Postpartum Hemorrhage Overview

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Questions and Answers

What is the first step taken when dealing with primary postpartum hemorrhage after the delivery of the placenta?

Administration of ecbolics

Surgical treatment

Uterine massage

Inspection of placenta & membranes (correct)

Which medication is administered as an ecbolic in the case of postpartum hemorrhage?

Fentanyl

Oxytocin (correct)

Warfarin

Aspirin

What is a positive test result during the balloon tamponade procedure indicative of?

Controlled hemorrhage (correct)

Need for surgical intervention

Immediate hysterectomy required

Failure of bimanual compression

What is the purpose of bimanual compression of the uterus?

To control bleeding by maintaining uterine contraction Signup and view all the answers

Which surgical treatment involves ligating the main trunks of uterine arteries?

Bilateral uterine artery ligation Signup and view all the answers

What could be a reason for performing an exploration of the uterine cavity?

To remove retained placental fragments Signup and view all the answers

In the event that balloon tamponade is unsuccessful, what is the next step?

Surgical intervention Signup and view all the answers

Which medication can be administered rectally as part of the treatment for postpartum hemorrhage?

Misoprostol Signup and view all the answers

What is the primary definition of postpartum hemorrhage (PPH)?

Excessive bleeding from the genital tract after delivery and until 6 weeks postpartum Signup and view all the answers

What is considered a primary postpartum hemorrhage (1ry PPH)?

Blood loss > 500 ml after vaginal delivery or > 1000 ml after cesarean section Signup and view all the answers

Which of the following is the most common cause of 1ry PPH?

Uterine atony Signup and view all the answers

Which factor is NOT a predisposing risk for uterine atony?

Low blood sugar levels Signup and view all the answers

What type of examination sign indicates hypovolemic shock?

Pale or clammy skin Signup and view all the answers

What is a necessary investigative action in diagnosing PPH?

CBC and coagulation profile Signup and view all the answers

Which condition is categorized under trauma-related PPH?

Acute inversion of uterus Signup and view all the answers

Which coagulation defect is associated with postpartum hemorrhage?

Hemophilia Signup and view all the answers

What is the primary purpose of compression of the abdominal aorta during laparotomy?

To provide time for treating hypotension and identifying the source of bleeding Signup and view all the answers

Which of the following is a side effect of uterine packing?

Infection and shock Signup and view all the answers

What is one method to treat traumatic postpartum hemorrhage (PPH)?

Direct injection of vasoconstrictors Signup and view all the answers

Which of the following is NOT a part of postpartum hemorrhage aftercare?

Immediate surgical intervention Signup and view all the answers

What is a common etiology of secondary postpartum hemorrhage?

Retained placental fragments Signup and view all the answers

What is the first step in the treatment of retained placental fragments associated with bleeding?

Administration of ecbolics and antibiotics Signup and view all the answers

How is severe postpartum hemorrhage due to retained placental fragments typically managed?

Vaginal evacuation under anesthesia Signup and view all the answers

Which of the following complications is NOT associated with the third stage of labor?

Severe hypertension Signup and view all the answers

What type of bleeding is characterized by dark clotted blood that comes in gushes?

Atonic PPH Signup and view all the answers

Which condition typically occurs immediately after the delivery of the fetus?

Traumatic PPH Signup and view all the answers

What is indicated by a flabby and doughy uterus?

Atonic PPH Signup and view all the answers

Which preventative measure is recommended for cases at risk of postpartum hemorrhage?

Detection and correction of anemia Signup and view all the answers

What should be done immediately in the presence of atonic PPH?

Immediate delivery of placenta Signup and view all the answers

Which of the following is NOT a post-delivery care recommendation for preventing hemorrhage?

Avoidance of monitoring urine output Signup and view all the answers

Which procedure is necessary for both assessing the cause of hemorrhage and ensuring proper treatment?

CBC and coagulation profile lab investigations Signup and view all the answers

What happens to the fundal level of the uterus in cases of traumatic PPH?

Constant fundal level Signup and view all the answers

Study Notes

Postpartum Hemorrhage (PPH)

Definition: Excessive bleeding from the genital tract after delivery, lasting until the end of the puerperium (6 weeks after delivery)
Incidence: 4% of all deliveries and 6% of cesarean sections in developed countries; still high in developing countries, as it's the leading cause of maternal mortality (30%)
Types: Primary PPH (within 24 hours after delivery) and Secondary PPH (after 24 hours but before 6 weeks)

Primary Postpartum Hemorrhage (1ry PPH)

