Postpartum Hemorrhage (PPH) Lecture Notes PDF

Postpartum hemorrhage (PPH)  Definition: Abnormal or excessive bleeding from genital tract after delivery of fetus till end of puerperium (6 weeks after delivery).  Incidence: In developed countries: 4% of all deliveries & 6% in CS. In developing countries:...

Postpartum hemorrhage (PPH)  Definition: Abnormal or excessive bleeding from genital tract after delivery of fetus till end of puerperium (6 weeks after delivery).  Incidence: In developed countries: 4% of all deliveries & 6% in CS. In developing countries: Still high as it is the commonest cause of maternal mortality (30%).  Types: According to time of occurrence, it may be 1ry or 2ry (puerperal).  Primary postpartum hemorrhage (1ry PPH) Definition: Excessive bleeding from genital tract during 3rd stage of labor or èin first 24 hours after delivery (> 500 ml after vaginal delivery or > 1000 ml after CS or blood loss that affects general condition of patient). Average blood loss in normal labor is 300 ml.  Etiology: 3 TTT+ Combined “Tone. Trauma, Clotting” A) Atonic PPH: Commonest cause of 1ry PPH is uterine atony & predisposing factors for atony are: 1) Multiparity. 2) Over distention of uterus (as in twins or polyhydramnios). 3) APH. 4) Uterine fibroids. 5) Uterine relaxants (tocolytics).  6) Halogenated anesthesia. 7) Chorioamnionitis. 8) Severe anemia. 9) Full bladder or rectum. 10) Prolonged labor or precipitate labor. 11) Retained placenta, placental fragments, pieces of membranes or blood clots. 12) Idiopathic.  B) Traumatic PPH: Due to: 1) Lacerations of perineum, vulva, vagina or cervix. 2) Rupture uterus. 3) Acute inversion of uterus. C) Coagulation defects: 1) DIC. 2) Others: Thrombocytopenia, Von Willebrand’s disease & hemophilia. D) Combination of the above types.  Diagnosis: A) History: 1) History of PPH in previous delivery. 2) Presence of predisposing factors: As twins, APH, use of anesthesia, anemia, prolonged labor, precipitate labor, malpresentation, instrumental delivery or previous uterine scar. 3) Time of onset of bleeding: During 3rd stage of labor or after delivery of placenta. 4) Amount of blood loss.  B) Examination: 1) General: Signs of hypovolemic shock (according to amount of blood loss). 2) Abdominal: Consistency of uterus & fundal level. 3) Local: a) Inspection for amount of bleeding & color & clotting of blood. b) Inspection of perineum, vulva, vagina & cervix for lacerations. c) Manual exploration of uterus for any defect or retained placental parts. C) Investigations: CBC & coagulation profile.  D.D.: ( ) the most important 2 types: Atonic PPH Traumatic PPH Few minutes after separation & Immediately after delivery of fetus Onset delivery of placenta even before placental separation Dark clotted blood which Continuous trickling of red Bleeding comes in gushes (venous) non clotted fresh blood (arterial) Uterus Flabby & doughy Contracted Fundal level Rising (accumulating blood) Constant Lacerations or tears or rupture Exploration Intact birth canal uterus  Prevention: A) Antepartum: 1) Detection & correction of anemia. 2) Hospital delivery è ready cross-matched blood for high risk cases.  B) Intrapartum: 1) Proper use of analgesia & anesthesia. 2) Avoid prolonged labor. 3) Avoid traumatic deliveries (e.g. application of forceps before full cervical dilatation). 4) Active management of 3rd stage of labor (associated è less incidence of atonic PPH). 5) Routine examination of placenta & membranes to ensure complete expulsion.  C) Postpartum: 1) Exploration of birth canal after any difficult or instrumental delivery. 2) Administration of rectal PGs (misoprostol). 3) Careful observation in 4th stage of labor (1-2 hours after delivery).  Treatment: A) 1st aid measures & resuscitation: 1) Establishment of IV lines: Insert 2 large wide pore cannulas & CVP catheter. 2) Antishock measures: a) Cross matched fresh blood transfusion. b) IV fluids (crystalloid solutions as lactated Ringer & saline). c) Corticosteroids.  3) Insertion of urinary catheter & monitoring of urine output. 4) Laboratory investigations: CBC, coagulation profile, blood gases & serum creatinine. 5) Confirmation of diagnosis & detection of the cause of Hge. 6) Close monitoring of vital data.  B) Arresting bleeding: 1) Atonic PPH: a) Bleeding before delivery of placenta (3rd stage bleeding): Immediate delivery of placenta disregarding time factor (see retained placenta). b) Bleeding after delivery of placenta (true 1ry PPH): The following steps are done in succession if each previous one failed to arrest bleeding: 1- Inspection of placenta & membranes: Any missed part should be removed manually under anesthesia. 