post partum haemorrhage
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POST PARTUM HAEMORRHAGE - A Challenge To Safe Motherhood
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 2
Taj Mahal-One of the seven wonders of the world, One of the Greatest monuments, dedicated to the memory of
“Queen Mumtaz” who died in child birth, by her husband “Emperor Sahajahan”, is a testimony and a grim reminder of the tragedy of maternal mortality,
that can befall any women in childbirth.
Taj Mahal
WEL COME TOWEL COME TO
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 3
POST ARTUM HAEMORRHAGE though preventable, accounts for the majority of the cases of obstetric haemorrhage, the other causes being – antepartum haemorrhage, abortion, ectopic pregnancy and ruptured uterus.
Obstetric Haemorrhage --- Ranks as the First cause of maternal mortality
accounting for 25 – 50 % of maternal deaths
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 4
. . . the most common and severe type of obstetric haemmorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.
POST PARTUM HAEMORRHAGE
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 5
Direct Causes (%) of Mat.Mort. in selected countries*
MAGNITUDE OF THE PROBLEM
*World watch paper 102Jacobson JL ed, 1991
Country +MMR Haemorrhage Sepsis Toxaemia Abortion Obstructed Labour
INDIA 874 18 14 16 14 03
Bangladesh 600 22 03 19 31 09
Ethiopia 566 6 2 6 25 4
Tanzania 678 18 15 03 17 --
Zambia 118 17 15 20 17 --
USA 15 10 08 17 06 03
+MMR – Maternal Mortality Rate / 100000 live births
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 6
Causes of Mat.Mort. In India
Cause Reg.Gen. India (1992) FOGSI (1982)
Haemorrhage 23.7% 22.3%
Toxaemia 15.2 10.7
Puerperal Sepsis 08.1 28.4
Anaemia 19.4 -
Obstructed Labour 07.1 -
Abortion 11.8 -
Others 14.7 -
MAGNITUDE OF THE PROBLEM
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 7
CAUSES OF 110 MATERNAL DEATHS AT OUR HOSPITAL FROM 1/1996-7/2000
31
23
17
12
754
11
0
20
40
60
80
100
120
CAUSES
NU
MB
ER
OTHERS
MALARIA
ANAEMIA
RUPTURED UERUS
UNSAFE ABORTION
VIAL HEPATIIS
PIH
HAEMORRHAGE
MAGNITUDE OF THE PROBLEM
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 8
Year Developed DevelopingDevelopingCountries CountriesCountries
1930 1:3000 Births Not AvailableNot Available
1950 1:20,000 Not AvailableNot Available
1980 1:60,000 1:10001:1000
2000 1:100,000 1:50001:5000
PPH - A world of difference
MAGNITUDE OF THE PROBLEM
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 9
POST PARTUM HAEMORRHAGE
DEFINITION: -
Blood loss of 500ml or more per vaginum
during the first 24hrs after the delivery of the
baby.
Risk of Maternal Mortality & Morbidity are 50 times more after PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 10
ASSESSMENT OF BLOOD LOSS AFTER DELIVERY
Difficult Mostly Visual estimation (So, Subjective &
Inaccurate) Underestimation is likely Clinical picture -Misleading Our Mothers-Malnourished, Anaemic,
Small built, Less blood volume
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 11
MECHANISM OF HAEMOSTASIS AFTER DELIVERY
• Uterine contraction & retraction
• Platelet aggregation clot
formation
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 12
Why PPH ?
1. Uterine atony (80%)
2. Retained Placenta
3. Trauma to genital tract
4. Coagulation disorders
5. Uterine inversion
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 13
1. UTERINE ATONY
Over distension of uterus Induction of labour Prolonged / precipitate labour Anaesthesia (halogeneted) & analgesia Tocolytics (Tocolytics (also called anti-contraction medications or
labor repressants) are medications used to suppress premature labor )
APH Grand multiparity Mismanagement of 3rd stage of Labour Full bladder
RISK FACTORSRISK FACTORS
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 14
2. RETAINED PLACENTASimple adhesionMorbid adhesion>Accreta, Increta &
Percreta
3. TRAUMATIC Large episiotomy & extensions Tears & lacerations of perineum, vagina
or cervix Haematoma Uterine rupture
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 15
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 16
4. COAGULATION DISORDERS
Abruptio placentaeSepsis :IUD,PROM(premature rupture
of membrane)Massive blood lossMassive blood transfusionSevere PET (Pre-eclamptic Toxemia)/
EclampsiaAmniotic fluid embolismHepatitis
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 17
5. UTERINE INVERSION
Mostly iatrogenic due to mismanagement of 3rd stage - strong traction on the cord with a relaxed uterus / adherent placenta.
