Peripartum haemorrhage

Definition

Bleeding in human childbirth

Vaginal delivery: ˂ 500 ml

Caesarean section: ˂1000 ml

2017 - revision of the definition of PPH

blood loss > 500 ml vaginal delivery

blood loss >1 000 ml Caesarean section

change in vital functions
- heart rate >15% ≥110 bpm,
- blood pressure ≤ 85/45 mmHg,
- saturation < 95%

There is strength in simplicity…

An acute, life-threatening condition

Peripartum haemorrhage – definition Czech Republic

According to the amount of blood loss:

minor blood loss (500 – 1 000 ml)
severe blood loss (> 1 000 ml)
life-threatening peripartum hemorrhage (LTPPH) (> 1 500 ml)
(clinical and/or laboratory signs of tissue hypoperfusion)

Incidence 7-8%

The incidence of LTPPH/PPH varies greatly depending on the criteria used to diagnose the pathology.
Estimate: 1 - 5% of births
Sheldon WR, Blum J, Vogel JP, et al. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG 2014; 121 Suppl 1:5.
Reale SC, Easter SR, Xu X, et al. Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesth Analg 2020; 130:e119.

Prospective study: 10% of births
Deneux-Tharaux C, Bonnet MP, Tort J. [Epidemiologie poporodního krvácení ]. J Gynecol Obstet Biol Reprod (Paříž) 2014; 43: 936.

Physiology of postpartum haemostasis

Woman

pregnant woman
2nd half of pregnancy

Haemostasis mechanism
=
combination of two factors

Mechanical haemostasis

retraction of the myometrium → compression = tourniquet of the vascular system of the uterus

Coagulation haemostasis

decidual/tissue factors
plasminogen activator type 1 inhibitor
systemic coagulation factors (circulating haemostasis factors, platelets, etc.)
Pathogenesis of most cases of PPH = disruption of one or both mechanisms.
Pathogenesis of other cases of PPH is loss of intact vasculature (i.e. trauma).

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LTPPH DIC

95% 5%

Physiology of retraction-tourniquet myometrium

perfusion
oxygenation
energy reserves
receptor readiness

Risk factors Specific etiology

Study (690,000 births): 4 risk factors associated with the highest probability of
predicting
the need for massive blood transfusion (n = 406) during hospitalization for
delivery
Mhyre JM, Shilkrut A, Kuklina EV, et al. Massive blood transfusion during hospitalization for delivery in New
York State, 1998-2007. Obstet Gynecol 2013; 122:1288.

abnormal placentation (pl. accreta or previa) (1.6/10,000 births, OR 18.5, 95% CI 14.7-23.3)
placental abruption (1.0/10,000 births, OR 14.6, 95% CI 11.2-19.0)
severe preeclampsia (0.8/10,000 births, OR 10.4, 95% CI 7.7–14.2)
intrauterine fetal death (0.7/10,000 births, OR 5.5, 95% CI 3.9–7.8)

Other risk factors for PPH

personal or family history of previous PPH, obesity, multiparity, Asian or Hispanic race, precipitous delivery, excessive uterine distention (e.g. multiple pregnancy, polyhydramnios, fetal macrosomia), chorioamnionitis, uterine inversion, uterine fibroids, Couvelair uterus, inherited bleeding diathesis, acquired bleeding diathesis (e.g. amniotic fluid embolism, abruptio placentae, sepsis, fetal death), assisted reproduction technology, anaemia and the use of certain drugs: muscle relaxants, antithrombotics.
ANTIDEPRESSANTS, especially selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) - ANAEMIA

Preventive measures

Recommendation
We recommend treatment of antenatal anaemia. Pregnant women should be given iron preparations if their hemoglobin level falls below 110g/l in the first trimester or below 105g/l in the 28th week of pregnancy.

