Active man agement of the third stage of labor should be used routinely to reduce its incidence. How well do postpartum blood loss and common definitions. Postpartum shock index as a predictor of postpartum hemorrhage morbidity 30k. It can be further subdivided into minor 500 ml or major ml.
In the optimization of management of postpartum hemorrhage we are still facing several challenges. Shock parameters and shock index during severe postpartum. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Conventional markers of haemodynamic compromise are relatively insensitive. Elrefaey introduction the physiology of postpartum hemostasis depends primarily upon mechanical events mediated by hormones, which induce strong uterine muscular contraction. Prevention and management of postpartum haemorrhage this is the first edition of this guideline. Moreover, average blood loss at birth frequently exceeds 500 or ml. Incidence and risk factors for postpartum hemorrhage among. Who recommendations for the prevention and treatment of postpartum haemorrhage 3 executive summary introduction postpartum haemorrhage pph is commonly defined as a blood loss of 500 ml or more within 24 hours after birth. This shock is caused when more than 20 percent of the body fluid including blood is lost during postpartum hemorrhage. Postpartum hemorrhage pph is commonly defined as blood loss exceeding 500 ml following vaginal birth and ml following cesarean. Clinical indicators of hemorrhagic shock in pregnancy. Based on data collected by the royal college of midwives the incidence of major obstetric haemorrhage is 3. Anesthetic considerations and management of obstetric.
Assessing and managing hypovolemic shock in puerperal women. Proposed alternate metrics for defining and diagnosing pph include change in hematocrit, need for. A new article in the british journal of obstetrics and gynecology bjog by ucsf safe motherhood program and kings college london finds shock index is a superior predictor of adverse outcomes in pph. Postpartum hemorrhage is a leading cause of maternal morbidity and mortality in the united states. Postpartum shock index as a predictor of postpartum. In total, 32 patients 64% who experienced massive pph required blood transfusion fig. Obstetric haemorrhage is no longer a major cause of maternal death in the uk. A longitudinal linked national cohort study in the netherlands.
Pointofcare lactate measurements in the emergency setting may facilitate early treatment of haemorrhagic shock after labour. Use of the shock index to predict maternal outcomes in women. Postpartum bleeding or postpartum hemorrhage pph is often defined as the loss of more than 500 ml or 1,000 ml of blood within the first 24 hours following childbirth. About 80% of postpartum maternal deaths in lowincome countries are related to postpartum haemorrhage pph 1. The evidencebased management of postpartum haemorrhage omphigfmer joint initiatives in 2010, omphi and gfmer started working together to produce elearning material in the field of maternal and perinatal health. An update on the risk factors for and management of. Moreover, combining lactate concentrations with the shock index, defined as the ratio of heart rate to systolic arterial blood pressure, can improve the predictive performance for massive transfusion. Management of postpartum hemorrhage effective health. Virtually all recent studies focus on the latter, but the phenomenon cannot be. Use of the shock index to predict maternal outcomes in women referred for. Incidence and recurrence rate of postpartum hemorrhage and manual removal of the placenta. Postpartum hemorrhage pph is defined more than 500 ml of blood bleeding following vaginal delivery. Postpartum hemorrhage management, the importance of timing. Methods this study included 81 pregnant trauma patients.
Pph is considered severe when blood loss exceeds 1,000 ml after a vaginal delivery, or results in signs or symptoms of circulating blood volume instability. Obstetric shock index osi for patients with massive postpartum hemorrhage case group. The effect of maternal body mass index on postpartum. Background several hemodynamic parameters have been promoted to help establish a rapid diagnosis of hemorrhagic shock, but they have not been well validated in the pregnant population. It is also known as puerperal uterine inversion and imposes severe threats to life of the patient. Postpartum haemorrhage pph is a major cause of maternal morbidity and remains one of the top five causes of maternal mortality in both.
Massive haemorrhage protocol mhp queensland clinical guidelines. It is a major cause of maternal mortality especially in developing countries and is the cause of 25% of maternal. Who recommendations for the prevention and treatment of. Relying solely on changes in bp and hr as individual parameters may delay vital interventions in women with postpartum haemorrhage pph. Role of anterior division of internal iliac artery.
