Primary postpartum haemorrhage Clinical Guideline Education Presentation v2.0 45 minutes Towards your CPD Hours References: The Queensland Maternity and Neonatal Clinical Guidelines Program clinical guideline Primary postpartum haemorrhage is the primary reference for this package. Recommended citation: Queensland Maternity and Neonatal Clinical Guidelines Program. Primary postpartum haemorrhage. Clinical Guideline Education Presentation I13.1-V2-R17. Queensland Health. 2013. Disclaimer: This presentation is an implementation tool and should be used in conjunction with the published guideline. This information does not supersede or replace the guideline. Consult the guideline for further information and references. Feedback and contact details: M: GPO Box 48 Brisbane QLD 4001 | E: MN-Guidelines@health.qld.gov.au | URL: www.health.qld.gov.au/qcg Funding: The Queensland Maternity and Neonatal Clinical Guidelines Program is supported by the Clinical Access and Redesign Unit, Queensland Health. Copyright: © State of Queensland (Queensland Health) 2013 This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the Queensland Maternity and Neonatal Clinical Guidelines Program, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en For further information contact Queensland Maternity and Neonatal Clinical Guidelines Program, RBWH Post Office, Herston Qld 4029, email MN-guidelines@health.qld.gov.au, phone (+61) 07 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email ip_officer@health.qld.gov.au, phone (07) 3234 1479. Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 2 Abbreviations Abbreviations ABC Airway, Breathing, Circulation CS Caesarean section CCT Controlled cord traction DIC Disseminating intravascular coagulopathy DRS Danger, Response, Send for help HELLP Haemolysis, Elevated Liver enzymes, Low Platelet count LAM List of Approved Medicines MTP Massive Transfusion Protocol OT Operating theatre/room RSQ Retrieval Services Queensland VTE Venous thromboembolism Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 3 Learning outcomes • At the end of this presentation the participant will be able to: ◦ Identify the common causes and risk factors for PPH ◦ Identify appropriate care and management to the woman experiencing PPH Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 4 Definitions Very severe or major: > 2500 mL Severe: ≥ 1000 mL Traditional: Vaginal birth > 500 mL CS > 1000 mL Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 5 Incidence • A leading cause of maternal morbidity and in some countries mortality • 2010 – reported 5.9% of births in Qld Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 6 Initial response [1/6] • Assess blood loss ◦ Rate and volume of bleeding ◦ Caution with visual underestimation  Weigh bloody linen, swabs and drapes  Pictorial guides ◦ Observe for changes in clinical findings:  Increasing tachycardia and hypotension  A healthy woman may only show mild signs of shock after a blood loss of 1000 mLs  Compromise may occur earlier in women with: – – – – Gestational hypertension with proteinuria Anaemia Dehydration Small stature Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 7 Blood loss BP (systolic) Signs and symptoms Degree of shock 500-1000 mL (10-15%) Normal Palpitations Dizziness Tachycardia Compensation 1000-1500 mL (15-25%) Slight decrease 80-100 mm Hg Weakness Sweating Tachycardia Mild 1500-2000 mL (25-35%) Marked decrease 70-80 mm Hg Restlessness Pallor Oliguria Moderate 2000-3000 mL (35-45%) Profound decrease 50-70 mm Hg Collapse Air hunger Anuria Severe Queensland Maternity and Neonatal Clinical Guidelines Program: PPH Permission to reprint has been provided courtesy of the Society of Obstetricians and Gynaecologists of Canada Initial response [2/6] 8 Initial response [3/6] • Address woman’s concerns • Position to lie flat • Assess DRS ABC ◦ ◦ ◦ ◦ Call for help – obstetrician/senior registrar Apply face mask oxygen @ 15 L/min Continuously monitor BP, HR, SpO2 Keep warm Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 9 Initial response [4/6] • Assess cause (4 Ts) ◦ Tone – palpate abdomen  If fundus atonic → massage fundus and give uterotonics ◦ Trauma – consider with contracted fundus and blood clotting  Examine genital tract ◦ Tissue – retained placenta or fundus atonic and unresponsive to uterotonics  Check completeness of placenta ◦ Thrombin  Presence of clinical signs of coagulopathy Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 