STEPS FOR THE MANAGEMENT
PPH
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OBJECTIVES
• Discuss the importance of the Golden Hour
• Present a follow-up sequence for PPH
Título da apresentação 3
STEPS FOR THE MANAGEMENT OF PPH
Early control of the bleeding is the most
effective measure for the treatment of PPH
STEPS FOR THE MANAGEMENT OF PPH & THE GOLDEN HOUR
A Lalonde et al. Int J Gynaecol Obstet. 2006 Sep;94(3):243 Protocolo HPP SES-MG, 2016. Protocolo HPP BH 2016
0 10 20 30 40 50 60 90
0 20 40 60 80 100
Minutos
% sobrevida
There is a relationship between the time elapsed to control the bleeding and the chance of death
Agressive and rapid interventions
Avoid the lethal triad of PPH:
Acidosis, hypothermia and coagulopathy
REMEMBER...
RED CODE AND TEAMWORK...
• TEAM
• LEADERSHIP
• COMUNICATION
• MONITORING
• MUTUAL SUPPORT
STEPS FOR THE MANAGEMENT OF PPH
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STEPS FOR THE MANAGEMENT OF PPH
CALL FOR HELP
• Communicate Clearly the diagnosis of PPH
• Call Interdisciplinary Team
• Communicate patient
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ESTIMATE INICIAL BLOOD LOSS
• Clinical evaluation - vital Signs
• Shock index (> 0.9: transfusion risk)
• Visual estimation, weighing of compresses, collecting devices
STEPS FOR THE MANAGEMENT OF PPH
Maternal Heart Rate
Maternal Heart Rate
Systolic Blood Pressure Systolic Blood
Pressure
SHOCK INDEX
> 0,9 0,9
SI ≥ 0,9 RELATED TO MASSIVE TRANSFUSION SI ≥ 0,9 RELATED TO MASSIVE TRANSFUSION
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RAPID ASSESSMENT OF HEMORRHAGE CAUSES (4T)
TONE - abnormalities of uterine contraction: 70%
TRAUMA - genital tract injury: 19%
TISSUE - retained products of conception: 10%
TROMBIN - abnormalities of coagulation: 1%
STEPS FOR THE MANAGEMENT OF PPH
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STEPS FOR THE MANAGEMENT OF PPH
Título da apresentação
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KEEP OXIGENATION AND PERFUSION
• Venous access: 02 caliber (J16 or 14)
• Rational infusion of heated liquids: re-evaluate every 300-500ml
• Oxygen: 8 to 10 l / min in face mask.
• Elevation of lower limbs
• Continuous monitoring (TAX: every 15 minutes)
• Delayed bladder catheter: (monitor diuresis)
STEPS FOR THE MANAGEMENT OF PPH
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Duschesne JC et al. J Trauma 2010; 69(4):976, Spinella PC &
Holcomb JB. Blood Reviews,2009; 23: 231 Maegele et al. Injury 2007;38(3):298
Excessive infusion of
fluids
Dilution of factors of coagulation
Acidosis
Elevation of blood pressure (before surgical control of
hemorrhage
Hypothermia
EXCESSIVE INFUSION OF FLUIDS
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REQUEST EXAMS
• Collect already in the 1st access puncture
• Hemogram, coagulogram, ionogram, cross-test, fibrinogen
• Severe cases: lactate and gasometry
EVALUATE ANTIBIOTICS
• Bimanual uterine massage
• Intrauterine Ballon Tamponade
• Surgeries
http://www.liaccentralsorologica.com.br/sit e/wp-content/uploads/1.png
STEPS FOR THE MANAGEMENT OF PPH
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FLUID AND BLOOD THERAPHY
• Estimate severity of volume loss (Shock Index)
• Crystalloid: rational use.
• Reevaluate every 300-500 ml
• Consider blood transfusion after 1500ml of crystalloids with no adequate and sustained maternal response
• Tranexamic acid, IV, 1 gram in 10 minutes
STEPS FOR THE MANAGEMENT OF PPH
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DETERMINE THE CAUSE OF PPH- 4T
• TONE - Is the uterus contracted ?
