1、Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology KaohsiungKaohsiung Medical University,Medical University,KaohsiungKaohsiung,TaiwanTaiwanAssociate Professor,Associate Professor,Te-Fu ChanTe-Fu ChanPostpartum Postpartum HaemorrhageHaemorrhage(PPH)(PPH)Substantial geogra
2、phic Substantial geographic disparities in maternal disparities in maternal mortalitymortalitySource:Trends in Maternal Mortality:1990 to 2010,WHO,UNICEF,UNFPA and the World Bank.Source:Trends in Maternal Mortality:1990 to 2010,WHO,UNICEF,UNFPA and the World Bank.HaemorrageHaemorrage is the leading
3、is the leading cause of maternal deathcause of maternal deathPostpartum Postpartum HaemorrhageHaemorrhage(PPH)(PPH)Postpartum Haemorrhage(PPH)is commonly defined as a blood loss of 500 ml or more within 24 hours after birth.Most deaths resulting from PPH occur during the first 24 hours after birth:t
4、he majority of these could be avoided through the use of prophylactic uterotonics during the third stage of labour and by timely and appropriate management.Improving health care for women during childbirth in order to prevent and treat PPH is an essential step.Cause of PPHCause of PPHUterine atony i
5、s the most common cause of PPH,but genital tract trauma(i.e.vaginal or cervical lacerations),uterine rupture,retained placental tissue,or maternal coagulation disorders may also result in PPH.Although the majority of women who experience PPH complications have no identifiable clinical or historical
6、risk factors,grand multiparity and multiple gestation are associated with an increased risk of bleeding after birth.PPH may be aggravated by pre-existing anaemia and,in such instances,the loss of a smaller volume of blood may still result in adverse clinical sequelae.Recommendations for Recommendati
7、ons for the the preventionprevention of of PPHPPHUterotonicsUterotonicsCord management and uterine Cord management and uterine massagemassageCaesarean SectionsCaesarean SectionsUterotonicsUterotonicsOxytocin(10 IU,IV/IM)is the recommended uterotonic drug for the prevention of PPH.In settings where o
8、xytocin is unavailable,the use of other injectable uterotonics(e.g.ergometrine/methylergometrine or the fixed drug combination of oxytocin and ergometrine)or oral misoprostol(600 g)is recommended.In settings where skilled birth attendants are not present and oxytocin is unavailable,the administratio
9、n of misoprostol(600 g PO)by community health care workers and lay health workers is recommended for the prevention of PPH.Cord management and uterine Cord management and uterine massagemassageIn settings where skilled birth attendants are available,CCT is recommended for vaginal births if the care
10、provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important.In settings where skilled birth attendants are unavailable,CCT is not recommended.Late cord clamping(performed approximately 1 to 3 minutes after b
11、irth)is recommended for all births while initiating simultaneous essential newborn care.Cord management and uterine Cord management and uterine massagemassageEarly cord clamping(1 minute after birth)is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitat
12、ion.Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin.Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women.Recommendation status of the individual Recommendat
13、ion status of the individual components of the active management of the components of the active management of the third stage of third stage of labourlabour,based on who delivers,based on who delivers the interventionthe intervention*Distribution of misoprostol during the antenatal period for self-
14、administration during the third stage of labour*Small reduction in blood loss and in the length of the third stage;adoption based on the values and preferences of the woman and the health care provider*Routine uterine tone assessment remains a vital part of clinical decision making and should be pra
15、ctised during the third stage of labour*Self-administered uterine massage in the absence of uterotonicsCaesarean SectionsCaesarean SectionsOxytocin(IV or IM)is the recommended uterotonic drug for the prevention of PPH in caesarean section.Cord traction is the recommended method for the removal of th
16、e placenta in caesarean section.Recommendations for Recommendations for the the treatmenttreatment of of PPHPPHManagement of Management of atonicatonic PPH PPHManagement of retained placentaManagement of retained placentaManagement of Management of atonicatonic PPH PPHMedical interventions for manag
17、ement of PPHNon-medical interventions for management of PPHSurgical interventions in the treatment of PPHMedical interventionsMedical interventionsoxytocin should be preferred over ergometrine aloneIf oxytocin is not availablesecond-line treatmentsa fixed-dose combination of ergometrine and oxytocin
18、,carbetocin,and prostaglandinsIf the bleeding does not respond to the second-line treatmentthird-line treatmentprostaglandinDrug doses for management of Drug doses for management of PPHPPHTranexamicTranexamic acid acidAntifibrinolytic agents are widely used in surgery to reduce blood loss.A systemat
19、ic review of randomized controlled trials of antifibrinolytic agents in elective surgery showed that tranexamic acid reduced the risk of blood transfusion by 39%Tranexamic acid may be offered as a treatment for PPH if:(i)administration of oxytocin,followed by second-line treatment options and prosta
20、glandins,has failed to stop the bleeding (ii)it is thought that the bleeding may be partly due to trauma.Recombinant factor Recombinant factor VIIaVIIaThe Consultation agreed that there was not enough evidence to make any recommendation regarding the use of recombinant factor VIIa for the treatment
