List the strategies available for the control of postpartum haemorrhage and give the advantages and disadvantages of each.
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 |
Method | Advantages | Disadvantages |
Mechanical haemostasis methods | ||
Uterine massage |
|
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Bimanual compression |
|
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Manual aortic compression |
|
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Pharmacological means of encouraging uterine contraction | ||
Oxytocin |
|
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Ergometrine |
|
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Carboprost |
|
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Misoprostol |
|
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Pharmacological measures to promote haemostasis | ||
Tranexamic acid |
|
|
Factor VIIa |
|
|
Surgical or radiological methods of haemostasis | ||
Gause pack tamponade |
|
|
Balloon tamponade |
|
|
Angio-embolisation |
|
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Ligation of the uterine or common iliac artery |
|
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Hysterectomy |
|
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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.
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.