Management of massive postpartum haemorrhage and coagulopathy

Postpartum haemorrhage (PPH) continues to remain the leading cause of maternal morbidity and mortality worldwide. Whilst this is especially true in resource limited countries, it also remains a significant problem in developed countries. The traditional definition of primary PPH is blood loss from the genital tract of 500 ml or more within 24 h of delivery (or >1000 ml during caesarean section). Secondary PPH refers to an excessive blood loss between 24 h and 6 weeks, postnatally. Massive PPH refers to a blood loss of over 2000 ml (or >30% of blood volume) and hence, is an obstetric emergency that requires a systematic, multi-disciplinary approach to restore the volume, clotting system and the oxygen carrying capacity of blood, whilst steps are taken to arrest bleeding as quickly as possible.The last confidential enquiry into maternal deaths (CEMACH, 2003–2005) in the UK cited ‘haemorrhage’ as the third highest cause of direct maternal deaths with 6.6 deaths per million maternities. This report found that 58% of these deaths may have been preventable and ‘too little being done, too late’ (failure to appreciate clinical picture, delay in instituting appropriate treatment, delay is summoning senior help and system failures) continues to contribute to maternal morbidity and mortality, even in the developed world.Massive obstetric haemorrhage may occur in the antepartum (placenta praevia, placental abruption and placenta accreta) or postpartum period. It is has been observed that the incidence of massive PPH is likely to be increasing due to the increased incidence of risk factors such as morbidly adherent placenta secondary to previous caesarean sections and maternal obesity. However, massive obstetric haemorrhage and the resultant coagulopathy can occur in women deemed to be at ‘low risk’ and hence, all clinicians managing women during pregnancy and labour need to possess knowledge and skills to recognize symptoms, signs and complications of massive obstetric haemorrhage. This may ensure institution of timely and appropriate treatment that could save lives.     

Post-partum haemorrhage

Obstetric haemorrhage accounts for 25% of maternal deaths in developing countries and post-partum haemorrhage (PPH) is the most common type. It accounts for 10.6% of all direct maternal deaths in the UK and, according to the recent Confidential Enquiries into Maternal and Child Health report, it is the third most common cause of maternal mortality. The enquiry concluded that a number of these deaths were avoidable and highlighted ‘doing too little too late’.Failure to assess the clinical picture, underestimating blood loss, delayed treatment, lack of multidisciplinary team work and failure to seek timely senior help are some of the issues highlighted. Clinicians should be aware of appropriate surgical measures and the timing of interventions. Effective team work, pooling of resources and the presence of a ‘rapid PPH response teams’ can improve outcome.     

Postpartum haemorrhage and haematological management

Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality around the world. In the UK, the Centre for Maternal and Child Enquiries (CMACE) confirmed a reduction in maternal deaths due to postpartum haemorrhage during the last Triennium (2006–2008). However, substandard care continues to contribute to more than half of maternal deaths due to postpartum haemorrhage.     

Medical and Conservative Surgical Management of Postpartum Hemorrhage

Massive postpartum hemorrhage (PPH) is a major cause of maternal mortality in the United Kingdom and worldwide. Life-threatening PPH occurs with a frequency of I in 1000 deliveries in the developed world. In the latest triennial Why Mothers Die: Confidential Enquiries into Maternal Deaths in the United Kingdom (1997–1999), PPH was the fifth most common cause of maternal mortality. In this review, we discuss the role of medical management in primary PPH and the use of the “tamponade test” when such management fails. The less radical surgical options discussed include uterine compression sutures, uterine or internal iliac artery ligation, and arterial embolization, all of which have the advantage of potentially preserving reproductive function. Radical surgical options, including subtotal or total hysterectomy, are not discussed in this review. A systematic or algorithmic method of tackling the problem is described. The suggested management approach is likely to reduce maternal morbidity from bleeding, hysterectomies, and maternal deaths.     

Massive postpartum haemorrhage and management of coagulopathy

Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality in both the developed and developing world. By definition, PPH refers to a blood loss of>500 ml (or>1000 ml during a caesarean section) after the delivery of the fetus. However, this is an arbitrary value as women who are ‘small made’ (low blood volume) or anaemic may not tolerate even a blood loss of 500 ml. Massive PPH refers to the loss of 30–40% (generally>2 L) of the patient's blood volume, resulting in changes in the haemodynamic parameters which lead to moderate or severe shock. Consequences of such massive blood loss include sudden and rapid cardiovascular decompensation and coagulopathy, as well as iatrogenic complications of fluid replacement and multiple blood transfusions (pulmonary oedema, transfusion reactions and adult respiratory distress syndrome).     

