Postpartum Hemorrhage Management 2006 PDF

OBSTETRICS OBSTETRICS Postpartum Hemorrhage Gowri Ramanathan, MBBS, MRCOG,1 Sabaratnam Arulkumaran, MBBS, MD, PhD, FRCOG2 1 Specialist Registrar, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, London UK 2...

OBSTETRICS OBSTETRICS Postpartum Hemorrhage Gowri Ramanathan, MBBS, MRCOG,1 Sabaratnam Arulkumaran, MBBS, MD, PhD, FRCOG2 1 Specialist Registrar, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, London UK 2 Professor and Head, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, London UK Abstract year 2000 was approximately 529 000. These deaths were Postpartum hemorrhage (PPH) is the most important single cause divided almost equally between Africa (251 000) and Asia of maternal death in both developing and developed countries. It (253 000); about 4% (22 000) occurred in Latin America and arises from abnormalities in one of four basic processes, with uterine atony being the most common. A multidisciplinary approach the Caribbean, and less than 1% (2500) in the more devel- to management is important. The value of oxytocin and oped regions of the world.1 prostaglandins, including misoprostol, in treatment is discussed. Recently developed, less invasive treatment options, namely Globally, postpartum hemorrhage (PPH) is the most uterine tamponade and compression sutures, are fast becoming important single cause of maternal death, accounting for valuable alternatives to the traditional options of pelvic devascularization and hysterectomy. With a stark contrast in about 25% of the total and claiming an estimated 150 000 maternal mortality from PPH between the developing and lives annually.2,3 The majority of these deaths (88%) occur developed countries, public health strategies and medical interventions intended to minimize this are further discussed. within four hours of delivery,4 indicating that they are a con- sequence of events in the third stage of labour. Further- Résumé more, a significant predisposing factor, anemia, has a high L’hémorragie post-partum (HPP) est la cause la plus importante de prevalence in developing countries; one half of women of décès maternel, tant dans les pays développés que dans les pays childbearing age in Africa are anemic.5,6 en développement. Elle est attribuable à des anomalies au sein d’un processus fondamental (il en existe quatre); l’atonie utérine Because immediate and effective professional care during est l’anomalie rencontrée le plus fréquemment. Il est important and after labour and delivery can mean the difference d’aborder la prise en charge sous un angle multidisciplinaire. La valeur de l’oxytocine et des prostaglandines (y compris le between life and death, we present a review of the misoprostol) en ce qui a trait au traitement est débattue au sein du pathophysiology and recommended management of this présent article. Des options de traitement moins effractives most common cause of maternal death in both developing élaborées récemment, comme le tamponnement utérin et les sutures de compression, sont de plus en plus considérées comme and developed countries. étant des solutions de rechange précieuses à la dévascularisation pelvienne et à l’hystérectomie, options plus conventionnelles. Étant POSTPARTUM HEMORRHAGE donné le contraste marquant qui existe entre les taux de mortalité maternelle attribuable à l’HPP des pays développés et ceux des PPH is defined as the loss of 500 mL or more of blood from pays en développement, le présent article aborde plus à fond la question des stratégies de santé publique et les interventions the genital tract. Primary PPH occurs within the first 24 médicales visant à réduire cet écart. hours after delivery, and secondary PPH occurs after this J Obstet Gynaecol Can 2006;28(11):967–973 time. The ability of a woman to cope with blood loss depends on a number of factors, including her previous INTRODUCTION health, the presence or absence of anemia, and the presence omplications of pregnancy and childbirth remain a of absence of volume contraction due to dehydration or C leading cause of death and disability among women of reproductive age in developing countries. The esti- preeclampsia. Estimation of blood loss is subjective and generally underestimated. Emergency measures should be initiated if there is perceived loss of more than one third of mated number of maternal deaths around the world in the estimated blood volume (blood volume [mL] = weight [kg] Key Words: Postpartum hemorrhage, misoprostol, tamponade, x 80) or