10 [5/6] • Apply bimanual compression ◦ Particularly with a delay in treatment or maternal collapse Queensland Maternity and Neonatal Clinical Guidelines Program: PPH Image reproduced with permission from Advance Life Support Obstetrics (ALSO) Asia Pacific. Initial response 11 Initial response [6/6] • Insert 2 x 14-16g cannulas → send urgent: ◦ FBC ◦ Group & hold/X-match ◦ U&Es (include Ca2+, lactate) • IV-1 – fluid & blood component replacement: ◦ Avoid excessive crystalloid use – give 2-3 L ◦ Transfuse RBC (O-Neg or group specific as available) • IV-2 – IV drug therapies • Consider intraosseous access if required • Insert IDC – monitor output • Assess/record vital signs 5 minutely & temp 15 minutely Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 12 70 % of PPHs Tone – risk factors Antenatal • > 35 years of age • Asian ethnicity • BMI > 35 • Grand multiparity • Previous PPH • Uterus overdistension: ◦ Multiple pregnancy ◦ Polyhydramnios ◦ Macrosomia Intrapartum Postnatal • Precipitate • Drug induced labour hypotonia • Prolonged labour ◦ MgSo4 • Chorioamnionitis ◦ Anaesthetic • Oxytocin • Bladder distension • Uterine inversion • Assisted vaginal birth • Caesarean section Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 13 Tone The uterine cavity must be empty of tissue for effective uterine contraction Uterine atonia: • Massage fundus • Ensure 3rd stage oxytocic given • Check placenta and membranes are complete • Expel uterine clots • Ensure bladder is empty • Assess need for bimanual compression Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 14 Tone – drugs [1/2] Administer 1st line drugs: • IV Syntocinon 5 IU slowly • IV Ergometrine 250 micrograms o Repeat after 15 minutes to total of 500 micrograms • Syntocinon infusion 40 IU/1 L crystalloid @ 125-250 mL/hr (via sideline & pump) • PR Misoprostol 800-1000 micrograms • Not approved as first line drug in Qld Health’s LAM Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 15 Tone – drugs [2/2] Administer 2nd line drug: • Prostaglandin F2 alpha (Dinoprost): o Intramyometrial injection as limited efficacy with peripheral IM injection o 0.5-1 mg at a time into each side of the uterine fundus or 1 mg into the uterine fundus o Aspirate to avoid systemic injection o Inject through anterior abdominal wall after vaginal birth o Inject directly into myometrium at CS o Repeat if required to a maximum of 3 mg o Refer to Guideline/LAM for restrictions o Not a TGA approved indication Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 16 Trauma [1/2] Ensure the uterus is well contracted before assessing for trauma 20 % of PPHs Genital trauma • Inspect cervix, vagina, perineum o Consider uterine site • Clamp obvious arterial bleeders • Repair – secure apex • Transfer to OT if: o Unable to see/access trauma site Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 17 Trauma Uterine rupture • Risk factors: o Previous uterine surgery/CS o Administration of oxytocin o Malpresentation o Dystocia during second stage of labour • Signs of postpartum rupture: o Signs of shock out of proportion to blood loss o Pain, abdominal distension, persistent vaginal bleeding o Possible haematuria • Urgent transfer to OT [2/2] Uterine inversion • Risk factors: o Uterine over distension o Invasive placentation o Umbilical cord – excessive traction • Immediate life threatening haemorrhage and shock • Consider anaesthesia prior to repositioning • If placenta in place – leave in place until after reduction Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 18 Tissue The uterine cavity must be empty of tissue for effective uterine contraction 10 % of PPHs Retained placenta: • Do not massage fundus • Ensure 3rd stage oxytocic given o Not recommended: Ergometrine, IV Oxytocin infusion • Apply CCT & attempt delivery o If undue traction: stop CCT o If placenta in vagina: attempt removal • Post delivery: check placenta complete • Massage fundus: assess tone • Transfer to OT if: o Placenta adherent/trapped o Cotelydon + membranes missing • Consider need for bimanual compression during OT transfer Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 19 Thrombin [1/2] Intractable bleeding can lead to coagulopathy Antenatal risk factors: • Maternal blood disorders • Severe pre-eclampsia or HELLP syndrome • Antepartum haemorrhage • Intrauterine fetal death Intrapartum risk factors: • Chorioamnionitis • Amniotic fluid emboli/DIC <1% of