Postpartum Hemorrhage (PPH) PDF

Postpartum Hemorrhage Dr Justus Ngatia MB.ChB ; M.Med (NRB) Lecturer Kenyatta University  Defn Denotes excessive bleeding > 500ml in Normal del Before, during or after del of placenta Early PPH = during first 24 hrs Late PPH = btn 24 hrs and 6/52  Primary PP...

Postpartum Hemorrhage Dr Justus Ngatia MB.ChB ; M.Med (NRB) Lecturer Kenyatta University  Defn Denotes excessive bleeding > 500ml in Normal del Before, during or after del of placenta Early PPH = during first 24 hrs Late PPH = btn 24 hrs and 6/52  Primary PPH is the most common form of major obstetric haemorrhage. Primary PPH is the loss of >= 500 ml of blood within 24 hours of del. PPH can be minor (500–1000 ml) or major (more than 1000 ml). Major PPH can be Moderate (1000–2000 ml) or Severe (more than 2000 ml). Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 6 weeks postnatally  Incidence 5-8% Is the commonest cause of M.M in our set-up  Morbibity/mortality Worse in women already compromised by anemia or intercurrent illnesses PPH predisposes to puerperal infections Hypotension =)Acute renal Failure & other organ injuries Hypotension =) Sheehans syndrome (post-partum panhypopituitarism) = necrosis of ant. Pit - failure to lactate - amenorrhea - decreased breast size - loss of pubic & axillary hair - hypothyroidism & adrenal insuffi.  Morbibity/mortality Morbidity associated with transfusion therapy (eg HIV, hepatitis, transfusion Rxns are rare) Sterility from STH  Etiology Indirect Causes : 3 levels of Delay (1.Home, 2.Way, 3.Hospital) Direct causes 1. Uterine atony - PPH physiologically controlled by constriction of the interlacing myometrial fibres that surround the blood vessels supplying the placental implantation site. Atony exists when myometrium can’t contract.  Uterine atony Uterine atony – ( is the commonest cause of PPH (50% of the cases) 1. Uterine overdistension ( multiple preg, polyhydr) 2. Uterine leiomyomas 3. Uterine infection 4. Couvelaire uterus = extravasation of blood into the myometrium Couvelaire uterus (Pt had severe concealed abruption placenta)  Uterine atony 5. Intrinsic myometrial dysfn 6. Prolonged labour 7. oxytocin induction or augmentation of labor 8. GA (halogenated cpds eg halothen) 9. Excessive manipulation of uterus + operative del. Be expectant as u manage the ᷉᷉ẽ  2. Obstetric lacerations Causes about 20% of PPH Lacerations (uterus, Cx, vagina, vulva) Episiotomy – more if involving arteries or large varicosities, if episiotomy is large, delay prior to del or repair Precipitate del Operative del of large infant Any del  Obstetric lacerations Laceration underneath vaginal/vulval epithelium =) hematomas Uterine rupture - previous scars, obstr labor, malpresent, etc 3. Retained placental tissue Causes 5-10% of PPH Occurs in : - placenta accreta, inccreta, percreta - Manual ROP - misMx of 3rd stage of labour - unrecognised placenta succenturiata Do not be indifferent  4. Coagulation defects Acquired coagulopathies in asso. with severe obstetr. Disorders eg - abruptio placenta - retained IUFD – excess thrombopastin - amniotic fluid embolism - eclampsia/severe preeclampsia - sepsis  4. Coagulation defects These may present as hypofibrinogenemia, thrombocytopenia or DIC Massive transfusion > 8 Units of blood may induce dilutional coagulopathy Von Willebrand’s dx, autoimmune thrombocytopenia or leukemia may occur in pregnant women  Management Prevention of PPH is preferable to even the best treatment 1. Predelivery preparation - preparing for high risk ? pts Gp /Xm. Iv line. For pts with severe anemia, transfuse even prior to del  2. Delivery Uterine massage after del. Excessive / vigorous massage is discouraged =) may cause PPH 3. Third stage of labor normal placental separation Placenta typically separates from the uterus and is delivered within 5 minutes of del of infant  Attempts to speed separation may cause harm eg uterine inversion Placenta separation is impending if - 1. uterus becomes round and firm - 2. sudden gush of blood comes from vagina - 3. uterus seem to be rising in the abdomen - 4. umbilical cord moves down and out Brandt-Andrews maneuver. Current study  Placenta inspected for completeness immediately after del// cotyledons, membranes  Manual ROP If pt bleeding, do it immediately Allow normal mechanisms of separation b4 manual ROP Technique Never apply the words of Abr Lin  Immediate postpartum period Uterotonic agents if adm after del of ant shoulder risk : entrapment of placenta or 2nd twin Given at time of placental separation avoids such Oxytocin im 10 units or 10-20 units infusion Avoid bolus admin, since large doses (>5 units) can cause hypotension Empty the bladder  Repair of lacerations Cervical tear repair Mx of hematoma. Hematoma+laceration=extend the laceration, drain & Ligate the bleeding vessels. Hematoma alone=incise it, drain & Ligate the bleeding vessels. Hematoma cavity left open Repair of episiotomy/ vulvo-vaginal tears  Uterus – repair or hysterectomy Following del, recovery room attendants to frequently massage uterus & check for vaginal bleeding  Measures to control bleeding Bimanual compression & massage Manual exploration of uterus Uterine packing = catheter tamponade Uterotonic agents / Oxytocin 20-40 units infusion, egormetrin im, intramyometrial PGF2α, intravaginal or rectal PG suppositories  Operative Mx - uterine A ligation - hysterectomy - internal iliac A ligation - pressure occlusion of aorta (few minutes) Radiographic embolization of pelvic vessels Blood transfusion B-Lynch stitch Prof Christopher B-Lynch & Dr J.W Ngatia in Feb 2015 Aristotle : the secret of success is to know something nobody else knows. Thank You