Postpartum Hemorrhage (PPH) - 5+ Obs. Shock + Emergencies - PDF

Post partum hemorrha ge Melad Alias  PPH Definition Types Classification Prevention Management Postpartum complication from having PPH Excessive bleeding from genital tract after d baby. primary (within the 1st 24 hours ) secondary which is...

Post partum hemorrha ge Melad Alias  PPH Definition Types Classification Prevention Management Postpartum complication from having PPH Excessive bleeding from genital tract after d baby. primary (within the 1st 24 hours ) secondary which is after 24 hours till 6 weeks after delivery. Primary PPH is a major & important cause of maternal mortality & morbidity in both developed & developing countries. it account for 28% of pregnancy related deaths worldwide.  WHO Definition of primary PPH Bleeding in excess of 500ml after vaginal delivery Or 1000ml after CS in the First 24h Another proposal suggests using a 10% fall in hematocrit value to define PPH Incidence 3.7 - 8.6%  There are differing capacities of individual patients to cope with blood loss. A healthy woman has a 30-50% increase in blood volume in a normal singleton pregnancy and is much more tolerant of blood loss than a woman who has * preexisting anemia, * an underlying cardiac condition, * volume-contracted condition secondary to dehydration or preeclampsia. Each year about 500000 women die from pregnancy related causes & 98% of those occur in developing countries of which 25% are due to PPH In the developed countries ,primary PPH is the fourth major cause for maternal mortality after Thrombo-embolic diseases Hypertensive diseases causes Tone (Uterine tone) Tissue (Retained tissue--placenta) Trauma (Lacerations and uterine rupture) Thrombin (Bleeding disorders) 4T  A traumatic primary PPH After separation of placenta about 200 cc & further blood loss is prevented by contraction & retraction of myometrium. 1. Causes Uterine atony (ineffective contraction & retraction) a. Retained product if conception either placental piece or even a large piece of membrane. b. Prolonged or obstructed labour. c. Operative delivery spatially if GA is used ( general anesthetic drugs may cause relaxation of myometrium as halothane & cyclopropane ) d. Over distention of uterus as in polyhydraminus & multiple pregnancy. e. Large placental site as in multiple pregnancy. f. Placenta previa because of inability of the lower segment to contract. g. Abruptio placenta due to interstitial uterine hemorrhage & later due to hypofibrinogenemia. h. Multiparty due to increase in fibrous tissue & decrease in muscular tissue. i. Multiple uterine fibroids spatially the intramural type. j. Full bladder. couvelaire uterus Blue color  2. Abnormally adherent placenta Placenta accreta Placenta increta Placenta pericreta  3. Clotting disorders 1.heredetory blood disorders 2. D I C (disseminated intravascular coagulation) DIC is associated with 1.placental abruption 2.amniotic fluid embolism 3.intra uterine death (IUD) & retained dead fetus for several weeks.  Prevention of development of PPH 1. Correction of anemia 2. Previous history of PPH have 2 – 4 times ↟↟PPH. 3. Active management of 3rd stage of labor 1. Utero-tonic administration (preferably oxytocin) immediately upon delivery of the baby, 2. Early cord clamping and cutting. 3. Gentle cord traction with uterine counter- traction when the uterus is well contracted ( Brandt-Andrews maneuver) The oxytocic drugs include syntocinon, ergometrin syntometrin (1 ml contain 5units oxytocin & 0.5 mg ergometrin).  Those drugs either given with the crowning of fetal head, with the delivery of the anterior shoulder or after delivery of the placenta.  Method of syntometrinuse is used , it is given IM with the crowning of fetal head except in case of multiple pregnancy that it is given after the delivery of the last baby. The alternative method is to give ergometrin (0.5 mg ) or OXYTOCIN (10 units ) IV with the delivery of the anterior shoulder which is the standard prophylactic method spatially for patient at high risk for developing PPH together with oxytocin infusion IV These drugs when given IV will act during 30-45 second. PG IM, IV or rectaly ? Management Call for a help ABC 1. Ensure that at least 2 peripheral infusion lines are established using a wide bore canola (gauge 14 ). 2. Grouping cross matching. 6 units of blood (preferably fresh whole blood ) prepared. 4. Vital signs CVP. 5. Restoration of blood loss by iv fluids (Hartman’s or hemacel ) till cross matched blood is available & if group Oˉ blood is given till preparation of the appropriate blood group. 6 Insert a urinary catheter. Start replacement and identify the cause Atony Palpate the uterus ( lax ) utero-tonic drugs is effective Uterine massage Bimanual compression of the uterus Intra uterine balloon Uterine packing Uterine artery embolisation Uterine artery ligation Internal artery ligation B lynch suture  Bi-manual compression The right hand is formed as a fist & inserted into the vagina at the anterior fornix above the cervix while the left hand is placed on the abdomen & pressed downward onto the posterior wall of the uterus so that it is compressed between the 2 hands till it become firm & contracted  Uterine massage  Trauma If placenta is delivered & the uterus is well contracted Transfer the patient to the operation theater for examination under anesthesia. Arrest of atraumatic bleeding If the placenta had already delivered If it is soft & lax , uterine massage Meanwhile an oxytocic drug is given intravenously , usually ergometrin 0.5 mg with infusion of 10 units oxytocin in iv infusion drip. Remove any retained piece of placenta manually under GA. If still bleeding & uterus is contracted (Think ) look for traumatic lesion of the genital tract.  If the placenta is not delivered Signs of placental separation expelled from the upper to the lower segment Uterus is firm , rounded mass about 10 cm at the level of the umbilicus moves from side to side Umbilical cord will have be elongated Part of the placenta is felt in the vagina Brandt- Andreus If the placenta is not separated Should be removed manually under GA after stabilization of the patient & correction of shock & we should avoid giving oxytocic drugs till after removal of the placenta. Traumatic lesions of genital tract Rupture of uterus A. During pregnancy is rare, weak scar like classical C/S myomectomy metroplasty  During labor 1. Obstructed labour 2. Internal pudalic version 3. Forceps may lead to extended cervical tear 4. The improper use of oxytocic drugs. 5. S car in the uterus 6. Multi-parity. Complete & incomplete uterine rupture  Lacerations of cervix Precipitated rapid labor. Forceps on un-fully dilated cervix Rapid delivery of the after coming head in breech presentation Scar in the cervix from previous injury.  Infralevator heamatoma HEAMATOMA OF THE VULVA & PERINIUM PARAVAGINAL HEAMATOMA HEAMATOMA OF THE ISCHIORECTAL FOSSA This type of heamatoma occur due to rupture of the paravaginal plexus of veins following distention of the lower genital tract even though the vaginal epithelium may remain intact. imperfect repair of an episiotomy  The vulval heamatoma appear as a very tender purple swelling on one side of the vulva or on the vaginal wall. The pain is sever in this type  Supralevator heamatoma Cervical laceration extending into the vaginal vault. Extra peritoneal rupture of uterus During CS hematoma is formed above the pelvic diaphragm & spreads into the base of the broad ligament & a soft mass appear in one of the iliac fossa Conservative & blood Tr If severe & shock operation