Postpartum haemorrhrage

Postpartum haemorrhrage

Primary PPH is defined as blood loss of greater than 500 mL within 24 hours of delivery and affects about 5% of deliveries.

There are many known risk factors: prolonged third stage pf labor, preeclampsia, multiple gestation, foeceps delivery, and mediolateral episiotomy.

The three most common causes of PPH are uterine atony, retained placenta, and cervical/vaginal lacerations.

Retained placenta

This is the second most important etiology of PPH (roughly 20%–30% of cases).

It is suggested by the finding of an absent or incomplete placenta. If delivery of the placenta has not taken place, it must lead without delay to manual removal of the placenta, under anesthesia whenever possible, to ensure uterus emptying.

Uterine atony

Uterine atony is the leading cause of PPH, observed alone in 50% to 60% of cases; it presents as painless continuous bleeding, often developing slowly at the beginning.

 The other key diagnostic criterion is abdominal palpation of a soft and oversized uterus.

Prevention relies on active management of the third stage of labor.

Treatment is based on bladder emptying and oxytocin (10–20 IU; ±uterine massage). When these measures are not quickly effective cervical/vaginal lacerations must be searched for and then be followed by rapid implementation of prostaglandin treatment if bleeding still persists.

Cervical/vaginal lacerations

This is the third cause of PPH (roughly 10% of cases), and it is more likely to occur after instrumental extraction, fetal macrosomia, or quick labor and delivery before full cervical dilation.

Diagnosis is also suggested when retained placenta and uterine atony have been discarded. this diagnosis is often made much too late (the bleeding can be concealed in the vaginal wall or pelvis), when the parturient displays hemodynamic instability, coagulation disorders, and increasing pelvic pain.

Uterine inversion

This is a rare iatrogenic event (!1/1000) where the internal surface of the uterus is partially or completely exteriorized into the vagina. Clinical features include abdominal pain and often severe hemodynamic instability.

Immediate uterine reversion must be performed by the obstetrician and can be facilitated by short-time tocolysis (trinitrine as first line), using usually a potent IV vasopressor at the same time to counteract hypotension (phenylephrine or adrenaline).

Coagulation disorders

Coagulation disorders can be the cause or the consequence of PPH. Many causes can be listed (congenital, such as von Willebrand disease, or acquired,

such as HELLP syndrome, disseminated intravascular coagulopathy, anticoagulation therapy, etc). In fact, coagulation disorders are rarely a true triggering

cause of PPH.

Planning for obstetric hemorrhaged organizational aspects

The effective management of obstetric hemorrhage relies on very simple but often overlooked principles that all concur to timely treatment:

_ Simultaneous, coordinated, multidisciplinary management (ie, obstetricians, anesthesiologists, hematologists, laboratory and blood bank technicians, radiologists).

_ Consensual and practical definition of hemorrhage: any abnormal bleeding (in rate or duration) should trigger at once the diagnosis ofhemorrhage. This is particularly important after delivery where the border between physiologic bleeding and PPH must be clear-cut to avoid

any treatment delay.

_ Consensual, preplanned, step management available as a written operational protocol.

_ As a first step, the obstetric team needs to focus on the search and basic treatment of the three most common causes of PPH: retained placenta

(manual removal of the placenta and manual uterine exploration), uterine atony (bladder emptying and IV oxytocin _ uterine massage), and cervical/vaginal lacerations (examination of the vagina and cervix with

appropriate valves, and repair as needed). Simultaneously, the anesthetic team provides basic resuscitation and adequate analgesia for these obstetric interventions.

_ The second step is implemented as soon as the first step has proven ineffective at stopping the bleeding and no later than 30 minutes after initial PPH diagnosis, to improve effectiveness. It mainly relies on prostaglandin administration, either IV prostaglandin E2 (PGE2)

sulprostone or intramuscular 15-Methyl prostaglandin F2a

(PGF2a) carboprost; uterine tamponade can also be useful. More advanced resuscitation and monitoring are also usually needed and provided by the anesthetic team at this stage.

