communication between the uterine
  cavity and the peritoneal cavity.

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UTERINE RUPTURE

• Incomplete rupture describes a defect of the
  uterine wall that is contained by the visceral
  peritoneum or broad ligament. In patients with
  prior cesarean section,

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UTERINE RUPTURE

• dehiscence describes partial separation of the
  scar with minimal bleeding, with the peritoneum
  and fetal membranes remaining intact.

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Management of Rupture Uterus

• The identification or suspicion of uterine
  rupture must be followed by an immediate and
  simultaneous response from the obstetric team.
• Surgery should not be delayed owing to
  hypovolemic shock because it may not be easily
  reversible until the hemorrhage is controlled.

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Management of Rupture Uterus

• Upon entering the abdomen, aortic compression can
  be applied to decrease bleeding.
• Oxytocin should be administered to effect
  uterine contraction to assist in vessel
  constriction and to decrease bleeding.
• Hemostasis can then be achieved by ligation of
  the hypogastric artery, uterine artery, or
  ovarian arteries.

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Management of Rupture Uterus

• At this point, a decision must be made to perform
  hysterectomy or to repair the rupture site. In
  most cases, hysterectomy should be performed.
• In selected cases, repair of the rupture can be
  attempted. When rupture occurs in the body of the
  uterus,
• bladder rupture must be ruled out by clearly
  mobilizing and inspecting the bladder to ensure
  that it is intact. This avoids injury on repair
  of the defect as well.

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Management of Rupture Uterus

• A lower segment lateral rupture can cause
  transection of the uterine vessels. The vessels
  can retract toward the pelvic side wall, and the
  site of bleeding must be isolated before placing
  clamps to avoid injury to the ureter and iliac
  vessels.
• Typically, longitudinal tears, especially those
  in a lateral position, should be treated by
  hysterectomy, whereas low transverse tears may be
  repaired.

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Uterine Artery Ligation

• Uterine artery ligation involves taking large
  purchases through the uterine wall to ligate the
  artery at the cervical isthmus above the bladder
  flap .

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Hypogastric Artery Ligation

• The hypogastric artery is exposed by ligating and
  cutting the round ligament and incising the
  pelvic sidewall peritoneum cephalad, parallel to
  the infundibulopelvic ligament The ureter should
  be visualized and left attached to the medial
  peritoneal reflection to prevent compromising its
  blood supply.

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Hypogastric Artery Ligation

• .

The common, internal, and external iliac arteries
must be identified clearly. The hypogastric vein,
which lies deep and lateral to the artery, may be
injured as instruments are passed beneath the
artery, resulting in massive, potentially fatal
bleeding.
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Hypogastric Artery Ligation

• The hypogastric artery should be completely
  visualized. A blunt-tipped, right-angle clamp is
  gently placed around the hypogastric artery, 2.5
  to 3.0 cm distal to the bifurcation of the common
  iliac artery. Passing the tips of the clamp from
  lateral to medial under the artery is crucial in
  preventing injuries to the underlying hypogastric
  vein .

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Hypogastric Artery Ligation

• the artery is double-ligated with a nonabsorbable
  suture, with 1-0 silk, but not divided .The
  ligation is then performed on the contralateral
  side in the same manner.

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Thank you

• ?

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The Use of Blood and Blood Components

• Various blood components
• and how they function
• The indications and
• contraindications for use

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Red Blood Cells - RBC Description

• Whole blood is collected into an anticoagulant
  then centrifuged to separate the red cells from
  the plasma.
• The plasma is then expressed from the whole blood
  bag and the remaining red blood cells (RBC) are
  filtered.
• The filtering process removes all but 5 x 106
  white blood cells (WBCs).
• 85 of the original RBC volume will remain after
  filtration.
• A typical unit has a volume of 240-340 mL and a
  hematocrit of 80.

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Red Blood Cells - RBC Function

• Increase the oxygen carrying capacity of the
  blood by increasing the circulating red blood
  cell mass.
• Carry oxygen and nourishment to the tissues and
  take away carbon dioxide.

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Red Blood Cells - RBC Indications

• Component of choice for virtually all patients
  with a deficit of oxygen carrying capacity, e.g.,
  blood loss or anemia.
• The majority of the WBC are removed thereby
  decreasing the risk of cytomegalovirus (CMV)
  infection in immunocompromised patients. This is
  because the CMV virus is carried in the WBC.
• Use of RBC reduces the risk of the patient
  forming antibodies against WBC (HLA) antigens.
  This is especially important for potential organ
  or bone marrow transplant candidates.

