Page 106 - Hospital Authority Convention 2017

Masterclasses
HOSPITAL AUTHORITY CONVENTION 2017

M7.2 Massive Primary Postpartum Haemorrhage 16:15 Theatre 2

Second Line Therapies – Balloon Tamponade, Compression Sutures and Others
Lau WL
Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong
Postpartum haemorrhage (PPH) is an obstetrical emergency and remains a major cause of maternal morbidity and mortality.
Early use of second line therapies could reduce blood transfusions, hysterectomies, admissions to intensive care units, and
maternal deaths. Second line therapies include compression sutures, balloon tamponade and uterine artery embolisation.

B-lynch brace compression suture or its modification is effective in controlling bleeding due to uterine atony. Hwu’s stitches
(two vertical compression sutures at lower segment) are useful to control bleeding due to placenta praevia/accreta. Balloon
tamponade is effective in controlling bleeding due to uterine atony or placenta praevia. Uterine artery embolisation performed
by intervention radiologist could be employed either for placenta accreta/percreta prophylactically or in case of failed balloon
tamponade/compression sutures on emergency basis. Furthermore, various combinations of these second therapies have
been proposed. Early recognition of maternal deterioration is critical to initiate active resuscitation. For example, Obstetric
Shock Index (OSI) more than 1, measured at 10 minutes and 30 minutes after the onset of postpartum bleeding could be a
useful indicator in estimating blood loss in cases of massive PPH, and in predicting the need for blood transfusion. The OSI
was calculated as pulse rate divided by systolic blood pressure. One should be aware of the potential pitfall in the presence
of maternal fever or pre-eclampsia. Close monitoring with regular assessment after application of second line therapies is
essential to detect any on-going bleeding. We should be prepared for definitive interventions promptly when second therapies
Tuesday, 16 May knowledge, skills and attitude.
failed to arrest the bleeding. Active involvement of consultant, multi-disciplinary team approach and massive transfusion
protocol are pivotal to the management of massive PPH. Regular drills and workshops are essential in the dissemination of

M7.3 Massive Primary Postpartum Haemorrhage 16:15 Theatre 2

Massive Transfusion Protocol in Obstetric Haemorrhage
Lee CK
Hong Kong Red Cross Blood Transfusion Service, Hong Kong

In the last decade or so, coagulopathy associated with tissue damage and ischaemia in trauma has resulted in widespread
use of massive transfusion protocol (MTP) in clinical practice. With the use of early and optimal transfusion support to correct
coagulopathy and to sustain organ perfusion and oxygenation, patient outcome is enhanced.

In obstetrics, postpartum haemorrhage is serious and life-threatening but can happen without conspicuous clinical
symptoms and signs. It is also complicated by serious coagulopathy and bleeding within a short time which needs prompt
management including both bleeding control and transfusion support. Therefore, alertness to the impending or ongoing
massive haemorrhage remains the crucial factor to call for early use of MTP and team approach in management. However,
one should be reminded that MTP relies heavily on timely communication and co-ordination among different parties, namely,
haematology laboratory, blood bank and the caring team members, i.e. obstetricians and anaesthetists.

Availability of formula ratio of blood components at blood banks of major acute hospitals with labour ward, greatly facilitates
early transfusion support with the obstetrician works to achieve bleeding control. However, a few practical points have to be
noted. Firstly, team members should be aware of time lapse from blood components ordered to be ready and the dilutional
effects from the fluid used in the resuscitation. If a larger quantity of blood components, in particular, platelet and plasma
is required, blood bank and even the blood transfusion service should be alerted early. Secondly, ongoing laboratory
assessment of coagulopathy is often necessary to guide further transfusion support. Point-of-care testing measurement of
haemostasis in operating room providing early assessment and guidance of ongoing component therapy is becoming more
common. Last but not the least, drill training and practice should be regularly performed to allow members familiar with MTP
and management workflow.

In summary, availability of MTP allows optimisation of clinical and haematological environment for active resuscitation of the
mother who suffers from severe obstetric haemorrhage where a better outcome is anticipated.

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