loss of 1000 mL or a change in vital signs. compression sutures, developing countries, public health strategies Excessive bleeding occurs because of an abnormality in one Competing Interests: None declared. of four basic processes, referred to in the “4Ts” mnemonic, Received on March 23, 2006 either individually or in combination: tone (poor uterine contraction after delivery), tissue (retained products of con- Accepted on April 27, 2006 ception or blood clots), trauma (to genital tract), or NOVEMBER JOGC NOVEMBRE 2006 l 967 OBSTETRICS Table 1. Etiology and risk factors for the 4Ts processes involved in PPH7 Process Etiology Risk Factors Tone Uterus over-distension Multiple pregnancy Macrosomia Polyhydramnios Fetal abnormalities e.g., severe hydrocephalus Uterine muscle fatigue Prolonged/precipitate labour, esp. if stimulated High parity (20-fold increased risk) Previous pregnancy with PPH Uterine infection/chorioamnionitis Prolonged SROM Fever Uterine distortion/abnormality Fibroid uterus Placenta previa Uterine relaxing drugs Anaesthetic drugs, nifedipine, NSAIDs, beta-mimetics, MgSO4 Tissue Retained placenta/membranes Incomplete placenta at delivery, esp. < 24weeks Abnormal placenta-succinturiate / Previous uterine surgery accessory lobe Abnormal placenta on ultrasound Trauma Cervical/vaginal/perineal tears Precipitous delivery, manipulations at delivery Operative delivery Episiotomy esp. mediolateral Extended tear at CS Malposition Fetal manipulation, e.g., version of second twin Deep engagement Uterine rupture Previous uterine surgery Uterine inversion High parity Fundal placenta Excessive traction of cord Thrombin Pre-existing clotting abnormality History of coagulopathy/liver disease e.g., hemophilia/ vWD/ hypofibrinogenemia Acquired in pregnancy High BP, bruising ITP Fetal death Fever, raised WCC PET with thrombocytopenia (HELLP) APH, sudden collapse DIC from PET, IUD, abruption, AFE, severe infection/sepsis Dilutional coagulopathy from massive transfusions Anticoagulation History of DVT/PE Aspirin, heparin PPH: postpartum hemorrhage; SROM: spontaneous rupture of membranes; NSAID: non-steroidal anti-inflammatory drug; CS: Caesarean section; vWD: von Willebrand’s disease; ITP: idiopathic thrombocytopenic purpura; BP: blood pressure; PET: preeclamptic toxemia; WCC: white cell count; HELLP: hemolysis, elevated liver enzymes, and low platelets; APH: antepartum hemorrhage; DIC: disseminated intravascular coagulation; IUD: intrauterine death; AFE: amniotic fluid embolism; DVT/PE: deep vein thrombosis/pulmonary embolism. thrombin (coagulation abnormalities).7 The many risk fac- disorders becoming pregnant) and advances in technology tors associated with PPH may be attributed to an abnormal- (e.g., assisted reproduction leading to an increased rate of ity in one of these four physiological mechanisms. Table 1 multiple pregnancy, increasing Caesarean section rates lead- outlines some of these risk factors. ing to placenta previa and its sequelae), some of these risk factors may become more important and others less so in Prevention of PPH the future. Great grand multiparas were traditionally The prediction of PPH using antenatal risk assessment is thought to be at high risk of PPH, but some studies suggest poor: only 40% of women with an identified risk factor develop PPH.8 However, with changes in the obstetric pop- that their risk may be no greater than that of women of ulation (e.g., increased mean maternal age at childbirth, lower parity.9 Women with these risk factors should be increasing number of women with complex medical transferred to centres with transfusion facilities and an 968 l NOVEMBER JOGC NOVEMBRE 2006  Postpartum Hemorrhage Table 2. Clinical findings in hypovolemia and varying degrees of shock14 Blood volume loss BP (systolic change) Symptoms and signs Degree of shock 500–1000 mL Normal Palpitation, tachycardia, dizziness Compensated (10–15%) 1000–1500 mL Slight fall Weakness, tachycardia, sweating Mild (15–25%) (80–100 mm Hg) 1500–2000 mL Moderate fall Restlessness, pallor, oliguria Moderate (25–30%) (70–80 mm Hg) 2000–3000 mL Marked fall Collapse, air hunger, anuria Severe (35–45%) (50–70 mm Hg) intensive care unit (ICU) for delivery if these are not underestimation of volume and rapidity of blood loss, delay available locally. in symptoms of hypovolemia developing in women with The management of the third stage of labour to minimize good compensatory mechanisms, concerns that over- the risk of PPH has been discussed comprehensively.6 