Incomplete Inversion- Fundus felt through the Cx
Complete Inversion with placenta accreta attached to the
fundus
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 18
SYMPTOMS & SIGNS
Blood loss (% B Vol)
Systolic BP( mm of Hg)
Signs & Symptoms
10-15 Normal postural hypotension
15-30 slight fall PR, thirst, weakness
30-40 60-80 pallor,oliguria, confusion
40+ 40-60 anuria, air hunger, coma, death
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 19
PREVENTION Regular ANC Correction of anaemia Identification of high risk cases Delivery in hospital with facility for Emergency
Obstetric Care. Otherwise transport to the nearest such hospital at
the earliest.Keep speedy transport available
Local / Regional anaesthesia ACTIVE MANAGEMENT OF 3RD STAGE OF
LABOUR 4th Stage of labour - Observation, Oxytocin
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 20
ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR (WHO-1989)
Oxytocics - Routine use in third stage blood loss by 30-40% 10 Units Oxytocin IV bolus Syntometrine 1 Amp IV Ergometrine 1 Amp IV Carboprost ( better than Ergometrine) 0.125 – 0.25 Mg IM
Early cord clamping Controlled cord traction Inspection of placenta & lower genital tract
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 21
TEAM- Obstetrician, Anesthesiologist, Haematologist and Blood Bank
Correction of hypovolaemiaAscertain origin of bleedingEnsure uterine contractionSurgical managementManagement of special situation
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 22
CORRECTION OF HYPOVOLEMIA
Large bore IV line (two) Crystalloids (RL)-3ml / ml of
blood loss Urine output (desired) –30ml / hr Whole blood / pack cell
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 23
ENSURE UTERINE CONTRACTION
Palpate fundus Uterine massage Bimanual compression Compression of Aorta against
sacral promontory Foleys catheters
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 24
OXYTOCICS Oxytocin:
Bolus of 10 units IV followed by Continuous Infusion 100 mu / min
Ergometrine 0.2 - 0.5mg IV Prostaglandins-
Carboprost- 0.25mg start, Rpt.15-30 min, Maximum 2.0mg, Route-IM / intramyometrial
Sulprostone- 400-600 micro gm
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 25
OTHER MODES
M.A.S.T (Military Anti Shock Treatment)
UTERINE PACKING
UTERINE TAMPONADE
• Large bulb Foleys
• Sangstaken blakemole tube
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 26
SURGICAL TREATMENT
Depends on
Extent & cause of haemorrhage
General condition of patient
Future reproduction
Experience & skill
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 27
SURGICAL TREATMENT Repair of trauma if any Uterine Artery ligation Utero ovarian A. Ligation Internal Iliac A. Ligation Brace suturing of Uterus Hysterectomy Angiographic embolisation
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 28
RETAINED PLACENTA EUA(examination Under
Anaesthesia & Manual Removal If Placenta accreta-
ObservationCytotoxic drugs- MethotrexateHysterectomy
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 29
ACUTE INVERSION OF UTERUS
Manual replacement- Under GA / Uterine relaxant
Hydrostatic method
Surgical method ( Usually delayed
procedure)
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 30
MANAGEMENT OF DIC
Fresh blood transfusion
Blood productsCryoprecipitateFresh frozen plasmaPlatelet concentrate
MANAGEMENT OF PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 31
MORBIDITY & MORTALITY from PPH
Shock & DIC Renal Failure Puerperal sepsis Lactation failure Blood transfusion reaction Thromboembolism Sheehan’s syndrome >25% Maternal deaths are due to PPH>25% Maternal deaths are due to PPH
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 32
Intelligent anticipation, skilled supervision, prompt detection and effective institution
of therapy can prevent disastrous consequences of PPH.
Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 33
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