STEPS FOR THE MANAGEMENT PPH OBJECTIVES Discuss the

STEPS FOR THE MANAGEMENT PPH

OBJECTIVES • Discuss the importance of the Golden Hour • Present a follow-up sequence for PPH 1

STEPS FOR THE MANAGEMENT OF PPH Early control of the bleeding is the most effective measure for the treatment of PPH 2 Título da apresentação

STEPS FOR THE MANAGEMENT OF PPH & THE GOLDEN HOUR There is a relationship between the time elapsed to control the bleeding and the chance of death 100 Agressive and rapid interventions % sobrevida 80 60 Avoid the lethal triad of PPH: Acidosis, hypothermia and coagulopathy 40 20 0 0 10 20 30 Minutos 40 50 60 A Lalonde et al. Int J Gynaecol Obstet. 2006 Sep; 94(3): 243 Protocolo HPP SES-MG, 2016. Protocolo HPP BH 2016 90

REMEMBER. . . RED CODE AND TEAMWORK. . . • • • TEAM LEADERSHIP COMUNICATION MONITORING MUTUAL SUPPORT

STEPS FOR THE MANAGEMENT OF PPH 5 Título de la presentación

STEPS FOR THE MANAGEMENT OF PPH CALL FOR HELP • Communicate Clearly the diagnosis of PPH • Call Interdisciplinary Team • Communicate patient

STEPS FOR THE MANAGEMENT OF PPH ESTIMATE INICIAL BLOOD LOSS • Clinical evaluation - vital Signs • Shock index (> 0. 9: transfusion risk) • Visual estimation, weighing of compresses, collecting devices 7

SHOCK INDEX Maternal Heart Rate Systolic Blood Pressure > 0, 9 SI ≥ 0, 9 RELATED TO MASSIVE TRANSFUSION

STEPS FOR THE MANAGEMENT OF PPH RAPID ASSESSMENT OF HEMORRHAGE CAUSES (4 T) TONE - abnormalities of uterine contraction: 70% TRAUMA - genital tract injury: 19% TISSUE - retained products of conception: 10% TROMBIN - abnormalities of coagulation: 1% 9

STEPS FOR THE MANAGEMENT OF PPH 10 Título da apresentação

STEPS FOR THE MANAGEMENT OF PPH KEEP OXIGENATION AND PERFUSION • Venous access: 02 caliber (J 16 or 14) • Rational infusion of heated liquids: re-evaluate every 300 -500 ml • Oxygen: 8 to 10 l / min in face mask. • Elevation of lower limbs • Continuous monitoring (TAX: every 15 minutes) • Delayed bladder catheter: (monitor diuresis) 11

EXCESSIVE INFUSION OF FLUIDS Dilution of factors of coagulation Excessive infusion of fluids Acidosis Elevation of blood pressure (before surgical control of hemorrhage Duschesne JC et al. J Trauma 2010; 69(4): 976, Spinella PC & Holcomb JB. 12 Blood Reviews, 2009; 23: 231 Maegele et al. Injury 2007; 38(3): 298 Hypothermia

STEPS FOR THE MANAGEMENT OF PPH REQUEST EXAMS • Collect already in the 1 st access puncture • Hemogram, coagulogram, ionogram, cross-test, fibrinogen • Severe cases: lactate and gasometry EVALUATE ANTIBIOTICS • Bimanual uterine massage • Intrauterine Ballon Tamponade • 13 Surgeries http: //www. liaccentralsorologica. com. br/si te/wp-content/uploads/1. png

STEPS FOR THE MANAGEMENT OF PPH FLUID AND BLOOD THERAPHY Estimate severity of volume loss (Shock Index) Crystalloid: rational use. Reevaluate every 300 -500 ml Consider blood transfusion after 1500 ml of crystalloids with no adequate and sustained maternal response • Tranexamic acid, IV, 1 gram in 10 minutes • • 14

STEPS FOR THE MANAGEMENT OF PPH DETERMINE THE CAUSE OF PPH- 4 T • 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 15

TRANEXAMIC ACID: 1 g, IV, 10 minutes UTERINE ATONY BIMANUAL UTERINE COMPRESSION OXYTOCIN ONSET OF ACTION: (IV): 1 min No response ERGOT ONSET OF ACTION IM: 2 -5 min No response YES MAINTANANCE DOSE YES MAINTANENCE DOSE, if necessary MISOPROSTOL ONSET OF ACTION (OR): 7 -11 min (R): 15 -20 min No response NON PNEUMATIC ANTI-SHOCK GARMENT Associate with Intrauterine Ballon No response INTRAUTERINE BALLON TAMPONADE If uterotonics fail to stop bleeding No response SURGICAL MANAGEMENT compressive uterine sutures, ligature of vessels, hysterectomy, damage control Título da apresentação 16

TRAUMA TRANEXAMIC ACID = 1 g, IV, SLOW INFUSION (100 mgmin) TRANEXAMIC ACID = REPAIR TEARS HAEMATOMA UTERINE RUPTURE: UTERINE INVERSION : Título da apresentação 17 Repair tears Check perineum, cervix and vagina Explore it in some cases Check vagina after birth Laparotomy Primary repair or hysterectomy TAXE MANEVEUR Laparotomy / Intrauterine Balloon

TISSUE TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100 mgmin) TRANEXAMIC ACID = RETAINED PLACENTA 30 -45 min after delivery MANUAL REMOVAL The lack of cleavage plane: Risk of Placenta acreta and severe PPH) RETAINED PART OF PLACENTA ACCRETA CURETTAGE DO NOT try to remove The placenta CURETTAGE 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 Hysterectomy with placenta in situ Conservative management

COAGULAPATHY TRANEXAMIC ACID = 1 g, EV, SLOW INFUSION (100 mgmin) TRANEXAMIC ACID = DIAGNOSIS SPECIFIC TREATMENT + TRANSFUSION ADJUVANT TREATMENT 19 Título da apresentação 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 NASG Surgery: be careful with this choice! Damage Control, if DIC.

STEPS FOR THE MANEGEMENT FOR PPH 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. 20

STEPS FOR THE MANEGEMENT FOR PPH 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 21

MOTIVATION TO 0 MMXH “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 22