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Gestational Diabetes mellitus  :Screening and Dietary management

Dr.Shobhana Mohandas: Article from TOGS, .

 


India has the highest number of diabetic patients in the world. For every person known to have diabetes, there are more than 2 people who have diabetes but are unaware of it. Gestational diabetes mellitus (GDM) is defined by abnormal glucose tolerance during pregnancy; the glucose tolerance test is normal before, and which will usually be normal, after pregnancy. It is present in 3-4% of all pregnancies. The cornerstone of treatment is proper diet management and exercise. To know that diet management is adequate, it is necessary to monitor the patient properly.

Significance of impaired glucose tolerance : The growth and maturation of the foetus is closely associated with the delivery of maternal nutrients, particularly glucose. In patients with severe carbohydrate intolerance, there is an increased rate of miscarriage, congenital malformations, prematurity, pyelonephritis, preeclampsia, in utero meconium, fetal distress, cesarean section deliveries, and stillbirth. However, controversy continues to surround every aspect of this clinical entity known as gestational diabetes. There is no consensus regarding diagnostic criteria, the utility of universal screening, or the association of gestational diabetes with perinatal morbidity and mortality. A recent Cochrane review found no difference in the prevalence of birth weights greater than 4,000 g (8 lb, 13 oz) or cesarean deliveries in women with gestational diabetes who were randomly assigned to receive primary dietary therapy or no specific treatment. The review concluded that insufficient evidence exists to recommend dietary therapy in patients with altered glucose metabolism. The level at which maternal glucose intolerance has no effect on pregnancy outcome is unknown. The risk of congenital anomalies is high in women who are already diabetic at the time of conception, but not in gestational diabetes. Cathy Fagen et al state that” The risk of congenital anomalies in infants of mothers with GDM appears to be no different from that of mothers without diabetes and. Most likely, this is so because glucose intolerance caused by the hormonal changes of pregnancy develops after the first 8 weeks of organogenesis. A woman diagnosed with GDM in her first trimester may have had undiagnosed non-insulin-dependent diabetes mellitus before conception and has a higher risk of birth anomalies. The most serious complication of undetected or untreated GDM is intrauterine fetal demise. This complication is rare when women achieve normal fasting and 2-hour postprandial blood glucose levels .”

Pathophysiology: Approximately 90% of patients diagnosed with gestational diabetes mellitus have a deficiency of insulin receptors (prior to pregnancy) or a marked increase in weight in the abdominal region. The other 10% have deficient insulin production and will proceed to develop mature-onset insulin-dependent diabetes. Early gestation can be viewed as an anabolic condition because of the increases in maternal fat stores and decrease in free fatty acid concentrations. There are progressive increases in insulin secretion in response to an intravenous glucose challenge with advancing gestation. The second half of pregnancy is considered a diabetogenic state because the elevated gestational hormones and increased maternal weight place a demand on the body for extra insulin. Thus gestational diabetes in prone patients tends to manifest more in the latter half of pregnancy.
Need for screening: Screening for gestational diabetes in the past was done only in target populations. However it has now been proved that screening universally all women attending antenatal clinics can reduce the incidence of uncontrolled glucose intolerance.
How to screen: The American Diabetes Association recommends that all pregnant women be screened for GDM between 24 and 28 weeks of gestation. The standard screening test at present is measurement of plasma glucose 1 hour after a 50-g glucose load . Women with glucose levels of 7.8 mmol/L or more are then given a 100-g glucose load for a 3-hour oral glucose tolerance test. It is accepted that ADA criteria is a more stringent criteria and if followed, will show a lesser prevalence of diabetes mellitus.

WHO recommends glucose challenge test using 75g glucose. A blood sugar value is taken after ingestion of 75 gm glucose. A value after 2 hours of > 140 mg/dl is taken as diagnostic of GDM. Seshiah et al, in a study from Chennai, where all women who cheked in for ANC check up in the second or third trimester were screened for diabetes by both methods have concluded that “Using 2 hr plasma glucose > or = 140 mg/dl as a one step procedure is simple and economical, particularly for the countries ethnically more prone to high prevalence of diabetes”. There is a tendency all over the world to accept the 75gm test as a universal test for screening.
Whom to screen: The test should be carried out at the time of initial visit and at the start of every trimester; high risk patients may require more frequent testing. High risk patients need a 75 gm 2 hour OGTT. It is recommended for for older women, those with a previous history of glucose intolerance, those with a history of large-for-gestational-age babies, and any pregnant woman who has a raised fasting or casual blood glucose.
Detailed testing using OGTT is also recommended for
1. Patients with a fasting venous whole blood glucose level of more than 80 mg% (venous plasma glucose more than 90 mg%).
2. A 1 hour post 50 gms. glucose load venous whole blood glucose value greater than 120 mg/% (venous plasma glucose more than 140 mg%).
3. A 2 hour post 75mg glucose load showing > 140mg/dl .
4. A "random" venous blood glucose level exceeding 105 mg% (plasma glucose >120 mg%).
5. Ultrasound findings of fetal weight 70% for gestational age
6. Polyhydramnios (AFI 20).
7. Midline congenital anomalies.
8. An abdominal circumference measurement that exceeds the femur growth by 2 weeks.
9. Other clinical findings indicating possible diabetes are edema developing early in pregnancy and excessive weight gain.
OGTT: For the OGTT, the patient fasts, then receives 100 grams of glucose after a fasting glucose level is obtained. A blood sample is then taken every hour for 3 hours. The patient is advised to sit quietly during the test to minimize the impact of exercise on glucose levels. The diagnosis of GDM is made if there are two abnormal values on the 100-g oral glucose tolerance test.
Plasma Glucose (mg/100ml) Whole Blood Glucose(mg/100ml)
Fasting 105 90
1 hour 190 165
2 hour 165 145
3hour 145 125

