Ergometrine A drug used to prevent/ control excessive bleeding during the third stage of labour.

It causes a contraction of the muscles of the womb.

after 24 weeks. The occurrence of multiple pregnancies, hypertensive disorders, diabetes mellitus and antepartum haemorrhage were significantly higher in group I than in the control group. In pregnancy bleeding is usually called antepartum haemorrhage and after the birth it is called postpartum haemorrhage. APH occurs in 2% of pregnancies and is an important cause of foetal and maternal death - 30% of maternal deaths are caused by APH, of which 50% are associated with avoidable factors. When antepartum haemorrhage of any type occurs, the diagnosis of placenta praevia should be suspected and hospital admission advised. Incidental antepartum haetnorrhage is haemorrhage which occurs from the genital tract but not from the site of the placenta or its implantation. Such haemorrhage may result from injury, infection, ulcers on the neck of the womb, polyps or, I1lOstcommonly, the onset of labour. The diagnosis should be established by ultrasound imaging. Vaginal examination should be performed only in an operating theatre prepared for caesarean section, with blood crossmatched. There are only two indications for performing a vaginal examination: When there is serious doubt about the diagnosis When bleeding occurs in established labour.

Causes of Antepartum Haemorrhage

No definite cause is diagnosed in about 40% of all women who present with antepartum haemorrhage. Major causes are

Placenta praevia Abruptio placentae or accidental haemorrhage Uterine rupture Placenta praevia 31% Placental abruption 22% Vasa praevia (rare) Unclassified 47% Unknown aetiology.

Treatment of Antepartum Haemorrhage

May need resuscitation measures if shocked. Admit to hospital, even if bleeding is only a very small amount. There may be a large amount of concealed bleeding with only a small amount of revealed vaginal bleeding. No vaginal examination should be attempted at least until a placenta praevia is excluded by ultrasound. May initiate torrential bleeding from a placenta praevia.

Resuscitation can be inadequate because of under-estimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs 2 . Take blood for full blood count and clotting studies. Cross match as heavy loss may require transfusion. Gentle palpation of the abdomen to determine gestational age of fetus, presentation and position. Fetal monitoring . Arrange urgent ultrasound. With every episode of bleeding, a Rhesus negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin 3 .

Pathophysiology
Over the course of a pregnancy, maternal blood volume increases by approximately 50% (from 4 L to 6 L). The plasma volume increases somewhat more than the total RBC volume, leading to a fall in the hemoglobin concentration and hematocrit value. The increase in blood volume serves to fulfill the perfusion demands of the lowresistance uteroplacental unit and to provide a reserve for the blood loss that occurs at delivery.[5] At term, the estimated blood flow to the uterus is 500-800 mL/min, which constitutes 10-15% of cardiac output. Most of this flow traverses the low-resistance placental bed. The uterine blood vessels that supply the placental site traverse a weave of myometrial fibers. As these fibers contract following delivery, myometrial retraction occurs. Retraction is the unique characteristic of the uterine muscle to maintain its shortened length following each successive contraction. The blood vessels are compressed and kinked by this crisscross latticework, and, normally, blood flow is quickly occluded. This arrangement of muscle bundles has been referred to as the "living ligatures" or "physiologic sutures" of the uterus.[4] Uterine atony is a failure of the uterine myometrial fibers to contract and retract. This is the most important cause of PPH and usually occurs immediately following delivery of the baby, up to 4 hours after the delivery. Trauma to the genital tract (ie, uterus, uterine cervix, vagina, labia, clitoris) in pregnancy results in significantly more bleeding than would occur in the nonpregnant state because of increased blood supply to these tissues. The trauma specifically related to the delivery of the baby, either vaginally in a spontaneous or assisted manner or by cesarean delivery, can also be substantial and can lead to significant disruption of soft tissue and tearing of blood vessels. Even after placental delivery, blood may collect in an atonic uterus. For this reason, the uterine size and tone should be monitored throughout the third stage and in the socalled fourth stage, following delivery of the placenta. This is accomplished by gently palpating the uterine fundus. If the cause of bleeding is not uterine atony, then blood loss may be slower and clinical signs and symptoms of hypovolemia may develop over a longer time frame. Bleeding from trauma may be concealed in the form of hematomas of the retroperitoneum, broad ligament or lower genital tract, or abdominal cavity. The clinical findings in hypovolemia are listed in Table 2.

