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POSTPARTUM POSTPARTUM HAEMORRHAGE AND HAEMORRHAGE AND OBSTETRIC SHOCKOBSTETRIC SHOCK

DR. SAMAA NAZER DR. SAMAA NAZER Assistant Professor of Obstetrics & Gynecology Assistant Professor of Obstetrics & Gynecology

Jeddah, Saudi Arabia Jeddah, Saudi Arabia

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Content:Content: Definition Definition Causes Causes Predisposing factor Predisposing factor How to evaluate haemorrhage How to evaluate haemorrhage Prevention Prevention Management Management Definition of Obstetric shock Definition of Obstetric shock Systemic approach to diagnosis and Systemic approach to diagnosis and

managementmanagement

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DEFINITION OF PPH:DEFINITION OF PPH:

Blood loss in excess of 500 mls during the Blood loss in excess of 500 mls during the

first 24 hours after delivery first 24 hours after delivery

At vaginal delivery 500 mls At vaginal delivery 500 mls

At cesarean section 1000 mls At cesarean section 1000 mls

TypesTypes: Early: 1: Early: 1stst 24 hours 24 hours

Late: after 24 hours – 6 weeks Late: after 24 hours – 6 weeks

Incidence: 4% Incidence: 4%

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Causes:Causes:

1.1. Uterine atony Uterine atony

2.2. Genital tract trauma Genital tract trauma

3.3. Retained placental tissue Retained placental tissue

4.4. Low placental implantation Low placental implantation

5.5. Uterine inversion Uterine inversion

6.6. Coagulation disordersCoagulation disorders

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I – Uterine Atony (75% - 80%)I – Uterine Atony (75% - 80%) Causes: Causes: General anesthesia: Halogenated hydrocarbon General anesthesia: Halogenated hydrocarbon Over distended uterus Over distended uterus

large fetus, twins, hydramnios large fetus, twins, hydramnios Following prolonged labour Following prolonged labour Following very rapid delivery Following very rapid delivery Following oxytocin induced labourFollowing oxytocin induced labour High parity High parity Uterine atony in previous pregnancy Uterine atony in previous pregnancy Chorioamnionitis Chorioamnionitis

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II – Genital tract traumaII – Genital tract trauma

It is usually suspected if bleeding persists in the It is usually suspected if bleeding persists in the presence of a firmly contracted intact uterus.presence of a firmly contracted intact uterus.

Sites: Cervix, vagina, uterus Sites: Cervix, vagina, uterus

Diagnosis: Proper exposure of the upper vagina Diagnosis: Proper exposure of the upper vagina and cervix using sims speculum and two ovum and cervix using sims speculum and two ovum forceps, under good sedation. forceps, under good sedation.

Uterine laceration can be associated by blood Uterine laceration can be associated by blood accumulation in the uterus and uterine atony. accumulation in the uterus and uterine atony.

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PREDISPOSING FACTOR OF PREDISPOSING FACTOR OF TRAUMA:TRAUMA:

Delivery of a large baby Delivery of a large baby Mid forceps delivery Mid forceps delivery Intra uterine manipulation Intra uterine manipulation Vaginal delivery after cesarean section, or Vaginal delivery after cesarean section, or

any, uterine incision any, uterine incision

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VULVOVAGINAL HEMATOMAVULVOVAGINAL HEMATOMA

Hematoma can be associated with early or Hematoma can be associated with early or late haemorrhage late haemorrhage

Classification:Classification: Vulvar haematoma classified according to Vulvar haematoma classified according to their location in relation to the levator ani their location in relation to the levator ani muscle,muscle,

a. a. Below levatorBelow levator, associated with vaginal , associated with vaginal delivery limited from spread by levator ani delivery limited from spread by levator ani muscle muscle

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and limited from spread to the thigh by and limited from spread to the thigh by colle’s facia and facia lata.colle’s facia and facia lata.

The central tendon of perineum prevents The central tendon of perineum prevents from spreading across the midline.from spreading across the midline.

b. b. Supra levatorSupra levator associated with uterine associated with uterine rupture and dissect into the broad ligament rupture and dissect into the broad ligament and retroperitoneal space leading to and retroperitoneal space leading to hypovolemia.hypovolemia.

