Post-Partum Hemorrhage
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POST-PARTUM HEMORRHAGE
Nahida Chakhtoura, M.D.
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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
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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
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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
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ETIOLOGY Genital Trauma
PerineumVaginal wallsCervixUterus
Risk FactorsMistimed episiotomy Induced laborPrecipitate laborC/SForceps DeliveryProlonged laborPrevious uterine surgeryAnemiaDelay in Tx
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MANAGEMENT Priorities
Call for Help!Rapid assessment of patient’s condition Identify source of bleedingStop the bleedingStabilize/resuscitatePrevent further bleeding
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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
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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
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MANAGEMENT Traumatic PPH
Lithotomy position Identify site of bleeding
and repair
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CONTINUING MANAGEMENT Close monitoring over next 24-48hrs
Uterine toneVS; Ins and OutsBlood lossSerial CBC
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MANAGEMENT Developing Countries
Active management of laborUterine massageDraining the bladder10 U oxytocin IMMisoprostolUterine packingHysterectomy
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THANK YOU!
Fausto Astudillo-Davalos, M.D. Mabel Marotta Danielle Kramer
Nahida Chakhtoura, M.D.