MEDICAL MANAGEMENT OF PPH

DR INDRANIL DAS
JUNIOR RESIDENT , JULY 2021
MODERATORS : PROF JAYALAKSHMI
DR ASHWINI V
 OVERVIEW

 INITIAL ASSESSMENT/ RESUSCITATION

 FLUID THERAPY
 BLOOD COMPONENTS
 PHARMACOLOGICAL MEASURES
 NON PHARMACOLOGICAL MEASURES
 PREVENTION
 Resuscitation
 Adequate resuscitation is must… definitive management + diligent
monitoring
 First hour is GOLDEN HOUR
 Rule of 30 – 30% blood loss
Heart rate 30 beats/ min
Systolic blood pressure 30 mmHg
Hb/Hct 30%
Respiratory rate > 30/min
Urine output <30 ml/ hour
 Resuscitation

 Position – supine with leg end elevation, keep warm

 Oxygen via face mask 10-15 L/min
 14 gauze IV line (2 )
 Blood samples for CBC, BUN, coagulation profile, electrolytes, cross
match
 Catheterise
 Monitor BP, PR, RR, SpO2,urine output , SHOCK INDEX
 Fluid therapy
 Aim : Replenish lost volume, maintain tissue oxygenation, prevent
coagulopathy
 Best : blood components
 Crystalloids > colloid ( WHO 2012,FIGO 2022)
 3.5 litres of warm clear fluids ( 2 L crystalloids +1.5 L colloids)*
 Ringer lactate 1-2 ml/ 1 ml blood loss**
 Nature of fluid is less important than rapid administration and
warming of infusion

** SOGC 2022
* RCOG 2016
 Fluid therapy
 Evidence from trauma – limited fluid replacement may be
advantageous than liberal fluid replacement

 Side effects :dilutional coagulopathy, electrolyte imbalance,

hyponatremia
 Blood transfusion
 No firm criteria for time of initiation
 ACOG (2017) : In women with ongoing bleeding (>1.5 L) or with
abnormal vital signs – immediate preparation for transfusion to be
made
 SOGC (2022): haemorrhage unresponsive to uterotonic+ BL >150
ml/min or approaching MABL or signs of inadequate perfusion
 PRBCs are first step in transfusion process
 Before blood reports available – transfuse 4 units PRBC *

* SOGC
2022
 Different blood components
FFP
WHOLE BLOOD PRBC
180-200 ML
350-450 ml 200-240 ml
all coagulation
Hb 1-1.5 gm/dl Hb 1-1.5 gm/dl
factors

CRYOPRECIPITATE PLATELET
15-18 ML RDP (40-70 ML)
FIBRINOGEN, SDP (200-300 ML
FACTOR 8, 13,VWF, 5-6 RDP = 1 SDP
FIBRONECTIN 1 rdp raise platelet by 5000-10000/µl
1 sdp raise paltelet by 30000-
60000/µl
 Blood transfusion
 In emergency group O , RhD –ve blood to be issued till group specific
blood is available
 FFP administration to be guided by haemostatic testing and whether
haemorrhage is continuing

 Ongoing haemorrhage with prolonged PT/APTT : 12-15 ml/kg

 Ongoing haemorrhage after 4 packed cell : 4 unit FFP to be
administered
 Blood transfusion
 Platelets transfusion if <75,000, to keep level > 50,000

 Fibrinogen level 1-1.5g/l - too low for adequate hemostasis

<3 g/l – progression of bleeding, component requirement
 Cryoprecipitate to be administered 2 pools if fibrinogen level <2 g/l
( level by 1 g/l, 60 mg/kg fibrinogen concentrate)

RCOG 2016
 Contd..

 No consensus on optimal ratio of blood product replacement

 Estimate blood loss every 15-30 min, lab parameters every 30-60
minutes to guide product replacement
 Haematological parameters to achieve
Hb >8 gm%
Platelet >75000 / ml
Fibrinogen >1 gm/L
PT/APTT <1.5 times mean control
MASSIVE TRANSFUSION PROTOCOL
 Pacheo et al suggested activation of massive transfusion protocol
when bleeding continues after transfusion of 4 U packed cells in a
short time or SBP <90/ HR>120 in presence of uncontrolled bleeding

Coagulation parameters
to be repeated
periodically

Fibrinogen level to be
maintained above 150-
200 mg/dl
 DEFINITIVE MANAGEMENT

 Uterine atony is the most common cause of PPH

 Administration of uterotonic is the key intervention along with

uterine massage and compression
 Non pharmacologic method

 Uterine massage stimulates uterine contraction

 Bimanual uterine massage is another technique
 Massage to continue until uterus remains firm
 Pharmacological methods

