Hello, I am
Dr. Swati Naik and once again welcome back on Emcure AICOG TV live from Bhubaneswar. am pleased to have with me Dr. Sheela Mane. She is one of my favorite teacher and she is a professor and she is practicing at Anugraha Nursing Home in Banglore. Thanks a lot madam for joining us on Emcure AICOG tv. We are going to have some very good insights from madam on the topic of postpartum hemorrhage. I think the topic very very critical to every obstetrician and gynecologist, but it is very difficult to predict. We need to prepare and we need to respond in time, so that we do not have a maternal mortality because of the condition, which is easily treatable and manageable Yes. So let me begin with the first question mam. Why did you think the PPH is on rise and why do we come to end in result of a maternal mortality with PPH? Thank you for the invitation, really speaking it is not on the rise, even today the maternal mortality in India postpartum hemorrhage is the major cause and the IME is that postpartum hemorrhage is preventable so what is more important today is that we have to take all the precautions to see that we prevent postpartum hemorrhage. Now all of us we know about acute management of third stage of labor we do practice that, but it happens sometimes that even though we are practicing and we call it as AMTSL which prevents atonic PPH almost in 70% of the cases, but even though we know the risk factors and we have predicted it can still happen so what is more important is that we have to be prepared, it is not only the mortality, but also the morbidity because if the patient is losing blood she becomes anemic and then she can have many problems due to this. The co morbidities can come like anemia then sepsis, failure of lactation and the women remains anemic even later on in the postnatal period so it is very important that not only the mortality just it causes, but also morbidity we have to look into that to see to it that we diagnose it in time and we are prepared for handle it because that is very important to prevent the mortality and morbidity. Madam how do we predict? I mean if a patient is coming to me on a regular antenatal care what is those that raise my suspicion factors, till now I would predict that this is likely to end up in postpartum hemorrhage is there anything or? No in India like if we look at we have a different scenario most of the women are anemic, they are small made and also the hypertension in pregnancy. Now these 3 factors again make them vulnerable to have postpartum hemorrhage. Like the regular definition of the postpartum hemorrhage is 500 mL blood loss in viaginal delivery, if it is more than that, but for these women even if the blood is 350 mL it matters because they get show the signs of hypovolemia with this much, that is one thing, the other predicting factors will be other risk factor like if they have multiple pregnancies, if they are multi gravidas, if they have polyhydramnios associated, if they are elderly and if they are obessed All this factors coming too and also if suppose we have induced labor so these are things, which are risk factors, which can lead to, so we have to better prepared and be careful in these cases. Absolutely, so the risk factor identification. Yeah, and also the abnormal placentas like placenta previa and adherent placenta if we diagnosed early. We have to be really better prepared and this type of cases like placenta previa and adherent placenta. It is better we manage Tertiary Care Center where all the facilities are available. The blood bank backup is there is very important because these patients they can have massive hemorrhage. Absolutely, so one needs to be very very vigilant with those risk factors coming into picture. Mam what is the golden hour in the management of postpartum hemorrhage where one need to be really on toes What do you have to say? See the golden hour starts the moment we diagnose postpartum hemorrhage and from that time every minute is important. Right. It is not that we wait for an hour like for a neonatologist every second is important when the neonatologist is resuscitating the baby, that one minute, that way every minute so in that golden hour the main aim for postpartum hemorrhage is arrest bleeding, arrest bleeding and arrest bleeding so we start our Oxytocic drill. We do by manual compression. We can do aortic compression so we do all the measures to see that we arrest bleeding, because if we arrest bleeding then the patient will not bleed She will not going to hypovolemic shock and it is very important that clinically we have to assess. Now we have to do the blood loss assessment. We know that it is very subjective but we can also assess bleeding and one simple measure to assess the blood loss clinically is shock index Shock index is heart rate divided by systolic blood pressure. Okay. Now, always the heart rate is lesser than the systolic blood pressure. Once the patient starts bleeding, there is a hypovolemia in a normal person the shock index is 0.5 to 0.7 and in a pregnant women it is 0.7 to 0.9 if it rolls beyond 0.9 that means she is hypovolemic. If it is 1.2 that means already she has lost 30% of blood. Oh really. And if the 30% of blood loss if we do not correct. Okay, and it is very a simple measure even those who are at the remote places or in the periphery they know that the patient has problem and the simple measure can tell you and immediately you can action and correct so in golden hour as I said Oxytocins now we use Oxytocin. We use Carboprost. We use Misoprostol as well as we use Ergometrine. Now the new drug which come now is that Tranexamic acid after the Women crime and earlier we use to the W.H.O. recommendation was that use only in a traumatic postpartum hemorrhage, but now that the FIGO and women trial have told us that use it as early as possible. Absolutely, irrespective of the cause of the bleeding. Yes irrespective 1 gram, either you can push it slowly over a period of 10 minutes or it can be added to 100 ml normal saline and you give it and it really helps so now again Tranexamic acid is there and we have found that if we use it quickly they say that if it is used within 3 hours it reduces the mortality by 30% which will be really a large number, Yeah. okay, apart from that other measures whatever we have to do like the balloon tamponade we can do simple measure that is compression from inside, then we can use a light wrap that is anti shock garment if it is applied to lower part of the body it prevents the blood loss and also it shifts the blood from the periphery to vital organs like the heart and lung and patient’s blood pressure can be maintained till the help arise, till the blood arise, so it is very important. First the patient is losing we do have blood immediately give IV fluids particularly isotonic fluids like either RLR or normal saline. No question of giving 5% Dextrose here. We have to give at least 1:3 in that ratio, but not too much also because that can cause washout phenomenon and coagulation, coagulopathy because of the washout phenomenon. The blood yes it is very important that if you are in remote place at least you have a blood storage facility. If the patient is RH negative be careful know her group, get the people in the blood cross match and kept in the blood bank ready so that in case of an emergency or at least donor is ready who has been cross match so that you can ask the person to come and donate the blood so these are things which needs to be kept ready so what is important is I always say that postpartum hemorrhage is prevent or predict. prepare and handle so one has to be well prepared so that in golden hour we do not land with up with problems. Absolutely, thank you so much I think key message coming up is a shock index, which I have heard from many few people and it is a very doable in clinic tool, it will guide you what exactly is the percentage of the blood loss And how is the clinical condition? In a clinical condition of the patient. Second thing is a role of Tranexamic acid which has been raised up all the guidelines including W.H.O. earlier the better and the third thing I think one need to be very vigilant and I think you were referring to the anti-pneumatic shock garment okay So that is a new thing that is coming up. It is not new actually it is already there, but it is not been used in a country like India, where if you look at the maternal death review which every state is doing and if you look that you will find that the maximum deaths are due to postpartum hemorrhage and they are happening in transit transit right..right.. so it is very important in remote places when the blood is not available. you apply garment and shift the patient at least she reaches to the hospital in a stable condition and not in irreversible shock so Tamil Nadu is the only state which is using it all levels. I think and we all know that Tamil Nadu has already achieved MDG role file Oh! Nice. I think we do not have to look at others. There are so many states with whom I mean… we can collaborate and learn lessons from them. Definitely madam. Thank you so much madam for sharing all those wonderful views on the management of PPH Thanks a lot for joining us on Emcure AICOG TV. Thank you so much. And one more message I would like give dear friends. I take this opportunity to invite you all to Bangalore in 2019 for AICOG from 8 January to 12 January. Now our logo is “Women’s Health is Nation’s Wealth” so it is very important that we take care of our goals and women in our country. Thank you very much.