Role of testing glycosylated Hb:

Glycoselated Hb levels is a good method to know the overall glycemic control of a patient who is diabetic and is on treatment. Because the average erythrocyte lifespan is 120 days, the HbA1c level is proportional to ambient blood glucose levels during the previous 2 to 3 months. For this reason, HbA1c testing is usually performed quarterly or more frequently. Because lower HbA1c levels have been found to be strongly associated with decreased microvascular and neuropathic complications of diabetes, HbA1c levels have been used as an index of long-term glycemic control. For example, if a patient had a high glycemic diet till 4 days back, but has been on tight control with insulin or otherwise in the past 2 days, a GCT(Glucose challenge test) or OGTT (Oral Glucose Tolerance Test ) will show normal values, but HbA1c values will actually show that the patient did not have good glycemic control in the long run by showing higher values.
However, it has poor value as a primary screening test. Campochiaro et al have, in a study of 442 pregnant women found that, HBA1C as a screening test proved to have many false positives, making many women undergo GTT unnecessarily. They concluded that “Despite all the progress in methodology, HBA1c remains a poor test to screen for GDM”. Mukesh Aggarwal in a study from Taiwan have found that if HBA1c is used as a screening test, to pick up 82% of the diseased patients, 79% of patients without GDM would have to undergo the OGTT. Thus, nearly 80% of all the women screened being higher than the selected (5:5%) threshold, would need the OGTT; and despite performing all these OGTTs nearly one-fifth (17:9%) of the GDM patients would be missed.
In a pregnant woman doing HbA1C test quarterly after she has been diagnosed to have gestational diabetes at 24-28 weeks will mean that the test will be repeated only after she is almost near term. It will be more useful in patients with type 1 diabetes.

                                                   Diet management of gestational diabetes

Nutritional counseling, exercise and dietary therapy are key factors in the management of gestational diabetes. Calories should be prescribed at 20–25/kcal per kilogram of present body weight (generally 1800–2400 kcal) and should not induce post-prandial hyperglycemia. Mild caloric restriction with modification of the carbohydrate component may be advised in obese GDM women. Restricting calories to a great extent may lead to hypoglycemia and elevated ketone levels. Attempting to give a tight dietary control may also lead to acute and chronic fetal malnutrition resulting in growth retardation.
Foods of lower glycemic index, for example, seem to be suited best for women who have diabetes during pregnancy. A formal nutritional consultation should be arranged. In general, the diet should consist of 30 kcal/kg/d to 35 kcal/kg/d—in the form of three main meals and one to two snacks—that consist of 50% to 60% carbohydrates, less than 30% fat, and adequate amounts of dietary fiber. Further restriction of carbohydrates to 40% of total calories may assist in the management of uncontrolled postprandial glucose readings. Women with GDM should be prescribed dietary therapy alone for at least 2 weeks before they are prescribed insulin. In those with fasting glucose above 95 mg/dL, insulin may be prescribed after 1 week of dietary therapy, or at diagnosis.

Practical dietary management of a Kerala patient:
To know how to manage patients with GDM in Kerala, it is best to understand the dietary practices of women who come here for antenatal care. Sample diets from 2 Euglycemic patients, one from a low-income group and one from a high income group is provided below:


Low income group


                                                  Calories               CHO                            Protein                       Fat
Morning


Tea 1 cup                                       72                     13                                  1.4                            1.6
Parboiled Rice 2 cups                     340                    79                                  8.2                            0.94
Coconut chutney  

                                                     121                     6.6                                2                              10.4
Lunch


Parboiled Rice 2 cups                      340                    79                                 8.5                             0.6
fish curry                                        124                     8.7                              11.6                            4.8
Brinjal curry ½ plate                        122                     4.9                                1.4                           10.7