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RETAINED PLACENTAL TISSUERETAINED PLACENTAL TISSUE

Retained placenta is a common cause of Retained placenta is a common cause of bleeding late in the puerperium inspection bleeding late in the puerperium inspection of the placenta after delivery must be of the placenta after delivery must be routine.routine.

Retention of asuccenturiate lobe is an Retention of asuccenturiate lobe is an occasional cause of postpartum occasional cause of postpartum haemorrhagehaemorrhage

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PLACENTA ACCRETA, INCRETA, PLACENTA ACCRETA, INCRETA, PERCRETAPERCRETA

As the consequence of partial or total absence of the As the consequence of partial or total absence of the

decidua basalis and imperfect development of the fibrinoid decidua basalis and imperfect development of the fibrinoid

layer (Nitabuch layer), placental villi are attached to the layer (Nitabuch layer), placental villi are attached to the

myometrium in myometrium in placenta accretaplacenta accreta. .

If invade the myometrium in If invade the myometrium in placenta incretaplacenta increta

If penetrate through the myometrium in If penetrate through the myometrium in placenta percretaplacenta percreta

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ETIOLOGY ETIOLOGY

• Implantation in the lower uterine segment over Implantation in the lower uterine segment over previous cesarean section scar, or other previous cesarean section scar, or other uterine incision, or occurrence after uterine uterine incision, or occurrence after uterine curettage. curettage.

• Placenta previa without prior uterine surgery Placenta previa without prior uterine surgery incidence of placenta accreta is 4%. incidence of placenta accreta is 4%.

• In patient with previous cesarean section and In patient with previous cesarean section and placenta previa the incidence of placenta placenta previa the incidence of placenta accreta is 15% - 25% accreta is 15% - 25%

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LOW PLACENTA IMPLANTATIONLOW PLACENTA IMPLANTATION

Due to the relative decrease in the Due to the relative decrease in the

Content musculature in the lower Content musculature in the lower uterine segment which will be uterine segment which will be insufficient in controlling the placental insufficient in controlling the placental site bleeding specially in placenta site bleeding specially in placenta previa. previa.

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UTERINE INVERSIONUTERINE INVERSION

It is due to premature strong traction on an It is due to premature strong traction on an umbilical cord attached to a placenta umbilical cord attached to a placenta implanted in the fundus of the uterus. implanted in the fundus of the uterus.

It can be associated with placenta accreta.It can be associated with placenta accreta. It is usually the cause of shock which tend It is usually the cause of shock which tend

to be disproportionate to blood loss. to be disproportionate to blood loss.

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CLASSIFICATIONCLASSIFICATION

Acute Acute Sub acute Sub acute Chronic Chronic

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COAGULATION DISORDERS COAGULATION DISORDERS

Abruptio placenta Abruptio placenta Amniotic fluid embolism Amniotic fluid embolism Retained dead fetus Retained dead fetus Inherited coagulopathy (Von-Wille brand’s Inherited coagulopathy (Von-Wille brand’s

disease) disease) DIC DIC

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CLASSIFICATION OF CLASSIFICATION OF HAEMORRHAGEHAEMORRHAGE

4 CLASSES depend on volume lost 4 CLASSES depend on volume lost 60 Kg pregnant woman has a blood volume of 6,000 ml 60 Kg pregnant woman has a blood volume of 6,000 ml

at 30 weeks at 30 weeks

1. 1. Class I:Class I: – Volume loss of less than 900 ml, such – Volume loss of less than 900 ml, such patient rarely exhibit sign or symptoms of volume patient rarely exhibit sign or symptoms of volume deficit. deficit.

2. 2. Class II:Class II: – haemorrhage, blood loss 1200 ml to 1500 – haemorrhage, blood loss 1200 ml to 1500 mls patient will show rise in pulse rate and / or mls patient will show rise in pulse rate and / or possibly a rise respiratory rate. This class will have possibly a rise respiratory rate. This class will have

or thostatic blood pressure changes, and narrowing of or thostatic blood pressure changes, and narrowing of the pulse pressure. the pulse pressure.

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3. 3. Class IIIClass III:: Is defined as blood loss sufficient to cause Is defined as blood loss sufficient to cause overt hypotensionovert hypotension

Blood loss of 18,00 mls – 2,100 mls Blood loss of 18,00 mls – 2,100 mls

These patient will have marked tacchycardia, cold, lammy These patient will have marked tacchycardia, cold, lammy

skin, tachypnea. skin, tachypnea.

