Management of true postpartum hemorrage

Management of true postpartum hemorrage

1. MANAGEMENT OF TRUE POSTPARTUM HEMORRAGE TRUE PPH – Bleeding followed by expulsion of placenta .

2. PRINCIPLE of Management Communication Resuscitation Monitoring Arresting of bleeding THESE are essential in all cases of major PPH(>1L blood loss ) or in clinical shock .

3. Management Management having two measures - 1) immediate measures- taken by attending doctor / midwife . 2) actual management – involving a) atonic b) traumatic c) Retained Tissues d) coagulopathy

4. Immediate MeasurE By doctor – Put in two large bore (14-gauge) intravenous cannulas . Keep patient flat and warm . Send blood for CBC , Blood group , cross matching , RFT ,LFT ,coagulation screening (fibrinogen ) and for 2 units of bood ( atleast ). Infuse rapidly 2ltr of NS to reexpand the vascular bed . Give oxygen by mask 10-15L/min. 20 units of oxytocin in 1L NS iv.at 60 drops/min . Transfuse blood as possible

5. Monitoring Midwife or doctor should monitor- BP Temperature Respiratory rate and oximeter Type and amount of fluids received by pt. Urine output ( continous catheterisation ) Drug –type , dose ,time Central venous pressure

6. Actual Management First is to control the fundus and feel the uterus . If the uterus is flabby then bleeding is likely from the atonic uterus . And if the uterus is firm and contracted the bleeding is likely from the traumatic origin .

7. Management of Atonic uterus Involving following steps – STEP -1 Massage the uterus – to make it hard and express the blood clots . M ethergine 0.2 mg iv. Slowly Oxytocin 10-20 units in 500ml NS at 40-60 drops /min . Monitor urine ouput and keep bladder empty . 5. Examine the expelled placenta and membranes But if uterus fails to contract – proced to next step

8. STEP -2 Uterus is explored under general anesthesia . Simultaneously inspection of cervix , vagina ( paraurethral region ) to exclude bleeding from injured area . Blood transfusion Continue oxytocin drip

9. I f fails to contract Then start with – 1) 15 methyl PGF2@ 250 microgram IM in deltoid every min. (max. up to 2mg). 2) Misoprostol (PGE1) 1000microgram per rectum is effective . 3) Carbetocin 100 microgram IM /IV 4) Calcium gluconate 1g iv. Slowly if uterus atony is due to tocolytics (CCB). If fails to contract then next step

10. Bimanual compression

11. Step -3 Bimanual Compression Involve uterine message and bimanual compression. Procedure – 1) whole hand is introduced into vagina in cone shaped fashion after separating labia with other hand finger. 2) Hand is clenched into fist inside with back of the hand directed posteriorly knuckles in anterior fornix. 3) Other hand is placed over the abdomen behind the uterus to make it anteverted . 4) Uterus is squeezed between hands 5) And compression is prolonged untill the tone of uterus is regained

12. If uterus remain refractory and bleeding is continous -- may be some coagulative disorder . blood transfusion and oxytoxic are continous upto specific measure . almost all cases respond well to these . in rare cases uterus fails to contract .

13. Step -4 Uterine tamponade Uterine tamponade involve two methods Tight intra uterine packing . 2. Balloon tamponade . TIGHT INTRA UTERINE PACKING is done under general anesthesia . PROCEDURE - 5 m long strip of gauge and 8 cm wide folded twice . The gauge should be shocked in antiseptic cream before introduction . The gauge is placed in fundal area first , while the uterus is steadied by other hand .

14. Balloon tamponade Various hydrostatic balloon catheter replaced the uterine packing . Mechanism is similar to uterine packing . Ballon tamponade are- foley catheter , bakri balloon , caondom catheter . These balloons are inserted into the uterine cavity and inflated with NS (200-500ml). Kept for 4-6 hrs .

15. UTERINE TAMPONADE Successful in atonic PPH This avoid hysterectomy in 78% cases . Considered as first line surgical intervention in most of women with atonic PPH DIAGRAM showing bakri balloon .

