Postpartum Hemorrhage (PPH) and abnormalities of the Third Stage Sept 12 – Dr. Z. Malewski Definition • Excessive bleeding from the genital tract after the birth of the child • Conventionally defined as a loss of more than 500ml of blood • May be immediate (or primary) or if it occurs more than 24 hours after delivery it is described as secondary Primary Postpartum Hemorrhage • Two sources: the placental site and lacerations of the genital tract. • Incidence is reported to be between 1-2% of deliveries, although PPH accounted for over 60% of all maternal death from hemorrhage. PPH from placental site – causes: • Ineffective uterine contraction and retraction may occur • After a long labor caused by weak and uncoordinated uterine action • If prolonged deep anesthesia has been administered • In multipara with an atonic uterus • If the uterus has been over distended (big child, polyhydromnios, twin pregnancy) • In a case of antepartum hemorrhage – placenta praevia and abruptio placentae PPH from placental site – causes: continuation • Mismanagement of the 3rd stage (if the uterus is manipulated during the interval after a normal delivery and before complete separation has occurred, the placenta may be partly separated and bleeding may begin) • Abnormally adherent placenta ( placenta accreta – villi penetrate through the decidua and placenta increta – villi penetrate into myometrium • Disseminated intravascular coagulation (DIC) and other clotting disorders – concealed abruptio placentae, amniotic embolism, after dead fetus has been retained in the uterus for some weeks – rapid depletion of coagulation factors and platelets resulting in catastrophic bleeding • Inversion of the uterus and hourglass constriction and placental retention Clinical events • The escape of blood • In rare instances severe bleeding occurs into the cavity of an atonic uterus, with only some of the blood appearing externally. This should be suspected if the patient becomes shocked, the fundus of the uterus appears to be abnormally high in the abdomen and the uterus feels larger and softer than normal • If hemorrhage continues, the blood pressure falls, the pulse rate rises, and in severs cases pallor and air-hunger occurs. Clinical events continuation • Circulatory collapse caused by hemorrhage (immediate blood transfusion is essential to restore the blood volume, and an infusion of plasma or saline may be started while the transfusion is being arranged) • Postpartum necrosis of the anterior love of the pituitary gland as a sequel of PPH in which the blood pressure has remained at a low level of some hours. Prevention • Anemia must be corrected during pregnancy because an anemic patient tolarates hemorrhage badly • Prolonged labor can lead to uterine exhaustion – the second stage of labor should be short • The correct management of the third stage is using OXYTOCIN or ERGOMETRINE Treatment Two principles govern the treatment of PPH: 1. The bleeding must be arrested 2. The blood volume must be restored Treatment continuation • Treatment if the placenta has already been delivered (rubbing the uterus with the hand, ergometrine injections, other causes of bleeding – a laceration of the cervix or vagina) • Treatment if the placenta is not delivered – if the placenta has separated or if it has not separated Secondary Postpartum Hemorrhage • This occurs more than 24 hours after delivery of the child • It is usually caused by the retention of a piece of the placenta or membranes, and frequently complicated by intrauterine infections with pyrexia • Ultrasound examination will show whether there is retained placental tissue.