4. 4. Class IVClass IV:: Class 4 patients, the volume deficit exceed Class 4 patients, the volume deficit exceed 40% 40%

These patients are in profound shock absent pulse and These patients are in profound shock absent pulse and

oliguria. oliguria.

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PREVENTIONPREVENTION

1.1. Identify patient at risk of postpartum Identify patient at risk of postpartum haemorrhage haemorrhage

2.2. Prepare blood at least 4 units of packed Prepare blood at least 4 units of packed red blood cells. red blood cells.

3.3. Active management of third stage of Active management of third stage of labour for all patientslabour for all patients

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4.4. Use of oxytocin infusion after placental Use of oxytocin infusion after placental deliverydelivery

5.5. Carefully inspection of the placenta and Carefully inspection of the placenta and membranemembrane

6.6. Use of oxytocin infusion in the umbilical vein to Use of oxytocin infusion in the umbilical vein to prevent retained placenta.prevent retained placenta.

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MANAGEMENT OF UTERINE MANAGEMENT OF UTERINE ATONYATONY

1.1. Patient showing signs of class II or Patient showing signs of class II or greater volume loss should receive greater volume loss should receive crystalloid intravenous fluids pending the crystalloid intravenous fluids pending the arrival of blood and blood products. arrival of blood and blood products.

2.2. Put two intravenous large – bore catheter Put two intravenous large – bore catheter and connected to IV fluids. and connected to IV fluids.

3.3. Insert fuley catheter to determine input Insert fuley catheter to determine input and out put chart. and out put chart.

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4.4. Inform anesthesia and keep patient nil per Inform anesthesia and keep patient nil per mouth mouth

5.5. Ask for assistant Ask for assistant 6.6. Bimanual compression and massaging of Bimanual compression and massaging of

the uterusthe uterus7.7. Initial therapy include administration of a Initial therapy include administration of a

diluted solution of oxytocin (10 – 20 units) diluted solution of oxytocin (10 – 20 units) in 1,000 mls of physiological saline in a in 1,000 mls of physiological saline in a rate of 500 mls in 10 min. rate of 500 mls in 10 min.

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8.8. If failed prostaglandin F2If failed prostaglandin F2αα the total dose the total dose is 1 – 2 mg diluted in 10 – 20 ml of saline is 1 – 2 mg diluted in 10 – 20 ml of saline

9.9. Use of mesoprestol rectaly in a dose 400 Use of mesoprestol rectaly in a dose 400 microgram microgram

10.10. Intramural ergonovine Intramural ergonovine

When pharmacological methods fail,surgicalWhen pharmacological methods fail,surgical

method should be under taken. method should be under taken.

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SURGICAL METHODSURGICAL METHOD

1.1. Ligation of the ascending branch of the Ligation of the ascending branch of the uterine arteries uterine arteries

2.2. Ligation of hypogastric artery Ligation of hypogastric artery

3.3. Hysterectomy Hysterectomy

4.4. Uterine artery embolization Uterine artery embolization

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OBSTETRIC SHOCKOBSTETRIC SHOCK

Hypotension without significant external Hypotension without significant external

bleedingbleeding

CausesCauses::

1.1. Concealed haemorrhage Concealed haemorrhage

2.2. Uterine inversion Uterine inversion

3.3. Amniotic fluid embolism Amniotic fluid embolism

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CAUSE OF CONCEALED CAUSE OF CONCEALED HAEMORRHAGEHAEMORRHAGE

1.1. Spontaneous uterine rupture Spontaneous uterine rupture

2.2. Retroperitoneal bleeding from vaginal Retroperitoneal bleeding from vaginal tears tears

3.3. Perineal hematoma Perineal hematoma

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AMNIOTIC FLUID EMBOLISMAMNIOTIC FLUID EMBOLISM

Rare, 1 of 30,000 deliveries Rare, 1 of 30,000 deliveries

Mortality rate is 50% Mortality rate is 50%

The definitive diagnosis of AFE can be The definitive diagnosis of AFE can be

made by the demonstration of fetal made by the demonstration of fetal

squamous and Lanugo in the pulmonary squamous and Lanugo in the pulmonary

vascular space. vascular space.

