MANAGEMENT OF OBSTETRIC HEMORRHAGE

(PPH)

DONE BY MAYAR ALATRASH

RECALL..

Definition Significant blood loss after getting birth , >500 ml after vaginal delivery

>1000 ml after cesarean section

( if you can determine the amount of bleeding precisely )

Or

- Decrease 10% or more in hematocrit baseline

Or

- Need blood transfusion

Or

- Change of mother’s vitals (hypotension, tachycardia) , oliguria , lightheadedness ,dizziness , syncope.

Causes : 4 T (Tone, Tissue ,Trauma ,Thrombin)

PPH ACCORDING TO THE TIME OF ONSET

Primary

Within 24 hours following delivery

Secondary

After the first 24 hours following delivery up to 12 weeks

IT’S AN IMPORTANT ISSUE

- Affect 2% of all women get birth.

- One quarter of maternal death globally.

- Leading cause of maternal death in low income countries.

- Not affect mortality only but also interfere with maternal morbidity , while blood loss may cause shock and organ dysfunction.

EMERGENCY !!

Risk factors Prevention PPH Treatment Complications

Death!

Delivery

Risk factors are the first step in the way of PPH causes

TONE(UTERINE ATONY)

1- uterine over distention, so anything that makes the uterus stretch out too much:

- multiple pregnancy - more than 4 previous deliveries - hydramnios

- baby >4 kg - maternal obesity - previous PPH - induction of labor

2- uterine muscles fatigue during the delivery process

- prolonged labor > 12 h - prolonged 3rd stage

3- prior C-sections or uterine surgery

4- full bladder (develop in females that are unable to pass urine following anesthesia)

, as well as halothaneespecially - anestheticsobstetric medications like some -5can all increase the risk of uterine terbutaline, and nifedipine, magnesium sulfate

atony.

TRAUMA

or or vaginal lacerations cervical canal: any kind of injuries to the birth uterine rupture.or tearsperineal , hematomas

- large fetus.

- hasty deliveries.

- and iatrogenic causes like an episiotomy

TISSUE

Retained products of conception (especially placenta)

- prior uterine surgery, especially when the placenta implants itself near a scar from the previous surgery.

THROMBIN (COAGULATION DISORDER)

Primary : hemophilia

Secondary to obs. condition : preeclampsia , placental abruption , amniotic fluid embolism.

PREVENTION

Efficient prevention >> efficient outcomes >>lower mortality and morbidity

Achieved by :

1- access to appropriate medications

2- trained health care workers in procedures relevant to the management of PPH

3-countries need evidence-based guidance to inform their health policies and improve their

health outcomes.

ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR

-- package of interventions performed during the third stage of labor

-- cornerstone for the prevention of PPH

-- Include:

the administration of a prophylactic uterotonic after the delivery of a baby, early cord clamping and cutting,

the controlled traction of the umbilical cord,

Uterine massage

UTEROTONICS AGENTS 1- syntocinon (synthetic oxytocin )

2- misoprostol (prostaglandin E1 analogues )

3- carboprost tromethamine (15-methyl prostaglandin F2 alpha derivative)

4- ergometrine / ergonovine or methylergonovine (ergot alkaloids )

5- carbetocin (longer acting relative of oxytocin)

of onesingle , any low risk for uterine atonyor at no risk factors In females with these agents is recommended.

like oxytocin and combinationsfor uterine atony, high risk In females at misoprostol or oxytocin and methylergonovine are recommended.

PPH LIFE-THREATENING LIFE SAVING SUPPORTIVE MANAGEMENT DEFINITIVE

MANAGEMENT

SUPPORTIVE MANAGEMENT 1- call for help

2- A B C

A stands for airway, so you’ll want to protect the airway, especially when there’s loss of consciousness.

B stands for breathing, so you’ll want to administer Oxygen through a non-rebreather mask.

