Postpartum Hemorrhage - Download as PowerPoint

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   An estimated loss of ≥ 500 mL following a vaginal birth
   An estimated loss of ≥1,000 mL following cesarean birth
   After completion of the third stage labor
   Early:  24 hr. after delivery
    •   Uterine atony  80%
    •   Retained placenta
    •   Defect in cogaulation
    •   Lacerations
    •   Uterine invertion
   Late:  24 hr. but  6 wks
    •   Subinvolution of placental site
    •   Retained products of conception
    •   Infection
    •   Inherited coagulation defects (eg. Von-Willebrand)
    •   Tumor in uterus
              Etiology : 4Ts

Tone       : Uterine atony

Trauma     : Uterine, cervical or vaginal lacerations

Tissue     : Retained placental tissue

Thrombin   : Coagulopathy
           Initial management
   Diagnosis : Estimated blood loss
   Signs & symptoms of hypovolumia
Uterine atony
         Failure of the uterus
         to contract properly
         following delivery

            The finding of soft,
             poorly contracted
             (“boggy”) uterus
               uterine atony
                Risk factors
   Full bladder
   Prolonged labor or very rapid labor
   Induced or augmented labor
   Some general anesthetics - halogenated hydrocarbon
   Overdistended uterus: large fetus, twins, hydramnios
   Multiparity
   Uterine atony in previous pregnancy
   Chorioamnionitis
        Treatments of uterine atony
   Uterine massage
   Uterotonic agents
       Oxytocin - given after placental delivery to prevent
        uterine atony
       Ergot Derivatives
            Give Methylergometrine maleate IV or IM in third stage
             of labor
            If oxytocin does not prove effective to reverse uterine
             atony, given 0.2 mg of methylergonovine IM
       Prostaglandin analogs
       Administration of oxytocin

   Oxytocin 10 units + 5% D/N/2 1000 cc iv drip
    10 drops/min for 30 min

   If still atony, increase to 20, 30, and 40
    drops/min, respectively.
 Bleeding Unresponsive to Oxytocics

1.   Initiate bimanual uterine compression
    If patient continue bleeding after
           multiple oxytocin…
2. Call for help!
3. Add a 2nd large-bore IV catheter
4. Begin blood transfusion (known blood gr.)
5. Explore uterine cavity
6. Inspect the cervix an vagina for laceration
7. Foley catheter for monitoring urine output
8. Continue volume resuscitation
              Surgical treatment
   Uterine tamponade
       Packing with gauze
       Foley catheter
       Sengstaken-Blakemore tube
       SOS Bakri tamponade
 Surgical treatment
B-lynch uterine compression suture
            Surgical treatment
   Hemostatic multiple square suturing
          Surgical treatment
   Uterine atery ligation
   Internal iliac atery ligation
   Hysterectomy

1.   Perineal lacerations
2.   Vaginal lacerations
3.   Cervical lacerations
4.   Ruptured uterus
         Diagnosis of lacerations
   Careful inspection of the perineum, vagina,
    cervix, and uterus is essential
   Bleeding while the uterus is firmly contracted
    - genital tract laceration > atony
   Bright red blood
Treatment of perineal & vaginal
 Surgical repair
                   Potential complications
                   1. Chronic perineal pain
                   2. Dyspareunia
                   3. Urinary and fecal
Treatment of cervical laceration

                  1. Surgical repair
                  2. Angiographic
                     embolization for
                     treatment of a high
                     cervical tear after
                     failed surgical repair
              Retained placenta
1.   Avulsed lobule and Succenturiate lobe
2.   Placenta adherens
     I.     Accreta
     II.    Increta
     III.   Percreta
    Avulsed lobule
and Succenturiate lobe

              One or more small
              accessory lobes develop
              in the membranes at a
              distance from the
              main placenta, to which
              they usually have
              vascular connections of
              fetal origin
             Placenta adherens
Defective decidual formation from partial or total absence of the decidua
 basalis and imperfect development of the fibrinoid or Nitabuch layer

   Accreta                      Increta                   Percreta
                 Risk factors
   Placenta previa
   Prior C- section
   Prior myomectomy
   Submucous leiomyoma
   Undergone curettage
   Gravida of 6 or more
   Maternal age older than 35 years
   Asherman’s syndrome AKA "uterine synechiae" or
    “intrauterine adhesions (IUA)”
 Diagnosis of placenta adherens

Transabdominal sonogram of placental invasion

                                       Retroplacental vessel
                                       invade the myometrium

                                       Abnormal intraplacental
                                       venous lakes
    Treatment of placenta adherens
   Considered appropriate surgical and blood banking
   Uterine or internal iliac artery ligation, balloon
    occlusion, or embolization
   Delivery of the Placenta : manual placental removal
    (need to go under GA)
   The safest treatment is hysterectomy

Treatment of retained placenta
Manual placental removal or by curretage
              Coagulation defect
   Patient or family history of coagulopathy
   Observation of the clotting status of blood
    recently lost
   When suspected, order coagulation tests
            Associated risks of
            coagulation defect
   HELLP syndrome
   Abruptio placenta
   Prolonged intrauterine fetal demise
   Sepsis : Endotoxin
   Amniotic fluid embolism
   DFIU
    Treatment of coagulation defect

   FFP
   For DIC, correct the cause
   Blood bank should be notified that transfusion
    may be necessary
   Human recombinant factor VIIa for severe,
    life-threatening hemorrhage
     Management for prevent PPH
1.   Evaluation of risk factors eg. hx of coagulopathy,
     previous labor, placenta previa etc.
2.   Check Hct, prepare for blood transfusion
3.   Be careful when use analgesics, sedatives, or uterine
4.   Avoid prolonged or rapid labor
5.   Administration of an uterotonic agent soon after the
     delivery of the anterior shoulder
6.   Proper methods of placenta delivery
7.   Administration of oxytocin after placental delivery
8.   Uterine massage after placental delivery
9.   Urine catheter after delivery
          Complications of PPH
   Adult respiratory distress syndrome
   Coagulopathy
   Shock
   Loss of fertility
   Pituitary necrosis (Sheehan syndrome)
Thank you for your attention

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