Outline the causes and management of severe postpartum haemorrhage (PPH). 

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College answer

Causes can be broken down into 4 main groups: the “4 T’s” 
Tone: uterine atony (most common) 
Trauma: Bleeding at surgical sites including episiotomy, genital tract laceration [vagina/cervix etc], uterine rupture 
Tissue: Retained tissue (placenta) and/or membranes  
Thrombin: Previously present or acquired maternal coagulation defect. Examples of acquired defects 
include those seen in severe pre-eclampsia, severe sepsis, amniotic fluid embolism, placental abruption or in the setting of massive transfusion.                          
                                              
Management can be broken down into initial resuscitation and specific treatment, with specific treatment having surgical and non-surgical modalities. Resuscitation and treatment should occur simultaneously. 
 

Resuscitation 
ABCDE approach. Assemble team (ICU/Anaesthesia/Obstetrics etc) 
Appropriate monitoring: ECG / NIBP / Arterial line / CVC if time or indication 
Large bore IV access x2 
Initial resuscitation with crystalloids / 4% albumin 
Activation of PPH protocol 
Activation of massive transfusion protocol / Use O neg blood (but likely to know blood group already and use group specific blood) early if no X matched blood available 
No specific Hb triggers for when to use blood, suggested after no more than 30mls/kg resusc fluids or evidence of ongoing bleeding 
Other products as required: NBA Obstetric guidelines suggest FFP 15mls/kg, platelets 1 pooled bag, cryoprecipitate 3-4g (8-10 bags): use local protocols if possible and involve specialist Haematologist. Keep fibrinogen >2.0 or replace if dropping (normal in pregnancy 4-6g/L: use cryoprecipitate or fibrinogen concentrate) Emphasis on early fibrinogen 
Viscoelastic tests 
Avoid hypothermia, hypocalcaemia and acidosis 
 
Non-Surgical Treatment 
Bimanual uterine compression 
Pharmacological Therapy (uterotonics): oxytocin, misoprostol, prostaglandin F2 alpha 
Tranexamic Acid (TXA): [the WOMAN trial showed a substantial mortality benefit if given within 3 hours] 
Balloon tamponade (Bakri balloon) 
Vaginal/Uterine packing 
Interventional Radiology: selective arterial embolization/balloon tamponade Consider Factor VIIa as rescue therapy 
 
Surgical treatment 
EUA: repair of lacerations / evacuation of retained placental fragments etc
Laparotomy: Uterine or iliac artery ligation, B-lynch brace suture 
Pelvic packing 
Aortic compression / X clamp 
Hysterectomy 
      
 

Discussion

Causes of PPH

It is not possible to add much to the (already comprehensive) list of causes offered by the model answer. 

  • Uterine atony
    • Prolonged labor
    • Polyhydramnios
    • Multiple gestations
    • Chorioamnionitis
    • Oxytocin augmentation of labor
  • Peripartum uterine trauma
    • Instrumental delivery
    • Surgical mishap
    • Laceration during labour (including episiotomy)
    • Uterine rupture
  • Postpartum retained products
    • Placenta 
    • Membranes
  • Coagulopathy
    • DIC
    • Amniotic fluid embolism
    • Sepsis 
    • Intrauterine foetal demise
    • HELP
    • Massive transfusion
  • Placental abnormality
    • Placenta previa
    • Placental abruption

Management of PPH

This structure and a lot of the components are borrowed from the RANZCOG statement C-Obs 43.

Resuscitation

  • A: either secure the airway if unprotected,  or prepare to do so with appropriate expertise (i.e. get an anaesthetist)
  • B: preoxygenate with high flow oxygen
  • C: establish IV access and give a fluid bolus; avoid hypothermia and use fluid warmers
  • D: reassure patient and ensure analgesia is adequate
  • E: correct ionised calcium (essential component of clotting); corrrect acidosis
  • F: monitor fluid resuscitation efficacy by observing urine output
  • G: fast the patient in preparation for surgery
  • H: correct coagulopathy and commence transfusion
    • Activate massive transfusion protocol: the college answer to Question 17 from the second paper of 2018 mentions the National Blood Authority's obstetric guidelines, which are endoresed by CICM. The guidelines recommend:
      • FFP: 15 mL/kg
      • platelets: 1 adult therapeutic dose
      • cryoprecipitate: 3–4 g
    • Fibrinogen is all-important- the same NBA guidelines recommend a fibrinogen level of > 2.0 as a therapeutic  target
    • Tranexamic acid is also known to be beneficial (WOMAN trial -Shakur et al, 2017) - to be given within 3 hours of haemorrhage
  • I: antibiotics are not routinely indicated for primary PPH outside of the scenario of septic abortion or endometritis. 

Specific management

  • Uterine massage
  • Bimanual compression
  • Manual aortic compression
  • Oxytocin
  • Ergometrine
  • Carboprost
  • Misoprostol
  • Gause pack or balloon tamponade
  • Angioembolisation
  • Brace sutures
  • Ligation of the uterine artery
  • Hysterectomy

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).

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.

Edhi, Muhammad Muzzammil, et al. "Post partum hemorrhage: causes and management.BMC research notes6.1 (2013): 236.

Sheiner, Eyal, et al. "Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study." The Journal of Maternal-Fetal & Neonatal Medicine 18.3 (2005): 149-154.

Mousa, Hatem A., and Steven Walkinshaw. "Major postpartum haemorrhage.Current opinion in Obstetrics and Gynecology13.6 (2001): 595-603.

Mousa, Hatem A., et al. "Treatment for primary postpartum haemorrhage." Cochrane Database Syst Rev 2.2 (2014): CD003249.