16. d) Then gradually rest of the cavity is packed so that no empty space is left . e) Separate pack is used for filling the vagina . this intra uterine plug acts by stimulating uterine contraction and by exerting direct hemostatic pressure ( tamponade effect ) which opens the uterine sinuses antibiotic should be given and plug should removed after 24 hrs. this method is useful in uncontrolled postpartum hemorrhage where other methods fail and when patient is prepared for tertiary care centre .

17. Step -5 Surgical methods 1. B-Lynch Compression suture and multiple square sutures - both of th ese methods works like bimanual compression of the uterus. and the success rate is about 80% and can avoid hysterectomy . 2. LIGATION OF UTERINE arteries - ascending branch of uterine artery is ligated at lateral border b/w lower and upper uterine segment. a) suture is passed into myometrium 2cm medial to artery . In atonic hemorrhage bilateral ligation is effective in about 75% of cases .

18. 3. Ligation of ovarian and uterine artery anastomosis – ligation occur just below the ovarian ligament 4. Ligation of anterior division of internal iliac artery - may be unilateral or bilateral . a) reduces the distal blood flow . b) by reducing pulse pressure up to 85% it helps in stable clot formation . c) extensive circulation prevent pelvic tissue necrosis. And Bilateral ligation avoid hysterectomy in 50% cases.

19. Left side - showing ligation of utero-ovarian artery R ight side – B-Lynch brace suture

20. STEP-5 HYSTERECTOMY RARELY if uterus fails to contract and bleeding continues in spite of above steps . This should be involving a second consultant . And the decision should be taken earlier in parous women . It may be total or subtotal HYSTERECTOMY .

21. TRAUMATIC PPH IF uterus is hard and contracted then it will be traumatic origin involve trauma to perineum , vagina and cervix is also be there so have to search under good light by speculum examination . hemostasis is achieved catgut suture . And repair is done under general anesthesia . oxytocics are given and then bleeding controlled and patient is under continous observation .

22. Secondary postpartum hemorrhage Hemorrhage occur after 24 hr of delivery of baby . Bleeding usually occur betweeen 8 th and 14 th day of the delivery .

23. Causes Retained bits of membranes Infection and separartion of slough over a deep cervicovaginal laceration . Endometritis and subinvolution of the placental site ( due to healing processes) Secondary hemorrhage from cesarian section wound due to - a) from granular tissue b) separation of slough exposing a bleeding vessel . 5. withdrawl bleeding following estrogen therapy for suppression of lactation 6. Other rare causes – carcinoma cervix, placental polyp , infected fibroid , fibroid polyp occur usually beyond 4 weeks of delivery .

24. Diagnosis Bleeding is bright red and of varying amount . Rarely it may be brisk Varying degree of anemia (<10g/dl) and sepsis is present . Internal examination reveals evidence of sepsis , subinvolution of the uterus and often a patulous cervical os . USG – detects bts of placenta inside the uterine cavity .

25. Management PRINCIPLE - 1) Assess the amount of blood loss and replace with blood transfusion . 2) Find out the cause and take appropriate steps for treatment . supportive therapy- blood transfusion ( if necessary). 2) routine - antibiotics adm. (clindamycin , metronidazole ) 3) Methergine adm. 0.2mg if bleeding is uterine origin .

26. Management conservative – if bleeding is slight then careful watching of 24 hrs is to be done . Active management - 1. exploration of the uterus under general anesthesia shou ld be done – (because the most common cause is retained bits of cotyledon and membrane ). 2. Products are removed by ovum forceps . 3.GENTLE Curettage is done by using flushing curette.

27. Active management 4. Methergine 0.2 mg is given intramuscularly . 5. Removed materials are sent for histological examination . 6 . Hemostatic sutures – to control the bleeding from sloughing wound of cervicovaginal canal . Bleeding from uterine wound can be controlled by hemostatic suture , rarely require ligation of internal iliac artery or in end with HYSTERECTOMY .