Rodolfo carvalho pacagnella, anderson borovacpinheiro. Along with the amount of blood loss, clinical signs, and specifically the shock index heart rate divided by systolic blood pressure appear to aid in more accurate diagnosis of postpartum hemorrhage. A potential criterion for a maternal early warning. Shock index and heart rate standard reference values in the. Primary postpartum haemorrhage is excessive bleeding occurring during the third stage of labour, or. Methods a retrospective casecontrol analysis was conducted involving pregnant women admitted to st georges hospital for delivery. The aim of this case series is to describe the experience of using the nonpneumatic antishock garment nasg in the management of severe postpartum hemorrhage pph and shock, and the value of implementing this concept in highcomplexity obstetric hospitals. Postpartum hemorrhage is common and can occur in patients without risk factors for hemorrhage. Blood lactate concentration and shock index associated with. Prevention and management of postpartum haemorrhage. In the 20062008 report of the uk confidential enquiry into maternal deaths, haemorrhage was the sixth highest direct cause of maternal death. The data for systolic and diastolic blood pressure, mean arterial pressure, pulse pressure, heart rate, and shock index measured at the time of diagnosis of postpartum hemorrhage were analyzed.
Patient summary heavy bleeding after a baby is born postpartum haemorrhage is a complication of pregnancy that has the potential to be very serious, even resulting in death in rare cases. Nonpneumatic antishock garment nasg, a firstaid device to decrease maternal mortality from obstetric hemorrhage. Classifications based on the timing of bleeding are. We hypothesised that lactate concentrations are independently associated with massive transfusion in patients with primary postpartum haemorrhage. This shock is also associated with excessive blood loss along with shock. Definition loss of blood more than 500 ml from the genital tract post delivery of a baby who excessive pvb that cause haematocrit drop more than 10% that require immediate transfusion acog 3. Comparison of performance of shock index and conventional vital. Shock parameters and shock index during severe postpartum haemorrhage and implications for management. The traditional definition of primary pph is the loss of 500 ml or more of blood from the genital tract within 24. Objective we aimed to better understand how well postpartum blood loss and common postpartum hemorrhage pph definitions i. The evidencebased management of postpartum haemorrhage.
Use of the obstetric shock index as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage. Experience in the use of nonpneumatic antishock garment. Postpartum hemorrhage postpartum hemorrhage is defined as blood loss of 500 ml or more from genital tract in the first 24 h of delivery. Claudia claroni 1, marco aversano 1, cristina todde 1, maria grazia frigo 1. Postpartum haemorrhage can be classified based upon the timing of the bleeding following delivery of the baby and the cause of the bleeding.
Descriptive case series of 77 women that received nasg in the management of pph with severe hypovolemic shock from june 2014 to december 2015. Diagnosis and management of postpartum haemorrhage the bmj. Postpartum shock index as a predictor of postpartum hemorrha. Purpose and scope primary postpartum haemorrhage pph is the most common form of major obstetric haemorrhage. An effective predictor of outcome in postpartum haemorrhage. Introduction early recognition of haemodynamic instability following pph is necessary to instigate interventions to prevent maternal morbidity and mortality. Postpartum hemorrhage pph is the leading cause of maternal mortality in lowincome countries, contributing to nearly a quarter of maternal. Shock index and deltashock index are superior to existing maternal early warning criteria to identify. Pph is the leading cause of maternal mortality in lowincome countries and the primary cause of nearly one quarter of all. According to dalton 2017, postpartum haemorrhage remains a significant cause of maternal mortality with primary pph occurring between 1% and 5% of all deliveries, and secondary pph occurring between 0. Primary postpartum haemorrhage refer to online version, destroy printed copies after use page 4 of 37 flow chart.
Massive pph is defined as the blood loss of 14ml or more. Postpartum haemorrhage is a major cause of death during pregnancy and early motherhood, accounting for 25% of maternal deaths worldwide, 1 and is the second leading direct cause of maternal deaths in the uk. Methods secondary analysis of data from three randomized trials that objectively measured postpartum blood loss and pre and postdelivery hemoglobin. Definitions vary, however, and are often based on inaccurate estimates of blood loss. Blood lactate concentration and shock index associated. In this study, we examined the association between three measures of shock and early blood transfusion requirements among pregnant trauma patients. According to the world health organization, postpartum haemorrhage constitutes 25% of all maternal deaths worldwide 1. Rule of 30, shock index and the golden hour post pph.
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