Table 2. Clinical Findings in Obstetric Hemorrhage[20] (Open Table in a new window) Blood Volume Loss 500-1000 mL (1015%) 1000-1500 mL (15-25%) 1500-2000 mL (25-35%) 2000-3000 mL (35-50%) Blood Pressure (systolic) Normal Symptoms and Signs Degree of Shock Compensated Mild Moderate Severe

Palpitations, tachycardia, dizziness Slight fall (80-100 Weakness, tachycardia, mm Hg) sweating Moderate fall (70-80 Restlessness, pallor, mm Hg) oliguria Marked fall (50-70 Collapse, air hunger, mm Hg) anuria

Two important facts are worth bearing in mind. The first is that caregivers consistently underestimate visible blood loss by as much as 50%. The volume of any clotted blood represents half of the blood volume required to form the clots. The second is that most women giving birth are healthy and compensate for blood loss very well. This, combined with the fact that the most common birthing position is some variant of semirecumbent with the legs elevated, means that symptoms of hypovolemia may not develop until a large volume of blood has been lost.[21] Rapid recognition and diagnosis of PPH is essential to successful management. Resuscitative measures and the diagnosis and treatment of the underlying cause must occur quickly before sequelae of severe hypovolemia develop. The major factor in the adverse outcomes associated with severe hemorrhage is a delay in initiating appr

Management of massive obstetric hemorrhage

The following is a plan for managing massive obstetric hemorrhage, adapted from Bonner.[26] The word order is a useful mnemonic for remembering the basic outline.

Organization 1. Call experienced staff (including obstetrician and anesthetist). 2. Alert the blood bank and hematologist. 3. Designate a nurse to record vital signs, urine output, and fluids and drugs administered. 4. Place operating theater on standby. Resuscitation 1. Administer oxygen by mask. 2. Place 2 large-bore (14-gauge) intravenous lines. 3. Take blood for crossmatch of 6 U PRBCs, and obtain a CBC count, coagulation screen, urea level, creatinine value, and electrolyte status. 4. Begin immediate rapid fluid replacement with NS or Ringer lactate solution. 5. Transfuse with PRBCs as available and appropriate.

Defective blood coagulation 1. Order coagulation screen (International Normalized Ratio, activated partial thromboplastin time) if fibrinogen, thrombin time, blood film, and D-dimer results are abnormal. 2. Give FFP if coagulation test results are abnormal and sites are oozing. 3. Give cryoprecipitate if abnormal coagulation test results are not corrected with FFP and bleeding continues. 4. Give platelet concentrates if the platelet count is less than 50 X 109/L and bleeding continues. 5. Use cryoprecipitate and platelet concentrates before surgical intervention. Evaluation of response 1. Monitor pulse, blood pressure, blood gas status, and acid-base status, and consider monitoring central venous pressure. 2. Measure urine output using an indwelling catheter. 3. Order regular CBC counts and coagulation tests to guide blood component therapy. Remedy the cause of bleeding 1. If antepartum, deliver the fetus and placenta. 2. If postpartum, use oxytocin, prostaglandin, or ergonovine. 3. Explore and empty the uterine cavity, and consider uterine packing. 4. Examine the cervix and vagina, ligate any bleeding vessels, and repair trauma. 5. Ligate the uterine blood supply (ie, uterine, ovarian, and/or internal iliac arteries). 6. Consider arterial embolization. 7. Consider hysterectomy.

Management of the underlying cause of PPH

Initial assessment

The patients risk factors and the events leading to the diagnosis of PPH may suggest an underlying etiology, but knowledge that most cases are caused by uterine atony and the need to be systematic argues for a planned, stepwise approach to assessment and management. The status of the patient, the severity of the bleeding, and the response to initial management steps determine if and when the protocol for massive obstetric hemorrhage is instituted.
Uterine atony

Assess uterine size and tone by placing a hand on the uterine fundus and massaging the uterus, which serves to express any clots that have accumulated in the uterus or vagina. If the uterus is found to be boggy and not well contracted, commence vigorous massage and therapeutic oxytocin. Oxytocin can be administered as a 5-U intravenous bolus, as 20 U in 1 L of NS intravenously run as fast as possible, or as 10 U intramyometrially with a spinal needle if no immediate intravenous access is available.

