POST-PARTUM HEMORRHAGE

Nahida Chakhtoura, M.D.

EPIDEMIOLOGY Postpartum hemorrhage (PPH): leading

cause of maternal mortality worldwide Prevalence rate: 6% Africa has highest prevalence rate:

10.5% In Africa and Asia PPH accounts for more

than 30% of all maternal deaths Maternal death rates attributable to PPH

vary considerably between developed and developing countries, suggesting that deaths from PPH are preventable

ETIOLOGY Uterine Atony

Placenta: retained placenta, placental tissue or membrane, incomplete separation

Full bladderAntepartum hemorrhage: placenta

previa or placental abruptionOverstretched uterus: high parity,

multiple pregnancy, polyhydramnios, macrosomia, fibroids

ETIOLOGY Uterine Atony

Prolonged active phaseMedical factors: anemia, coagulopathyOthers: severe pre-eclampsia and eclampsia,

precipitate labor, induction/ augmentation, IUFD, h/o PPH, c/s, gen. anesthesia, chorioamnionitis or endometritis

ETIOLOGY Genital Trauma

PerineumVaginal wallsCervixUterus

Risk FactorsMistimed episiotomy Induced laborPrecipitate laborC/SForceps DeliveryProlonged laborPrevious uterine surgeryAnemiaDelay in Tx

MANAGEMENT Priorities

Call for Help!Rapid assessment of patient’s condition Identify source of bleedingStop the bleedingStabilize/resuscitatePrevent further bleeding

MANAGEMENT Atonic PPH

Massage the uterus to promote contraction and expel clots

Oxytocin 10 IU IM Assess EBL Type and cross, CBC, coagulation profile Start IVF: if shock 1L NS or LR in

15min up to 3L Foley catheter Check placenta and membranes. If

placenta cannot be delivered, manually extract

Examine cervix, vagina, and perineum

MANAGEMENT If bleeding persists…

Oxytocin 20 units in 1L of IVF @ 60 drops per minAdd other IV accessContinue uterine massage Assess clotting status and transfuse if necessaryConsider transferring to higher level Uterine or utero-ovarian ligation; hypogastric

artery ligationUterine balloonB-lynch sutureHysterectomyDocument properly

MANAGEMENT Traumatic PPH

Lithotomy position Identify site of bleeding

and repair

CONTINUING MANAGEMENT Close monitoring over next 24-48hrs

Uterine toneVS; Ins and OutsBlood lossSerial CBC

MANAGEMENT Developing Countries

Active management of laborUterine massageDraining the bladder10 U oxytocin IMMisoprostolUterine packingHysterectomy

THANK YOU!

Fausto Astudillo-Davalos, M.D. Mabel Marotta Danielle Kramer

Nahida Chakhtoura, M.D.