• TRAUMA - IS there any tract trauma – lacerations ?
• TISSUE - Is there any tissue left or placenta acreta ?
• TROMBIN - Is there any coagulophaty ? TREAT THE SPECIFIC CAUSE
STEPS FOR THE MANAGEMENT OF PPH
U TE R IN E A TO N Y
Título da apresentação17
BIMANUAL UTERINE COMPRESSION
ERGOT
ONSET OF ACTION IM: 2-5 min
OXYTOCIN
ONSET OF ACTION: (IV): 1 min
MISOPROSTOL
ONSET OF ACTION (OR): 7-11 min \ (R): 15-20min
NON PNEUMATIC ANTI-SHOCK GARMENT
Associate with Intrauterine Ballon INTRAUTERINE BALLON TAMPONADE If uterotonics fail to stop bleeding
SURGICAL MANAGEMENT
compressive uterine sutures, ligature of vessels, hysterectomy, damage control
MAINTANANCE DOSE
YES
No response
No response No response No response
No response
MAINTANENCE DOSE, if necessary
YES
TRANEXAMIC ACID: 1 g, IV, 10 minutes
TRAUMA
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HAEMATOMA REPAIR TEARS
UTERINE INVERSION :
UTERINE RUPTURE: Laparotomy
Primary repair or hysterectomy
Repair tears
Check perineum, cervix and vagina
Explore it in some cases
Check vagina after birth
TAXE MANEVEUR
Laparotomy / Intrauterine Balloon TRANEXAMIC ACID = 1 g, IV, SLOW INFUSION (100mg\min)
RETAINED PLACENTA
30-45 min after delivery RETAINED PART
OF PLACENTA PLACENTA ACCRETA
MANUAL REMOVAL
The lack of cleavage plane:
Risk of Placenta acreta and severe PPH)
CURETTAGE DO NOT try to remove The placenta
CURETTAGE
Hysterectomy with placenta in situ Conservative management
TISSUE
Imagens: https://rphcm.allette.com.au/publication/cpm/Manual_removal_placenta.html Imagem: http://wellroundedmama.blogspot.com.br/2013/09/placenta-accreta-part-four-diagnosis.html
TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100mg\min)
Título da apresentação
COAGULAPATHY
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SPECIFIC TREATMENT +
TRANSFUSION DIAGNOSIS
ADJUVANT TREATMENT
NASG
Surgery: be careful with this choice!
Damage Control, if DIC.
Prior history of specific deficiencies, (eg. Von Willebrand's disease); Use of Anticoagulants; intra-operative excessive bleeding (DIC), thrombocytopenia,
hypofibrinogenemia
RBC, FFP, platelets, cryoprecipitate, Activated Factor VIIa, desmopressin,
protamine, among others
TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100mg\min)
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EVALUATION AFTER INITIAL APPROACH:
• Reassessment of hemorrhage and hemodynamic status
• NASG for the patients with hemodynamic instability
• Blood transfusion: if necessary ( to be based on patient's clinical evolution)
• Avoid hypothermia: Body temperature, heated fluids, thermal blanket.
• If conservative treatment fails: evaluate surgical treatment.
STEPS FOR THE MANEGEMENT FOR
PPH
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STRICT MONITORING AFTER HEMORRHAGE
• Strict monitoring in the recovery room in the first 24 hours (it can not be in postpartum ward that offers low risk monitoring)
• ICU according to the severity of the case
STEPS FOR THE MANEGEMENT FOR
PPH
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“For each mother who dies, there is a family that suffers, a community that becomes weaker,
a country that gets poorer ”
Carissa F Etienne. PAHO/WHO Director
“For each mother who dies, there is a family that suffers, a community that becomes weaker,
a country that gets poorer ”
Carissa F Etienne. PAHO/WHO Director