Early resuscitation will lead to pulmonary edema, or failure to be oxytocic therapy, cord clamping, and placental delivery by aware of the dynamics of fluid shifts in the body. A loss gentle controlled cord traction following signs of placental of 1 litre of blood requires replacement with 4 to 5 litres of separation reduce the incidence and severity of PPH, crystalloid (0.9% normal saline or lactated Ringer’s solu- postpartum anemia, and the need for blood transfusion.10,11 tion) or colloids until cross-matched blood is available, as Syntometrine (combined oxytocin and ergometrine) is most of the infused fluid shifts from the intravascular to the superior to oxytocin in the reduction of PPH more than interstitial space. 500 mL, but either is useful in PPH more than 1000 mL, Blood and blood product transfusion may be required if although Syntometrine increases the risk of hypertension.12 blood loss is continuing, if the blood volume lost is over The value of prophylactic prostaglandins, either intramus- 30%, or if the patient’s clinical status reflects developing cular prostaglandins or misoprostol, in a hospital setting shock despite aggressive resuscitation. Uncross-matched was shown to be no better than conventional injectable group-specific blood or O group, Rh-negative blood may oxytocin in reducing measured blood loss of 1000 mL or be required until fully cross-matched blood becomes avail- more.13 able. Dilutional coagulopathy occurs when approximately 80% of the original blood volume has been replaced. One Management of PPH litre of fresh frozen plasma (FFP) should be administered Rapid recognition, resuscitation, and restoration of circulat- (15 mL/kg) with every 6 units of blood transfused. Platelet ing blood volume and simultaneous identification and treat- concentration should be kept at more than 50 x 109/L or ment of the cause is the key to the management of PPH. more than 80–100 x 109/L if surgical intervention is neces- Although the presentation of PPH is often dramatic, bleed- sary. Cryoprecipitate, which provides a more concentrated ing can occur slowly, highlighting the importance of recog- form of fibrinogen and other clotting factors (VIII, XIII, nizing the clinical signs of varying degrees of hypovolemia von Willebrand factor), would be required if there is dis- and shock14 (Table 2). seminated intravascular coagulation (DIC) or if the Resuscitation and establishing etiology fibrinogen level is less than 10 g/L. Help from a multidisciplinary team is vital at an early stage A search for the cause of bleeding should be made while in PPH, as PPH can lead to circulatory collapse within min- resuscitation is continued. The 4Ts mnemonic provides a utes. Relevant senior staff should be contacted urgently; in simple, systematic approach for identifying the cause of our institution, we would alert the obstetric team, consul- bleeding. Thorough assessment and exploration of the tant obstetrician, midwife in-charge, anaesthetist, operating uterus and genital tract should be performed. If the uterus is theatre staff, blood bank, hematologist, hospital porters, atonic, vigorous massage and therapeutic uterotonic agents and the intensive care unit. should be commenced. If there is doubt about the com- Assessment of vital signs (level of consciousness, pulse, pleteness of delivered placenta and membranes, manual blood pressure, and oxygen saturation if available) and the exploration of the uterine cavity should be undertaken, ide- amount of blood loss must be made initially and continually ally under anaesthesia. If bleeding persists despite a throughout resuscitation. Fluid resuscitation in obstetric well-contracted uterus, genital tract trauma should be sus- hemorrhage is often overly conservative because of pected. Examination under anaesthesia should look for NOVEMBER JOGC NOVEMBRE 2006 l 969 OBSTETRICS extended tears in the cervix or high in the vaginal vault, as successfully in life-threatening PPH, but its safety and effi- these may involve the uterus or lead to broad ligament or cacy remain untested in clinical trials.20 retroperitoneal hematomas. Care should be taken not to involve the ureters at the lateral vaginal fornices and the Surgical management bladder at the anterior fornix during repair, as poorly placed Ongoing bleeding requires evaluation in the operating thea- sutures can lead to genitourinary fistulas. Although tre. Uterine tone must be reassessed, uterine inversion polyglycolic sutures have largely replaced catgut, the