Management

Management of PPH involves timely recognition of severity of blood loss, effective multidisciplinary communication, prompt resuscitation to ensure maternal haemodynamic stability (ABC – airway, breathing, circulation) and identification and treatment of the underlying cause of PPH. In reality, all these actions should occur simultaneously to improve outcomes. In massive PPH, a multidisciplinary approach is essential and the presence and advice of a senior obstetrician, midwife, anaesthetist and haematologist are vital.

It is good practice to involve colleagues with gynaecological surgical experience to assist in complex surgical procedures that may be required to arrest bleeding. Similarly, transfer to a tertiary hospital should be considered early once the woman is haemodynamically stable, if further complex treatment is anticipated.

An initial assessment regarding the degree of blood loss and the severity of the haemodynamic instability is vital and it is always better to overestimate the blood loss and to anticipate the possibility of further bleeding. However, caution should be exercised as over-treatment with excessive intravenous fluid and oxytocics may be equally harmful.

The degree of pallor, level of consciousness, vital signs (pulse, blood pressure, respiration and temperature) and, if facilities are available, oxygen saturation should be monitored. Management algorithms are useful for this serious and potentially fatal condition. ‘HEMOSTASIS’ (Table 15.6) is one such algorithm that spells out the suggested actions that may facilitate the management of atonic PPH in a logical and stepwise manner. It has been reported that this enables a logical and stepwise management with a low peripartum hysterectomy rate.

Resuscitation of the patient and identification of the specific causes of PPH to institute immediate appropriate management should be carried out simultaneously, so as to avoid any delay in correcting of hypovolaemia.

A and B: Assess Airway and Breathing

A high concentration of oxygen (10–15 l/min) via a facemask should be administered, regardless of maternal oxygen concentration. If the airway is compromised owing to impaired consciousness, anaesthetic assistance should be sought urgently. Securing the airway and ensuring adequate oxygenation are paramount. This should be followed by replacement of blood volume to restore the oxygen-carrying capacity of blood. Investigations to determine the degree of blood loss and the integrity of the coagulation system, as well as monitoring of the vital signs, should be carried out. Usually, level of consciousness and airway control improve rapidly once the circulating volume is restored.

C: Circulation

Two large-bore (14 G) intravenous cannulae should be inserted and blood should be taken for investigations. These include full blood count (FBC), clotting profile, urea and electrolytes, and grouping and cross-matching. Rapid fluid infusion with crystalloids and colloids should be carried out until cross-matched blood is available. Crystalloids (0.9% normal saline or Hartmann’s solution) are preferred over colloids, as the latter are associated with a 4% increase in the absolute risk of maternal mortality compared with crystalloids [8]. Colloids may also interfere with cross-matching and platelet function. If they are used, the maximum recommended dosage of colloids is 1500 ml in 24 hours.

By consensus, total volume of 3.5 l of clear fluids (up to 2 l of warmed Hartmann’s solution as rapidly as possible, followed by up to a further 1.5 l of warmed colloid if blood is still not available) comprises the maximum that should be infused while awaiting compatible blood. There is controversy as to the most appropriate fluids for volume resuscitation. The nature of fluid infused is of less importance than rapid administration and warming of the infusion. The woman needs to be kept warm using appropriate measures.

It is vital to try to identify a cause of ongoing PPH while resuscitation is being carried out to save valuable time. The single most common cause of haemorrhage is uterine atony, which accounts for about 80% of PPH. Hence, the bladder should be emptied to aid uterine contractions and a bimanual pelvic examination should be performed. The finding of the characteristic soft, poorly contracted (boggy) uterus suggests atony as a causative factor. The uterine contractions can be enhanced by uterine massage or bimanual compression. Both of these may help reduce blood loss, expel blood and clots, and allow time for other measures to be implemented. Once atonic uterus has been identified as the cause of PPH, measures should be taken to ensure optimum uterine contraction and retraction. These include the use of pharmacologic agents, use of uterine balloon tamponade, interventional radiology (uterine artery embolization) and surgical measures (exploratory laparotomy, uterine compression sutures, ligation of blood vessels and total or subtotal hysterectomy), if needed.

If bleeding persists despite measures to correct uterine atony, other causes must be considered. Even if atony persists, there may be other contributing or co-existing factors such as a retained placenta, a tear of the vaginal wall or cervix, a vulval or paravaginal haematoma, a uterine scar rupture, DIC and, rarely, amniotic fluid embolism.

One should be aware of possible concealed bleeding, which may be intrauterine or ‘BAD’ (within the broad ligament, abdominal cavity or deeper tissue planes such as the paravaginal tissues). Lacerations should be ruled out by careful visual assessment of the lower genital tract.

Restoration of the oxygen-carrying capacity of the blood and correction of any derangements in coagulation by blood transfusion and the use of blood products should be considered. This is especially so in cases of massive PPH, where more than 30% of blood volume is lost, as further bleeding may result in hypoxia and metabolic acidosis that may affect the vital organs. Furthermore, the clotting factors may be lost along with excessive blood loss (‘washout phenomenon’). Until cross-matched blood is available, O negative or uncross-matched group-specific blood may be transfused, if there were no abnormal antibodies in the recipient’s blood. In special circumstances, auto-transfusion (or cell salvaging) may be considered, although during a caesarean section (CS) this carries a theoretical risk of amniotic fluid embolism and infection. Auto-transfusion involves collection of maternal blood and the use of a cell-saver device (Figure 15.1) to wash and filter the blood to remove the leukocytes and re-infuse the red cells.

Figure 15.1

Cell-saver for ‘auto-transfusion’.

Apart from intravenous (IV) crystalloids, colloids, blood and oxytocin, the infusion of blood products needs to be considered. In massive obstetric blood loss, rapid infusion of fresh frozen plasma (FFP) may be required to replace clotting factors other than platelets. It is recommended that with every six units of blood transfusion, 1 l of FFP should be administered (15 ml/kg). Hence, 4–5 bags of FFP are required, as each bag contains about 200–250 ml of FFP. Platelet count should be maintained above 50 000 by infusing platelet concentrates, if indicated. Cryoprecipitate may also be needed if the patient develops DIC and her fibrinogen drops to less than 1 g/dl (10 g/l) [9].