POST PARTUM HAEMORRHAGE by zqa20601

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									                                                       PPH
                                                        Developed countries
POST PARTUM                                              – PPH cause maternal mortality ~14/100,000
HAEMORRHAGE                                                births
                                                         – 3rd or 4th leading cause of maternal mortality
                                                         – Pulmonary embolus No 1 cause because
Dr John Grove                                              haemorrhage, infection, and hypertension better
                                                           managed
11 March 2008
                                                        Emerging countries
                                                         – 25-40% of all maternal deaths due to primary
                                                           PPH




PPH Definition                                         PPH primary

  Primary PPH                                          Note
   – Bleeding > 500ml within 24 hrs of                 a) volume expansion
     delivery
                                                       b) relative haemodilution in pregnancy
   – Haemocrit drops > 10%

                                                        At delivery there is an auto
  Secondary PPH
                                                        transfusion thus loss of 500ml has
   – Excessive loss up to 6/52 postpartum               little effect




PPH primary                                            PPH primary
AETIOLOGY
   Atonic uterus
                                                         PPH incidence ~ 4-6% overall
   Retained placenta
   Tears to cervix vagina, or perineum
   Uterine rupture                                      Greater if there is a previous history of PPH
   Coagulation defects
   Preceding APH
   Spontaneous rupture of uterine or ovarian vessels

    High parity
    Previous PPH
    Placenta praevia / accreta




                                                                                                             1
PPH primary                                    PPH primary
                                               Causes of uterine atony
       Haemostasis                               –   Long labour
                                                 –   Use of oxytocic infusion
                                                 –   Retained placenta
 Uterine muscle contraction- tonic               –   Anaesthetic
                                                 –   Operative delivery
                                                 –   Over distended uterus
 Clotting in vessels                                    Multiple pregnancy
                                                        Polyhydramnios
                                                        Macrosomia




PPH primary                                    PPH primary
 Consider bleeding from the uterus with the     Placenta out – management
 placenta delivered
                                                – Rub up the uterus
 Primary PPH                                    – Call for help !!
                                                – Oxytocics –Ergometrine-IM /Syntocinon-IV
 – Without oxytocic agent ~10%                  - Resuscitation +/- Syntocinon infusion
   Retained placenta 1%                         – Blood for FBE, cross match, coagulation study
                                                – Inspect the placenta ? Complete
 – With ocytocic agent ~1-2%
                                                – Check the perineum vagina and cervix
   Retained placenta 10%
                                                – If bleeding continues – EUA




PPH primary                                    PPH primary

 Placenta retained                                   RUB UP             HELP    OXYTOCIC
 – Rub up
 – Call for help                                 Ergometrine avoid if hypertensive
 – Oxytocic                                      Infusion wide bore cannula
 – Resuscitate                                   Blood to path
 – Take blood: FBE, crossmatch, coagulation      Atonic or Other cause ?
   study                                         Bleeding continues – Explore
 – Controlled cord traction / Brandt Andrews     Prostaglandins I.M. or I.U.
 – Manual removal




                                                                                                  2
PPH primary                                          PPH primary

 Uterine packing / Balloon tamponade

 Ligation of uterine or internal iliac                 “ The empty uterus does not bleed ”
 artery
                                                            Always check the placenta !
 Hysterectomy




PPH primary                                          PPH primary

     Management of the 3rd stage                      Uterine rupture
 – Check the fundus ? 2nd baby!!                      – Neglected obstruction
 – Oxytocic agent - Syntocinon / Ergometrine          – Previous classical caesarean section
 – Signs of separation - show, the cord lengthens,
   fundus rises, suprapubic test +ve                  – Traumatic external e.g. MVA
                                                      – Iatrogenic: forceps, ventouse
 – Ensure the uterus is contracted
 – Controlled cord traction / Brandt Andrews
                                                      – Repair or hysterectomy
 – Observations - regular checks for 1 hour
 – Check the placenta




PPH secondary                                        PPH secondary

 From 24 hrs to 6 weeks                               Acute loss
 An excessive loss                                    Often about the 10th postpartum day
                                                      Sudden heavy bleeding, may be shocked
 Slight loss up to 6/52
                                                      Fever
                                                          RETAINED PRODUCTS / Infection
 Retained products                                    Resuscitate
 Intrauterine infection                               Explore
                                                      Antibiotics




                                                                                               3
PPH secondary

 Chronic loss
 Subinvolution - infection plus retained
 products

    Swabs for culture
    Antibiotics
    Wait then ? explore




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