Evening


Tea 1 cup                                         72                    13                                  1.4                             1.6
Banana chips                                  147                    16.5                               0.7                             9.5
Dinner
Parboiled Rice 2 cups                      340                     79                                 8.5                             0.6
Beans thoran                                   200                     17.89                            4.49                          21.1
fish curry 124 8.7 11.6 4.8

Total                                              2042                   326.29(66%)                  60.39(12.32)       67.32(13%)

High income group


Break fast


Tea                                                     72                    13                                 1.4                             1.6
2 dosa                                               216                   29.4                               4.1                             9.7
Coconut chutney                                121                     6.6                               2 10.                          4


Mid-morning


2 idli                                                  130                    27.6                              4.6                              0.2
Coconut chutney                                 121                     6.6                              2                                10.4


Lunch


Parboiled Rice 2 cups                          340                    79                                 8.5                            0.94
sambhar                                               32                    4 1.                               8                               0.9
Fish fry                                               220                       1.4                            17.5                          16.2
Cabbage and carrot currry                       81                      6.1                              1.5                            5.6
Grapes 100 gm                                      45                     10.2                              0.3                            0.1


Evening  


milk 216 9.2 8.4 16
Cashews 1oz 156 9 5 12

Dinner
Parboiled Rice 2 cups                             340                   79                                 8.5                          0.94
fish curry                                                124                     8.7                             11.6                         4.8
Cabbage and carrot currry                          81                     6.1                               1.5                        5.6
1 big banana(200gm)                                306                   72.8                               2.6                       0.4


Total                                                      2541                365.42(67%)                 81.3(15%)             95.38(17%)


From the above diet chart, it is obvious that the average Kerala patient is taking adequate calories. The carbohydrate content of both patients show only a marginal rise from the expected 60%. The fat content is well below 30%. So all that the Kerala patient will need is to reduce foods with high glycemic content, instead of prescribing rigid diet charts. If the post-prandial blood glucose level is high, further reduction of carbohydrates may be needed.


Glycemic index (GI) is the widely used index of carbohydrate foods. It is defined as the incremental area under the blood glucose response curve of a 50g carbohydrate portion of a test food expressed as a percent of the response to the same amount of carbohydrate from a standard food taken by the same subject. Simply speaking, it is a measure of the ability of a food to raise blood sugar levels after it is eaten.

The following steps may help in achieving that goal. The glycemic index of the foods mentioned are given in brackets.

1. Avoid sugar(100-96) in tea, milk and avoid sweets. The 40 calories lost could be made up by consuming additional cheera leaves (62 cal/100g) or a green mango(44cal/100g) per day.
Salted green mango will be a welcome prescription for pregnant women!!
2. Avoid carrots(92-71), Pumpkins(75), Potatoes(75), raisins(66-64),Tapioca, (70, after steaming for 1 hour)
3. It could be replaced by vegetables of low glycemic index like, green peas(48-45), Beans(46-29), tomatoes(15), under ripe Banana(36), nuts(30-15)Cabbage(15), Onion(7)
4. Bengal gram dal(11),(Chana dal, used for kadala kari in Puttu), peanuts and dates(15) are all foods with low glycemic index.
5. Eggs, fish, meats, Chicken etc have 0 glycemic index.
6. Yoghurt with fruit(36) is a good option for vegetarians.
7. Obese diabetics should consume green leafy vegetables before each meal. This will add fibre to the diet, reduce calories and at the same time give a sense of fullness.


Carbohydrate content
in mg per 100gm of some common food stuffs is given below. Appropriate substitutions could be made to reduce CHO content in the diet of patients with poorly controlled post-prandial glucose levels.
Food                                     CHO                                                 Food                                          CHO
Rice, parboiled                       79                                                     French beans                              6.7
Whole wheat flour                    69.4                                                 tomato                                        3.6
Wheat, semolina                     74.8                                                 pumpkin                                      4.6
Wheat, vermicelli                     78.3                                                 Coconut fresh                             13
Bengal gram, whole(kadala)      60.9                                                Ground nut roasted                      26.7
Black gram(uzhunnu )              59.6                                                Apple                                          13.4
Green peas                            15.9                                                 Banana, ripe                                27.2
Red gram (Thuvara)                  57.6                                                Grapes , blue                               13.1
Amaranth (cheera)                     3.5-                                             8 Grapes, green                              16.5
Cabbage                                   4.6                                                Guava                                           9-11
Cauliflower                                7.6                                                 Lemon, sweet(musambi)                7.3
Beet root                                  8.8                                                 orange                                         10.9
potato                                     22.2                                                 Mango ripe                                   16.9
Tapioca                                   38.1                                                 fish                                           0.2-4.6
Colocasia(Chembu)                  18.1                                                 Beef muscle                                  0.2
Yam(Chena)                            26                                                     egg                                              0
onion                                      11                                                    Goat meat                                      0
Lades finger                               6.4                                                 milk                                    Around 5
Plantain green                          14                                                   Curd,butter milk                           3,0.5