Antepartum haemorrhage

Antepartum haemorrhage (APH) is defined as bleeding from or into the genital tract occurring between 24+0 weeks' gestation until birth and seen in 3–5% of pregnancies. Moreover, up to 20% of preterm deliveries are associated with APH. In the UK, the 2013–1015 report of the UK Confidential Enquiries into Maternal Deaths showed that whilst maternal mortality remained stable, there was a non-significant rise in deaths due to haemorrhage. APH can be caused by a range of pathologies and due its high prevalence and strong association with maternal mortality, maternal and perinatal morbidity, a thorough understanding of APH is essential for the practising obstetrician. The objective of this review is to define the most common causes of APH (placenta praevia, placental abruption and local causes), together with its management.     

Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions

OBJECTIVES: Following the results of the Confidential Enquiries into Maternal Deaths report, which claims two maternal deaths annually in the UK from postpartum haemorrhage, our aim was to assess the accuracy of 'visual estimation of blood loss' and produce suitable pictorial and written algorithms to aid in the recognition and management of massive obstetric haemorrhage. DESIGN: Observational study to determine discrepancy between actual blood loss (ABL) and estimated blood loss (EBL). SETTING: Teaching hospital. POPULATION: Hundred and three obstetricians, anaesthetists, midwives, nurses and healthcare assistants. METHODS: Clinical scenarios were reproduced in the form of 12 Objective Structured Clinical Examination (OSCE) style stations augmented with known volumes of whole blood. Individual staff estimated the blood loss visually and recorded their results. Digital photographs were used to produce a pictorial 'algorithm' suitable for use as a teaching tool in labour ward. MAIN OUTCOME MEASURES: Areas of greatest discrepancy between EBL and ABL. RESULTS: Significant underestimation of the ABL occurred in 5 of the 12 OSCE stations: 500-ml (50-cm diameter) floor spill, 1000-ml (75-cm diameter) floor spill, 1500-ml (100-cm diameter) floor spill, 350-ml capacity of soaked 45- x 45-cm large swab and the 2-l vaginal postpartum haemorrhage on bed/floor. CONCLUSIONS: Accurate visual estimation of blood loss is known to facilitate timely resuscitation, minimising the risk of disseminated intravascular coagulation and reducing the severity of haemorrhagic shock. Participation in clinical reconstructions may encourage early diagnosis and prompt treatment of postpartum haemorrhage. Written and pictorial guidelines may help all staff working in labour wards.     

Surgical management of severe postpartum haemorrhage

In the UK maternal deaths as a result of postpartum haemorrhage (PPH) numbered 1 in 60 000 births in the 1970s, falling to 1 in 200 000 births in the 1990s. However, in developing countries this figure may be as high as 1 in 2000–5000 births. The morbidity is 50 times more common than in developed countries. The improved figures from England and Wales are largely due to prophylactic use of oxytocics in the management of the third stage of labour and is similar to the figures of other developed countries. Confidential enquiries in the developed countries point to avoidable factors. Replacement of blood that is ‘too little and too late’ and ‘delay to initiate and perform definitive surgery’ when there is severe PPH that does not respond to medical management have been highlighted. The role of surgery and various surgical methods in the management of severe PPH is discussed.     

Postpartum hemorrhage--update on problems of definitions and diagnosis

Maternal mortality due to postpartum hemorrhage (PPH) continues to be one of the most important causes of maternal death worldwide. PPH is a significantly underestimated obstetric problem, primarily because a lack of definition and diagnosis. The 'traditional' definition of primary PPH based on quantification of blood loss has several limitations. Notoriously, blood loss is not measured or is significantly underestimated by visual estimation and there are no generally accepted cut-offs limits for estimated blood loss. A definition based on hematocrit change is not clinically useful in an emergency such as PPH, as a fall in hematocrit postpartum shows poor correlation with acute blood loss. The need for erythrocyte transfusion alone to define PPH is also of limited value, as the practice of blood transfusion varies widely. Definitions based on symptoms of hemodynamic instability are problematic, as they are late signs of depleted blood volume and commencing failure of compensatory mechanisms threatening the mother's life. There is thus currently no single, satisfactory definition of primary PPH. Proper and timely diagnosis of PPH should above all include accurate estimation of blood loss before vital signs change. Estimation of blood loss by calibrated bags has been shown to be significantly more accurate than visual estimation at vaginal delivery. Careful monitoring of the mother's vital signs, laboratory tests, in particular coagulation testing, and immediate diagnosis of the cause of PPH are important key factors to reduce maternal morbidity and mortality.     