PPHs Postnatal risk factors: • Amniotic fluid emboli/DIC Coagulopathy is a criterion for MTP activation Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 20 Thrombin [2/2] Coagulopathy • Ensure baseline FBC, Coags+X-match, ELFTs (include Ca2+, lactate), ABGs • Monitor 30-60 minutely FBC, Coags, 2+ Ca , ABGs • Do not wait for blood results to treat • Activate MTP give: o RBC, FFP, platelets o Cryoprecipitate if fibrinogen < 2.5 g/L 2+ o Ca Gluconate if Ca < 1.1 mmol/L • Avoid hypothermia & acidosis Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 21 If PPH continues [1/2] Be alert for signs of coagulopathy: • Oozing from puncture/cannulation/injection sites or surgical field • Haematuria • Petechial, subconjunctival and mucosal haemorrhage • Blood that no longer clots • Uterine atonia secondary to increased fibrin degradation products Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 22 If PPH continues [2/2] • Transfer to OT: ◦ Lie flat / lateral ◦ Maintain face mask oxygen • Review criteria for MTP activation • Rural/remote areas: ◦ Emergency donor panel activation ◦ Contact RSQ Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 23 Criteria for MTP activation LEAD CLINICIAN ASSESSES FOR MTP CRITERIA: Woman is actively bleeding and has: Ø 4 units of RBC in < 4 hours PLUS haemodynamic instability OR Ø An estimated blood loss of > 2.5 L OR Ø Clinical or laboratory signs of coagulopathy MTP ACTIVATED • Notify laboratory/blood bank • Identify time frame for product delivery CONTACT HAEMATOLOGIST Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 24 Massive transfusion protocol OPTIMISE • Oxygenation • Cardiac output • Tissues perfusion • Temperature/metabolic state MONITOR 30-60 MINs • FBC • Coagulation screen • Ionised Calcium • Arterial blood gases MTP PACK 1 • 4 units RBC • 4 units FFP – 20-30 minutes to thaw • Cryoprecipitate 10 units – 20-30 minutes to thaw MTP PACK 2 INCLUDE • 4 units RBC • 4 units FFP • 1 adult dose platelets • IV Calcium Gluconate 10% 10 mL 2+ o If Ca < 1.1 mmol/L Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 25 OT interventions – Tone [1/2] • Consider ◦ Intrauterine balloon tamponade © 2007 Lisa Clark courtesy of Cook Medical Inc. Permission for use granted by Cook Medical Incorporated, Bloomington, Indiana ◦ Angiographic embolisation Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 26 OT interventions – Tone [2/2] ◦ Laparotomy:  Interim aortic compression  B-Lynch compression suture  Bilateral uterine artery ligation  Hysterectomy (consider early) B-Lynch arterial ligation Images reproduced with permission from Wiley Reference: B-Lynch C, Coker A, Lawal A, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG 1997; 104:372–375 Uterine artery ligation © 2012 Saunders, An imprint of Elsevier. Reference: Francois K, Foley M. Chapter 19: Antepartum and postpartum hemorrhage. In: Gabbe S, Niebyl J, Simpson J, Landon M, Galan H, Jauniaux E, et al., editors. Obstetrics: normal and problem pregnancies. 6th ed. Philadelphia: Saunders, Elseiver; 2012 Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 27 OT interventions Tissue • Manual removal curettage Trauma • • • • • Administer anaesthetic Optimise exposure with retractors Inspect cervix, vagina and perineum Assess uterus intact Repair – secure apex Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 28 OT interventions Thrombin • Consider: ◦ Angiographic embolisation ◦ Bilateral uterine artery ligation ◦ Hysterectomy (consider early) Unknown cause • Laparotomy – examination under anaesthetic Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 29 After bleeding controlled • High dependency/intensive care/ inter-hospital transfer if indicated • If condition not critical, monitor: ◦ In birth suite for 2 hours ◦ First 24 hours – 4 hourly vital signs, fundal tone, vaginal blood loss ◦ After 24 hours – as indicated • Haemoglobin ◦ 6 hours after stabilisation ◦ Repeat within 24 hours after birth ◦ Treat anaemia Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 30 Postnatal care • High risk of VTE therefore prophylaxis: ◦ Monitor for deep vein thrombosis/pulmonary embolus • Psychological support: ◦ Debrief post event and prior to discharge ◦ Counsel family ◦ Offer social work review • Inform woman of increased risk of PPH in subsequent pregnancies and the need to inform future primary carers of PPH complication • Follow-up Queensland Maternity and Neonatal Clinical Guidelines Program: PPH 31