Rule of 30, Shock index and

New aspects - treating severe PPH
• General remarks
• New methods
•Drugs
•Balloons
•Radiology
•Surgery
• Rule of 30, Shock index and
”the golden hour”
• Post PPH
•Intravenous iron

Post partum hemorrhage - PPH
> 500 ml/24 hrs
3-5% of vaginal births
5-7% of CS
> 1000 ml/24 hrs
0.5-2% of all deliveries

PPH - Risk factors
Previous PPH
Antenatal bleeding
Polyhydramnios, twins, macrosomia
Protracted labour
Placenta praevia (marginalis)
High age and/or BMI
PE, DIC, IUFD, Abruption

PPH - prophylaxis
Active management of 3rd stage
Oxytocin i.m. - after anterior
shoulder is delivered
Cord clamped and cut at once
Light cord traction
Reduces severe PPH by 2/3

PPH prophylaxis in Norway 2001
Maternity units
Hospitals N n %
University 7 4 57
Level 2 10 7 70
Other 29 11 38
Midwife led units 9 4 44
Total 55 26 47
Bjørnerem et al. Tidsskr Nor Lægeforen 2002;122:2536-7

PPH - causes
Remember the 4 T’s !
Tone - uterine atony 70%
Tissue - retained placenta 20%
Tears - vagina/cervix 10%
Thrombin - coagulopathy

PPH - initial steps
Call for help
I.v. access (2 green/gray i.v. bores)
ABC, monitor BP, pulse, respiration
Bimanual compression of uterus
Uterotonics (Oxytocin & Misoprostol)
Check Hb, platelets - blood avaialable
Proceed to advanced methods

Algorithm for management of Atonic PPH
H Ask for Help
HAEMOSTASIS
A Assess (vital parameters, blood loss) and
resuscitate
E Establish etiology + Ensure availability of
blood
M Massage uterus
O Oxytocin infusion + Prostaglandins
intravenous/ per rectal/ intramuscular/
intra-myometrial

Prostaglandin potentiates the
action of oxytocin
Stepwise quick progression
Oxytocin and/or Ergometrine infusion
Prostaglandins IV; IM; IntraMyometrial
Misoprostol 800 ug rectally/400 ug orally
whilst using oxytocin infusion

New drug: rFVIIa (NovoSeven R )
Tissue factor via extrinsic pathway
Binds to platelets and activates FX

FVIIa (NovoSeven R )
Recommended - 1,5 X blood volume lost
Dose: 70 kg - 90 µg/kg - NOK 40 000,-
Reduced effect
Thrombocytopenia (platelets > 50 000)
Low fibrinogen (fibrinogen > 1 g/l)
Hypothermia
Acidosis (pH < 7.1)
Review - Int J Obstet Anesth 2007;16:29-34

Algorithm for management of Atonic PPH
HAEMOSTASIS
S Shock Garment & Shift to theatre – exclude
Tissue or Trauma / Bimanual compression
T Tamponade – Balloon or uterine packing
A Apply compression sutures
B-Lynch or modified
S Systematic Pelvic devascularisation
Uterine/Ovarian/Quadruple/Internal iliac
I Interventional Radiologist
If appropriate uterine artery embolisation
S Subtotal / Total abdominal hysterectomy

Algorithm for management of Atonic PPH
HAEMOSTASIS
S Shock Garment & Shift to theatre – exclude
Tissue or Trauma / Bimanual compression
T Tamponade – Balloon or uterine packing
A Apply compression sutures
B-Lynch or modified
S Systematic Pelvic devascularisation
Uterine/Ovarian/Quadruple/Internal iliac
I Interventional Radiologist
If appropriate uterine artery embolisation
S Subtotal / Total abdominal hysterectomy

Literature Review of the conservative
surgical (& radiological) measures
Series of at least 5 cases
English language
Single interventions
Uterine ballon tamponade
B-Lynch/ compression sutures
Arterial embolization
Int. iliac artery ligation/ uterine
devascularization
Success rates

Condous G et al. Obstet Gynecol 2003; 101: 767-72
The “Tamponade Test”
Therapeutic
No further intervention in 14 of 16 PPH
Continue oxytocin infusion for 12 hrs,
small vaginal pack, IV antibiotics, check
fundal height and bleeding
Prognostic
The need to do a laparotomy - answer
known in few minutes