The surgical management of post-partum haemorrhage

Life-threatening post-partum haemorrhage (PPH) occurs with a frequency of 1 per 1000 deliveries in the developed world. In the 1994-1996 Triennial Confidential Enquiry into Maternal Deaths in the United Kingdom primary PPH was responsible for five deaths. In this chapter we discuss briefly the assessment and initial medical management of the patient with primary PPH but concentrate on the surgical management where medical treatment has failed. The surgical management discussed includes both traditional or long-established management strategies together with newer, less radical surgical options, such as embolization techniques, uterine compression sutures and methods involving uterine tamponade, which are less hazardous to perform and have the advantage of preserving reproductive function. The recommendations of the reports from the Confidential Enquiries into Maternal Deaths in the UK are summarized at the end of the chapter.     

Postpartum haemorrhage--a continuing problem

The factors responsible for postpartum haemorrhage (PPH) in singleton vaginal deliveries, not complicated by a retained placenta, were identified by comparing labour characteristics in 86 women who had a PPH (blood loss greater than 500 ml) with 351 women whose blood loss at delivery was less than 350 ml. Primiparity, induction of labour by amniotomy/oxytocin, forceps delivery, long first and second stages, oxytocin compared with syntometrine (oxytocin plus ergometrine maleate), as a prophylactic oxytocic, were identified as significant risk factors. Epidural analgesia contributed indirectly to an increase in the risk of postpartum haemorrhage. The changes in labour ward practice over the last 20 years have resulted in the re-emergence of PPH as a significant problem.     

Postpartum haemorrhage—a continuing problem

Summary. The factors responsible for postpartum haemorrhage (PPH) in singleton vaginal deliveries, not complicated by a retained placenta, were identified by comparing labour characteristics in 86 women who had a PPH (blood loss > 500 ml) with 351 women whose blood loss at delivery was < 350 ml. Primiparity, induction of labour by amniotomy/ oxytocin, forceps delivery, long first and second stages, oxytocin com-pared with syntometrine (oxytocin plus ergometrine maleate), as a prophylactic oxytocic, were identified as significant risk factors. Epi-dural analgesia contributed indirectly to an increase in the risk of postpartum haemorrhage. The changes in labour ward practice over the last 20 years have resulted in the re-emergence of PPH as a significant problem.     

Second-line treatment of postpartum haemorrhage (PPH)

Introduction

Postpartum haemorrhage (PPH) remains to be the most common cause of maternal mortality and is responsible for 25?% of the maternal deaths worldwide. Although the absolute risk of maternal death is much lower, a recent increase of PPH and related maternal adverse outcomes has been noted in high-income countries as well. Generally, PPH requires early recognition of its cause, immediate control of the bleeding source by medical, mechanical, invasive-non-surgical and surgical procedures, rapid stabilization of the mother??s condition, and a multidisciplinary approach. Second-line treatment of PPH remains challenging, since there is a lack of univocal recommendations from current guidelines and sufficient data from randomized controlled trials.

Materials

For this review, electronic searches were performed in PubMed, Embase, and the Cochrane Central Register of Controlled Trials using the keywords ??postpartum haemorrhage?? in combination with ??uterine tamponade?? and, especially with ??arterial embolisation??, ??uterine compression sutures??, and ??post(peri)partum hysterectomy?? (from January 2000 to November 2011). Reference lists of identified articles were searched and article references to the keywords selected.

Results

Treatment options such as uterine compression sutures, embolisation, arterial ligation and hysterectomy were evaluated with regard to their prerequisites, benefits, drawbacks and respective success rate. In addition, a treatment algorithm for the second-line treatment of PPH is presented.     

Surgical aspects of postpartum haemorrhage

Postpartum haemorrhage (PPH) refers to excessive bleeding from the genital tract after birth. Failure of medical treatment to control bleeding would necessitate surgical measures to arrest haemorrhage, to save lives. Algorithms such as HAEMOSTASIS have been proposed as aids to the systematic and stepwise management of primary PPH. Clinicians need to be aware of various surgical techniques that could be employed to arrest haemorrhage, the appropriateness of a chosen surgical intervention to the specific clinical situation and the timing of instituting the intervention. Surgical measures to arrest PPH include repair of genital tract trauma, evacuation of retained products of conception, uterine balloon tamponade, exploratory laparotomy and uterine compression sutures, systematic pelvic devascularization, uterine artery embolization, subtotal and total abdominal hysterectomy. Consideration should also be given to the experience and the skill of the operator, as well as to the familiarity with the chosen surgical procedure.     

