Postpartum Hemorrhage

Report
Postpartum Hemorrhage
Abdulah Al-Tayyem;MD;JBOG
Consultant Ob&Gyn
Urogynaecology
Zarka Govern. Hospital
PPH: excessive blood loss after delivery sufficient to
affect the general condition of the mother
(tachycardia and or hypotension).
Types:
-primary within 24h
-secondary after the first 24h up to 42nd day
Causes
-uterine atony
-genital trauma
-coagulations disorders
-3rd stage complications:
-mismanagement of the 3rd stage of labour
-acute inversion of the uterus
-abnormal or incomplete placental
separation
Factors predispose to uterine atony
• Overdistended uterus:-polyhydramnios -macrosomia
-multiple pregnancy
• Uterine muscle exhaustion: -prolonged labour
-grand multiparity -precipitate labour
• Intrauterine infection: -prolonged ROM -chorioamionitis
• Functional or anatomic distortion of the uterus:
-fibroid uterus – placenta previa –uterine anomalies
• Certain general anesthetics( halothane)
• History of previous PPH
Factors predispose to genital tract trauma
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A precipitate delivery, or an operative or manipulative delivery
predispose the genital tract to lacerations :
-cervix - vagina -perineum
Malposition ,malpresentations or deep engagement of the
fetal head ) CS,instrumental deliveries)
Previous uterine surgery
Abuse of oxytocin
Factors predispose to retained product of
conception
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An incomplete placenta at delivery
Previous uterine surgery
Multiparity
An abnormal placenta on US
Intrauterine infections may lead to adherent placenta
Abnormalities of coagulation
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Hemophilia A or Von Willebrad’s disease
Idiopathic thrombocytopenic purpura(ITP)
History of liver disease
Use of anticoagulants
Acquired in pregnancy:
-thrombocytopenia with PET(HELLP syndrome)
-DIC caused by: -abruptio placentae
-chorioamionitis
-IUFD
Diagnosis
• History taking
• Physical examination
tachycardia and hypotension my be present without evidence of
excessive blood loss in cases of uterine rupture
• Consistency of the uterus( lax,firm)
• Asses amount of vaginal bleeding
• Look for laceration
• Determine whether the placenta has been delivered
In women with hypertension or pre-eclampsia,
severe blood loss may cause a misleading normal blood
pressure reading and an under diagnosed state of shock
Degree of Hemorrhagic Shock
Grade type
Volume loss
%of B.V
Systolic B.P
Symptom
Grade 1
compensated
500-100 ml
(10-15%)
normal
Palpitation
dizziness
Grade 2
1000-1500 ml
(15-25%)
Slight fall
Weakness
sweating
Grade 3
1500-2000 ml
(25-35%)
70-80 mmHg
Restlessness,
pallor,oliguria
Grade 4
2000-3000 ml
(35-45%)
50-70 mmHg
Collapse,anuria
Shortness off
breath
• Investigations : as in APH
After the history and physical examination are
completed, the cause of PPH can be determined
as follow:
Diagnosis off PPH
Symptoms and sings
typically present
Symptoms and sings
sometimes present
Probable diagnosis
•Primary PPH ,
•Uterus soft and not
contracted
•shock
Atonic uterus
•Primary PPH
•Complete placenta
•Uterus contracted
Tears of cervix,
Vagina or perineum
•Placenta not delivered
•Primary PPH
with 30 min after delivery •Uterus contracted
•Portion of the maternal
surface of the placenta
missing or torn
membranes with vessels
•Immediate PPH
•Uterus contracted
Retained placenta
Diagnosis off PPH
Symptoms and sings
typically present
Symptoms and sings
sometimes present
Probable diagnosis
•Uterine fundus not felt on
abd.palpation
•Slight or intense pain
•Inverted uterus apparent at
vulva
•Primary PPH
Retained placental fragments
•Primary PPH ) bleeding
intraabdominal a/o vaginal)
•Severe abdominal pain(may
decrease after ruptrure
•Amount of bleeding is not
related to the degree of
shock
•Tender abdomen
•Rapid maternal pulse
•State of shock
Rupture uterus
•Bleeding occurs more than
24h after delivery
•Uterus softer and larger
than expected for time since
delivery
Bleeding is variable) light to
heavy,continuous or
irregular) and may be foulsmellig
Anemia Fever
Secondary PPH
Management
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Preventive are during the antenatal period.
Preventive care during labour and delivery.
Emergency rules
First aid management
Use of utertonic agents :oxytocin,misoprostol
Active Management
• Placenta retained: manual removal under adequate
anesthesia.
• Uterine inversion reposition of the uterus
• Placenta delivered:
-uterus soft use oxytocin
-exploration under general anesthesia ,
repair any cervical tears.
-tear extends beyond the vaginal vault
do laparotomy.
At Lapatotomy :
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Surgical compression suture-(Lynch suture)
Balloon tamponade
Surgical repair
Ligation of the uterine ,utero-ovarian or hypogastric
arteries
• Subtotal hysterectomy
Important Considerations
• Remember that a postpartum women can lose a large amount of
blood in a very short time.
• You must act promptly and anticipate complications
• Assure adequate team coverage
• A laparotomy for PPH is an extremely urgent situation, do not
delay while waiting for blood transfusion.
• Administer prophylactic antibiotics, Ampicillin 2 gm IV ,before
and after the procedure
• Do not give oxytocin as an undiluted IV push since the women
may collapse
Thank you

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