Recommendation
We suggest considering parenteral iron in women with sideropenic anaemia unresponsive to oral iron supplementation.
Life-threatening peripartum haemorrhage

Anamnesis

Risk factors 40%

multiple pregnancy
preeclampsia/gestational hypertension
placenta praevia
suspected premature separation of the placenta
suspected amniotic fluid embolism

Life-threatening peripartum haemorrhage in previous childbirth
Asians
Obesity (BMI > 35)
Anaemia (< 9g/ml)

Acute Caesarean section
Induction of labour
Placenta adhaerens
Operative vaginal delivery
Prolonged labour (> 12 hours)
Large fetus (> 4 kg)
Fever during labour
Morther's age (> 40 years)

Risk Factors 60%

Preventive measures

Recommendation
Women with risk factors for life-threatening PPH should give birth in medical facilities appropriately staffed and materially equipped to deal with life-threatening PPH.

Recommendation
For patients with a high risk of PCOS (abnormal placentation), we recommend formulating a care plan with the participation of a multidisciplinary team in a reasonable time before delivery.

Bleeding in human childbirth

Before delivery - DIC, Life-threatening PPH

placental abruption
amnioticfluid embolism
endo/myometritis
preeclampsia/HELLP

During delivery - Life-threatening PPH, DIC

in III. stage of labour (delivery of the placenta)
during the operation

After delivery - Life-threatening PPH

hysterotomy

4 T

Disorders of uterine Tonus 70 – 80%

postpartum uterine hypo-/atony
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Birth Trauma 10 – 15%

laceration of the cervix, vagina, perineum
pelvic haematomas
uterine rupture, intraoperative complications
inversion of the uterus

Trauma related to bleeding
= tissue laceration (including uterine rupture) or surgical incisions.

Lacerations/ruptures of the cervix and vagina will be caused by

fetus – passage through the birth canal
assistance - intervention during childbirth

Lacerations/ruptures

obvious
hidden (haematomas of the vulva, paracolpia, retroperitoneum)

Tissue pathology 1 – 5%

placenta adherens, placenta accreta

Coagulopathy (Thrombin) 1 – 5%

DIC early (amniotic fluid embolism, abruption!!!)

Coagulopathy (Thrombin)

about 1 in 500 births in the U.S.
- < 7% of PPH cases (placental abruption, amniotic fluid embolism)
  Reale SC, Easter SR, Xu X, et al. Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesth Analg 2020; 130:e119.
- Congenital coagulopathies
  von Willebrand disease = high risk of PPH
  - von Willebrand factor level during pregnancy ↑, after delivery ↓↓↓
- Acutely acquired coagulopathy
  - amniotic fluid embolism
  - placental abruption
  - severe preeclampsia
HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)
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Causes of PPH
Disorders of uterine tonus 70 – 80%

postpartum uterine hypo-/atony

Delivery trauma 10 – 15%

laceration of the cervix, vagina, perineum
pelvic haematomas
uterine rupture, intraoperative complications
uterus inversion

Tissue pathology 1 – 5%

placenta adherens, placenta accreta

Coagulopathy 1 – 5%

DIC early (amniotic fluid embolism, abruption!!!)

Clinical note:
During pregnancy, a woman's blood volume increases physiologically, where at the end of pregnancy the increase is up to 40% of the original volume.

Initial symptoms of a haemorrhagic shock are therefore less pronounced during pregnancy.
As long as the blood loss does not exceed 1000 ml, the systemic pressure and the heart rate of the pregnant/partum/six-weeks-postpartum woman are maintained within the physiological range.

Causes of non-standard care for a woman with PPH

delayed diagnosis
delayed treatment due to underestimated blood loss
delayed preparation of blood products and coagulation factors
lack of management protocols
insufficient professional training of personnel
poor communication between the interdisciplinary team
deficiencies in organization and delays in initiation of treatment

Reduction of maternal mortality and morbidity

timely identification of PPH
timely and correct diagnosis of the cause of bleeding
rapid intervention/treatment of PPH

High risk of excessive bleeding during delivery

III. stage of labour = myometrial perfusion 600 ml/min. about 15% of the mother's cardiac output
Haemostasis = after delivery of the placenta

Life-threatening peripartum bleeding

When? = start (time)

Where? = localization

How? = amount

Management of life threatening
peripartum haemorrhage – applies !!!

rapid anti-shock measures
rapid surgical treatment
.rapid intensivist treatment = substitution of blood factors

Real time

collection time
time required for transport to the laboratory
material processing
result available…..???