Tranexamic acid for treatment of postpartum haemorrhage

Postpartum haemorrhage remains the leading cause of maternal mortality globally. Mortality and severe morbidity due to postpartum haemorrhage is highest in lower-resource settings. Tranexamic acid is an anti-fibrinolytic drug that has been in use in humans for nearly five decades. It is a structural analogue of lysine that binds irreversibly to plasminogen, thereby inhibiting the binding of plasmin to fibrin. This in turn inhibits fibrinolysis, thus stabilizing blood clots. Tranexamic acid has been shown to improve outcomes in trauma-related bleeding. New research has shown that early use of tranexamic acid (within 3 hours of birth), in addition to standard care, safely reduces deaths due to bleeding in women with clinically diagnosed postpartum haemorrhage, regardless of the mode of birth.     

Hypertension in pregnancy

Hypertension is a common complication of pregnancy. Maternal and foetal outcomes depend upon the nature of the hypertension affecting the pregnancy, which can range from mild gestational hypertension to severe preeclampsia with its associated multisystemic complications. Preeclampsia is a leading cause of maternal mortality. The World Health Organization estimates that, worldwide, over 100 000 women die from preeclampsia each year, and the condition has remained one of the leading causes of maternal death in the UK over recent decades. Features of substandard care were shown in 46% of the 14 deaths associated with preeclampsia or eclampsia in the last report on Confidential Enquiries into Maternal Deaths in the UK. Intracranial haemorrhage was the single largest cause of death, reflecting a failure of effective antihypertensive therapy and in particular ineffectual treatment of the raised systolic blood pressure. Although recent research has clarified the underlying aetiology of this condition, this has disappointingly not yet translated into a clinical useful prevention strategy. There is a clear need for greater awareness of the causes and optimal management of this common condition.     

Management in intractable obstetric haemorrhage: an audit study on 61 cases

OBJECTIVE: To refine the indications of bilateral hypogastric artery ligation (BHAL) and angiographic selective embolisation (ASE) in intractable obstetric haemorrhage. DESIGN: an audit study. SETTING: Tertiary care university hospital. POPULATION AND METHODS: Retrospective analysis of 61 cases of obstetric intractable post partum haemorrhage (PPH) initially managed either by hysterectomy or a conservative approach in a tertiary referral centre between 1983 and 1998. Procedures were reviewed as a primary (P) or secondary (S) attempt to arrest the haemorrhagic process. RESULTS: Ten hysterectomies (5 P, 5 S), 49 BHAL (48 P, 1 S) and 9 ASE (8 P, 1S) were successfully performed in arresting the haemorrhagic process. There were 7 maternal deaths, 5 following hysterectomy and 2 following a conservative approach. Atony of the uterus was the main cause of haemorrhage (n=21) and genital tract laceration was associated with the worst prognosis. Time-elapse between delivery and surgery appears to be the main prognostic factor. Nine patients became pregnant 1 to 4 years later following a conservative approach. CONCLUSIONS: ASE seems to be indicated in haemodynamically stable patients with birth canal trauma or uterine atony and clotting anomalies. BHAL is indicated when haemorrhage occurs after a cesarean section or when the patient is haemodynamically unstable. BHAL should be taught to Junior doctors in an attempt to decrease the number of patients transferred in tertiary referral centers for intractable PPH. This might also decrease the number of hysterectomies in intractable PPH.     

Postpartum ultrasound: postpartum assessment using ultrasonography

Postpartum haemorrhage (PPH) is a potential cause of maternal mortality, and obstetricians must be prepared to rapidly diagnose and treat this condition. Optimal treatment is dependent upon the underlying cause of haemorrhage. Ultrasonography is the most helpful tool for prompt diagnosis of PPH aetiology and obstetricians must have a strong understanding of postpartum ultrasonography. In our previous report, we demonstrated the utility of ultrasonography using the focused assessment with sonography for obstetrics (FASO) technique (a modified version of FAST) as the primary postpartum obstetric survey. In the present article, we review the ultrasonographic findings of PPH, differentiated by the underlying cause of haemorrhage, including retained placenta, morbidly adherent placenta, uterine rupture, uterine inversion and uterine artery abnormalities.     

再谈产后出血患者出血量的计算

产后出血(postpartum hemorrhage)是产科最常见、最凶险的并发症之一,是导致全球孕产妇死亡的主要原因。准确地预估出血量,对临床上选择何种方法预防和治疗产后出血具有重要的指导意义。临床上常用的方法有：目测法、面积法、称重法、血红蛋白测定法以及休克指数等方法,近年又有学者研究发明了一种新型直观、较为精确的容量袋法。