                                                         Monitoring patients on insulin:

In India, the insulin doses are usually calculated using urine sugar charts, where urine is tested traditionally as Before dinner, Before lunch, and Before breakfast. However, Measurement of blood glucose is preferable to urine glucose owing to its accuracy, its ability to guide diabetes management through real-time feedback, its ability to reflect postprandial excursions, its ability to provide real-time measurements , and its ability to improve safety for patients at risk of hypoglycemia. Blood glucose can be measured using glucometres, where capillary blood can be tested by the patient herself. Insulin doses could be adjusted by the patient if she is taught well.
Self-monitoring helps patients with gestational diabetes reach stringent goals of glycemic control by motivating adherence to and adjustments in diet and allowing more appropriate decision-making regarding insulin treatment and subsequent dose adjustment, which results in decreased incidence of fetal macrosomia and other fetal and maternal complications. Both fasting and postprandial blood glucose assessments are universally recommended in patients with gestational diabetes to help reach stringent targets for the best fetal outcome. The desired values are a fasting level of 70–90 mg/dL and a 1-hour level of 130 mg/dL. The average glucose levels should be 90 mg/dL.
Urine glucose monitoring is not useful in gestational diabetes.
                                                       Monitoring patients not on insulin:
Consensus has not been reached regarding the optimal frequency and timing of SMBG in non-insulin-treated patients with type 2 diabetes, particularly those who are stable on management with diet but not oral hypoglycemic agents. Most guidelines agree that SMBG can be useful for patients with type 2 diabetes using oral hypoglycemic agents and that some self-monitoring, even if not done daily, may be helpful for diet-treated patients with type 2 diabetes as well.

Barriers to self monitoring:
A longitudinal 12-month study found that easier availability (free of charge) of self-monitoring supplies increased frequency of use and improved glycemic control compared with more limited access (necessity to purchase).Financial, linguistic, and educational factors—as well as patient inability to interpret results of SMBG or act on them—have also been identified as barriers to more adherent self-monitoring and thus to more effective glycemic control. It could definitely be useful in well-to do educated patients. If more and more practitioners start using glucometres, the cost of the instrument might come down. There are some medical companies which rent glucometres for the time of pregnancy in gestational diabetes. Even though costly, once more and more people start using glucometres for patients on insulin therapy , stringent control of gestational diabetes is possible.

Recommendation of an Indian specialist in diabetes:
Dr. P.V.Rao, in www.endocrineindia.com July 2001 recommends Blood glucose monitoring to be initiated 1 week after the start of dietary therapy and consisting of weekly fasting and 2-hour post-breakfast plasma glucose determinations.
If fasting or 2-hour post-prandial plasma values equal or exceed 100 mg/dl or 126 mg/dl, respectively, insulin therapy and weekly ( daily in a few cases ) self-monitoring of blood glucose values should be initiated.

Conclusion: Tight control of blood glucose level can prevent many complications of gestational diabetes. Tight control can be achieved by avoiding food with high glycemic content and frequent monitoring to see that tight control has been achieved. Making patients follow rigid diet charts may be detrimental to the patients. A large multinational study involving 25 000 pregnant women is currently underway
in which all women will have a 75-g glucose tolerance test at the end of the second trimester, with only those women fulfilling the World Health Organization's definition of diabetes (a 2-h plasma glucose > 11.2 mmol L 1) being identified to their obstetric team and do not participate in the study. All others are followed blind to the team treating them and the outcome recorded. This study is called the `Hyperglycaemic Adverse Pregnancy Outcome (HAPO)' study and is planned to conclude in 2004. It is hoped that this study, by having untreated glucose intolerant women, will finally establish, using the 75 g glucose tolerance tests, the level of glycaemia that adversely affects pregnancy outcome and should be treated.


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The World Health Organization defines postpartum hemorrhage as blood loss of 500 mL or more in the first 24 hours postpartum . Although we have no studies to authenticate it, the fact remains that post-partum haemorrhage (PPH) is more common in institutions dealing with a large number of deliveries as also in government run hospitals which cater to women from the lower socio-economic strata.  Gynaecologists who have retired from government institutions and joined the private sector will vouch for the fact that they used to see more patients with PPH when they were working in the government sector.  Something more than the social status of the  patient  seems to be operative in the higher incidence in some hospitals compared to others.  Better patient care with sound following of scientific principles can prevent many catastrophes in the management of PPH.   What follows in this article is a review of some tips in the medical management along with descriptions of a few non-traditional  surgical  techniques in the management of this condition that has been described in literature.