Emptying the bladder may aid in ongoing assessment and facilitate uterine contraction and subsequent therapeutic maneuvers. Wearing a waterproof gown, elbow-length gloves, and eye protection is prudent during the management of PPH. Sterile technique is used. If the uterus remains atonic, commence bimanual massage. A hand is placed on the fundus, and the second hand is placed anterior to the cervix in the vagina. Prepare the perineum and vagina. The vaginal hand may be covered in povidone-iodine solution (Proviodine) or a lubricant to allow it to enter the vagina with less difficulty. Take care to minimize the chance of causing or worsening trauma in the lower genital tract. Trauma to the vaginal sidewalls and cervix may be palpated as the hand is gently introduced into the vagina, and blood clots may be evacuated from the vagina, cervix, and lower uterine segment. The vaginal hand is placed in the anterior fornix, and the abdominal hand is placed on the posterior aspect of the fundus. The uterus is raised from the pelvis, pivoted anteriorly, and compressed between the two hands. The compression expels clots and decreases bleeding. Massaging the uterus between the hands aids in promoting and sustaining contraction. Bimanual massage results in a decrease in bleeding, even if the uterus remains relatively atonic, thus allowing resuscitation a chance to begin to catch up with blood loss. Use other uterotonic agents if the uterus remains atonic despite oxytocin administration and bimanual massage. The traditional second-line agent for uterine atony has been ergonovine (or ergotrate) given as an initial dose of 100 or 125 mcg intravenously or intramyometrially or 200 or 250 mcg intramuscularly. The maximum total dose is 1.25 mg. Hypertension is a relative contraindication. In some regions, the availability of ergot preparations has become problematic. Every effort should be made to secure supplies of this inexpensive and useful agent. Many authorities now recommend the use of intramuscular carboprost as the secondline agent when it is available. The recommended dose is 250 mcg intramuscularly or intramyometrially, not to exceed 2 mg (8 doses). Asthma is a relative contraindication. Carboprost has been shown to be 80-90% effective in stopping PPH in cases refractory to oxytocin and ergonovine. Intramuscular administration of these agents is not recommended if the patient demonstrates evidence of shock because absorption would be compromised. Misoprostol may also become a valuable agent in the treatment of PPH. One small case series reported that a dose of 1000 mcg given rectally was effective in causing sustained uterine contraction in 14 cases refractory to oxytocin, ergonovine, or both.[36, 37] Recent trials are examining whether the more rapid onset of sublingual/buccal misoprostol will improve its efficacy in the setting of acute PPH.[38] At this time, however, misoprostol remains a third-line agent in the management of PPH.[39] The low cost of the drug and its heat stability (does not require refrigeration) makes it especially appealing for use in the developing world. More trials are pending. Winikoff et al examined sublingual (SL) misoprostol for PPH when oxytocin is not feasible to administer. Oxytocin is considered the standard of care for treating

postpartum hemorrhage, but because of refrigeration requirements and the need for intravenous administration, it is not always clinically viable, particularly in primitive clinical settings. Active bleeding was controlled within 20 min for 440 (90%) women administered misoprostol 800 mcg SL (n=488) and 468 (96%) administered oxytocin 40 units IV (n=490) (relative risk [RR], 0.94; 95% confidence interval [CI], 0.910.98). Additional blood loss of 300 mL or greater after treatment occurred for 147 (30%) of women receiving misoprostol and 83 (17%) receiving oxytocin (RR, 1.78; 95% CI, 1.40-2.26). The authors concluded that in circumstances where it is not feasible to use oxytocin for postpartum hemorrhage, misoprostol is a suitable alternative.[40] The investigational agent carbetocin has been compared with oxytocin for prevention of postpartum hemorrhage. Attilakos et al compared the effectiveness of carbetocin and oxytocin when given for postpartum hemorrhage after cesarean delivery in a double-blind, randomized trial. The primary outcome measure was women who required additional pharmacologic oxytocic interventions. Results showed that significantly more women required additional oxytocics in the oxytocin group compared with the carbetocin group.[41]
Retained tissue

