List the strategies available for the control of postpartum haemorrhage and give the advantages and disadvantages of each. 

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College answer

Tx

Advantages 

Disadvantages

Physical – 

vigorous bi-manual massage

Immediate use, no specific equipment.

Only works in uterine atony Worsens traumatic injury

Pharmacological  

 Oxytocin (first line)

Simple, rapid action

Hypotension and tachycardia Risk on the CVS unstable pt with no haemorrhage control

 Ergometrine (second line)

Simple, rapid action

Hypertension, N&V

Vasospasm of the arteries in overdose-> gangrene, angina, ischaemia

Prostaglandin (third line)

Misoprostol PR 

Carboprost, IMI or intrauterine

Simple

B/Constriction, flushing 

Asthma is Contra Indic

May inc pulmonary shunting and maternal hypoxia

Surgical

Manual removal of placenta/retained products

Removes bleeding cause

Needs GA in theatre

Surgical repair Soft tissue trauma/artery ligation

Definitive Tx

Needs GA. 

Bakri Balloon +/- BT Cath

Immediate control

Infection risk

Not definitive Tx

Can mask ongoing bleeding.

Hysterectomy

Definitive Tx

fertility

Radiological

Selective embolisation of pelvic vessels

Balloon tamponade bilateral

fermoral arteries as a temporizing

measure

REBOA

May be definitive Can avoid hysterectomy

Only available in tertiary centres

Not suitable in catastrophic haemorrhage

Temporising measure 

Risk of ischeamia to pelvic organs

Maintain normal physiological milieu

Avoid acidosis

Not strictly a

May not be effective alone

Hypothermia

Hypocalcaemia

Correction of coagulopathy

control option but

will not allow normal haemostasis to occur if absent

Correction of coagulopathy may require product transfusion with attendant possible complications

Discussion

Advantages and disadvantages of Methods used to Control
Postpartum Haemorrhage
Method Advantages Disadvantages
Mechanical haemostasis methods

Uterine massage

  • Non-invasive
  • Requires zero training
  • Could be performed by the gravida herself
  • May assist in clot expulsion
  • Does not appear to have any harmful effects
  • May not be effective
  • Time-consuming and requires higher nursing workload
  • Lack of evidence regarding effect (WHO recommend against this practice and describe it as a time-wasting exercise) 

Bimanual compression

  • This is where you a fist
    in the vagina and a hand on the abdominal wall.
  • Effective to establish haemostasis.
  • Buys time for definitive management
  • Not exactly a long-term solution
  • All available evidence describing this technique is low quality. All society recommendations in support of it are weak recommendations.

Manual aortic compression

  • Effective to establish haemostasis
  • Buys time for definitive management
  • Only available intraoperatively
  • Not exactly a long-term solution
Pharmacological means of encouraging uterine contraction

Oxytocin

  • Synthetic analogue of endogenous hormone
  • Available widely, and cheap
  • Recommended universally in the management of the third stage of labour (Dahlke et al, 2015)
  • Fewer side-effects than ergometrine
  • Causes hypotension
  • Contraindicated in pre-eclampsia
  • Even though it's recommended as first  line by everyone, there are not randomised controlled trials which support its efficacy.

Ergometrine

  • Ergot alkaloid which increases uterine tone
  • Widely available
  • As prophylaxis, it is at least as effective as oxytocin
  • Causes vomiting, nausea, hypertension; more side-effects than oxytocin
  • Contraindicated in preeclampsia
  • May cause coronary vasospasm
  • May promote the retenion of the plancenta 

Carboprost

  • Synthetic prostaglandin analogue of PGF2α 
  • Increases uterine tone
  • May cause bronchospasm
  • No agreement as to when this should be used (i.e. no agreement as to where this drug belongs in line after the fisrt-line agents)

Misoprostol

  • Methyl ester synthetic analogue of  prostaglandin E1
  • High success rate if used with other uterotonic agents
  • Can be administered orally, sublingually, buccally, vaginally or rectally - by unskilled operators, in a resource poor setting
  • Not as effective as the other uterotonic agents (Tunçalp et al 2012)
  • Generally, only recommended as a co-uterotonic
  • Only indicated if other uterotonic agents are unavailable or are ineffective
Pharmacological measures to promote haemostasis