Uterine balloon tamponade

Uterine balloon tamponade
Authors Year Type of study Method No of
women
Success Rates
Goldrath 1983 Case series Foley catheter 20 19/20 (95%)
Bakri et al 2001 Case series Silicone Balloon 5 3*/5 (60%)
Condous et al 2003 Case series Sengstaken -Blakemore 16 14/16 87.50%
Akhter et al 2003 Case series Condom 23 23/23 (100%)
Penney et al
(Scottish
Audit)****
Penney et al
(Scottish
Audit)****
2003 Audit Balloon 6 5/6 (83.3%)
2004 Audit Balloon 21 15/21 (71.4%)
Seror et al 2005 Case series Sengstaken -Blakemore 17 12/17 (70.6%)
St George’s
ongoing series
2006 Case series Sengstaken -Blakemore 27 22/27 (81.5%)
Total 135 83.7%

COMPRESSION SUTURES
Quick, safe and effective
B-Lynch
Horizontal full thickness sutures
Vertical full thickness sutures
Square sutures
Combination of sutures

B-Lynch or Compression sutures
Authors Year Type of study Method No of
women
Success Rates
B-Lynch et al 1997 Case series B-Lynch 5 5/5 (100%)
Cho et al 2000 Case series Square sutures 23 23/23 (100%)
Pal et al 2003 Case series B-Lynch 6 6/6 (100%)
Smith et al 2003 Case series B-Lynch 7 6/7 (85.7%)
Penney et al (Scottish
Audit)
Penney at al (Scottish
Audit)
2003 Audit*** B-Lynch 10 9/10 (90%)
2004 Audit*** B-Lynch 19 13/19 (68.4%)
Wohlmuth et al 2005 Case series B-Lynch 12 11/12 (91.6%)
Pereira et al 2005 Case series Compressive
sutures
7 7/7 (100%)
Nelson et al 2006 Case series Modified B-Lynch 5 5/5 (100%)
Total 94 85/94 (90.4 %)

Int. Iliac / Step-wise devascularization
Authors Year Method No of
women
Success
Rates
Evans et al 1985 Internal iliac artery ligation 14 6/14 (42.8%)
Clark et al 1985 Bilateral hypogastric artery ligation 19 8/19 (42.1%)
Fahmy 1987 Uterine artery ligation 25 20/25 (80%)
Fernandez et al 1988 Internal iliac artery ligation 8 8/8 (100%)
Chattopadhyay
et al
1990 Bilateral hypogastric artery ligation 29 19/29 (65%)
AbdRabbo 1994 Stepwise uterine devascularization 103 103 (100%)
Ledee et al 2001 Bilateral hypogastric artery ligation 48 43/48 (89.5%)
Hebisch et al 2002 Vaginal uterine artery ligation 13 12/13 (92.3%)
Penney et. al**
(Scottish Audit)
2004 Bilateral uterine artery ligation 5 2/5 (40%)
Total 264 83.7%

Arterial embolisation
Authors Year Method No of
women
Success Rates
Greenwood et al 1987 Multiple pelvic arterial embolization 8 6/8 (75%)
Bakri et al 1992 Arterial embolization 14 14/14 (100%)
Gilbert et al 1992 Bilateral hypogastric artery
embolization
Mitty et al 1993 Int. pudendal and uterine artery
embolization
8 8/8 (100%)
8 8/8 (100%)
Yamashita et al 1994 Multiple pelvic arterial embolization 15 15/15 (100%)
Pelage et al 1999 Uterine artery embolization 37 (prim.) 14
(second.)
89%, 97%
Ledee et al 2001 Arterial selective embolization 7 5/7 (71.4%)
Deux et al 2001 Arterial embolization 25 24/25 (96%)
Cheng et al 2003 Arterial embolization 15 12/15 (80%)
Chung et al 2003 Arterial embolization 33 31/33 (94%)
Tourne et al 2003 Uterine artery embolization 12 11/12 (91.6%)
Tsang et al 2004 Arterial embolization 9 9/9 (100%)
Hong et al 2004 Internal iliac artery embolization 7 6/7 (85.7%)
Total 218 91%