latter excluded, and a re-examination performed to exclude may be useful in repairing lacerations in these areas as they retained tissue and trauma. Bimanual compression and are less likely to tear the friable tissues of the cervix and vag- direct pressure over lacerations may help control bleeding inal vault. Pressure or packing over the repair may be useful while preparations are made for further intervention and to achieve hemostasis. If exploration has excluded retained correction of superimposed coagulopathy. tissue or trauma, bleeding from a well-contracted uterus is Tamponade or uterine packing. Uterine packing fell into disfa- due to a defect in hemostasis. Blood product replacement vour during the 1960s because it was perceived as being should be commenced as appropriate, and consideration non-physiological, concealing ongoing blood loss, and given to an underlying cause for the coagulation abnormal- increasing the risk of infection. However, it has had a recent ity (e.g., placental abruption, HELLP syndrome, fatty liver resurgence of interest after reports of favourable outcomes of pregnancy, intrauterine fetal demise, amniotic fluid in selected circumstances.21 There have been reports of suc- embolus, or septicemia). cessful uterine tamponade using a variety of balloon devices, namely the Sengstaken-Blakemore esophageal Medical management catheter,22 the Rusch urological hydrostatic balloon,23 and Oxytocin. Although the vast majority of women with PPH the “Bakri SOS” balloon.24 The insertion of the balloon is can be managed without surgical intervention, those with simple; a volume of 300 to 500 mL is usually required to uterine rupture or genital tract trauma cannot. If the uterus exert the desired counter-pressure to stop the bleeding remains atonic after initial oxytocic therapy, Syntometrine from uterine sinuses. The ability of the tamponade to arrest or ergometrine should be repeated, or, alternatively, bleeding, or a positive “tamponade test,” has a predictive oxytocin 10 units can be given by slow IV bolus. Uterine value of 87% in successfully managing PPH without the massage should be commenced, either manually (hand on need for further surgical intervention.25 Recent reports of the fundus) or bimanually (vaginal hand in the anterior large series have confirmed the high success rates of balloon fornix; abdominal hand on the posterior aspect of the devices.26,27 Similar success rates have been reported with fundus). Bimanual massage reduces bleeding even if the the use of condoms in low-resource settings.28 uterus remains atonic, allowing resuscitation a chance to catch up with blood loss. Oxytocin infusion (40 units in Compression suture. If the tamponade test fails, or if 500 mL of 0.9% normal saline, infused at a rate of life-threatening hemorrhage has occurred, a laparotomy 125 mL/hour) can be used to maintain uterine contraction. should be performed sooner rather than later, as delaying this decision in an attempt to avoid major surgery and possi- Prostaglandins. The traditional second-line agent for uterine ble hysterectomy may be fatal. atony is 15-methyl prostaglandin F2á (PGF2á), 0.25 mg deep intramuscularly and repeated every 15 minutes to a At laparotomy, if bimanual compression of the uterus suc- maximum dose of 2 mg.15 This is 80% to 90% effective in cessfully arrests the bleeding, then compression sutures are stopping PPH in cases that are refractory to oxytocin and likely to be of value. The anterior and posterior walls of the ergometrine. Intramyometrial injection of PGF2á has been uterus are compressed anteroposteriorly from the isthmus used clinically,16 but its effectiveness and adverse effects to the fundus using a delayed absorbable suture. The have not been adequately evaluated. B-Lynch suture29 and various modifications have shown promise. Using two or more separate vertical sutures Rectal administration of misoprostol (800–1000 mg), a instead of one30 not only increases the tension and com- prostaglandin E1 analogue, has emerged as a valuable agent pression force but also eliminates the need to open the in the treatment of PPH, especially in developing countries, uterus. Horizontal full thickness compression sutures at the because of its low cost and easier storage.17,18 placental site in placenta previa have also been described.31 Other hemostatic agents. The use of intravenous tranexemic There are numerous advantages of compression sutures: acid, an antifibrinolytic widely used in the management of they