Definition: Excessive bleeding from the genital tract during the third stage of labor or within the first 24 hours after delivery (more than 500 ml after vaginal delivery or more than 1000 ml after cesarean section, or any blood loss impacting the patient's overall condition)
Average blood loss in normal labor: 300 ml
Etiology (Tone, Trauma, Clotting):
- Atonic PPH (most common): Caused by uterine atony, predisposing factors include:
  - Multiparity
  - Uterine overdistention (twins or polyhydramnios)
  - Placenta previa
  - Uterine fibroids
  - Uterine relaxants (tocolytics)
  - Halogenated anesthesia
  - Chorioamnionitis
  - Severe anemia
  - Full bladder or rectum
  - Prolonged or precipitate labor
  - Retained placenta, placental fragments, membranes, or blood clots
  - Idiopathic
- Traumatic PPH: Caused by:
  - Lacerations of the perineum, vulva, vagina, or cervix
  - Uterine rupture
  - Acute uterine inversion
- Coagulation defects:
  - Disseminated intravascular coagulation (DIC)
  - Other conditions: thrombocytopenia, von Willebrand's disease, and hemophilia
- Combination of factors
Diagnosis:
- History: Previous PPH, predisposing factors, time of onset of bleeding, and amount of blood loss
- Examination: General (signs of hypovolemic shock), abdominal (uterine consistency and fundal level), and local (inspection for bleeding, color, and clotting, inspection for lacerations, manual exploration of the uterus)
- Investigations: Complete blood count (CBC) and coagulation profile
Differential diagnosis: Most crucial differentiations are between Atonic and Traumatic PPH:
- Atonic PPH: Onset a few minutes after placental separation and delivery; bleeding in dark clotted gushes (venous); uterus flabby and doughy; rising fundal level; intact birth canal on exploration
- Traumatic PPH: Onset immediately after fetal delivery, even before placental separation; continuous trickling of red, non-clotted blood (arterial); contracted uterus; constant fundal level; lacerations, tears, or uterine rupture on exploration

Prevention of PPH

Antepartum: Detection and correction of anemia; hospital delivery with cross-matched blood for high-risk cases
Intrapartum: Proper use of analgesia and anesthesia; avoidance of prolonged labor; avoidance of traumatic deliveries; active management of the third stage of labor (associated with less incidence of atonic PPH); routine examination of the placenta and membranes to ensure complete expulsion
Postpartum: Exploration of the birth canal after difficult or instrumental deliveries; administration of rectal prostaglandins (misoprostol); careful observation during the fourth stage of labor (1-2 hours after delivery)

Treatment of PPH

First-aid measures and resuscitation: Establishment of intravenous (IV) lines, antishock measures (blood transfusion, IV fluids, corticosteroids), insertion of a urinary catheter, laboratory investigations (CBC, coagulation profile, blood gases, serum creatinine), confirmation of diagnosis and cause of hemorrhage, and close monitoring of vital signs
Arrest of bleeding:
- Atonic PPH:
  - Bleeding before placental delivery (third-stage bleeding): Immediate delivery of the placenta regardless of time factor (see retained placenta)
  - Bleeding after placental delivery (true 1ry PPH):
    - Inspection of the placenta and membranes: Removal of any missed parts manually under anesthesia
    - Uterine massage: Slow, firm, rotatory movements with fingers behind the fundus and thumb in front; abdominal compression
    - Ecbolics: Oxytocin drip, ergometrine (methergin), prostaglandins (misoprostol rectally, methyl PGF2α IM or intramyometrial)
    - Exploration of the uterine cavity and birth canal under anesthesia: Removal of placental fragments, membranes, or clots; detection and repair of tears
    - Bimanual compression of the uterus: Closed fist of the right hand in the anterior vaginal fornix and the left hand abdominally behind the body of the uterus, maintained until the uterus is firmly contracted (ecbolics and blood transfusion are administered during compression)
    - Balloon tamponade (tamponade test): Hydrostatic balloon catheter (Foley's, Sengstaken-Blakemore, Rusch, or Bakri) inserted into the uterus and filled with 200-500 ml of warm saline to control bleeding
    - Surgical treatment: Bilateral uterine artery ligation, bilateral internal iliac artery ligation, bilateral ovarian artery ligation, uterine compression sutures (B-Lynch, modified B-Lynch, vertical, square), supravaginal hysterectomy
    - Other less common methods: Abdominal aortic compression, uterine packing, radiographic embolization of pelvic vessels, direct intra-arterial injection of vasoconstrictors
- Traumatic PPH: Treated according to the type of injury
- Coagulation defects: Treatment of the cause, fresh blood, fresh frozen plasma, or platelet transfusion, antifibrinolytics
Aftercare of PPH: Close monitoring, ecbolics to maintain uterine contraction, prophylactic antibiotics, and treatment of resulting anemia

Secondary Postpartum Hemorrhage (2ry PPH)

Definition: Abnormal or excessive bleeding from the genital tract after 24 hours and before 6 weeks after delivery
Etiology:
- Retained placental fragments, membranes, or blood clots, or formation of a placental polyp
- Infection (separation of infected retained parts, infected placental site, infected cesarean section wound, or infected genital tract lacerations)
- Subinvolution of the uterus
- Puerperal uterine inversion
- Submucous fibroid
- Choriocarcinoma
- Local gynecological lesions (such as cervical polyps or cervical cancer)
- General diseases (such as hypertensive heart failure)
Treatment:
- First-aid measures and resuscitation
- Treatment of the cause:
  - Retained placental fragments, membranes, or blood clots: Ecbolics and antibiotics for minimal bleeding; vaginal evacuation under anesthesia with histopathological examination of the products for choriocarcinoma if bleeding is severe or persistent
  - Infection: Antibiotics
  - Other causes: Treated according to the condition

Complications of the Third Stage of Labor

Retained placenta
Acute uterine inversion
Postpartum hemorrhage
Obstetric shock
Amniotic fluid embolism

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Description

This quiz covers the definition, incidence, and types of postpartum hemorrhage (PPH), focusing on both primary and secondary PPH. It also explores the causes and implications on maternal health, providing essential information for understanding this critical condition.