Postpartum Hemorrhage
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Transcript of Postpartum Hemorrhage
Postpartum Hemorrhage
by Shanyar Qadir
Shanyar.com
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Blood loss of: > 500 mL during vaginal delivery > 1,000 mL following cesarean delivery
Measurements are subjective and likely inaccurate
Primary (early): within 24 hrs of delivery Secondary (late): from 24 hrs – 12 wks post-
delivery
Definition
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Defined clinically as excessive bleeding that makes the patient symptomatic
10% drop in hematocrit Signs/symptoms of blood loss
Objective Criteria
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One of the most common obstetrical emergencies
Major cause of maternal morbidity One of the top 3 causes of direct maternal
death in both developing and developed countries
Leading cause of admission to the ICU Incidence
4% after vaginal delivery 6.5% after C/S delivery
Why is it important?
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Causes of PPH can be remembered as the 4 ‘Ts’
Tone Uterine atony
Trauma Injury to cervix, vagina, perineum
Tissue Retained placenta &/or membranes
Thrombin Clotting disorders
Etiology
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Call for help, ABCs O2 by mask initially 2 x 14-gauge IV lines FBC & clotting studies Test for renal function & liver function tests Cross-match at least 6 units of blood IV fluid resuscitation Notify blood bank & consult hematologist Foley catheter into the bladder & fluid balance chart Blood transfusion asap, O- if not available Central venous pressure & arterial lines May need FFP, platelets & cryoprecipitate (consult hematologist) Eliminate the cause
Initial Management
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Most common cause of excessive PPH
Risk Factors: Overworked: Rapid or prolonged labor (most
common) Infected: Chorioamnionitis Relaxed: MgSO4, β-agonists, halothane Overdistended: Multiple pregnancies,
macrosomia, polyhydramnios
Uterine Atony (80%)
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Clinical Findings: A soft uterus (feels like dough) palpable above the
umbilicus.
Management: Uterine massage Uterotonics (oxytocin, ergonovine, misoprostol,
carboprost) Surgical: Uterine packing or compression balloon,
B-Lynch suture, sequential arterial ligation, selective arterial embolization, hysterectomy
Uterine Atony (80%)
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Bimanual Uterine Massage
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CompressionBalloons
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Risk Factors: Difficult delivery (shoulder dystocia, macrosomia) Instrumental delivery (forceps, vacuum extractor)
Clinical Findings: Identifiable lacerations (cervix, vagina, perineum)
in the presence of a contracted uterus.
Management: Surgical repair.
Genital Lacerations (15%)
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Cervical Laceration Repair
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Risk Factors: Accessory placental lobe (most common) Abnormal trophoblastic uterine invasion
Clinical Findings: Missing placental cotyledons in the presence of a
contracted uterus.
Management: Manual removal or uterine curettage under US
guidance.
Retained Placenta (5%)
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PlacentaFetal side
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PlacentaMaternal side
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Succenturiate Placental Lobe
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Manual removal of placenta
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Uterine curettage
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Risk Factors: Abruptio placenta (most common) Severe preeclampsia Amniotic fluid embolism Prolonged retention of a dead fetus
Clinical Findings: Generalized oozing Bleeding from IV sites or lacerations in the presence of a
contracted uterus. Management:
Removal of pregnancy tissues from the uterus Intensive care unit (ICU) support Selective blood-product replacement.
DIC (Rare)
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Risk Factors: Fundal placentation Excessive cord traction Previous uterine inversion.
Clinical Findings: Beefy-appearing bleeding mass in the vagina and
failure to palpate the uterus abdominally. Management:
Elevating the vaginal fornices and lifting the uterus back into its normal anatomic position
IV oxytocin.
Inverted Uterus (rare)
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Progressive degrees of inversion
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Manual replacement of uterine inversion
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Clinical Diagnosis Management
Uterus not palpable
Inversion (rare) ↑ fornices, IV oxytocin
Uterus like dough Atony (80%) Uterine massage, oxytocin, ergot, PG F2α
Tears in vagina, cervix
Laceration (15%) Suture & repair
Placenta incomplete
Retained placenta (5%)
Manual removal or curettage
Diffuse oozing DIC (rare) Remove POC, ICU care, blood products
Summary
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Thank You!
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1. Obstetrics by Ten Teachers, 19e - 20112. Williams Obstetrics, 24e - 20143. A Comprehensive Textbook of Postpartum
Hemorrhage, 2e - 20124. Step Up to Obstetrics & Gynecology – 20145. Obstetrics & Gynecology Lecture Notes – 20136. Postpartum hemorrhage on Wikipedia
(http://en.wikipedia.org/wiki/Postpartum_hemorrhage)
Sources