postpartum hemorrhage dr. alongkone phengsavanh. objectives define and discuss risk factors and...
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Postpartum Hemorrhage
Dr. Alongkone Phengsavanh
Objectives
• Define and discuss risk factors and causes
• Describe management and prevention
Postpartum Hemorrhage
• Leading cause of maternal deaths worldwide
• Responsible for 1/3 of maternal deaths worldwide and 60% in developing countries
• Majority of deaths within 4 hours of delivery
Postpartum Hemorrhage(PPH)
• Primary (immediate)– Hemorrhage in first 24
hours after delivery– 70% due to uterine atony
• Secondary (delayed)– Hemorrhage after 24 hours
up to 6 weeks postpartum– Caused by
• Retained placental tissue
• Infection
• Definitions – Volume loss (Traditional)– Spontaneous vaginal
delivery• >500 cc blood
– C/Section• >1000 cc blood
• Clinical– Any blood loss that has the
potential to produce hemodynamic instability
Clinical Findings & Blood Loss
Mild
Hypovolemia
Moderate Hypovolemia
Severe Hypovolemia
Definition
(blood volume)
<20% 20 - 40% >40%
HR Mild tachycardia >110 bpm tachycardia
RR Normal >30 rpm tachypnea
Clinical Cool extremities, decreased urine output, dizziness, normal neuro status
Marked pallor, hypotension with sitting, anxious state
Oliguria / anuria, agitation, confusion, loss of consciousness, BP unstable
PPH Etiology
• Tone - Uterine tone
• Tissue - Retained tissue / clots
• Trauma - Laceration, rupture,
uterine inversion
• Thrombopathy - Coagulopathy
PPH Risk Factors - Tone
• Overdistended uterus– Polyhydramnios– Multiple gestation– Macrosomia
• Uterine muscle exhaustion– Rapid labor– Prolonged labor– High parity
• Intra-amniotic infection– Fever– Prolonged Rupture of
Membranes• Uterine abnormalities
– Fibroid uterus– Congenital uterine
abnormalities– Placenta previa / placental
abruption• Uterine relaxing agents
– Magnesium sulfate– Halogenated anesthetics– Nitroglycerin
PPH Risk Factors - Tissue
• Retained tissue, abnormal placentation (succinuriate lobe, retained cotyledon)– Incomplete placental delivery– Previous uterine surgery– High parity
• Retained blood clots– Atonic uterus
PPH Risk Factors - Trauma
• Lower genital tract lacerations (cervix, vaginal wall, perineum)– Precipitous delivery– Operative delivery– Poorly timed or inappropriate episiotomy
• Caesarean section – extensions / lacerations– Deep engagement of head– Malposition
• Uterine rupture– Prior uterine surgery
• Uterine inversion– High parity– Fundal placenta
PPH Risk Factors - Thrombin
• Pre-existing states– Hereditary conditions– History of liver disease
• Therapeutic anticoagulation– History of thrombotic disease
• Other (DIC, ITP, Pre-eclampsia, placental abruption, severe infection)– Intrauterine fetal demise– Bruising– Elevated blood pressure– Fever– Elevated WBC– Antepartum hemorrhage– Sudden collapse
PPH Prevention
• Active management of the Third Stage of Labor– Administer oxytocin with delivery of anterior shoulder
or immediately after delivery of baby• Oxytocin 10 units IM or 5 units IV
– Clamp and cut cord– Palpate uterine fundus & confirm uterus contracting– Perform controlled cord traction with suprapubic
counter traction with next strong contraction– Perform uterine massage after delivery of placenta– Examine placenta for completeness
Controlled Cord Traction
PPH Management
• Prevention– Active management of the third stage of labor– Identify patients at potential risk of PPH
PPH Management
• Primary PPH– Active management of third stage of labor– Call for HELP– ABC (Airway, Breathing, Circulation)– Estimate / measure blood loss– Closely monitor vital signs– Catheterize bladder (urine volume)– Give oxygen– Give oxytocin (IV/IM) or misoprostil (PR)
PPH Management – Tone
• Determine source of bleeding– Assess the uterine
fundus– Do Internal Bimanual
Massage of uterus
PPH Management – Tissue
Examine placenta for completeness
Examine maternal side of placenta Examine fetal side of placenta
PPH Management – Tissue
1 2
3 4
Manual removal of placenta – if incomplete placenta
PPH Management - Trauma
• If fundus firm & placenta complete, then examine for trauma– Upper vaginal tract - identify and repair tears– Lower & external genital tract – apply
pressure and repair tears
PPH Management
• If bleeding continues consider– IV oxytocin
• Oxytocin 40 units/1 liter Normal Saline run wide open
– Misoprostil• 800 ug pr (4 tablets per rectum)
– Correct hypovolemia• Normal Saline• Ringers Lactate• Blood products – RBC transfusion
PPH Management
• Consider transfer to center with additional resources– Surgery
• B-Lynch Stitch• Hysterectomy
PPH ManagementConsider aortic compression
Uterine inversion
• Rare• Caused by over vigorous
cord traction• More common in grand
multiparous women• Treatment
– Replace uterus promptly– Replacement is “last out” is
“first in”– Consider uterine relaxation
with nitroglycerin
Uterine rupture
• Can occur with:– Prolonged or obstructed labor– Prior uterine surgery – caesarean section– Grand multiparous women being induced or
augmented
• Management– Vigorous resuscitation– Emergency laparotomy
• Delivery of fetus / repair of uterus• Hysterectomy
– Prophylactic antibiotics
Secondary PPH
• Cause– Retained tissue– Infection– Breakdown of uterine wound following C/S
• Management– ABC – treat for shock– Antibiotics– Assess patient carefully for source of bleeding
Secondary PPH
• After bleeding controlled monitor woman for:– 24 – 48 hours for further bleeding
• Urine output• Vital signs• Uterine tone• CBC
• Educate patient and family about PPH and when to return to hospital
Conclusion – Key message
• PPH is a serious obstetrical emergency requiring urgent diagnosis and treatment.
• PPH is prevented with Active Management of the Third Stage of Labor.
• Patient may need to be transferred to referral hospital if local resources inadequate.