Postpartum Hemorrhage

Postpartum Hemorrhage
- Definition
- Etiologies
- Management

1. Postpartum Hemorrhage by Shanyar Qadir Shanyar.com

2. Blood loss of: > 500 mL during vaginal delivery > 1,000 mL following cesarean delivery Measurements are subjective and likely inaccurate Primary (early): within 24 hrs of delivery Secondary (late): from 24 hrs – 12 wks post-delivery Definition

3. Defined clinically as excessive bleeding that makes the patient symptomatic 10 % drop in hematocrit Signs/symptoms of blood loss Objective Criteria

4. One of the most common obstetrical emergencies Major cause of maternal morbidity One of the top 3 causes of direct maternal death in both developing and developed countries Leading cause of admission to the ICU Incidence 4% after vaginal delivery 6.5% after C/S delivery Why is it important?

5. Causes of PPH can be remembered as the 4 ‘ Ts ’ T one Uterine atony T rauma Injury to cervix, vagina, perineum T issue Retained placenta &/or membranes T hrombin Clotting disorders Etiology

6. Call for help, ABCs O 2 by mask initially 2 x 14-gauge IV lines FBC & clotting studies Test for renal function & liver function tests Cross-match at least 6 units of blood IV fluid resuscitation Notify blood bank & consult hematologist Foley catheter into the bladder & fluid balance chart Blood transfusion asap, O- if not available Central venous pressure & arterial lines May need FFP, platelets & cryoprecipitate (consult hematologist ) Eliminate the cause Initial Management

7. Most common cause of excessive PPH Risk Factors: Overworked: Rapid or prolonged labor ( most common ) Infected: Chorioamnionitis Relaxed: MgSO 4 , β -agonists , halothane Overdistended : Multiple pregnancies, macrosomia , polyhydramnios Uterine Atony (80%)

8. Clinical Findings: A soft uterus (feels like dough) palpable above the umbilicus. Management: Uterine massage Uterotonics (oxytocin , ergonovine , misoprostol, carboprost ) Surgical: Uterine packing or compression balloon, B-Lynch suture, sequential arterial ligation , selective arterial embolization , hysterectomy Uterine Atony (80%)

9. Bimanual Uterine Massage

10. Compression Balloons

11. B-Lynch Suture

12. Risk Factors: Difficult delivery (shoulder dystocia, macrosomia ) Instrumental delivery (forceps, vacuum extractor) Clinical Findings: Identifiable lacerations (cervix, vagina, perineum) in the presence of a contracted uterus . Management: Surgical repair. Genital Lacerations (15%)

13. Cervical Laceration Repair

14. Risk Factors: Accessory placental lobe ( most common ) Abnormal trophoblastic uterine invasion Clinical Findings: Missing placental cotyledons in the presence of a contracted uterus . Management: Manual removal or uterine curettage under US guidance. Retained Placenta (5%)

15. Placenta Fetal side

16. Placenta Maternal side

17. Succenturiate Placental Lobe

18. Manual removal of placenta

19. Uterine curettage

20. Risk Factors: Abruptio placenta (most common) Severe preeclampsia Amniotic fluid embolism Prolonged retention of a dead fetus Clinical Findings: Generalized oozing Bleeding from IV sites or lacerations in the presence of a contracted uterus. Management: Removal of pregnancy tissues from the uterus Intensive care unit (ICU) support Selective blood-product replacement. DIC (Rare)

21. Risk Factors: Fundal placentation Excessive cord traction Previous uterine inversion. Clinical Findings: Beefy-appearing bleeding mass in the vagina and failure to palpate the uterus abdominally. Management : Elevating the vaginal fornices and lifting the uterus back into its normal anatomic position IV oxytocin. Inverted Uterus (rare)

22. Progressive degrees of inversion

23. Manual replacement of uterine inversion

24. Clinical Diagnosis Management Uterus not palpable Inversion (rare) ↑ fornices , IV oxytocin Uterus like dough Atony (80%) Uterine massage, oxytocin, ergot, PG F2 α Tears in vagina, cervix Laceration (15%) Suture & repair Placenta incomplete Retained placenta (5%) Manual removal or curettage Diffuse oozing DIC (rare) Remove POC, ICU care, blood products Summary

25. Thank You!

26. Obstetrics by Ten Teachers, 19e - 2011 Williams Obstetrics, 24e - 2014 A Comprehensive Textbook of Postpartum Hemorrhage, 2e - 2012 Step Up to Obstetrics & Gynecology – 2014 Obstetrics & Gynecology Lecture Notes – 2013 Postpartum hemorrhage on Wikipedia ( http:// en.wikipedia.org/wiki/Postpartum_hemorrhage ) Sources