21、of PPH.Recombinant factor VIIa for the treatment of PPH should be limited to women with specific haematological indications.Recommendations for the Recommendations for the Medical interventionsMedical interventionsIntravenous oxytocin is the recommended uterotonic drug for the treatment of PPH.If in
22、travenous oxytocin is unavailable,or if the bleeding does not respond to oxytocin,the use of intravenous ergometrine,oxytocin-ergometrine fixed dose,or a prostaglandin drug(including sublingual misoprostol,800 g)is recommended.Recommendations for the fluid Recommendations for the fluid resuscitation
23、 and resuscitation and tranexamictranexamic acidacidThe use of isotonic crystalloids is recommended in preference to the use of colloids for the intravenous fluid resuscitation of women with PPH.The use of tranexamic acid is recommended for the treatment of PPH if oxytocin and other uterotonics fail
24、 to stop the bleeding or if it is thought that the bleeding may be partly due to trauma.Non-medical interventionsNon-medical interventions Uterine massage Uterine massage as a therapeutic measure is defined as rubbing of the uterus manually over the abdomen sustained until bleeding stops or the uter
25、us contracts.Initial rubbing of the uterus and expression of blood clots is not regarded as therapeutic uterine massage.Uterine massage should be started once PPH has been diagnosed.Non-medical interventionsNon-medical interventions Uterine massage The use of bimanual uterine compression is recommen
26、ded as a temporizing measure until appropriate care is available for the treatment of PPH due to uterine atony after vaginal delivery.The instruments used included Sengstaken-Blakemore and Foley catheters,Bakri and Rusch balloons,and condoms.Case series have reported success rates ranging from 71%to
27、 100%.Non-medical interventionsNon-medical interventions Intrauterine balloonIf women do not respond to treatment using uterotonics,or if uterotonics are unavailable,the use of intrauterine balloon tamponade is recommended for the treatment of PPH due to uterine atony.No trials were found describing
28、 the use of external aortic compression in the treatment of PPH.The use of external aortic compression for the treatment of PPH due to uterine atony after vaginal birth is recommended as a temporizing measure until appropriate care is available.External aortic compression has long been recommended a
29、s a potential life-saving technique,and mechanical compression of the aorta,if successful,slows down blood loss.Non-medical interventionsNon-medical interventions External aortic compressionSuccess rates(i.e.no need for hysterectomy or other invasive procedure)ranging from 75%to 100%are reported in
30、these studies.Uterine packing is not recommended for the treatment of PPH due to uterine atony after vaginal delivery.The GDG noted that there was no evidence of benefit of uterine packing and placed a high value on concerns regarding its potential harm.Non-medical interventionsNon-medical intervent
31、ions Uterine packingIf other measures have failed and if the necessary resources are available,the use of uterine artery embolization is recommended as a treatment for PPH due to uterine atony.Studies report success rates ranging from 82%to 100%Non-medical interventionsNon-medical interventions Uter
32、ine artery embolizationPercutaneous transcatheter arterial embolization of the uterine artery has been reported from institutions that have adequate radiological facilities for this intervention.Non-medical interventionsNon-medical interventions Uterine artery embolizationSurgical interventionsSurgi
33、cal interventionsThe B-Lynch technique seems to be the most commonly reported procedure.A wide range of surgical interventions have been reported to control postpartum haemorrhage that is unresponsive to medical or mechanical interventions.Success rates(i.e.no need for hysterectomy or other invasive
34、 procedure)range from 89%to 100%.Management of retained Management of retained placentaplacentaRecommended:Recommended:Additional oxytocin(10 IU,IV/IM)in combination with controlled cord traction A single dose of antibiotics(ampicillin or first-generation cephalosporin):if manual removal of the plac
35、enta is practised.Not Recommended:Not Recommended:Ergometrine:as this may cause tetanic uterine contractions which may delay the expulsion of the placenta.prostaglandin E2 alpha(dinoprostone or sulprostone)Health Systems and Organization of Health Systems and Organization of Care recommendations for
36、 the Care recommendations for the prevention and treatment of PPHprevention and treatment of PPHThe use of formal protocols by health facilities for the prevention and treatment of PPH is recommended.The use of formal protocols for referral of women to a higher level of care is recommended for healt
37、h facilities.The use of simulations of PPH treatment is recommended for pre-service and in-service training programmes.Monitoring the use of uterotonics after birth for the prevention of PPH is recommended as a process indicator for programmatic evaluation.Statements related to topics for which Stat
38、ements related to topics for which there is insufficient evidence to issue a there is insufficient evidence to issue a recommendationrecommendationThere is insufficient evidence to recommend one oxytocin route over another for the prevention of PPH.There is insufficient evidence to recommend the use
39、 of recombinant factor VIIa for the treatment of PPH.There is insufficient evidence to recommend the use of intraumbilical vein injection of oxytocin as a treatment for retained placenta.There is insufficient evidence to recommend the antenatal distribution of misoprostol to pregnant women for self-administration for the prevention of PPH.There is insufficient evidence to recommend the measurement of blood loss over clinical estimation of blood loss.