are easy to perform, can be performed quickly, and menorrhagia, has been reported.19 Its use has never been require little surgical expertise. Furthermore, recent reports systematically studied in PPH. Similarly, the hemostatic have shown that fertility and subsequent pregnancy out- agent recombinant activated factor VIIa has been used comes are unaffected, and no deaths were reported in 970 l NOVEMBER JOGC NOVEMBRE 2006  Postpartum Hemorrhage women who had compression sutures placed for the man- mothers, but most maternal deaths occur in the poorest agement of PPH in the recent Confidential Enquiry into countries. The lifetime risk of maternal death in sub- Maternal and Child Health.32 The success rate of compres- Saharan Africa is 1 in 16, compared with 1 in 2800 in devel- sion sutures used in 19 cases of massive obstetric hemor- oped countries. The reasons for these inequalities are com- rhage was as high as 68%.27 plex and include poverty, inequality, war and civil unrest, Systematic devascularization. If bleeding continues, ligation of and the destructive influence of HIV/AIDS, as well as failure uterine arteries (which provide approximately 90% of uter- to translate life-saving knowledge into effective action and ine blood flow), the tubal branches of ovarian arteries, and to invest adequately in public health and a safe environment. the internal iliac artery is an option. Ligating the uterine Public Health Strategies arteries and the tubal branches of the ovarian arteries is a The member countries of the United Nations agreed to relatively simple procedure. Internal iliac artery ligation, reduce maternal mortality by three quarters by 2015 as part however, is much more difficult to perform and may cause of the Millennium Development Goals. Unless progress is damage to nearby structures. Since internal iliac artery liga- accelerated significantly, there is little hope of achieving tion has a success rate of about 50% in controlling blood this.33–35 loss,27 its use in the management of massive obstetric hemorrhage is questionable. Postpartum hemorrhage can kill even a healthy woman within two hours if unattended. In low-income countries, Subtotal or total abdominal hysterectomy. Hysterectomy is cura- home birth may be the preferred option and is often the tive and is usually the final option in the management of only option for many women. Approximately 60% of births PPH. It may, however, be warranted earlier if the in low-income countries occur outside a health facility.36 hemodynamic condition of the patient is unstable or if there is uncontrollable bleeding despite other medical and surgi- The presence of skilled attendants at delivery has been high- cal measures. Although subtotal hysterectomy may be per- lighted, as both maternal and neonatal mortality are lower in formed faster, may be effective for bleeding due to uterine countries where women giving birth have skilled profes- atony, and is associated with less morbidity and mortality, it sional care, with the equipment, drugs and other supplies may not be effective for controlling bleeding from the lower needed for the effective and timely management of compli- segment, cervix, or vaginal fornices; thus, total cations.37,38 Care by a skilled attendant includes safe deliv- hysterectomy is preferred overall. ery, cord care, identification of complications, first aid, and timely referral of complicated cases. Management in a high dependency or intensive care unit is usually necessary after massive blood loss and transfusions, In settings where blood banks and other life-saving opera- as multiple organ failure with damage to nearly all major tive resources are limited, the non-pneumatic anti-shock organs is possible. The loss of child-bearing potential in garment (NASG) and the pneumatic Military Anti-Shock those needing a hysterectomy and the psychological conse- Trousers (MAST) have been used to provide counter- quences must also to be addressed. pressure to the lower body, enabling resuscitation and sta- bilization of women in hypovolemic shock caused by Interventional radiology. Despite its use for more than 30 years, obstetric hemorrhage until definitive treatment becomes there are no trials of the effectiveness of uterine artery available. A small observational study conducted in embolization in the management of PPH. Selective arterial Pakistan described six women with hypovolemic shock embolization may be useful in situations where preservation being managed with the NASG for 16 to 