Prevention:

PPH should be anticipated in patients with large uterus due to various factors, uterine atony due to abnormalities in labour like prolonged or precipitate labour,maternal parity more than four,  prolonged use of oxytocin for labor induction or augmentation, chorioamnionitis, use of magnesium sulfate as treatment for preterm labor or pre-eclamsia and in patients with clotting disorders.

Active management of third stage of labour is known to reduce blood-loss post-partum and should be diligently practiced in such patients.

The blood loss at this time can be significant, with approximately 700 mL/min flowing to the term uterus. The average blood loss at a vaginal delivery, which is typically 500 mL causes little or no change in the blood pressure or pulse in most normal pregnant women. Pregnancy-induced hypervolemia accounts for the 30% to 70% increase in blood volume—or an additional 1 to 2 L that prevents symptoms with the typical 500-mL blood loss. A loss of more than 500 mL for a vaginal, 1000 mL for a cesarean and 1500 mL for a repeat cesarean delivery has been defined by many investigators as a postpartum hemorrhage. 

Examination of placenta:

The placenta should be examined thoroughly in the third stage to look for missing cotyledons.

This is specially important, in patients with placenta accrete, percreata, etc. 

A few words on this condi-tion: Placenta accreta occurs at a variable rate and is noted to occur in 1 in 1600 to 70,000 pregnancies. It has an affinity to arise in multiparous women and women with advanced maternal age. The two most important risk factors for a placenta accreta are a known placenta previa and a prior cesarean delivery. Other risk factors include uterine curettage, uterine infection leading to scarring, previous manual placental removal, nonfundic implantation sites (eg, cornual or cervical), leiomyomatous uteri, and a uterus with a rudimentary horn.  Since all the predisposing factors for this condition, like LSCS, leiomyomata, uterine curettage, etc seem to be on the rise, the incidence of this condition may be on the rise.  Patients may quite often forget to give history of uterine curettage .  Uterine infection may also go unnoticed in history taking.  Thus proper evaluation of the patient at the time of first visit and documentation is also very important in predicting this condition. 

 

Active Management of third stage of labour:

Active and physiologic management are two different and well-studied strategies used in the management of the third stage of labor. The basic mechanisms of the active management include uterotonics with delivery of the anterior shoulder of the infant, gentle downward cord traction with counter traction of the uterine body, and early cord clamping. Physiologic management does not recommend uterotonics until after delivery of the placenta (if at all) and no cord traction, and the timing of cord clamping varies, usually after pulsation of the cord has ceased. 

{Although not actually relevant to pph, as an aside, a point about cord clamping is worth mentioning.    In many labour rooms undue hurry is shown by the nursing staff in trying to clamp the cord, as they feel the baby is “safe” once the connection has been severed.  In case the baby has not cried, or seems acidotic, they feel that expediting the cord cutting will help in baby resuscitation.  It should be remembered that as long as the cord pulsation is present, the baby is still receiving oxygen from the mother and more attention should be paid to sucking the baby’s mouth and nose. Clamping of the cord could be delayed till the pulsation of the cord has ceased. }

In a metaanalysis, it was found that  for every 12 patients who received active rather than physiologic management, one postpartum hemorrhage was prevented. For every 67 patients who were actively managed, 1 woman would avoid a transfusion with blood products.

The three key elements in active management of labour are:

1.  Provision of a uterotonic drug within 2 minutes of birth,

2.  Controlled cord traction and

3.  Uterine massage after delivery of the placenta.

Administration of uterotonics: Oxytocic prophylaxis significantly reduces the risk of postpartum hemorrhage by 40% to 50%.

Oxytocin:

The usual intravenous dose of oxytocin  is 10 to 40 U/L of normal saline or lactated Ringer’s solution, and it has no contraindications. Oxytocin should be given in a continuous infusion, and bolus therapy should be avoided. Bolus therapy (intravenously and rapidly) has been linked with maternal cardiovascular collapse.

Methyle ergonovine:

Methylergonovine, an ergotamine, is usually administered intramuscularly in a 0.2-mg dose.  Slightly increased rates of hypertension, nausea, and vomiting are observed with ergot preparations but not with oxytocin.  Oxytocin causes increased frequency and strength of contractions, whereas ergots can cause tetanic contractions of the uterus. 

Misoprostol:

Misoprostol, 800 to 1000 ìg administered rectally or 400 to 600 ìg administered orally, is  proven to prevent and reduce postpartum blood loss.

Removal of placenta at lower segment caesarian section (LSCS):

The most recent Cochrane systematic review states that manual removal of the placenta at caesarean section may do more harm than good, by increasing maternal blood loss and increasing the risk of infection. Spontaneous placental removal appears to lessen blood loss by allowing time for the uterine musculature to contract around the spiral arteries, effectively stopping uterine hemorrhage. If the operator is awaiting spontaneous placental detachment and observes excessive bleeding from the uterine incision, this bleeding site can be clamped until spontaneous placental detachment occurs.

