DR. ISSA JABER AL BASHEER HOSPITAL Post partum hemorrhage
objectives 1 - list the important causes of PPH 2 -describe methods for preventing PPH 3 -know how to diagnose and treat PPH
TAJ MAHAL 1630 Sweeden medical college 1670 The first national registry was in sweeden 1750
Introduction Hemorrhage still the leading cause of maternal mortality M. M 2007 530000 deaths per year( 95 -97% in developing countries ) , one women dies every minute. 200000 die due to bleeding each year. Africa – asia Approximately 4% of vaginal deliveries are complicated by blood loss >500 ml
The optimal solution is prevention before birth by assuring that women are healthy. (Ex: treatment of anemia), and at the time of birth by using active management of 3 rd stage All pregnancies are at risk of PPH even if no predusposing factors are present Removal of the placenta leaves a 20 cm diameter wound that continue to bleed if uterine muscle does not contract
Time is very important it is estimated that if untreated or badly treated Death occurs on average in 2 h from PPH 12 h from APH 2 days from obstructed labour
definition 1 - classical : > 500 ml after vaginal delivery : > 1000 ml after ceaserian 2 - clinical : any blood loss that cause hemodynamic instability
Classification Primary 24 h ( 98% ) Secondary 24 h – 6 weeks (2%) uterine infection Retained products quntity of blood loss 1 - visual estimation of blood loss is not reliable 2 - brass v. drape ( india ) 3 - kangas. Africa - soaked piece of cloths 100 cm x 155 cm – 1 piece hold 500 ml Gause 10 x 10 cm 30 -20 -10 4 - change in hematoerit 10% change antipartunm and post partum
Classification based on causative : 4 TS A- TONE 70 -80 % - uterine over distintion MACROSOMIA …………… – relaxation – betamimetic –niphidipine , Mg. SO 4 - rapid and prolonged labour – fibroid – previous PPH Trauma 10 -15 % B- precipitate delivery – ruptum uterus , previous scar , abuse of oxytocin. Operative delivery , uterine inversion
tissue C retained placental tissue , abnormal placenta , PL , accreta , increta , percreta D- Thrombin acquiered syndrome , anticoagulant preexisting WILLIBRAND , HEMOPHILIA ( DIC , hellp (ITP , VON
Classification based on clinical signs and symptoms % ml Blood pressure Signs and symptoms 10 -15 500 -1000 normal Palpitations , diziness 15 -25 1000 -1500 Sligtly low Weakness , sweatty tachy 25 -35 1500 -2000 low Restlessness, pallor, oliguria 35 -45 2000 -3000 Very low Collapse, air hunger, anuria
identification risk factord Antinatal risk factor Previous history of PPH Previous CS Pre eclamsia nulli parity Multiple pregnancies Medical disease , obesity
Intra partum risks factors of PPH 1 - increase with induction of labour and strumental delivery 2 - increase with prolonged 3 rd stage ( greate than 30 min) 3 - increase with lacerations and episiotomy
Diagnosis of PPH Failure to diagnose and manage PPH results in several complications , IDA , pituitary infarction , risk of blood transfusion , hypo volemic shock , coagulopathy , accute tubular nicrosis , coma and death.
Prevention 60 % can be avoidable 1 - correct anemia before delivery 2 -performing episitomy if endicated 3 - practicing active management of 3 rd stage 4 - return to examine the patient before transfer
Active management of rd 3 stage Consist of : 1 - administring utero tonic drugs within one minute of birth 2 - applying controlled cord traction and counter traction to the uterus 3 - massaging the uterus
agent dose Cautions oxytocin 5 -10 U i. m / i. v followed by i. v Influsion of 20 IU in 500 ml Hypotension if given by rapid i. v , water intossication Ergometrine 0. 25 mg i. m/i. v Contraindicated in preeclapsia , can cause nausia and vomiting Carboprost (PGF 2 a) 0. 25 mg i. m /myometrial. Bronchospasm misoprostol 600 -1000 microgram per rectum r. FVIIa 60 -120 microgram /kg i. v. Fever , hypertension Gastrointestinal disturbance
General approach with PPH Call for Help securing the air way , breathing , circulation 2 large bore IV’s( normal saline , o 2 , prepare blood , CBC, coagulation studies ) If bleeding is observed prior to the removal of the placenta oxytocin should be used with control cord traction If not succeed manual removal will be required After removal of the placenta if bleed still mostly is caused by uterine atony. Uterine massage and uterotonic drugs ( oxytocin , methergine , prostaglanding , mesoprostol ). If still bleeding the patient should be examined in operating room.
by manual uterine massage compresses uterine vessels and stimulate uterine contractions : 1 - insert one hand into the vagina and push up against the body of the uterus 2 - place the other hand above the uterus and compress the uterus against the hand in the vagina 3 - massage the anterior and posterior wall
Uterine inversion is rare 1: 10000 – 15000 lifethreatening cause hemorrhage and shock. Placental implantation in the fundus , uterine atony , fundal pressure , and cord traction may lead to uterine inversion. The inverted uterus appears as a bluish –grey mass protruding from the vagina.
Manual replacement under general anesthasia should be made to replace the uterus quickly. Hydrostatic teqnique : the vagina is filled with warm saline 4 L If failed laparatomy should be done.
Uterine rupture Incidence : scarred uterus 1% : unscarred 1: 10000 Complete and incomplete , spontaneous and traumatic and dehescence of a scar. Sign and symptoms : 1. fetal bradycardia 2. vaginal bleeding
3. abdominal tenderness 4. maternal tachycardia 5. collapse. If the rupture is extensive and hemorrhage cannot be stopped by suture , hysterectomy maybe necessary with ovarian conservation.
Cervical and vaginal laceration vulval hematoma Can cause significant blood loss. should be repaired if still bleeding you can insert back in the vagina. Cervical tear , if the laceration reached the internal os means that the laceration reached the uterus should be repaired by laboratory. Hematoma infralevator and supralevator
tissue Retained placenta : failure to deliver the placenta within 30 minutes after birth. Risk factors for invasive placenta : Previous scars , placental previa , D&C. Acreta , increta , percreta (total and partial ). Can be diagnosed antenataly Treated by hysterectomy
conclusion A) call for help b) active management of 3 rd stage reduces PPH C) Early recognition systemic evaluation and treatment minimize morbidity and mortality. D)consider tamboned (baloon) b-lynch E) surgical approach : - hysterectomy - uterine artery lagation and ovarian - internal iliac lagation - uterine embolization THANK YOU
