Primary postpartum haemorrhage Clinical Guideline Education Presentation v2.0

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: [email protected] | 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 [email protected], 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
[email protected], 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
`