If the uterus continues to contract poorly or to relax when bimanual compression and massage are stopped despite the administration of uterotonics, perform manual exploration. Some authorities advocate earlier exploration; however, this is difficult without general anesthesia unless the patient is in severe shock or an epidural is already in place. Nitrous oxide (Entonox) may be useful in facilitating manual exploration if general anesthesia is not available. Ensure that resuscitation is well underway by this time, and, if not already started, institute the massive hemorrhage protocol. If possible, keep the vaginal hand in situ throughout because it minimizes patient discomfort, the risk of iatrogenic trauma, and, possibly, the risk of subsequent infection. If the placenta was not delivered before the onset of PPH, an attempt is now made to deliver it with cord traction and uterine countertraction. Care must be taken because the risk of uterine inversion is greater if the uterus remains poorly contracted. Perform manual removal if the placenta is not easily delivered or the cord is avulsed. Perform manual removal with a level of analgesia that matches the clinical urgency of the situation. The hand is passed through the cervix and into the lower segment. Care is taken to minimize the profile of the hand as it enters, keeping the thumb and fingers together in the shape of a cone in order to avoid damage. Control of the uterine fundus with the other hand is essential. If the placenta is encountered in the lower segment, it is removed. If the placenta is not encountered, the placental edge is sought. Once found, the fingers gently develop the space between the placenta and uterus and shear off the placenta. The placenta is pushed to the palmar aspect of the hand and wrist, and, once it is entirely separated, the hand is withdrawn. Do not stop uterotonics while the manual removal is being performed. Restart bimanual massage, and have an assistant examine the placenta for completeness.

If the placenta has been previously delivered, then exploration of the uterus is still indicated at this time. The hand is introduced in the same manner, with control of the uterine fundus with the other hand. Any clots are removed. The cavity is gently explored with attention to any defects suggestive of uterine rupture. Rupture in the absence of a previous scar is uncommon. Rupture or dehiscence of a previous lower segment scar does not usually bleed heavily. The presence of a uterine rupture dictates that a laparotomy be performed. A partial uterine inversion can be detected as the hand is introduced, just as a complete uterine inversion would have been detected as the hand was placed in the vagina. If the condition is encountered, return the uterus to its normal position by pressure on the inverted fundus from within the uterus. If retained placental tissue is encountered, it is sheared off the uterine wall and delivered. Adherent placental fragments may be left in situ or removed by gentle curettage. The risks of curettage include uterine perforation and increased bleeding caused by laceration of uterine vessels. This may be somewhat minimized by the use of a large, dull curette. Fragments left in situ may be removed by curettage sometime after the crisis has passed, although an increased risk of infection probably ensues. The administration of short-term, broad-spectrum antibiotics following manual removal, manual exploration, or instrumentation of the uterus in this context is commonly advocated. Evidence is very limited, but a single small, randomized trial supports the practice.[42] Immediately resume bimanual massage and compression following exploration and evacuation of the uterus. Continue infusion of oxytocin, and administer repeat doses of other uterotonics if the uterus fails to contract and maximal doses have not already been given. The uterus may contract well, and bleeding abates with massage, followed by uterine relaxation and increased bleeding when compression and massage are stopped. Prolonged massage at this point may allow the uterus to contract and retract if it can be kept empty of clots and if perfusion can be improved with adequate resuscitation. Any period of decreased bleeding allows fluid and blood component replacement to exceed blood loss and help improve the patients status. Surgical management is necessary if the uterus does not remain contracted and bleeding persists despite all efforts. Packing of the uterus may be an option until the operating room is ready or if surgery is not an immediately available option. Uterine packing fell into disfavor during the 1960s as being nonphysiological, concealing ongoing blood loss, and increasing the risk of infection; however, reports since then have been favorable in very select circumstances when all previously mentioned maneuvers have failed.[43] The uterus and vagina must be tightly packed with continuous, layered, 2- or 4-inch gauze under direct visualization using a speculum and/or retractors or a purpose-built uterine packer.[44] At times, packing may serve as a definitive treatment. In these cases, the packing is usually removed in 24-48 hours in a setting where recurrent bleeding can be managed if it occurs. Intrauterine catheters for tamponade of bleeding have also been used. In the past, large bulb Foley catheters or Sengstaken-Blakemore tubes have been used.[45] More recently, experience has been gained using catheters specifically designed for postpartum hemorrhage. One such device is the SOS Bakri tamponade balloon (Bakri,

2001). In low resource settings, condoms and surgical gloves have been used successfully to control bleeding.[46] Anti-shock garments are also being evaluated in low resource settings for both the definitive treatment of uterine atony as well as a method to allow time to bring other treatments to bear[47] Manual examination helps to exclude a cervical or vaginal laceration, but direct visualization confirms that bleeding is coming from the uterus and excludes the possibility of missing trauma to the lower genital tract. If packing is meant to be definitive treatment, then ongoing assessment of uterine size, blood loss, and patient status must be maintained. Continue uterotonics and commence broad-spectrum antibiotics. Remove the pack in 24-36 hours in a setting that allows for appropriate management if bleeding recurs. Packing may also be used as a temporizing measure before arterial embolization (see Selective arterial embolization). Isolated reports of successful uterine tamponade with balloon devices have also been published.[48]
Genital tract trauma