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Red Blood Cells RBC Contraindications

• RBC should not be used
• when anemia can be corrected with specific
  medications, e.g., iron, B12, folic acid,
  erythropoietin, etc
• for volume replacement

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Platelets PC Descriptions

• Platelets are prepared from a random unit of
  whole blood collected in CP2D anticoagulant
  solution and filtered to remove leukocytes. PC
  contain less than 8.3 x 106 leukocytes.
• Platelets are suspended in a small amount of the
  original plasma. A unit contains at least 55 x
  109 platelets suspended in 50-55 mL of plasma.
• Trace amounts of red blood cells can be present
  in some units.
• These will appear pink to salmon colored.
• Platelets may also be obtained by apheresis

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Platelets - PC Function

• The primary role of platelets is to prevent
  bleeding of injured blood vessel walls by forming
  an aggregate at the site of injury.
• Platelets also participate in blood coagulation,
  inflammation and wound healing.
• The transfusion of platelets to a patient with
  thrombocytopenia or bleeding should produce a
  rise in the platelet count and control bleeding.

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Platelets - PC Indications

• For treatment of patients with bleeding due to
  severely decreased production or abnormal
  function of platelets.
• Treatment of bleeding patients with platelet
  consumption or dilutional thrombocytopenia (in
  most instances of dilutional thrombocytopenia,
  bleeding stops without transfusion).
• Useful if given prophylacticaly to patients with
  rapidly falling or low platelet counts, less than
  10 x 109/L (10,000/uL), secondary to cancer or
  chemotherapy.
• Useful in selected cases of postoperative
  bleeding with platelet count less than 50 x 109/L
  (50,000/uL).

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Platelets PC Contraindications

• Platelets should not be used if bleeding is
  unrelated to decreased numbers or abnormal
  platelet function.
• Should not be used in patients with consumption
  of endogenous and exogenous platelets, such as in
  Thrombotic Thrombocytopenia Purpura (TTP) or
  Idiopathic Thrombocytopenia Purpura (ITP), unless
  the patient has a life threatening hemorrhage.

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Platelet Incubator
Stored with constant agitation
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Fresh Frozen Plasma - FFP Description

• Fresh frozen plasma is separated from whole blood
  and frozen within 8 hours of collection. It can
  be obtained from a whole blood donation (approx.
  250 mL) or by apheresis (approx. 500 mL).
• Fresh frozen plasma contains a normal
  concentration of fibrinogen and the labile
  coagulation factors VIII and V.

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Fresh Frozen Plasma FFP Function

• Fresh frozen plasma contains the clotting factors
  that are necessary for hemostasis.
• Plasma also has volume expansion and oncotic
  properties.

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Fresh Frozen Plasma FFP Indications

• The majority of clinical situations for which FFP
  is currently used do not require FFP.
• FFP is indicated for massive transfusion
  (replacement of the patients blood volume in
  lt 24 hours) with a demonstrated deficiency of
  Factor VIII and V, otherwise frozen plasma is
  adequate.
• Fresh frozen plasma is also indicated in exchange
  transfusion in neonates.

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Fresh Frozen Plasma FFP Contraindications

• Fresh frozen plasma should not be used when a
  coagulopathy can be corrected more effectively
  with specific therapy, such as vitamin K,
  cryoprecipitate, or Factor VIII concentrates.
• Fresh frozen plasma has the same infectious
  disease risk as whole blood.
• Fresh frozen plasma should not be used when the
  blood volume can be replaced with other volume
  expanders such as 0.9 sodium chloride, lactated
  ringers, albumin or pentaspan.

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Frozen Plasma FP

• Frozen plasma is prepared from whole blood,
  collected in CP2D anticoagulation solution.
• The plasma is separated after cold centrifugation
  and processed to the frozen state within 24 hours
  of collection.

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Frozen Plasma FP

• Frozen plasma contains stable coagulation factors
  such as Factor IX and fibrinogen in
  concentrations similar to FFP, but reduced
  amounts of Factor V
• and VIII.
• On average, each unit of frozen plasma contains
  an average of 250 mL (gt100 mL) of anticoagulated
  plasma.
• The indications and side effects are the same as
  for FFP, except that FP should not be used to
  treat coagulation factor deficiencies of Factor V
  and Factor VIII.