36 hours while of fertility is desired, where bleeding is not severe or in post- awaiting definitive treatment. All women were successfully operative bleeding, in the management of hematomas, and resuscitated within five minutes using the NASG.39 The use in the presence of coagulopathy. The drawbacks of the pro- of this reusable and lightweight device for stabilizing and cedure are the need for radiological expertise, the time transporting women in low-resource settings needs further required to organize and complete the procedure in an exploration as a step towards decreasing maternal mortality acute situation, and the rare complications, which include and morbidity in developing countries. vessel perforation, hematoma, infection, contrast-related adverse effects, and uterine necrosis. Active management of the third stage of labour, with administration of prophylactic oxytocin, cord clamping, Postpartum Hemorrhage in Developing Countries and delivery of the placenta by controlled cord traction can In developing countries, complications of pregnancy and reduce the incidence and severity of PPH.11 childbirth remain the leading cause of death, disease, and Health education on the initial management of PPH at the disability in women of reproductive age. There are signs of basic level of emergency obstetric services includes the use global improvement in the health and well-being of of additional oxytocin, uterine massage, manual removal of NOVEMBER JOGC NOVEMBRE 2006 l 971 OBSTETRICS Table 3. Algorithm for management of atonic postpartum hemorrhage: HAEMOSTASIS43 H Ask for help A Assess (vital parameters, blood loss) and resuscitate E Establish etiology, ensure availability of blood, ecbolics (Syntometrine, ergometrine, bolus oxytocin) M Massage uterus O Oxytocin infusion/prostaglandins – IV/per rectal/IM/ intramyometrial S Shift to operating theatre – exclude retained products and trauma/bimanual compression T Tamponade balloon/uterine packing A Apply compression sutures – B-Lynch/modified S Systematic pelvic devascularization – uterine/ovarian/quadruple/internal iliac I Interventional radiologist – if appropriate, uterine artery embolization S Subtotal/total abdominal hysterectomy the placenta, the use of balloon tamponade, and repair of home deliveries in low-income countries where the effec- lacerations. Care in a facility with comprehensive emer- tive use of injectable oxytocin is more difficult because it gency obstetric services should include the availability of requires safe administration and special storage to maintain blood transfusion, capacity for the management of stability (especially in tropical climates). The life-saving hypovolemic shock, and surgical interventions ranging potential of misoprostol, with its ease of administration, sta- from compression sutures to hysterectomy. bility, and low cost, could have major implications in these Although effective and efficient maternal health services are rural settings where emergency health care is virtually inac- available at different resource levels, and preventive, cessible. Misoprostol has been shown to reduce the community-based interventions are highly cost effective, incidence of PPH resulting in blood loss of greater than universal access to clinical facility-based health services 1000 mL.41 If further research can demonstrate its effec- remains a problem. A coordinated response involving other tiveness in the many cases where oxytocin is not an option, non-health sectors is required to improve education. Health misoprostol could save many lives and reduce the number systems need to be strengthened, and financial, moral, and of women who suffer anemia as a result of a postpartum political commitment will be needed to achieve the reduc- hemorrhage, currently 1.6 million every year. A multicentre tion in maternal morbidity and mortality outlined in the randomized controlled trial to assess the effects of Millennium Declaration. misoprostol adjunct to the use of injectable oxytocics in women requiring additional uterotonics following active Anemia management of the third stage of labour is currently Iron deficiency anemia, a common and widespread nutri- underway.42 tional disorder that affects every second pregnant woman in developing countries, is frequently exacerbated by malaria, We encourage a stepwise management of PPH using the HIV/AIDS, hookworm infestation, schistosomiasis, and mnemonic “HAEMOSTASIS” (Table 3), following each tuberculosis. It contributes to 20% of all maternal