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We recommend monitoring coagulation and the initiation of measures to adjust coagulations as soon as possible
after identifying the condition of life-threatening PPH.

To identify the type of coagulation disorder in life-threatening PPH we recommend using viscoelastometric methods (TEG, ROTEM), if available.

Recommendation

We recommend fibrinogen substitution in patients with life-threatening PPH when its level drops below 2 g/l and/or when its functional deficit is detected by viscoelastometric methods or when there is a justified clinical assumption of fibrinogen deficiency even without knowledge of its levels.
As a minimum initial dose for life-threatening PPH, we recommend the administration of an initial dose of at least 3 g (4 g) of fibrinogen or the equivalent of this dose when using transfusion preparations with increased fibrinogen content.

Recommendation

We recommend prophylactic administration of uterotonics in III. stage of labour immediately after the birth of the child before ligation of the umbilical cord. The drug of first choice is oxytocin.

Recommendation

We suggest considering the administration of carbetocin in women with an increased risk of life-threatening PPH.

Recommendation

For women with an increased risk of life-threatening PPH undergoing Caesarean section, we suggest considering a single administration of tranexamic acid (TXA) along with carbetocin.

Midwife

statim mask for oxygen supply
IV securing with a strong cannula
permanent urinary catheter

Doctor

ANAMNESIS - informed by the midwife

inquiry about the suspected cause of bleeding
blood loss estimation query
Monitoring of BP, P, saturation
BP falls and heart rate rises

Identifying the source of bleeding:

examination in mirrors
palpation bimanual examination
ultrasound examination

Differential diagnostics

uterine hypotonia/atony
retention of the placenta
retention of part of the placenta
uterine rupture/dehiscence
uterus inversion
birth canal injury
DIC (PLT, APTT, PT, fibrinogen, D-dimers, antithrombin)
primarily haematological disorder

The doctor checks the previous procedures:

assessment and provision of basic life functions
initiation of monitoring of basic vital functions
initiation of oxygen therapy
ensuring/controlling entry into the bloodstream
initiation of fluid replacement/fluid resuscitation
IV administration of uterotonics

He will recommend an initial laboratory examination:

blood count
basic coagulation examination (aPTT, PT)
fibrinogen level
pre-transfusion examination (blood group, screening for irregular antibodies against erythrocytes, compatibility test)
orientation test of blood clotting with thrombin

Initial requirements for transfusion products:

plasma (in the initial phase of ensuring the availability of at least 4 transfusion units)
erythrocytes (in the initial phase of ensuring the availability of at least 4 transfusion units)

Uterine hypotonia/atony

Step 1

uterine massage
uterotonics
1. oxytocin, better carbetocin
2. methylergometrine
prostaglandins
digital or instrumental revision of the uterine cavity

In case of failure - Step 2

removal of coagulum
uterotonics
Bakri balloon catheter, (eventual vaginal tamponade)

In case of failure, immediately - Step 3.

surgical intervention (gradual devascularization of the uterus)

- ligation aa. uterinae and aa. ovaricae

- B-Lynch uterine suture

- ligation aa. iliacae internae

2. selective catheter embolization aa. uterinae (if interventional radiology is available)

3. consideration of administration of recombinant activated factor VII (NovoSeven®)

Coagulation support
General principles

Basic initial procedures to restore the effectiveness of the body‘s
hemostatic mechanisms and to support coagulation:

maximum possible correction of hypothermia
maximum possible correction of acidosis
correction of hypocalcemia
correction of other system homeostasis parameters

- fibrinogen

- tranexamic acid

Ensuring/control of entry into circulation (insertion of at least 2 peripheral catheters with the largest possible diameter is recommended)

Initiate/continue fluid resuscitation (crystalloids and/or colloids)

crystalloids, balanced solutions are preferred, the usual starting dose is approx. 2000 ml
colloids, usual starting dose 500-1000 ml

Medicines and their dosage

Oxytocin (Oxytocin®)
Initiation of treatment: 10 IU i.m. and 20-40 IU in 1000 ml infusion solution, rate: 60 drops/min,
further: 20 IU in 1000 ml of infusion solution.
Rate: 40 drops/min, until bleeding stops.