Tranexamic acid

  • Systemic antifibrinolytic
  • Inexpensive and requires minimal training to use
  • Can be added if uterotonics have been ineffective in controlling the bleeding
  • Supported by the WOMAN trial (Shakur et al, 2017)
  • Increased risk of VTE
  • Decreased seizure threshold

Factor VIIa

  • Expensive
  • May not be available
  • Thrombotic adverse event rate was 2.5% in on study
Surgical or radiological methods of haemostasis

Gause pack tamponade

  • "several yards of wide gauze placed inside the uterine cavity"
  • Acts by mechanical pressure effect as well as the prothrombotic effect of the fabric
  • May conceal haemorrhage
  • May encourage infection

Balloon tamponade

  • Provides more reliable tamponade than gauze packs
  • Includes a drainage channel to monitor blood loss
  • Can be inflated and deflated to test for re-bleeding
  • Inappropriate if there has been significant genital tract laceration
  • Uncomfortable
  • Invasive

Angio-embolisation

  • Minimally invasive means of devascularising the uterus
  • May be able to localise the precise territory from where blood loss is occuring
  • Radiation exposure is involved (not great for the breasts)
  • May not be available everywhere

Ligation of the uterine or common iliac artery

  • "stepwise uterine devascularisation" should terminate blood supply, preventing further bleeding
  • Apparently, this does not have any major adverse effects on fertility (Doumouchtsis et al, 2013)
  • Controls bleeding only in 50% of cases

Hysterectomy

  • May be a lifesaving step
  • High maternal morbidity
  • Fertility will obviously be affected
  • Bleeding may continue in spite of this procedure, because of coagulopathy
  • A more extensive procedure with risk of complications such as ureteric or bladder injury

For extra credit, the trainees were expected to mention the WOMAN trial (Shakur et al, 2017). Bleeding PPH patients were randomised to receive 1g of tranexamic acid (and another 1g if needed). A whopping 20,060 patients were enrolled. The difference in death from haemorrhage was 1.5% vs 1.9%, in favour of tranexamic acid by 0.4% of absolute risk reduction - a difference which only achieved statistical significance because the numbers were massive and because the sample size was increased by 5000 patients mid-study. The number needed to treat are 267. 

References

References

Oh's Manual, Chapter 64 ("General obstetric emergencies") by Winnie TP Wan and Tony Gin, p. 684

Mousa, Hatem A., et al. "Treatment for primary postpartum haemorrhage.The Cochrane Library (2014).

Oh's Manual, Chapter 64 ("General obstetric emergencies") by Winnie TP Wan and Tony Gin, p. 684

Mousa, Hatem A., et al. "Treatment for primary postpartum haemorrhage.The Cochrane Library (2014).

Tunçalp, Özge, G. Justus "Prostaglandins for preventing postpartum haemorrhage."Hofmeyr, and A. Metin Gülmezoglu. "Prostaglandins for preventing postpartum haemorrhage." Cochrane Database Syst Rev 8.8 (2012): CD000494.

Alfirevic, Zarko, et al. "Use of recombinant activated factor VII in primary postpartum hemorrhage: the Northern European registry 2000–2004." Obstetrics & Gynecology 110.6 (2007): 1270-1278.

Dahlke, Joshua D., et al. "Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines." American journal of obstetrics and gynecology 213.1 (2015): 76-e1.

Doumouchtsis, S. K., et al. "Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review." BJOG: An International Journal of Obstetrics & Gynaecology 121.4 (2014): 382-388.

Smith, J., and H. A. Mousa. "Peripartum hysterectomy for primary postpartum haemorrhage: incidence and maternal morbidity." Journal of obstetrics and gynaecology 27.1 (2007): 44-47.

World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization, 2012.

Weeks, A. "The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?.BJOG: An International Journal of Obstetrics & Gynaecology122.2 (2015): 202-210.

Shakur et al  "Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial." The Lancet 389.10084 (2017): 2105-2116.