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Postpartum Hemorrhage_PPH_

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					Postpartum Hemorrhage(PPH)

          DR Feroz
      Major causes of death for
        pregnancy women
       (maternal mortality)

•   Postpartum hemorrhage(28%)
•   heart diseases
•   pregnancy-induced hypertension
•   (or Amniotic fluid embolism )
•   infection
           Definition of PPH
• be defined as a blood loss exceeding 500ml
  after delivery of the infant

• PPH: occurs in 24 hour of delivery
• the late PPH: occurs after 24 hour of delivery
  to 6 weeks
               Major causes
•   Uterine atony (90%)
•   lacerations of the genital tract(6%)
•   retained placenta(3%-4%)
•   coagulation defects (blood dyscrasia)

• (4T: tone, tissue,trauma,thrombin)
          1. Uterine atony
Local factors
• overdistention of the uterine
  (hydramnios, multiple pregnancy,
  macrosomia )
• condition that interfere with
  contraction(leiomyomas)
• complications(PIH,anaemia, placenta
  praevia
Systemic factors:
• nervous
• drugs(magnesium sulfate,sedative)
• abnormal labor(prolonged,precipitous)
• History of previous PPH
• Preeclampsia, abnormal placentation,
             pathology
• Contraction constricting the spiral
  arteries
• preventing the excessive bleeding from
  the placenta implantation site
• the uterine atony give rise to PPH
  when no contraction occur
 Prevention and therapeutic of
         uterine atony
• Administration of medicine:
• promotes contraction of the uterine corpus
• decreases the likelihood of uterine atony

• Oxytocin agents
• Methegine
• prostaglandin
• Mechanical stimulation of uterine contraction:

• Massage of uterus through the abdomen and
  bimanual compression

• intrauterine packing
            Surgical methods
•   If massage and agents are unsuccessful:
•   Ligation of the uterine arteries
•   ligation of the hypogastric arteries
•   selective arterial embolization
•   hysterectomy
    taking into account the degree of
    hemorrhage,the overall status of patient,her
    future childbearing desires
   2. Lacerations of the genital
               tract
Causes:
• Instrumented delivery (forceps)
• manipulative delivery(breech
  extraction,precipitous labor, macrosomia)
Types:
• perineum laceration
• vaginal laceration
• cervical laceration
 perineum and vaginal laceration

• The first degree tear:
  involves only skin and a minor part of the
  perineal body
• the second degree tear:
  involves the perineal body and vagina
• the third degree tear:
  involves the anal sphincter and anal canal
             management
• Vaginal examination soon after delivery

  repair:
• cervical laceration >2cm in length and be
  actively bleeding
• laceration of vaginal and perineum
         3. Retained placenta

• Separation and explosion of placenta is
  caused by strong uterine contraction

• Placenta tissue remaining in the uterus
  prevent adequate contraction and predispose
  to excessive bleeding
causes:
• adherence of placenta (previous cesarean
  delivery,prior uterine curettage)

• succenturiate placenta

• placenta accreta (into the decidua)
• placenta increta(into the myometrium)
• placenta pericreta(through the myometrium
  to the peritoneal)
    Prevention and treatment
• The placenta should be examined to see that it
  is complete or not
• part of placenta is missing, removed digitally
• not separated, manual removal of placenta is
  done
• hysterectomy is required for placenta
  increta(percreta,accreta)
• uterine contraction drugs
      4. Coagulation defects
Acquired abnormality in blood clotting:
• abruptio placenta,
• amniotic fluid embolism
• severe preclampsia
congenital abnormality in blood clotting:
• thrombocytopenia
• severe hepatic diseases
• leukemia
   disseminated intravascular
       coagulopathy(DIC)
• if bleeding persists in spite of all other
  treatment described, DIC should be
  suspected
• the blood passing from the genital tract is
  not clotting
• shock: reduction of effective circulation
          inadequate perfusion of all tissues
         oxygen depletion
         depression of functions
Record:
• pulse
• blood pressure
• maternal heart rate
• central venous pressure
• urine output
•
Lab tests:
• Hb,
• BT(bleeding time), CT( clotting time),
• platelets count
• fibrinogen
• prothrombin time and patial thromboplastin
  time
• FDP
• women’s group and cross-matching
Treatment:
• the key is correcting the coagulation defect
• resuscitation must be started as soon as possible
• infusion of crystalloid(saline) and Dextran is
  started firstly while arranging the blood
  transfusion
• blood transfusion is essential
• infusion of platelets, fresh frozen plasma, FDP ,
  clotting factors,
•   Potential complications of PPH:
•   Postpartum infection
•   Anemia
•   Transfusion hepatitis,
•   Sheehan’s syndrome
•   Asherman’s syndrome



• The best management of PPH is prevention
                 Key words

•   the definitio n of HHP
•   The causes of HHP
•   treatment methods of Uterine atony
•   the types of retained placenta
•   the degrees of the perineal and vaginal
    laceration

				
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posted:4/29/2010
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