Conservative (Surgical) Treatment for PPH
Method No. of Cases Success rates
B-Lynch + other
Compression sutures
94 91%
Arterial embolisation 218 91%
Arterial ligation 264 84%
Uterine balloon
tamponade
NovoSeven
(NEFOH)
135 84%
97 80-85%

Algorithm for management of Atonic PPH
HAEMOSTASIS
S Shock Garment & Shift to theatre – exclude
Tissue or Trauma / Bimanual compression
T Tamponade – Balloon or uterine packing
A Apply compression sutures
B-Lynch or modified
S Systematic Pelvic devascularisation
Uterine/Ovarian/Quadruple/Internal iliac
I Interventional Radiologist
If appropriate uterine artery embolisation
S Subtotal / Total abdominal hysterectomy

Maternal mortality due to PPH
CONFIDENTIAL ENQUIRY INTO
MATERNAL DEATHS
TOO LITTLE – TOO LATE
Too Little (IV fluids, oxytocics,
BLOOD, Clotting factors)
Too Late (PG, resuscitation -
blood replacement, decision for
surgery + to get senior surgeon &
anaesthetist involved)

Blood loss
ml %
PPH
Symptoms
500-1000 10-15 Slight tachycardia,
palpitations, drowsiness
1000-1500 15-25 Tachycardia, cold &
sweating, malaise
1500-2000 25-35 Uneasy, pale, oligouria
BP 60-80
2000-3000 35-45 Severe shock, colapse,
anuria, BP 40-60

Rule of 30
30% blood loss > moderate shock
HR – increase > 30 bpm
Respiratory rate > 30/min
Systolic BP – down 30 mm Hg
Urinary output < 30 ml/hour
Haematocrit drop > 30% & to be kept at
an absolute value of > 30

Shock index
Shock Index = HR / Systolic BP
Normal = 0.5-0.7
Shock index > 0.9 indicates state
of shock that needs urgent
resuscitation

THE GOLDEN HOUR
As more time elapses between the point
of severe shock and the start of
resuscitation, the percentage of
surviving patient decreases (metabolic
acidosis)
The “Golden Hour” is the time in which
resuscitation must begin to achieve
maximum survival

Subtotal or Total Hysterectomy
Severe hypotension > 20-30 min
Continued blood loss (>3 L) despite
other surgical measures
Inadequate response to blood
replacement
ECG changes
Placenta praevia/acreta with bleeding
DIC/ Washout phenomenon with
difficulty in getting clotting factors

PPH Coagulation disorders
‘Washout Phenomenon’
DIC - FDP inhibits clotting
“Washout phenomenon” - the
coagulation factors are consumed and
washed out at the site of bleeding
The “washout” is the major
phenomenon that prevents arrest of
haemorrhage

Intravenous iron post PPH
RCT - Bhandall et al. BJOG - nov. 2006
Anaemic (Hb< 9 g/dL) women (N = 44) pp.
intravenous iron vs Fe sulphate po.
Intravenous iron group significant higher
Hb after 5 days, but not after 40 days
Ferritin even after 40 days

Norwegian RCT
Unpublished - in the pipeline - Westad et al
Anaemic (6,5

Intravenous ferric carboxymaltose
compared with oral iron in the
treatment of postpartum anemia:
a randomized controlled trial
Van Wyck DB, Martens MG, Seid MH, Baker JB,
Mangione A. Obstet Gynecol 2007;110:267-278

Material & methods
Randomized, controlled trial
Anaemic women (Hb

Results
Hb response (≥2.0 g/dL) earlier and higher in IV
group vs oral group (p

Conclusions
Large dose IV ferric carboxymaltose is a new
agent that is effective in postpartum anemia
When compared with oral ferrous sulfate
IV ferric carboxymaltose is better tolerated,
prompts a more rapid Hb response and corrects
anemia more reliably
Van Wyck et al. Obstet Gynecol 2007;110:267-78

Is Erythropoietin beneficial
in the treatment of
postpartum anaemia?
No!
Wågstrøm E, Åkesson A, van
Rooijen M, Larson B, Bremme K.
Acta Obstet Gyn Scand
2007;86:957-62