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Fresh Frozen Plasma (FFP)
Unit of FFP (Approx. 250 mL)
Apheresis FFP (Approx. 500 mL)
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Cryoprecipitate (Cryo)Description

• Cryoprecipitate is prepared by thawing fresh
  frozen plasma at a temperature between 1C and
  6C. After centrifugation, the supernatant
  plasma is removed and the insoluble
  cryoprecipitate is refrozen.
• On average, each unit of cryoprecipitate contains
  80 IU or more Factor VIII (FVIIIC) and at least
  150 mg of fibrinogen in 5-15 mL of plasma.

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Cryoprecipitate (Cryo)Function

• Cryoprecipitate provides a source of coagulation
  factors. Factor VIII, Factor XIII and von
  Willebrand Factor.
• Fibrinogen and fibronectin are present.

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Cryoprecipitate (Cryo)Indications

• Currently the main indication for this component
  is as a source of fibrinogen or Factor XIII.
• It may be used as a source of Factor VIII only
  when inactivated fractionation products or
  recombinant Factor VIII are not available.

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Cryoprecipitate (Cryo)Contraindications

• Cryoprecipitate should not be used unless results
  of laboratory studies indicate a specific
  hemostatic defect for which this product is
  indicated.
• Specific factor concentrates are preferred, when
  available, because of their reduced risk of
  transmissible diseases (because of viral
  inactivation during manufacturing).
• Cryoprecipitate can be used to make fibrin glue.
  Alternatively, virally inactivated commercial
  products can be purchased for this purpose.

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Cryoprecipitate (Cryo)
Cryoprecipitate
Pooling Cryoprecipitate
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Blood its Usage
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Components

• Cells
• Plasma
• molecules ions
• water

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Function

• Medium of transport
• Oxygen
• Carbon dioxide
• Other gases
• Ions
• Carbohydrates, proteins, fats
• Immune response
• Humoral
• cellular

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Cells

• Erythrocyres
• White cells
• Granulocyes
• neutophiles
• Eosinophiles
• Basophiles
• Lymphocyes
• Monocytes
• Platelets

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Molecules ions

• Ions
• Na, Cl-, K, HCO2-, etc
• Molecules
• Proteins enzymes, precursors, active agents,
  immunoglobulins, carriers
• Proteoglycans
• Lipoproteins

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Body Water

• Intracellular 55
• Interstitial Fluid 20
• Plasma 7.5
• Connective Tissue 7.5
• Bone Water 7.5
• Transcellular Fluid 2.5

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Blood products

• Whole blood
• Blood components
• Red cells
• Platelets
• Granulocytes
• Whole plasma (FFP, reconstituted)
• Cryoprecipitate
• Plasma fractions
• Clotting factor concentrates
• Immunoglobulin preparations
• Saline albumin solution
• Salt-poor albumin

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Volume replacement

• Haemorrhage or burns
• Replacement with RBC mass at early stage
  necessary in massive haemorrhage
• Initiate with rapid transfusion of plasma
  expanders, electrolyte solutions get blood type
  match in 30 minutes
• Unmatched Grp O Rh- blood rarely justified

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Massive Blood Transfusion

• pH K increase impair myocardial function
• Citrate lowers ionised Ca
• Significant hypothermia
• Platelet WBC aggregates precipitate ARDS

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Prevention

• 1 unit of fresh blood for every 5 10 units of
  stored blood
• IV 10 calcium gluconate 10 mls with every litre
  of transfused citrated blood
• Warming blood
• Microaggregate blood filters

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Fresh Blood

• DIVC
• Massive haemorrhage
• Major liver trauma
• Bleeding associated with liver disease

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Clotting factors

• Clotting disorders
• Haemophilia
• Liver disease

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Complications of Blood Transfusion

• Febrile reactions
• Bacterial contamination
• Immune reactions
• Physical complications
• Circulatory overload
• Air embolism
• Pulmonary embolism
• Thrombophlebitis
• ARDS

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Complications of Blood Transfusion

• Metabolic complications
• Hyperkalaemia
• Citrate toxicity hypocalcaemia
• Release of vasoactive peptides
• Release of plasticizers from PVC-phthalates
• Haemorrhagic reactions
• After massive transfusion of stored blood
• Disseminated intravascular coagulation

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Complications of Blood Transfusion

• Transmission of disease
• Hepatitis, CMV. EBV
• AIDS (Factor VIII)
• Syphilis
• Brucellosis
• Toxoplasmosis
• Malaria
• Trypanosomiasis
• Haemosiderosis
• After repeated transfusion in patients with
  haematological diseases

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Autologous transfusion

• Uses pt own blood
• Remove 500 ml store
• 2 weeks later, may be transfused in op
• or 1000 mls taken to increase the stored amount
• Multiplier effect
• No danger of transmitted infections