 Intravenous oxytocin is the preferred drug and route

 If it fails, guidelines suggests using additional drugs , such as

ergot alkaloid, injectable prostaglandins or misoprostol
PARAMETERS OXYTOCIN ERGOT ALKALOID MISOPROSTOL CARBAPROST
MECHANISM OF Direct stimulation of Non specific stimulates stimulates
ACTION oxytocin receptor activation of prostaglandin prostaglandin
adrenergic and receptor receptor
dopaminergic
receptors in uterine
and vascular
smooth muscle
DOSE AND ROUTE 10-40 U IN 500- 250 µg IM/IV 400-1000 µg oral, 250 µg
1000L NS IV infusion S/L, vaginal, rectal IM/ intra-
myometrial
ONSET 1-2 min IV 2-5 min IM 11 min S/L 5 min
3-7 min IM 1-2 min IV 8 min oral

HALF LIFE 4-10 min IV 10 min, 2 hrs 2 hrs S/L 30 min

15-30 min IM 1.5 hrs oral

DURATION Of 15-20 min IV 120 min 3 hrs S/L 60 min

ACTION 1-2 hr IM 2 hrs oral

ADVERSE ST depression, HR Nausea, vomiting, Fever, shivering, Diarrhoea,

EFFECTS water intoxication hypertension diarrhoea bronchospasm
 ROLE OF TRANEXAMIC ACID
 Antifibrinolytic agent , prevents binding of plasminogen and plasmin
to fibrin and prevent its lysis

 Offers an alternative way to support hemostasis

 Dose : 1 gm IV over 10 min, effect lasts upto 7-8 hours

Dose to be repeated if bleeding continues or restarts within 24
hour of first dose
  Administration within 3 hours of delivery in PPH decreases mortality
secondary to bleeding and reduces the need for laparotomy

TRAAP 2 trial : use of tranexamic acid for caesarean delivery resulted in

significant lower incidence of PPH compared to placebo, though the
mean difference in calculated blood loss was approximately 100 ml

WOMAN2 trial is being conducted to know effect of TXA in patient with

moderate to severe anemia giving vaginal birth
 PHARMACOLOGICAL METHODS
GUIDELINE OXYTON ERGOT MISOPROSTO INJECTABLE OTHERS
ALKALOID L PRODTAGLANDIN
WHO 2012 Dose not specified Dose not 800µg S/L Dose not specified TXA-
specified regardless of
cause
RCOG 5 U slow IV ERGONOVINE 800 µg S/L CARBOPROST consider 1gm
2016 40U IN 500 ML 0.5 MG slow IV 0.25 MG IM every TXA
crystalloid @125 or IM 15 min
ml/h MAX 2 GM

ACOG 10-40 unit in METHYL 600-1000 µg CARBOPROST TXA- to

2017 500-1000 ML NS as ERGONOVINE oral, S/L, 0.25 mg IM every consider when
continuous IV inf, 0.2mg IM every rectal 15- 90 min initial therapy
10 unit IM 2-4 hrs MAX 2 GM fails
 CONTD….

GUIDELINE OXYTOXIN ERGOT MISOPROSTO INJECTABLE OTHERS

ALKALOID L PRODTAGLANDI
N

SOGC 5 U IV push ERGOMETRINE 400-800 µg CARBOPROST TXA- 1gm IV as

2022 20-40 unit in 0.25 mg IM or IV, adjunct to 2nd 0.25 mg IM or adjunct to 2nd line
250 ml NS at can be repeated line agents IMM, every 15 agents
500-1000 every 2 h, min, max 5 dose
ml/h max 5 doses

FOGSI 20-40 U in METHYL 800-1000 µg CARBOPROST CARBETOCIN 100µg

2022 1 L NS, ERGOMETRINE PR 0.25 MG IM IM/IV
infuse 500 ml 0.2 mg IV/IM
over 10 min every 2-4 hours 600-800µg TXA- 1 gm IV
then 250 ml/h oral/SL
 CONTD….

GUIDELINE OXYTOXIN ERGOT MISOPROSTOL INJECTABLE OTHERS

ALKALOID PRODTAGLAN
DIN

FIGO 20-40 unit IN 1L NS ERGOMETRIN if OXYTOCIN CARBOPROST TXA-1 gm IV

2022 at 60 drops/min, E 0.2 mg IM or N/A, single dose (3RD line agent) early use
continue until slow IV , rpt 800 µg S/L
bleeding stops every 2-4 hours, 0.25 mg IM
max 5 doses every 15
minutes
max 2 gm
HEMOSTATIC RESUSCITATION
 Interventions aimed to diminish possibility of coagulopathy
 Limit crystalloid use with permissive hypotension
 Promote blood component use with 1:1 transfusion
 Early repositioning of fibrinogen
 Rapid blood component delivery and create massive transfusion
protocol
 Optimise coagulation system with early use of antifibrinolytics
 Regain homeostasis
 Rationale for hemostatic resuscitaion
 Permissive hypotension (SBP 80-100 mm hg) optimal prior surgical
control
 Early coagulopathy occur before hemodilution in trauma, obstetric
hemorrhage share some mechanism
 Hemostatic resuscitation aimed at preventing coagulopathy
 Early use of blood products with close relationship to components
(1:1:1) is the corner stone of hemostatic resuscitation
Moderate to high dose of
plasma and platelet was
independently associated
with improved 6hour
mortality; patients receiving
more had 3-4 times more
likely to die
Prevention of PPH
PPH prevention
 Identify risk factors and preparedness

