11.Postpartum+Hemorrhage

1. 1
Postpartum Hemorrhage

2. 2
Definition
Defined as blood loss in excess of
500 mL at the time of vaginal
delivery or more than 1000 mL
following cesarean delivery.
 A loss of these amounts within 24
hours of delivery.
Occurs in 4% of deliveries.

3. 3
Etiology
Uterine atony (tone)
genital tract trauma
Retained placental tissue
Coagulation disorders(thrombosis )

4. 4
Uterine atony
Uterus fails to contract to control bleeding
at placental site
Predisposing Causes
Excessive Uterine distension
Twin Gestation
Fetal Macrosomia
Polyhydramnios
Multiparity
Fibrosis in uterine muscle

5. 5
Uterine atony
Prolonged labor
Labor augmented with oxytocin
General Anesthesia
Magnesium sulfate infusion
chorioamnionitis

6. 6
genital tract trauma
Perineal body laceration
Periurethral area laceration
Vaginal sidewall laceration
Cervical laceration
Uterine rupture
Incision extention during cs
Uterine inversion

7. 7
Retained placental tissue
Retained placenta
placenta accreta.
placenta percreta
Low placental implantation

8. 8
Coagulation disorders
Thrombotic thrombocytopenia purpura
Amniotic fluid embolus
idiopathic thrombocytopenic purpura
Von Willebrand’s disease
Inability to form a stable blood clot in
the placental site,and susceptible to
immediate hemorrhage

9. 9
Obstetric shock
Defination: hypotension without significant
external bleeding may occasionally
develop in an obstetric patient.
 Causes:
concealed hemorrhage :an
improperly sutured episiotomy can
lead to a soft tissue hematoma.
uterine inversion
amniotic fluid embolism

10. 10
Differential Diagnosis
The fundus of the uterus: uterine atony,
uterine inversion
Inspection of the vagina and cervix:
Lacerations
Manual exploration of the uterine cavity:
retained placental tissue; uterine wall
lacerations,or partial uterine inversion
If no cause found for bleeding :
coagulopathy

11. 11
Management

12. 12
General Treatment
Screened for anemia and special type of
blood held in the lab
Intravenous infusion
Monitoring patient’s vital signs
Resuscitation with normal saline

13. 13
Uterine Atony
A rapid continuous intravenous infusion of dilute
oxytocin(40 to 80 U in 1L of normal saline)
Ergonovine maleate or methylergonovine,
0.2mg,im
Analogues of prostaglandin F2a, im
Bimanual compression and massage of the
uterine corpus
Packing the uterine cavity
Place an angiocatheter into the uterine arteries for
injection of thrombogenic materials.
Operative intervention: supracervical abdominal
hysterectomy; ligation of the uterine arteries.

14. 14
Genital Tract Trauma
Repair of vaginal lacerations :
the first suture must be placed well above
the apex of the laceration
without dead space
Cervical lacerations need not be sutured unless
they are actively bleeding
Large expanding hematomas require surgical
evacuation of clots and a search for bleeding
vessels that can be ligated.
A laparotomy and bilateral hypogastric artery
ligation may be necessary.
A uterine rupture: subtotal or total abdominal
hysterectomy.
Uterine Inversion: replaced

15. 15
Retained Placental Tissue
Manual removal of the placenta
A large curette
Hysterectomy: extensive placenta
accreta.

16. 16
Coagulopathy
Infusion of blood products
Thrombocytopenia: platelet concentrate
infusions
Von Willebrand’s disease: factor VIII
concentrate or cryoprecipitate
Hemoglobin level <100 g/L: Blood
transfusion