_ The third step is considered within an additional 30 minutes (and no longer than after 1 hour) if the second step has also failed to stop bleeding. It relies on invasive therapy, either surgical artery ligation _ B-lynch suture or

radiologic embolization.

_ The last step is hysterectomy; meanwhile, the use of recombinant activated factor VII (rFVIIa) can be considered.

Invasive therapy

Several invasive options are available to control PPH when medical treatment is unsuccessful at controlling bleeding: uterine balloon tamponade, arterial embolization, uterine compression sutures, and internal iliac artery ligation.

Uterine balloon tamponade

Uterine packing has long been the treatment of choice to manage PPH; it is safe, quick, and effective in a majority of cases. Various balloon devices have been used, with the Sengstaken-Blakemore esophageal catheter being the most frequently employed.

Uterine arterial embolization

Another less radical approach to control bleeding is the use of uterine artery embolization. It has become a well-recognized alternative method of treatment in the conservative management of PPH in association with

local or medical treatment, or in the event of their failure.

The reported success rate

of uterine artery embolization in the literature is more than 90%.

In most patients, fertility is preserved and normal menstruation returns almost 100%. Minor complications such as pain and transient inflammation with fever are rare (0%–10%). More severe complications such as

pelvic infection, pulmonary embolism, or uterus and bladder necrosis have been reported.

B-Lynch suture

the so-called B-Lynch uterine compression suture has been used successfully to control bleeding following failed conservative management.

This technique also allows uterus conservation for subsequent menstrual function and pregnancies and seems to be devoid of long-term sequelae.

Surgical iliac (or uterine) artery ligation

When uterine tamponade and arterial embolization fail, a laparotomy to perform iliac artery ligation is an option to preserve the uterus. It can also be performed as a first invasive option, during C-section delivery, or when

the patient is hemodynamically unstable or if embolization is not readily available.

When arterial ligation fails, hysterectomy is usually necessary. This may carry a higher risk of morbidity when compared with emergency hysterectomy performed

Without prior iliac artery ligation.

Hysterectomy

As a last resort, but decided on quickly when all other interventions have failed, peripartum emergency hysterectomy may be required to control bleeding and save lives.

Transfusion therapy and resuscitation

Transfusion should be initiated with red blood cells in all obstetric patients with signs of inadequate oxygen carrying capacity and inmost obstetric patients with a hemoglobin of less than 7 g/dL, or when blood loss is ongoing and the hemoglobin is around 7 g/dL. If

hemorrhage is accompanied by coagulation disorders, 15 to 20 mL/kg of fresh frozen plasma should be given as first-line treatment and target hemoglobin should be set higher, above 8 g/dL, to improve overall coagulation activity. Transfusion of platelet concentrates is recommended to treat active bleeding associated with thrombocytopenia below 50 G_L_1

Intraoperative cell salvage

Intraoperative cell salvage (or preoperative autologous donation in scheduled cases) has an undisputed role in obstetrics in patients with high risk such as placenta previa/accreta, massive fibroids, or rare blood type

or unusual antibodies. Intraoperative cell salvage can be also useful in the treatment of Jehovah’s Witnesses or in geographic areas where allogeneic blood supply is particularly problematic.

Recombinant factor VIIA (NovoSeven)

It was suggested that rFVIIa was often effective at

stopping or reducing the bleeding, particularly when other conventional treatments (see above) had failed. The dosage used varied roughly from 20 to 120 mcg/kg, without clear evidence of a dose-response relationship.

Nonetheless, because of lack of level 1 evidence, the use, dosage, and timing of rFVIIa are still a matter of debate.

‘‘rFVIIa may be considered as treatment for life-threatening post-partum hemorrhage, but should not be

considered as a substitute for, nor should it delay, the performance of a life-saving procedure such as embolization or surgery, nor the transfer to

a referring center.