 The CMQCC recommends intrapartum obstetric risk assessment at-

1. admission to labor room
2.start of 2nd stage
3.transfer to STUDY
RETROSPECTIVE postpartum care PREDICTIVE ACCURACY
COMPARED
OF CMCQCC,
4.anytimeACOG SMI,
patient AWOHNN
condition IN 11000 PATIENTS, NONE
changes
PERFORMED WELL IN PREDICTION WITHIN 48 HOURS

<5% OCUURS IN HIGH RISK PTS

USE OF TOOL IS BETTER THAN NO RISK

ASSESSMENT ,THOUGH <PREDICTIVE VALUE
 PPH prevention
 THIRD STAGE OF LABOUR : >18 minutes – significant PPH risk
>30 minutes – 6 fold increased risk
 AMTSL :For every 12 patients - one case of PPH is prevented
For every 67 patients - one woman would avoid transfusion
Prevents up to 60% PPH

RCT BY BRISTOL et al (1988)

AND HINCHINGBROOKE et
al(1998)
 CHANGE IN AMTSL

1. Uterotonic
1.Uterotonic administration
administration with 1. Uterotonic
anterior shoulder administration
2. CCT , skilled
delivery birth attendant
2.Immediate cord 2.CCT
available
clamping
3.CCT 3.Uterine masage
3. Uterine tone
assessment

RCT BY BRISTOL
et al (1988) AND ACOG 2017,
HINCHINGBROO
WHO 2007 WHO 2012
KE et al(1998)
CCT CAUSES

10ml less bleeding

6 min shorter 3rd

stage duration
 Uterotonic for prophylaxis
GUIDELIN 1ST LINE ROUTE OTHER
E
WHO 2018 OXYTOCIN 10 UNIT IV/IM MISOPROSTOL 400-600µg PO /CARBETOCIN 100
µg IM OR IV/ERGOT ALKALOIDS 200 µg IM OR IV
ACOG OXYTOCIN 10 UNIT IV/IM ERGOT ALKALOIDS
2017
RCOG OXYTOCIN 10 UNIT IM/5 U ERGOMETRINE-OXYTOCIN
2016 IV(LSCS)
SOGC VAGINAL- 10 U IM/ 20-40 CARBETOCIN 100 µg IM or slow IV
2022 OXYTOCIN IU IN 1000 ML @
150 ML/HR MISOPROSTOL 200-400 µg SL OR PO
CESAREAN-
CARBETOCIN
FOGSI OXYTOCIN 10 UNIT IM CARBETOCIN 100 MCG IM/IV, METHYL
2022 ERGOMETRINE/ MISOPROSTOL
FIGO 2022 OXYTOCIN 10 UNIT IV/IM ERGOMETRINE 0.2 MG IM/IV,ORAL MISOPROSTO
400-600 µg, CARBETOCIN 100 µg IM/IV
 CONTD…

 Meta-analysis by McDonald et al : syntometrine has similar efficacy

as oxytocin, but side effects are more
 Cochrane review: prostaglandins not superior to oxytocin/ergot
 2018 Cochrane review: misoprostol superior to placebo but inferior to
oxytocin for prevention, combination prevents need of additional
agent
 Carbetocin resulted in a statistically significant reduction in need of
further uterotonic in caesarean, but not in vaginal delivery
 CARBETOCIN

 Long acting synthetic oxytocin analogue ,agonist

 Dose : 30 µg slow iv over 30s to 1 min or im
 Onset of action : 1-2 min iv, 3-4 min im
 Half life : 40 min
 Duration of action : 1 hour
 Side effects : vomiting, abdominal pain, headache, tremor, dizziness,
chest pain
 Contraindications : serious cvs disorder/ hepato-renal disorder/
epilepsy
 SUMMARY
 Identify risk factors
 AMTSL with IM oxytocin , CCT, assess tone
 Early recognition of PPH
 Initiate resuscitation within golden hour
 Restrict crystalloid, early blood and component transfusion
 Uterine massage – oxytocin infusion – 2nd line uterotonics –
conservative methods
THANK YOU