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CLINICAL PRESENTATIONCLINICAL PRESENTATION

1.1. Respiratory distress Respiratory distress

2.2. Cyanosis Cyanosis

3.3. Cardio vascular collapse Cardio vascular collapse

4.4. Haemorrhage Haemorrhage

5.5. Coma Coma

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TREATMENTTREATMENT

1.1. Endotracheal intubation and maximum Endotracheal intubation and maximum ventilation and oxygenation ventilation and oxygenation

2.2. Restore cardio vascular equilibrium Restore cardio vascular equilibrium 3.3. Central monitoring of fluid therapy with a Central monitoring of fluid therapy with a

pulmonary artery catheter.pulmonary artery catheter.4.4. 40 – 50% risk of development of coagulopathy 40 – 50% risk of development of coagulopathy

with in 1-2 hours, - DIC results in depletion of with in 1-2 hours, - DIC results in depletion of fibronogen, platelet and coagulation factor, so fibronogen, platelet and coagulation factor, so whole blood and fresh frozen plasma is whole blood and fresh frozen plasma is essential. essential.

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MASSIVE BLOOD TRANSFUSIONMASSIVE BLOOD TRANSFUSION

It is the replacement of a patient entire blood It is the replacement of a patient entire blood volume in 24 hours ( 10 units or more) volume in 24 hours ( 10 units or more)

It require base line investigation inform of It require base line investigation inform of CBC, platelet count, fibrinogen,prothrombin CBC, platelet count, fibrinogen,prothrombin time (PT) partial thromboplastin time (PTT). time (PT) partial thromboplastin time (PTT).

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COMPLICATION OF MASSIVE COMPLICATION OF MASSIVE TRANSFUSIONTRANSFUSION

If more than 4 units of packed RBC,platelet If more than 4 units of packed RBC,platelet

count will drop, there will be consumption count will drop, there will be consumption

process (DIC) process (DIC)

Management, after 4 units transfusion, bloodManagement, after 4 units transfusion, blood

gas, PT, PTT has to be tested and continue gas, PT, PTT has to be tested and continue

with whole blood or fresh frozen plasmawith whole blood or fresh frozen plasma

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PROGNOSIS OF POSTPARTUM PROGNOSIS OF POSTPARTUM HAEMORRHAGEHAEMORRHAGE

Women with postpartum haemorrhage should not Women with postpartum haemorrhage should not die die

1.1. Renal failure from prolong hypotension Renal failure from prolong hypotension 2.2. Complication of blood transfusion: Complication of blood transfusion: Immediate reaction:Immediate reaction: fever, itching fever, itching Late complication:Late complication: blood born infection blood born infection3.3. Sheehan syndrome – It is anterior pituitary Sheehan syndrome – It is anterior pituitary

necrosis causing failure of lactation, necrosis causing failure of lactation, amenorrhea, atrophy of breast, loss of pubic amenorrhea, atrophy of breast, loss of pubic and axillary hair, super involution of the uterus, and axillary hair, super involution of the uterus, hypothyroidism, adrenal cortical insufficiency. hypothyroidism, adrenal cortical insufficiency.

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BLOOD PRODUCTSBLOOD PRODUCTS

1.1. Whole blood Whole blood

2.2. Packed red blood cells, most effective and Packed red blood cells, most effective and efficient way to provide increase oxygen efficient way to provide increase oxygen carrying capacity to the anemic patient, less carrying capacity to the anemic patient, less transfusion reaction due to lack of WBC , has transfusion reaction due to lack of WBC , has less coagulation factor. less coagulation factor.

3.3. Platelet Platelet

1 unit of platelet increase, platelet count 1 unit of platelet increase, platelet count between 5,000 and 10,000/µlbetween 5,000 and 10,000/µl

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4. 4. Cryoprecipitate :Cryoprecipitate :Prepared by warming fresh frozen plasma Prepared by warming fresh frozen plasma and collecting the precipitate. and collecting the precipitate. Factor VIII, vonwillebrand’s factor and fibrinogen Factor VIII, vonwillebrand’s factor and fibrinogen One unit of cryoprecipitate will raise the serum One unit of cryoprecipitate will raise the serum

fibrinogen 10 mg / dlfibrinogen 10 mg / dl5.5. Fresh frozen plasmaFresh frozen plasma1 unit of FFP should be given for every 4 units of 1 unit of FFP should be given for every 4 units of transfused blood. transfused blood.

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