PPH Algorithm
PPH Algorithm
PPH Algorithm
ALGORITHM
INCIDENCE OF PPH
• Incidence – 2 to 4% after vaginal delivery
6% after caesarean section
• Accounts for 35% of maternal deaths world wide
Loss of blood > 500ml from the genital tract post delivery of a baby.
(WHO)
Excessive per vaginal bleeding that cause haematocrit drop more
than 10% that require immediate transfusion.( ACOG )
Postpartum haemorrhage is
Loss of 500ml or more during vaginal delivery
More than 1000ml during caesarean section
Blood loss significant enough to cause hemodynamic instability
Primary postpartum haemorrhage
Bleeding which occurs during first 24 hours after delivery of
foetus.
Causes:
Atonic uterus.
Trauma "laceration or hematoma".
Haemorrhagic blood diseases.
Secondary postpartum haemorrhage
Bleeding which occurs after the first 24 hours of delivery
and up to the end of puerperium( 6 weeks postpartum)
Causes :
Infection - endometritis
Retained products of conception such as : Placental
fragments, Retained piece of membranes, Accessory lobe.
Placental polyp.
Placental site trophoblastic disease
AV malformation – pseudo aneurysm of the uterine artery
Categories of PPH
Minor PPH – blood loss of 500ml to 1000ml.
Major PPH – blood loss of more than 1000ml.
Major PPH is divided into
Moderate PPH – blood loss of 1000ml to 2000ml
Massive PPH – blood loss more than 2000ml ( loss of 30 t0 40% of
blood volume) with haemodynamic instability
Causes of PPH
T FEATURES RATE(%)
S.NO PRE EXISTING CONDITION UTERINE OVERDISTENSION,ATONY & DISORDERS OF PLACENTA, UTERINE
DIC & GENITAL TRACT TRAUMA
1 Thrombocytopenic purpura Polyhydramnios Acute uterine inversion
2 Hypertensive disease Multiple gestation LSCS
3 Uterine myoma Macrosomia Operative vaginal delivery
4 Anticoagulant therapy Induced labour Precipitate delivery
5 Coagulation factor deficiency Prolonged labour > 12hrs Previous uterine surgeries
6 Consumptive coagulopathy Chorioamnionitis Breech extraction
7 Mullerian anomalies Tocolytic agents Internal podalic version
8 Anaemia Halogenated anaesthetic agents Obstructed labour
9 Age > 40 years High parity Malpresentation
10 BMI > 35 Abruption /couvellaire uterus Subinvolution
E Establish aetiology, Ensure ABC, Ensure availability of blood and Ecbolics that contract the uterus
Dilutional coagulopathy
Myocardial ischaemia
Postpartum depression
TEG
ROTEM
Recombinant Factor VIIa
Indications
• In cases of intractable PPH with no other obvious indications for
hysterectomy
• When no blood is available
• In patients with acquired Haemophilia
• Jehovah witness – do not accept blood or blood component
transfusion
-Nigerian medical Journal
Mechanism of action
• Tissue factor (TF)/FVIIa, or TF/rFVIIa interaction, is necessary to
initiate hemostasis.
• At pharmacological concentrations, rFVIIa directly activates FX on the
surface of locally activated platelets.
• This activation will initiate the ‘thrombin burst’ independently of FVIII
and FIX. This step is independent of TF.
• The thrombin burst leads to the formation of a stable clot
Prerequisite for administration
• Hb >7gms/dl
• INR <1.5
• Platelet count is >50x109/l
• Fibrinogen >1 gm/l
• pH>7.2
• Temperature >340C.
Dose
• The recommended initial dose of rFVIIa for treatment of severe
postpartum hemorrhage is ~40–60 µg/kg administered intravenously.
• If bleeding still continuous beyond 15–30 min, following the first dose of
rFVIIa, an additional dose of ~40–60 µg/kg should be considered.
• Repeat 3–4 times at 15–30-min intervals if clinical signs of bleeding are
still present (based on visual evidence).
• If the response remains inadequate following a total dose of >200 µg/kg,
the preconditions for rFVIIa administration should be re-checked, and
corrected as necessary before another dose is considered.
• Only after these corrective measures have been applied should the next
dose of rFVIIa ~100 µg/kg be administered.
Side effects
• most common being pain at the infusion site, fever, headache,
vomiting, changes in the blood pressure and skin-related
hypersensitivity reactions.
• Thrombo- embolic events
Topical application of recombinant activated factor VII during cesarean
delivery for placenta previa
in patients with placenta previa, topical
recombinant activated factor VII may diminish bleeding from the
placenta site without initiation of systemic coagulation.
- AJOG , June , 2017
Thrombo elastography ( TEG )
provides a qualitative assessment of hemostasis in
a patient’s whole blood by testing both platelet
function and coagulation by assaying several
parameters of clot formation within whole blood.
The test is rapid and can be done at the bedside.
help guide the resuscitator in which factor
products are most needed to avoid DIC.
Helps in goal – directed transfusion approaches
rather than in fixed ratios.
Rotational Thrombo elastometry ( ROTEM )
provides the same results as
TEG
however the mechanism at
which it arrives at those
results differs slightly
In TEG, a pin rotates within a
cup, however in ROTEM, the
cup rotates around a
stationary pin.