Prevention and Treatment of Postpartum Haemorrhage

Prevention and Treatment of Postpartum Haemorrhage


This is a presentation on prevention and treatment of postpartum haemorrhage or, in short, PPH. The outline of the following presentation is as such. First, we’ll go on to the introduction of PPH, which is the definition, the epidemiology and etiology, followed by the management of PPH. And we’ll go through the prevention, the treatment, and the rescue measures in PPH. We can define postpartum haemorrhage as blood loss following delivery. In terms of vaginal delivery, any blood loss more than 500 mils is considered PPH, and for Cesarean delivery more than 1,000 mils is considered PPH. PPH can be divided into primary or secondary. Primary is defined as early onset, within the first 24 hours of delivery. And secondary can be defined as late, after 24 hours to 12 weeks postpartum. [INAUDIBLE] has a separate guideline or definition of PPH. Minor PPH is defined as blood loss between 500 to 1000 mils. Major PPH can be further divided into moderate, between 1000 and 2000 mils of blood loss, and severe PPH can be divided– can be defined as more than 2000 mils of blood loss. A separate guideline of the definition of PPH can be using hemoglobin levels, when there’s a 10% decline from the antepartum levels. Now let’s go on to epidemiology and etiology of PPH. The epidemiology of PPH is related to the management of the third stage of labor. As we can see, in industrialized countries, the prevalence rates for the following PPH is– we can– is seen here. For PPH that’s more than 500 mils, active management of PPH, there is a prevalence rate of around 5%, whereas if there is expectant management, 13% of PPH happens. And for PPH that’s more than 1000 mils, active management prevalence rates is around 1%, and for expectant management the prevalence rate is around 3%. In most cases of PPH, [INAUDIBLE] identifiable risk factors. In terms of the etiology of PPH, we can remember PPH by the mnemonic “4 T’s.” Most common of all is the tone, where uterine atony is the most common cause of PPH. Tissue, for example retained products of conception, for example placenta retained in the uterus, can also be a cause of PPH. The third cause of PPH can be trauma due to any lacerations in the uterus, in the cervix, or in the vaginal canal, or hematomas following episiotomy repairs. The last cause of PPH can be due to thrombosis. Sometimes, it may be due to DIBC or coagulopathic issues. Now we go on to prevention of PPH. The active management of third stage of labor is pertinent and integral to prevention of PPH. The first line of defense is, of course, the medical prophylaxis. And here we can see that there are three main types of medication we can use. First of all, we have oxytocin and carbetocin. Secondly, we have ergometrine and oxytocin plus ergometrine. Lastly, we have a prostaglandin, in this case, misoprostol. And there’s also non-medical management in terms of prevention of PPH. We can firstly use controlled cord traction. And we can also use early clamping. For medical prophylaxis, our first line– our first type of medical prophylaxis is oxytocin and carbetocin. And oxytocin is recommended by WHO, NICE, and FIGO. It may be given intramuscularly in 10 units, or intravascularly 10 units over one to two hours. Carbetocin is a longer-acting form of prophylaxis, and is now under comparison study. The second type of prophylaxis, ergometrine and oxytocin plus ergometrine. The use of ergometrine gives more sustained contractions as compared to oxytocin, which is more intermittent. However, there is a poorer side effect profile, such as an increase in hypertension, and also vomiting and nausea. And also, there is increase in retained placenta when administered intravascularly. The role is more dominant in treatment rather than prophylaxis for this medicine. The last type of medication for prophylaxis is misoprostol, given in 600 micrograms. This is available orally. It is, however, not as effective as oxytocin, and may be given when the oxytocin is unavailable. For example, in a home setting, which I’ll elaborate later on in the presentation. For non-medical management, we have the first type, which is the controlled cord traction. This gives no significant difference for severe PPH in a WHO trial, where there is a large number of patients being studied. It may decrease the incidence of minor PPH, and decrease the length of the stage of labor, thereby preventing retained products of conception, such as placenta. Last but not least, we have early clamping, which has been found not to have any effect on PPH rates and the timing of the placenta delivery. Delayed clamping reduces neonatal anemia, but causes hyperbilirubinaemia. Now we go on to treatment of PPH. The first line of treatment and management of atonic PPH is oxytocin. There is, however, no randomized trial at the moment to demonstrate the efficacy of oxytocin against placebo. It is now recommended by WHO on the basis of prophylactic use. Second-line management for treatment of PPH is ergometrine and/or oxytocin. The second type of medication that we can use here is any prostaglandin. And in this paper, it’s been cited that there is the use of misoprostol. However, the paper fails to mention that other forms of prostaglandins can be used, such as [INAUDIBLE]. Firstly, let’s talk about misoprostol. We see that there is little benefit in stocking misoprostol if the unit uses oxytocin. There is a paper demonstrated by Widmer and all, and this shows that there is no benefit for combined misoprostol oxytocin compared to oxytocin alone. Another paper that has demonstrated that oxytocin is more effective than misoprostol for PPH, if only patient has not been given oxytocin prophylactically. Compared to a high dose of oxytocin or misoprostol, there is less additional blood loss in oxytocin group as compared to the misoprostol group, thereby showing that oxytocin is by far a better choice in terms of treatment of PPH as compared to misoprostol. Other forms of treatment of PPH medically is the use of tranexamic acid. This is a non-obstetric surgical study, and it has demonstrated efficacy in reducing blood loss. A large randomized study is now ongoing to examine its role in PPH management. And this is the WOMAN trial. And it will be interesting to note the results of this trial. The last type of medicine that we are talking about here is ergometrine. However, there is minimal evidence for use in PPH, although it is recommended guidelines due to the demonstrated the efficacy in prophylaxis trials. Now let’s go on to the