It should be remembered that when blood loss at caesarean section is excessive this must be acknowledged and the patient must be carefully monitored afterwards, with regard to pulse and blood pressure. Collapse can occur without revealed bleeding. It should also be remembered that a young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs.

Patients with placenta praevia specially with previous LSCS are at high risk for PPH and these patients should be handled with care, with adequate back up. 

Management of  a patient who presents with PPH:

The routine drill of looking for a cause, whether traumatic or atonic PPH and immediate measures to prevent the patient from going into shock and treating the cause is familiar to all practicing gynaecologists.  Some salient points in the management of the patient’s circulatory status are worth mentioning.  Due to the 40% expansion in blood volume that occurs by the 30th week of gestation and the 30% rise in hematocrit that is observed in pregnancy, pregnant patients seem to tolerate the acute blood loss of delivery quite well.  A pregnant woman can  loose up to 20% of her blood volume before showing overt clinical signs. The fact that significant fluid shifts from the interstitial space take place within the first 3-4 hours after delivery, will partially correct any volume deficit and further mask signs of excessive blood loss.

Medical management of atonic PPH: 

Atonic PPH is the most common cause of PPH.  Uterotics remain the mainstay of treatment.  If it fails, other measures like packing the uterus or surgical ligations may be resorted to.  The uterotonic administered should last at least 2-3 hours.  (American College of Obstetricians and Gynecologists, 1998). This could be 10 U of oxytocin in 500 mL of intravenous fluid by continuous drip, 200-250 mcg of ergonovine intramuscularly, or 250 mcg of 15-methyl prostaglandin F2-alpha (carboprost) intramuscularly.  With the advent of newer agents in the management of atonic PPH, the need to use surgical methods for managing PPH is decreasing day by day.  Some of the doses in which uterotonics could be used to treat atonic PPH is given below:

Oxytocin:

It can be administered as 10 units intramuscularly or as 20 units diluted in 500 mL normal saline as an intravenous bolus, and can safely and effectively be given to the mother with the delivery of the baby or after the delivery of the placenta.    

Methyle ergonovine maleate:

It is an ergot alkaloid and may be given IM in the dose of 0.25mg and repeated every five minutes till a maximum dose of 1.25mg.  It may be given directly into the uterine muscle or IV in the dose of 0.125mg. It is associated with increased incidence of vomiting compared to oxytocin and can aggravate hypertension. 

Carbaprost:

It is a synthetic analogue of prostaglandin F2 alpha.  It could be given in the dose of 0.25mg IM repeated every 15 minutes to a maximum dose of 2mg.  It may cause nausea, vomiting, diarrhea, headache, hypertension and bronchospasm.  Sometimes it causes flushing, diaphoresis and restlessness. 

Misoprostol:

Cochrane reviews, 2006 have concluded that , Rectal misoprostol in a dose of 800 micrograms could be a useful ‘first line’ drug for the treatment of primary postpartum haemorrhage.  Oral prostaglandins should not be used for the prophylaxis of postpartum hemorrhage. Side effects from misoprostol include shivering, vomiting, diarrhea  and elevated body temperature.  

Mnagement of shock:

The amount of blood lost can be gauged from  clinical symptoms and signs as given in the table given on next page. 

As soon as a patient is seen in obstetric shock, one should call for help.  The next step is always to put up at least one large bore intravenous line with resuscitation fluid (such as Ringers Lactate) and add 20 units of oxytocin to the first litre of fluid. The patient’s bladder should now be emptied, again to allow an atonic uterus to contract and minimize the bleeding.  It is good to remember that the volume of any clotted blood represents half of the blood volume required to form the clots.  NS is a reasonable solution in the labor ward setting because of its low cost and compatibility with most drugs and blood transfusions. The risk of hyperchloremic acidosis is very low in the setting of PPH. If large amounts (>10 L) of crystalloid are being infused, a change to Ringer lactate solution can be considered.  Dextrose-containing solutions, such as 5% dextrose in water or diluted NS in 5% dextrose in water, have no role in the management of PPH. The loss of 1 L of blood requires replacement with 4-5 L of crystalloid because most of the infused fluid is not retained in the intravascular space but instead shifts to the interstitial space. This shift, along with oxytocin use, may result in peripheral edema in the days following PPH.  Use wide-open initial infusion rates, with the goal of infusing the required replacement volume over minutes rather than hours. PPH of up to 1500 mL in a healthy pregnant woman can usually be managed by crystalloid infusion alone Large volumes of colloid solutions (>1000-1500 mL/d) can have an adverse effect on hemostasis. No colloid solution has been demonstrated to be superior to NS, and, because of the expense and the risk of adverse effects with colloids, crystalloid is recommended. A meta-analysis in the Cochrane Library comparing resuscitation with colloid solutions versus crystalloid favored the use of crystalloids with respect to mortality (Choi, 1999; Alderson, 2000). Thus crystalloids should be preferred over colloids in the resuscitation of the PPH patient.