deaths.40 step in rapid succession until hemostasis is achieved.43,44 The management is both inexpensive and effective. Dietary The speed with which deterioration leads to maternal mor- advice and routine iron and folate supplementation during tality and the high success rates of simple surgical proce- pregnancy prevent anemia in the mother at delivery or dures prompt inclusion of the “tamponade test” with basic postpartum. Controlling infections by immunization and emergency obstetric functions and inclusion of compres- providing control programs for malaria, hookworm, and sion sutures with comprehensive emergency obstetric schistosomiasis in endemic areas can help reduce the inci- functions. dence of anemia in late pregnancy. Preventing and control- ling other nutritional deficiencies, such as vitamin B12, The stark differences between countries in the rates of folate, and vitamin A deficiencies, could similarly achieve maternal mortality from PPH highlight the need for better widespread improvement in maternal health and prevent education and universal access to clinical services. Effective maternal morbidity and mortality associated with PPH. medical and surgical interventions are available, and there is increasing evidence of the benefits of more non-invasive Misoprostol surgical management, including uterine tamponade and Although misoprostol was shown to be no better than compression sutures. We hope that this, together with the injected oxytocin in a hospital setting, it may have value in emerging value of misoprostol and global initiatives in the 972 l NOVEMBER JOGC NOVEMBRE 2006  Postpartum Hemorrhage management of PPH, will reduce the incidence of this 22. Katesmark M, Brown R, Raju KS. Successful use of a Sengstaken-Blakemore tube to control massive postpartum haemorrhage. Br J Obstet Gynaecol 1994;101:259–60. life-threatening condition in the next few years. 23. Johanson R, Cox C, Grady K, Howell C. Managing Obstetric Emergencies and Trauma: The MOET Course Manual. RCOG Press, London 2003. REFERENCES 24. Bakri YN, Amri A, Abdul Jabbar F. Tamponade balloon for obstetrical bleeding. Int 1. World Health Organization. Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva; 2004. J Gynaecol Obstet 2001;74:139–42. 2. AbouZahr C. Antepartum and postpartum haemorrhage. In: Murray CJL, Lopez AD, 25. Condous GS, Arulkumaran S, Symonds I, Chapman R, Sinha A, Razvi K. The eds. Health dimensions of sex and reproduction: the global burden of sexually “tamponade test” in the management of massive postpartum haemorrhage. Obstet transmitted diseases, HIV, maternal conditions, perinatal disorders, and congenital Gynecol 2003;101:767–72. anomalies. Cambridge, MA: Harvard School of Public Health on behalf of the World Health Organization and the World Bank; 1998 (Global Burden of Disease and Injury 26. Seror J, Allouche C, Elhaik S. Use of Sengstaken-Blakemore tube in massive Series, No. III):165–89. postpartum haemorrhage: a series of 17 cases. Acta Obstet Gynecol Scand 2005;84:660–4. 3. AbouZahr C. Global burden of maternal death and disability. In: Rodeck C, ed. Reducing maternal death and disability in pregnancy. Oxford: Oxford University 27. Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH). Press; 2003:1–11. Scottish Confidential Audit of Severe Maternal Morbidity, 2nd Annual Report, 2004. 4. Kane TT, El-Kady AA, Saleh S, Hage M, Stanback J, Potter L. Maternal mortality in SPCERH, 2005. Giza, Egypt: magnitude, causes, and prevention. Stud Fam Plann 1992;23:45–57. 28. Akhter S, Begum MR, Kabir J. Condom hydrostatic tamponade for massive 5. World Health Organization. The prevention and management of postpartum postpartum hemorrhage. Int J Gynaecol Obstet 2005;90:134–5. haemorrhage. Geneva: WHO; 1990. 29. B-Lynch C, Coker A, Lawal AH, et al. The B-Lynch surgical technique for the control 6. World Health Organization. Care in normal birth: a practical guide. (WHO/FRH/MSM/96.24) Geneva: WHO; 1996a. of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372–5. 7. Society of Obstetricians and Gynaecologists of Canada. Advances in Labour and Risk Management (ALARM) Course Manual. 9th ed. Ottawa, Ontario: Society of 30. Hayman RG, Arulkumaran S, Steer PJ: Uterine compression sutures: surgical Obstetricians and Gynaecologists of Canada; 2002. management of postpartum hemorrhage. Obstet Gynecol 2002;99:502–6. 8. Sherman SJ, Greenspoon JS, Nelson JM, Paul RH. Identifying the obstetric patient at 31. Tamizian O, Arulkumaran S. The surgical management of post-partum haemorrhage. high risk of multiple-unit blood transfusions. J Reprod Med 1992;37:649–52. Best Pract Res Clin Obstet Gynaecol 2002;16:81–98. 