Carbetocin (Duratocin®)
Replacement of oxytocin infusion 100 μg IV (administration time 1 minute)

Methylergometrine
Initiation of treatment: 0.2 mg i.m. or slowly i.v.
further: after 15 minutes, repeat administration of 0.2 mg methylergometrine i.m. r: 0.2 mg i.m. or slowly i.v. every 4 hours, do not exceed a dose of 1 mg (five doses of 0.2 mg)

Tranexamic acid (Exacyl®)

Initial dose 1 g in 10 minutes,
further: continue infusion at a dose of 1 g during 8 hours.
An alternative is a dosage of 20-25 mg/kg.

Fibrinogen'

The administration of fibrinogen is recommended for life-threatening PPH when its concentration drops below 2 g/l i.v.
Initial dose: for life-threatening PPH, 3 – 4 g i.v. is recommended.

Prostaglandins F2α

If bleeding continues even after administration of oxytocin, carbetocin, or ergometrine, prostaglandins are in order.

Dinoprost (Enzaprost F®)
5 mg in 500 ml of infusion solution, rate: 5 ml/min (= 300 ml/h) do not exceed a dose of 20 mg, if there is no response, give carboprost (Prostin 15M®).

Carboprost (Prostin 15M®)

Initiation of treatment: 0.25 mg i.m. alternatively intramyometrially,
further: as needed every 15 minutes 0.25 mg i.m., do not exceed a dose of 2 mg (eight doses of 0.25 mg).

Erythrocytes

the target hemoglobin value is recommended to be at least 70 g/l (significant anaemia reduces the effectiveness of haemostasis mechanisms)
recommended ratio of the number of TU erythrocytes and plasma is 1:1 to 1.5:1

Plasma

administration of plasma is recommended for clinical signs of bleeding and prolongation of PT and/or aPTT to 1.5 times normal values or more
the recommended minimum initial dose of plasma for life-threatening PPH is 15-20 ml/kg

Platelets

administration of platelets is recommended for life-threatening PPH when the number of platelets drops below 70 x 109/l

The role of interventional radiology

In all cases of peripartum life-threatening bleeding due to hypotony or atony of the uterus, we recommend using radiological interventional methods (selective embolization of the uterine arteries), if available, when the usual standard surgical procedures fail (or are impossible to perform) in the workplace.

Morbidity and mortality

Mortality of PPH approx. 2% (large differences worldwide)

0.6% Great Britain
20% in some parts of Afric

Transfusion Women Trial (study of approx. 20,000 women)

54% blood transfusion

Risks of transfusion infection, abnormalities of
electrolytes, allergic reactions, alloimmunization

Hysterectomy (Women Trial)

3.5% of women hysterectomies postpartum for PPH
USA 2014 hysterectomy 2.1% of women with PPH(atony 60%
Czech Republic

Thromboembolism (Women Trial)

0.3% of women with PPH have a thromboembolic event within 42 days after birth.

Haemodynamic instability and organ failure (Women Trial)

4% kidney, heart, respiratory, liver failure

Sheehan syndrome

postpartum hypopituitarism rare but potentially life-threatening complications

Abdominal compartment syndrome

organ dysfunction caused by intra-abdominal hypertension is a rare but life-threatening complication of PPH with intra-abdominal bleeding

Asherman syndrome

up to 90% of cases of severe intrauterine adhesions is related to revision/curettage of the uterus

Postpartum anaemia

postpartum anaemia is commo

Recurrence

Women with previous PPH have up to an 18% risk of recurrence in subsequent pregnancy.
Oberg AS, Hernandez-Diaz S, Palmsten K, et al. Patterns of recurrence of postpartum hemorrhage in a large population- based cohort. Am J Obstet Gynecol 2014; 210:229.e1.
Ford JB, Roberts CL, Bell JC, et al. Postpartum haemorrhage occurrence and recurrence: a population-based study. Med J Aust 2007; 187:391.
Ruiter L, Kazemier BM, Mol BWJ, Pajkrt E. Incidence and recurrence rate of postpartum hemorrhage and manual removal of the placenta: A longitudinal linked national cohort study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 2019; 238:114.