 Order blood transfusions if blood loss is ongoing and thought to be in excess of 2000 mL or if the patient’s clinical status reflects developing shock despite aggressive resuscitation.  Patients requiring massive transfusions (>10 units of blood products) should certainly be managed in a level 3 institution, since careful monitoring and the use of more specialised blood products will be needed.  As soon as it becomes apparent that a patient will need a massive transfusion, baseline coagulation studies and a complete blood count with platelet count should be ordered.  It is advisable that such a patient should first receive 4 units of packed red blood cells, to improve the oxygen carrying capacity, after which whole blood should be administered to replace volume loss and provide the coagulation factors and proteins needed to maintain hemostasis and colloid osmotic pressure.  Platelets should be replaced when depleted, because massive transfusion may impair platelet function.

Coagulopathy: Dilutional coagulopathy is not usually observed until approximately 80% of the original blood volume has been replaced.  . Regularly monitor hemostatic test results in all women who require a massive transfusion. If findings are abnormal in conjunction with ongoing bleeding or oozing from puncture sites, mucous surfaces, or wounds, additional blood products are required. Infuse fresh frozen plasma (FFP), beginning with 4 U and following with additional units to normalize the coagulation test findings.  Cryoprecipitate may be useful along with FFP because of the markedly depressed fibrinogen levels. Cryoprecipitate provides a more concentrated form of fibrinogen and other clotting factors (VIII, XIII, von Willebrand factor) and is faster to prepare in the blood bank. It is commonly given in 6- to 12-U doses and may also be helpful immediately before any surgical intervention in patients with abnormal coagulation test results. The use of heparin and antifibrinolytic therapy is not recommended in women with DIC of obstetric origin.

Thrombocytopenia is likely after 1.5-2 times the blood volume has been replaced. Keep the platelet count more than 50 X 109/L by using platelet transfusion. Each unit of platelets increases the platelet count by approximately 10 X 109/L. (Platelets are usually given in packs of 5-6 U.) If bleeding is continuing and the platelet count is less than 50 X 109/L, administer 10-12 U initially. If surgical intervention is necessary, maintain the platelet count at more than 80-100 X 109/L. Platelet preparations contain some RBCs, and the administration of anti-D immunoglobulin (RhoGAM, WinRho) is recommended for Rh-negative women after the crisis has passed.

DIC may also develop if shock has led to marked hypoperfusion of tissues, causing damage and release of tissue thromboplastins. In such cases, laboratory test results reveal that the D-dimer levels are elevated and fibrinogen levels are very low, with a prolonged thrombin time.

Summary of management in defective coagulation: Order coagulation screen (International Normalized Ratio, activated partial thromboplastin time) if fibrinogen, thrombin time, blood film, and D-The World Health Organization defines postpartum hemorrhage as blood loss of 500 mL or more in the first 24 hours postpartum . Although we have no studies to authenticate it, the fact remains that post-partum haemorrhage (PPH) is more common in institutions dealing with a large number of deliveries as also in government run hospitals which cater to women from the lower socio-economic strata.  Gynaecologists who have retired from government institutions and joined the private sector will vouch for the fact that they used to see more patients with PPH when they were working in the government sector.  Something more than the social status of the  patient  seems to be operative in the higher incidence in some hospitals compared to others.  Better patient care with sound following of scientific principles can prevent many catastrophes in the management of PPH.   What follows in this article is a review of some tips in the medical management along with descriptions of a few non-traditional  surgical  techniques in the management of this condition that has been described in literature.

Prevention:

PPH should be anticipated in patients with large uterus due to various factors, uterine atony due to abnormalities in labour like prolonged or precipitate labour,maternal parity more than four,  prolonged use of oxytocin for labor induction or augmentation, chorioamnionitis, use of magnesium sulfate as treatment for preterm labor or pre-eclamsia and in patients with clotting disorders.

Active management of third stage of labour is known to reduce blood-loss post-partum and should be diligently practiced in such patients.

The blood loss at this time can be significant, with approximately 700 mL/min flowing to the term uterus. The average blood loss at a vaginal delivery, which is typically 500 mL causes little or no change in the blood pressure or pulse in most normal pregnant women. Pregnancy-induced hypervolemia accounts for the 30% to 70% increase in blood volume—or an additional 1 to 2 L that prevents symptoms with the typical 500-mL blood loss. A loss of more than 500 mL for a vaginal, 1000 mL for a cesarean and 1500 mL for a repeat cesarean delivery has been defined by many investigators as a postpartum hemorrhage. 

Examination of placenta:

The placenta should be examined thoroughly in the third stage to look for missing cotyledons.

This is specially important, in patients with placenta accrete, percreata, etc. 