9. Abu-Heija AT, Chalabi HE. Great grandmultiparity: is it a risk? J Obstet Gynaecol 1998;18:136–8. 32. Royal College of Obstetricians and Gynaecologists. Why mothers die 2000–2002. Confidential Enquiry into Maternal and Child Health. The RCOG Press, 2004. 10. Prendiville WJ, Elbourne D, McDonald S: Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev 2000;2:CD000007. 33. Haines A, Cassels A. Can the Millennium Development Goals be attained? BMJ 2004; 329:394–7. 11. International Confederation of Midwives; International Federation of Gynaecologists and Obstetricians. Joint statement: management of the third stage of labour to prevent 34. Nullis-Kapp C. The knowledge is there to achieve development goals, but is the will? post-partum haemorrhage. J Midwifery Womens Health 2004;49:76–7. Bulletin of the World Health Organization 2004;82:804–5. 12. McDonald S, Prendiville WJ, Elbourne D. Prophylactic syntometrine versus oxytocin 35. United Nations Millennium Declaration. New York 2000 (United Nations General for delivery of the placenta (Cochrane Review). In: The Cochrane Library, Issue 2. Assembly resolution 55/2). Available at: http://www.un.org/millennium/ Oxford: Update Software, 1999. declaration/ares552e.pdf Accessed February 11, 2006. 13.Gülmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for prevention of 36. World Health Organization. Coverage of maternity care: a listing of the available postpartum haemorrhage. Cochrane Database Syst Rev 2004;1:CD000494. information, 4th ed. Geneva: World Health Organization; 1997. 14. American College of Obstetricians and Gynecologists: ACOG educational bulletin. 37. World Health Organization. Reduction of maternal mortality: a joint WHO/ UNFPA/ Hemorrhagic shock. Number 235. Int J Gynaecol Obstet 1997;57:219–26. UNICEF/ World Bank Statement. Geneva, 1999. 15. American College of Obstetricians and Gynecologists: ACOG educational bulletin. 38. Graham W, Bell J, Bullough CH. Can skilled attendance at delivery reduce maternal Postpartum hemorrhage. Number 243. Int J Gynaecol Obstet 1998;61:79–86. morbidity in developing countries? In: De Brouwere V, Van Lerberghe W, eds. Safe 16. Bigrigg A, Chissell S, Read MD. Use of intra myometrial 15-methyl prostaglandin F2 motherhood strategies: a review of the evidence, ITG Press, 2001. Studies in Health alpha to control atonic postpartum haemorrhage following vaginal delivery and failure Services Organisation and Policy 17:91–131. of conventional therapy. Br J Obstet Gynaecol 1991;98:734–6. 39. Hensleigh PA. Anti-shock garment provides resuscitation and haemostasis for obstetric 17. O’Brien P, El-Refaey H, Gordon A, et al: Rectally administered misoprostol for the hemorrhage. BJOG 2002;109:1377–84. treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: 40. World Health Organization. Iron deficiency anaemia: assessment, prevention and a descriptive study. Obstet Gynecol 1998;92:212–4. control. A guide for programme managers (document WHO/NHD/01.3). Geneva: 18. Lokugamage AU, Sullivan KR, Niculescu I, et al. A randomized study comparing WHO; 2001. rectally administered misoprostol versus Syntometrine combined with an oxytocin infusion for the cessation of primary post partum hemorrhage. Acta Obstet Gynecol 41. Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B, et al. Misoprostol in Scand 2001;80:835–9. the management of the third stage of labour in the home delivery setting in rural Gambia: a randomised controlled trial. BJOG 2005;112:1277–83. 19. Alok KA, Hagen P, Webb JB. Tranexemic acid in the management of postpartum haemorrhage. Br J Obstet Gynaecol 1996;103:1250–1. 42. World Health Organization. Misoprostol to treat postpartum hemorrhage: a randomized controlled trial. Controlled trials register WHO/HRP ID A 35042, 2005. 20. Boehlen F, Morales MA, Fontana P, Ricou B, Irion O, de Moerloose P. Prolonged treatment of massive postpartum haemorrhage with recombinant factor VIIa: case 43. Chandraharan E, Arulkumaran S. Management algorithm for atonic postpartum report and review of the literature. BJOG 2004;111:284–7. haemorrhage. J Paediatr Obstet Gynaecol 2005;31:106–12. 21. Hsu S, Rodgers B, Lele A, Yeh J. Use of packing in obstetric hemorrhage of uterine 44. Ramanathan G, Arulkumaran S. Postpartum haemorrhage. Curr Obstet Gynaecol origin. J Reprod Med 2003;48:69–71. 2006;16:6–13. NOVEMBER JOGC NOVEMBRE 2006 l 973