Postpartum Hemorrhage Abdulah Al-Tayyem;MD;JBOG Consultant Ob&Gyn Urogynaecology Zarka Govern. Hospital PPH: excessive blood loss after delivery sufficient to affect the general condition of the mother (tachycardia and or hypotension). Types: -primary within 24h -secondary after the first 24h up to 42nd day Causes -uterine atony -genital trauma -coagulations disorders -3rd stage complications: -mismanagement of the 3rd stage of labour -acute inversion of the uterus -abnormal or incomplete placental separation Factors predispose to uterine atony • Overdistended uterus:-polyhydramnios -macrosomia -multiple pregnancy • Uterine muscle exhaustion: -prolonged labour -grand multiparity -precipitate labour • Intrauterine infection: -prolonged ROM -chorioamionitis • Functional or anatomic distortion of the uterus: -fibroid uterus – placenta previa –uterine anomalies • Certain general anesthetics( halothane) • History of previous PPH Factors predispose to genital tract trauma • • • • A precipitate delivery, or an operative or manipulative delivery predispose the genital tract to lacerations : -cervix - vagina -perineum Malposition ,malpresentations or deep engagement of the fetal head ) CS,instrumental deliveries) Previous uterine surgery Abuse of oxytocin Factors predispose to retained product of conception • • • • • An incomplete placenta at delivery Previous uterine surgery Multiparity An abnormal placenta on US Intrauterine infections may lead to adherent placenta Abnormalities of coagulation • • • • Hemophilia A or Von Willebrad’s disease Idiopathic thrombocytopenic purpura(ITP) History of liver disease Use of anticoagulants Acquired in pregnancy: -thrombocytopenia with PET(HELLP syndrome) -DIC caused by: -abruptio placentae -chorioamionitis -IUFD Diagnosis • History taking • Physical examination tachycardia and hypotension my be present without evidence of excessive blood loss in cases of uterine rupture • Consistency of the uterus( lax,firm) • Asses amount of vaginal bleeding • Look for laceration • Determine whether the placenta has been delivered In women with hypertension or pre-eclampsia, severe blood loss may cause a misleading normal blood pressure reading and an under diagnosed state of shock Degree of Hemorrhagic Shock Grade type Volume loss %of B.V Systolic B.P Symptom Grade 1 compensated 500-100 ml (10-15%) normal Palpitation dizziness Grade 2 1000-1500 ml (15-25%) Slight fall Weakness sweating Grade 3 1500-2000 ml (25-35%) 70-80 mmHg Restlessness, pallor,oliguria Grade 4 2000-3000 ml (35-45%) 50-70 mmHg Collapse,anuria Shortness off breath • Investigations : as in APH After the history and physical examination are completed, the cause of PPH can be determined as follow: Diagnosis off PPH Symptoms and sings typically present Symptoms and sings sometimes present Probable diagnosis •Primary PPH , •Uterus soft and not contracted •shock Atonic uterus •Primary PPH •Complete placenta •Uterus contracted Tears of cervix, Vagina or perineum •Placenta not delivered •Primary PPH with 30 min after delivery •Uterus contracted •Portion of the maternal surface of the placenta missing or torn membranes with vessels •Immediate PPH •Uterus contracted Retained placenta Diagnosis off PPH Symptoms and sings typically present Symptoms and sings sometimes present Probable diagnosis •Uterine fundus not felt on abd.palpation •Slight or intense pain •Inverted uterus apparent at vulva •Primary PPH Retained placental fragments •Primary PPH ) bleeding intraabdominal a/o vaginal) •Severe abdominal pain(may decrease after ruptrure •Amount of bleeding is not related to the degree of shock •Tender abdomen •Rapid maternal pulse •State of shock Rupture uterus •Bleeding occurs more than 24h after delivery •Uterus softer and larger than expected for time since delivery Bleeding is variable) light to heavy,continuous or irregular) and may be foulsmellig Anemia Fever Secondary PPH Management • • • • • Preventive are during the antenatal period. Preventive care during labour and delivery. Emergency rules First aid management Use of utertonic agents :oxytocin,misoprostol Active Management • Placenta retained: manual removal under adequate anesthesia. • Uterine inversion reposition of the uterus • Placenta delivered: -uterus soft use oxytocin -exploration under general anesthesia , repair any cervical tears. -tear extends beyond the vaginal vault do laparotomy. At Lapatotomy : • • • • Surgical compression suture-(Lynch suture) Balloon tamponade Surgical repair Ligation of the uterine ,utero-ovarian or hypogastric arteries • Subtotal hysterectomy Important Considerations • Remember that a postpartum women can lose a large amount of blood in a very short time. • You must act promptly and anticipate complications • Assure adequate team coverage • A laparotomy for PPH is an extremely urgent situation, do not delay while waiting for blood transfusion. • Administer prophylactic antibiotics, Ampicillin 2 gm IV ,before and after the procedure • Do not give oxytocin as an undiluted IV push since the women may collapse Thank you