Genital tract trauma is the most likely cause if bleeding persists or is present despite a well-contracted uterus. Use appropriate analgesia along with good lighting and positioning, which facilitates excellent exposure. If not already initiated, moving the patient to an operating room is reasonable at this time. Experienced assistants and an excellent circulating nurse are essential. Directly visualize and inspect the cervix with the aid of ring forceps. The anterior lip is grasped, and the cervix is inspected by using a second ring forceps placed at the 2oclock position, followed by progressively "leap-frogging" the forceps ahead of one another until the entire circumference has been inspected. Small, nonbleeding lacerations of the cervix do not need to be sutured. Suture any laceration that is bleeding significantly or appears to have the potential to bleed significantly. Each side of the laceration can be grasped with a ring forceps back from the torn edge, and gentle traction can be used to aid exposure. Use an absorbable, continuous interlocking stitch, and use tapered (rather than cutting) needles for all repairs except for the perineal skin. Ensure that the stitch begins above the apex of the tear, as with vaginal lacerations and episiotomies. If the apex cannot be visualized, place the stitch as high as possible and then use it to apply gentle traction to bring the apex into view. Polyglycolic sutures have largely replaced catgut; however, the latter may be somewhat less likely to tear the friable tissues of the cervix and vaginal vault and may thus be useful in repairing lacerations in these areas. The laceration must be observed for bleeding after the torn edges of the cervix are approximated. The ring forceps can be replaced and left on for some time if oozing persists. Lacerations of the vaginal vault must be well visualized and their full extent realized prior to repair. Lacerations high in the vaginal vault and those extending up from the cervix may involve the uterus or lead to broad ligament or retroperitoneal hematomas. The proximity of the ureters to the lateral vaginal fornices, and the base of the bladder to the anterior fornix, must be kept in mind when repair is undertaken in these areas. Poorly placed stitches can lead to genitourinary fistulas. An absorbable, continuous interlocking stitch is used. The stitch must start and finish beyond the apices of the

laceration. Great care must be taken because the tissue is usually very friable. Take a good amount of tissue, and ensure that the needle reaches the full depth of the tear. Ongoing bleeding and hematoma formation are possible if small bites are taken. Again, the laceration must be observed for bleeding after the repair is complete. Pressure or packing over the repair may achieve hemostasis or allow for better placement of further hemostatic stitches. Cervical and vaginal vault lacerations that continue to ooze or those that are associated with hematomas may be amenable to selective arterial embolization (see Selective arterial embolization). Traumatic hematomas are rare and may be related to lacerations or may occur in isolation. They include vulvar and paravaginal hematomas in the lower genital tract and broad ligament and retroperitoneal hematomas adjacent to the uterus. Patients with lower genital tract hematomas usually present with intense pain and localized, tender swelling. Broad ligament hematomas may be palpated as masses adjacent to the uterus. All may result in significant blood loss that mandates resuscitation. Lower genital tract hematomas are usually managed by incision and drainage, although expectant management is acceptable if the lesion is not enlarging.[49] Any bleeding vessels are tied off, and oozing areas may be oversewn. Place a Foley catheter because urinary retention can occur because of pain and tissue distortion. Vaginal packing may be useful following drainage and repair of a paravaginal hematoma. Remove the pack in 24-36 hours. Embolization may be used in both vaginal and vulvar hematomas that are unresponsive to surgical management. Broad ligament and retroperitoneal hematomas are initially managed expectantly if the patient is stable and the lesions are not expanding.[50] Ultrasound, CT scanning, and MRI all may be used to assess the size and progress of these hematomas. Selective arterial embolization may be the treatment of choice if intervention is required in these patients. Use surgical procedures to evacuate the hematoma, and attempt to tie off any bleeding vessels. Consider involving a surgeon with extensive experience operating in the retroperitoneal space.
Coagulopathy

If manual exploration has excluded uterine rupture or retained placental fragments, bleeding from a well-contracted uterus is most commonly due to a defect in hemostasis. A review of the history and risk factors along with coagulation test results clarifies this diagnosis. Proceed with blood product replacement as previously described in order to correct abnormalities of hemostasis. If the coagulation status is normal and bleeding is ongoing despite a well-contracted uterus, then the possibilities of uterine rupture or an inadequately repaired uterine incision (if the patient had a cesarean delivery) must be considered. Revisit any repair to the cervix or vagina before proceeding to surgical management.