non-surgical, physical form of treatment for PPH. We have firstly the compression through the abdominal wall. And recent randomised trials have suggested that there is benefit for prophylaxis and treatment of PPH through such methods. Uterine compression through bimanual compression is written as a last resort in the paper due to the invasive nature and gender-based violence overtones that the paper has tried to portray and put across. However, we note that uterine compression through bimanual compression is a standard form of treatment in our current local settings if there is indeed a need for treatment of PPH using physical methods. A new form of PPH shelf is developing in the United Kingdom in Liverpool. It’s currently ongoing. And this is more for the usage of home and emergency cases where there is no trained professionals around to conduct other physical interventions, such as bimanual compressions. The last form of physical intervention is the aortic compression. It is effective, but uncomfortable. And the role for women with heavy bleeding awaiting removal of placenta is indicated for aortic compression. However, we know that, for women who have a larger girth, it will be much less effective and more difficult to enact in such situations. The last treatment of PPH is talking about surgical interventions. So commonly, and importantly, we know that there is uterine compression sutures, such as the B-Lynch sutures or the Haymann sutures. And this is used for PPH treatment at the time of Cesarean or laparotomy. Second type of surgical treatment is the use of internal tamponade. For example, we can use a packing with gauze, or we can use balloon catheters such as the Bakri balloon or, in low-resource centers, the use of Foley catheters plus condoms can be used as a tamponade within the uterus to attempt to stop the bleeding. However, packing with gauze is not used locally, as it’s related to inflammation and infection. The last set of treatment of PPH through surgical interventions is the use of complex procedures such as mass ligations of arteries and internal iliac artery ligation, hysterectomy, which is used as a last resort when all else methods have failed. Now we go on to talk about the rescue of women with severe PPH. This is used more likely in the event of– and in the locations where there are low resources and help with tertiary centers with modern equipment is far away. We know that 26% of PPH is as a result of blood loss, and therefore blood transfusion is definitely required when severe PPH happens. But in low-resource centers, we find that there is difficulty in getting sufficient blood products to enable the treatment of PPH in such women. The second type of measures for low-resource centers is a use of non-pneumatic anti-shock garment for transfer. This neoprene garment is wrapped around the legs and abdomen, allowing a translocation of blood up to 30% of total blood volume from the periphery and the lower limbs into central circulation. And this is therefore a temporising measure between transporting the patient from the low-resource center to a tertiary center where appropriate care is available. Now we go on to the current issues regarding PPH that is written in the paper. First, we talk about the blood loss assessment. Generally speaking, in major cluster– in a major cluster randomized control trial, there is a finding that accurate blood loss assessment did not reduce the total blood loss or improve adverse outcomes. And more research has to be done to treat based on physiological response, such as shock index or symptoms. And these may be more appropriate than having accurate blood loss assessment. However, we know that, in our current local setting, accurate blood loss assessments is still integral to the treatment and management of PPH. This is because, by the time the patient presents with physiological responses, such as clinical shock of tachycardia and hypertension, it may be too late for the patient, and more extreme interventions may have to be enacted at a point in time. Next, we talk about importance of oxytocics in death prevention from PPH. We realize that prophylactic oxytocics may not translate into reductions in death. It is definitely important in the reduction of PPH itself. However, the treatment of oxytocics does not benefit all women with PPH. This is because PPH, as we note previously, the etiology of PPH does not only include uterine [INAUDIBLE], even though it is the most common. Other causes, such as uterine ruptures, placenta previas, and lacerations and hematomas may come into play, and oxytocics in such situations and cases may not be helpful, and therefore the over-reliance of oxytocics should be avoided. Concurrent treatment should benefit the patient more in controlling the bleeding. And we are talking about here, in this case, blood transfusions, the use of other medications, such as prostaglandins, and such as other bimanual compressions and surgical methods. The third issue here we are trying to tackle is the delivering of prophylaxis for unintended home deliveries. Misoprostol has been found to be safe for self-administration after delivery in some trials. This is because of the usage of the misoprostol. It can be done orally, as compared to oxytocin, which has to be stored in a low temperature in the fridge, and has to be given intramuscularly or intravascularly. However, the issue of scaling up is still up for debate, because we have not been able to show that there is safe usage of and safe management of the unused tablets. And also patient education has not been found to be easy in terms of trying to educate a patient on how to use misoprostol in a safe manner. Last but not least, in terms of delivering emergency care when there is severe bleeding outside of a health care setting, currently there is the use of PPH Shelf, which is being delivered in the United Kingdom in Liverpool, which is based on a shelf pessary commonly used in uterine prolapsis. By inserting the pessary, it provides us a platform against the uterus for compression. This removes the need for inserting a fist or hand into the patient’s vagina, which may be too invasive for a layman to enact and do outside of health care setting. The use of pessary is also simple and reusable. It is also a therapeutic and diagnostic tool at the same time. Because if the bleeding does not stop after the use of the pessary, we know that the bleeding is most likely not within the uterine cavity itself. It may be due to lacerations along the vagina, or hematoma. That is the end of presentation.

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