C stands for circulation - meaning measuring vital signs and establishing the degree of hypovolemia

3- inserting two large caliber peripheral IV catheters - of at least 14 gauge or even larger. And starting fluid resuscitation immediately, with 500 milliliters of normal saline or lactated Ringer’s solution given over 30 minutes then adjusted accordingly

4- blood sample for CBC , blood group , cross match and clotting profile

5- apply Foley's catheter to empty bladder

6- empty uterus and vagina from clots

7- Cross match 4-6 units of blood

DEFINITIVE MANAGEMENT (UNDERLYING CAUSE )

Uterine atony Dx : palpation soft , boggy and enlarged

Vaginal examination bleeding not from vaginal or cervical laceration

Mx :

1- uterotonic medication

2- bimanual uterine compression

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( not sever bleeding + embolization uterine artery Another technique is -4stable patient ) // interventional radiology technique

arteriessurgical ligation of the uterine not stop , bleeding -5

lynch suture -B -6

placental invasion /Irreparable uterine ( refractive atony / hysterectomy -7rupture/vessel lacerations)

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Trauma - Cervical and vaginal lacerations

Dx : speculum examination.

MX : surgically suturing the laceration under local anesthesia.

- Hematomas : symptoms include labial, rectal, or pelvic pressure or pain.

are given and the , IV fluids hematomas in hemodynamically stable females smallFor .resorbs on its ownhematoma typically

IV fluids hematomas, or in hemodynamically unstable females, expanding rapidlyFor of the hematoma may be incision and drainage , along with and blood transfusions

required.

- Perineal tears can be seen on inspection

MX : perineal tears may be sutured under local or general anesthesia.(depending on degree )

Uterine rupture :

DX : sudden and severe abdominal pain./ ultrasound is needed to see the accumulation of blood.

Mx : emergency surgery to repair or remove the uterus.

Tissue (placenta accreta or related disorders, or when there’s an accessory placental

lobe.)

placenta accreta per se, placenta is burrowed deep into the endometrium, but doesn’t reach the myometrium.

placenta increta, placenta has invaded the myometrium, but doesn’t go all the way through.

placenta percreta, placenta invades all the way through the myometrium, and may extend to neighboring organs.

DX: closely inspecting the placenta after delivery

On palpation, the uterus feels firm

ultrasound will show the retained placental tissue as a hyperechoic mass.

MX: depends on the depth of invasion

- Small, focal accreta can usually be removed with curettage

- Burrowed more deeply into a large portion of the uterine wall hysterectomy

(manual removal of placenta accreta should not be attempted)

Thrombin * Can progress to DIC normal hemostasis can’t occur.

DX:

lab abnormalities like a high INR, prolonged PT, PTT, low platelets, or low levels of deficient clotting factors.

** Fibrinogen may be low, or normal, but bear in mind that a normal fibrinogen level, between 150 and 400 milligrams per deciliter, is low for a postpartum female, since fibrinogen levels usually increase during pregnancy.**

MX:

blood transfusions - red blood cells, platelets, fresh frozen plasma or cryoprecipitate.

uterine inversion can also cause postpartum hemorrhage.

With uterine inversion, the uterine fundus descends through the cervix and into the vagina - kinda like turning a bag inside out.

DX: on palpation - empty pelvis, the uterine fundus is missing from the pelvis.

MX:

- administering uterine relaxants like magnesium sulfate, halogenated anesthetics, and nifedipine.

- Then, the uterus can be manually put back in place.

- If unsuccessful, surgery may be required to put the uterus back in place.

Complications of PPH • Sheehan’s syndrome : Pituitary ischemic injury

(necrosis of the anterior lobe of the pituitary gland)

• Postpartum infection

• DIC

• Anemia

• Transfusion hepatitis

• Asherman’s syndrome (Intrauterine adhesion )

SECONDARY PPH

Causes of Secondary PPH

• Endometritis

• Retained placental tissue

• Sub-involution of placental site

• Ruptured pseudo-aneurysms and arteriovenous

malformations (rare)

Endometritis

• Combination of ampicillin (clindamycin if penicillin

allergic) and metronidazole

• In cases of endomyometritis (tender uterus) or overt sepsis,

add gentamicin

Retained tissues

Surgical measures (Evacuation of retained tissues)

o If excessive or continuing bleeding, irrespective of USS

findings

o Carries a high risk for uterine perforation

THANK YOU