2- Uterine massage: By slow firm rotatory movements è fingers behind fundus & thumb in front. Abdominal compression as in the figures.  3- Ecbolics: a- Oxytocin drip: 20 units in 500 ml normal saline. b- Ergometrine (Methergin): 0.25-0.50 mg IV or IM. c- PGs:  Misoprostol 800-1000 μg rectally.  0.25 mg methyl PGF2α IM or intramyometrial (in case of CS).  4- Exploration of uterine cavity & birth canal under anesthesia: For: a- Removal of any placental fragments, pieces of membranes or blood clots. b- Detection & repair of any tear (traumatic PPH should be excluded in every case of PPH as combined atonic & traumatic PPH may occur).  5- Bimanual compression of uterus: Under general anesthesia, uterus is firmly compressed for 5-30 minutes ( ) closed fist of Rt hand in anterior vaginal fornix & Lt hand abdominally behind body of uterus. Compression is maintained till uterus is firmly contracted (during this period, ecbolics & blood transfusion are given).  6- Balloon tamponade (tamponade test): Hydrostatic balloon catheter (Foley's catheter, Sengstaken-Blakemore esophageal catheter, Rusch urological balloon or Bakri balloon) is inserted in uterus & filled è 200-500 ml warm saline to control Hge: a- If PPH is controlled after inflation of balloon (+ve test): No need for surgical intervention. b- If PPH isn't controlled after inflation of balloon (–ve test): Surgical intervention is needed.  7- Surgical treatment: a- Bilateral uterine artery ligation: Ligate ascending branches or main trunks just before division into ascending & descending branches. b- Bilateral internal iliac artery ligation: Done è the following precautions:  Palpation of femoral pulse to exclude ligation of external iliac artery.  Avoid laceration of iliac veins.  Avoid injury of ureters. c- Bilateral ovarian artery ligation.  d- Uterine compression sutures:  B-Lynch suture.  Modified B-Lynch suture.  Vertical compression sutures.  Square compression sutures. e- Supravaginal hysterectomy: Done as a definitive measure to control intractable PPH if other measures failed.  8- Other less commonly used methods to arrest bleeding: a- Compression of abdominal aorta against sacral promontory: Done at laparotomy for few minutes to provide time for treating hypotension & identifying source of bleeding. b- Uterine packing: Packing uterine cavity è large gauze rolls (its side effects include infection & shock). c- Radiographic embolization of pelvic vessels: May be done by trained radiologists using angiographic techniques to control intractable bleeding in rare cases. d- Direct intra-arterial injection of vasoconstricting agents.  2) Traumatic PPH: Treated according to type of injury (in details). 3) Treatment of coagulopathy: a) Treatment of the cause. b) Fresh blood, fresh frozen plasma or platelet transfusion. c) Antifibrinolytics.  C) After care of PPH: 1) Close monitoring of patient: Due to massive blood loss. 2) Ecbolics: To maintain uterine contraction till stopping of bleeding. 3) Prophylactic antibiotics: To guard against puerperal sepsis. 4) Treatment of resulting anemia. Secondary postpartum hemorrhage (2ry PPH) Definition: Abnormal or excessive bleeding from genital tract ( ) 24 hours & 6 weeks after delivery.  Etiology: A) Retained placental fragments, pieces of membranes or blood clots or formation of placental polyp. B) Infection (separation of infected retained parts, infected placental site, infected CS wound or infected genital tract lacerations). C) Subinvolution of uterus. D) Puerperal inversion of uterus. E) Submucous fibroid. F) Choriocarcinoma. G) Local gynecological lesions (as cervical polyps or cancer cervix). H) General diseases (as hypertensive HF).  Treatment: A) 1st aid measures & resuscitation. B) Treatment of the cause: 1) Retained placental fragments, pieces of membranes or blood clots: a) Minimal bleeding: Ecbolics & antibiotics. b) Severe or persistent bleeding: Vaginal evacuation under anesthesia + histopathological examination of products of evacuation to exclude choriocarcinoma. 2) Infection: Antibiotics. 3) Other causes: According to condition.  N.B.: Complications of 3rd stage of labor include: 1) Retained placenta. 2) Acute inversion of uterus. 3) PPH. 4) Obstetric shock. 5) Amniotic fluid embolism.