A few words on this condi-tion: Placenta accreta occurs at a variable rate and is noted to occur in 1 in 1600 to 70,000 pregnancies. It has an affinity to arise in multiparous women and women with advanced maternal age. The two most important risk factors for a placenta accreta are a known placenta previa and a prior cesarean delivery. Other risk factors include uterine curettage, uterine infection leading to scarring, previous manual placental removal, nonfundic implantation sites (eg, cornual or cervical), leiomyomatous uteri, and a uterus with a rudimentary horn.  Since all the predisposing factors for this condition, like LSCS, leiomyomata, uterine curettage, etc seem to be on the rise, the incidence of this condition may be on the rise.  Patients may quite often forget to give history of uterine curettage .  Uterine infection may also go unnoticed in history taking.  Thus proper evaluation of the patient at the time of first visit and documentation is also very important in predicting this condition. 

 

Active Management of third stage of labour:

Active and physiologic management are two different and well-studied strategies used in the management of the third stage of labor. The basic mechanisms of the active management include uterotonics with delivery of the anterior shoulder of the infant, gentle downward cord traction with counter traction of the uterine body, and early cord clamping. Physiologic management does not recommend uterotonics until after delivery of the placenta (if at all) and no cord traction, and the timing of cord clamping varies, usually after pulsation of the cord has ceased. 

{Although not actually relevant to pph, as an aside, a point about cord clamping is worth mentioning.    In many labour rooms undue hurry is shown by the nursing staff in trying to clamp the cord, as they feel the baby is “safe” once the connection has been severed.  In case the baby has not cried, or seems acidotic, they feel that expediting the cord cutting will help in baby resuscitation.  It should be remembered that as long as the cord pulsation is present, the baby is still receiving oxygen from the mother and more attention should be paid to sucking the baby’s mouth and nose. Clamping of the cord could be delayed till the pulsation of the cord has ceased. }

In a metaanalysis, it was found that  for every 12 patients who received active rather than physiologic management, one postpartum hemorrhage was prevented. For every 67 patients who were actively managed, 1 woman would avoid a transfusion with blood products.

The three key elements in active management of labour are:

1.  Provision of a uterotonic drug within 2 minutes of birth,

2.  Controlled cord traction and

3.  Uterine massage after delivery of the placenta.

Administration of uterotonics: Oxytocic prophylaxis significantly reduces the risk of postpartum hemorrhage by 40% to 50%.

Oxytocin:

The usual intravenous dose of oxytocin  is 10 to 40 U/L of normal saline or lactated Ringer’s solution, and it has no contraindications. Oxytocin should be given in a continuous infusion, and bolus therapy should be avoided. Bolus therapy (intravenously and rapidly) has been linked with maternal cardiovascular collapse.

Methyle ergonovine:

Methylergonovine, an ergotamine, is usually administered intramuscularly in a 0.2-mg dose.  Slightly increased rates of hypertension, nausea, and vomiting are observed with ergot preparations but not with oxytocin.  Oxytocin causes increased frequency and strength of contractions, whereas ergots can cause tetanic contractions of the uterus. 

Misoprostol:

Misoprostol, 800 to 1000 ìg administered rectally or 400 to 600 ìg administered orally, is  proven to prevent and reduce postpartum blood loss.

Removal of placenta at lower segment caesarian section (LSCS):

The most recent Cochrane systematic review states that manual removal of the placenta at caesarean section may do more harm than good, by increasing maternal blood loss and increasing the risk of infection. Spontaneous placental removal appears to lessen blood loss by allowing time for the uterine musculature to contract around the spiral arteries, effectively stopping uterine hemorrhage. If the operator is awaiting spontaneous placental detachment and observes excessive bleeding from the uterine incision, this bleeding site can be clamped until spontaneous placental detachment occurs.

It should be remembered that when blood loss at caesarean section is excessive this must be acknowledged and the patient must be carefully monitored afterwards, with regard to pulse and blood pressure. Collapse can occur without revealed bleeding. It should also be remembered that a young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs.

Patients with placenta praevia specially with previous LSCS are at high risk for PPH and these patients should be handled with care, with adequate back up. 

Management of  a patient who presents with PPH:

The routine drill of looking for a cause, whether traumatic or atonic PPH and immediate measures to prevent the patient from going into shock and treating the cause is familiar to all practicing gynaecologists.  Some salient points in the management of the patient’s circulatory status are worth mentioning.  Due to the 40% expansion in blood volume that occurs by the 30th week of gestation and the 30% rise in hematocrit that is observed in pregnancy, pregnant patients seem to tolerate the acute blood loss of delivery quite well.  A pregnant woman can  loose up to 20% of her blood volume before showing overt clinical signs. The fact that significant fluid shifts from the interstitial space take place within the first 3-4 hours after delivery, will partially correct any volume deficit and further mask signs of excessive blood loss.