Postpartum Postpartum Hemorrhage Hemorrhage

Abdulah Al-Tayyem;MD;JBOGAbdulah Al-Tayyem;MD;JBOG

Consultant Ob&GynConsultant Ob&Gyn

UrogynaecologyUrogynaecology

Zarka Govern. HospitalZarka Govern. Hospital

PPH: PPH: excessive blood loss after delivery excessive blood loss after delivery sufficient to affect the general condition of sufficient to affect the general condition of the mother the mother

(tachycardia and or hypotension).(tachycardia and or hypotension).

Types:Types:

-primary within 24h-primary within 24h

-secondary after the first 24h up to 42-secondary after the first 24h up to 42ndnd day day

CausesCauses

-uterine atony-uterine atony

-genital trauma-genital trauma

-coagulations disorders-coagulations disorders

-3-3rdrd stage complications stage complications::

-mismanagement of the 3-mismanagement of the 3rdrd stage of stage of labourlabour

-acute inversion of the uterus-acute inversion of the uterus

-abnormal or incomplete placental -abnormal or incomplete placental separation separation

Factors predispose to uterine Factors predispose to uterine atonyatony

• Overdistended uterus:-polyhydramniosOverdistended uterus:-polyhydramnios --macrosomiamacrosomia -multiple pregnancy-multiple pregnancy• Uterine muscle exhaustion: -prolonged labourUterine muscle exhaustion: -prolonged labour -grand multiparity -precipitate labour -grand multiparity -precipitate labour • Intrauterine infection: -prolonged ROM -Intrauterine infection: -prolonged ROM -

chorioamionitischorioamionitis• Functional or anatomic distortion of the uterus:Functional or anatomic distortion of the uterus: -fibroid uterus – placenta previa –uterine anomalies-fibroid uterus – placenta previa –uterine anomalies• Certain general anesthetics( halothane)Certain general anesthetics( halothane)• History of previous PPH History of previous PPH

Factors predispose to genital tract Factors predispose to genital tract traumatrauma

• A precipitate delivery, or an operative or A precipitate delivery, or an operative or manipulative delivery predispose the genital manipulative delivery predispose the genital tract to lacerations :tract to lacerations :

-cervix - vagina -perineum-cervix - vagina -perineum• Malposition ,malpresentations or deep Malposition ,malpresentations or deep

engagementengagement of the fetal head of the fetal head ) ) CS,instrumental deliveries)CS,instrumental deliveries)

• Previous uterine surgeryPrevious uterine surgery• Abuse of oxytocinAbuse of oxytocin

Factors predispose to retained Factors predispose to retained product of conceptionproduct of conception

• An incomplete placenta at deliveryAn incomplete placenta at delivery• Previous uterine surgeryPrevious uterine surgery• MultiparityMultiparity• An abnormal placenta on USAn abnormal placenta on US• Intrauterine infections may lead to adherent Intrauterine infections may lead to adherent

placentaplacenta

Abnormalities of coagulationAbnormalities of coagulation

• Hemophilia A or Von Willebrad’s diseaseHemophilia A or Von Willebrad’s disease• Idiopathic thrombocytopenic purpura(ITP)Idiopathic thrombocytopenic purpura(ITP)• History of liver disease History of liver disease • Use of anticoagulants Use of anticoagulants

Acquired in pregnancy: Acquired in pregnancy:

-thrombocytopenia with PET(HELLP syndrome)-thrombocytopenia with PET(HELLP syndrome)

-DIC caused by: -abruptio placentae-DIC caused by: -abruptio placentae

-chorioamionitis-chorioamionitis

-IUFD-IUFD

DiagnosisDiagnosis

• History takingHistory taking• Physical examinationPhysical examination

tachycardia and hypotension my be present tachycardia and hypotension my be present without evidence of excessive blood loss in cases without evidence of excessive blood loss in cases of uterine ruptureof uterine rupture

• Consistency of the uterus( lax,firm)Consistency of the uterus( lax,firm)• Asses amount of vaginal bleedingAsses amount of vaginal bleeding• Look for lacerationLook for laceration• Determine whether the placenta has been Determine whether the placenta has been

delivered delivered

In women with hypertension or pre-In women with hypertension or pre-

eclampsia,eclampsia,

severe blood loss may cause a misleading severe blood loss may cause a misleading normal blood pressure reading and an normal blood pressure reading and an under diagnosed state of shock under diagnosed state of shock

Degree of Hemorrhagic ShockDegree of Hemorrhagic Shock

Grade typeGrade typeVolume lossVolume loss

%of B.V%of B.VSystolic B.PSystolic B.PSymptomSymptom

Grade 1Grade 1

compensatecompensatedd

500-100 ml500-100 ml

(10-15%)(10-15%)normalnormalPalpitationPalpitation

dizzinessdizziness

Grade 2 Grade 2 1000-1500 1000-1500 mlml

(15-25%)(15-25%)

Slight fallSlight fallWeaknessWeakness

sweatingsweating

Grade Grade 3 31500-2000 1500-2000 mlml

(25-35%)(25-35%)

70-80 70-80 mmHgmmHg

Restlessness, Restlessness, pallor,oliguriapallor,oliguria

Grade 4Grade 42000-3000 2000-3000 mlml

(35-45%)(35-45%)

50-70 50-70 mmHgmmHg

Collapse,anuriCollapse,anuriaa

Shortness off Shortness off breathbreath

• InvestigationsInvestigations : : as in APHas in APH

After the history and physical After the history and physical examination are completed, the examination are completed, the cause of PPH can be determined as cause of PPH can be determined as follow:follow:

Diagnosis off PPHDiagnosis off PPH

Symptoms and Symptoms and sings typically sings typically presentpresent

Symptoms and Symptoms and sings sometimes sings sometimes presentpresent

ProbableProbable diagnosis diagnosis

•Primary PPH ,Primary PPH ,•Uterus soft and Uterus soft and not contractednot contracted

•shockshockAtonic uterusAtonic uterus

•Primary PPHPrimary PPH•Complete Complete placentaplacenta•Uterus contractedUterus contracted

Tears of cervix,Tears of cervix,

Vagina or Vagina or perineumperineum

•Placenta not Placenta not delivered with 30 delivered with 30 min after deliverymin after delivery

•Primary PPHPrimary PPH•Uterus contractedUterus contracted

Retained placentaRetained placenta

•Portion of the Portion of the maternal surface of maternal surface of the placenta the placenta missing or torn missing or torn membranes with membranes with vesselsvessels

•Immediate PPHImmediate PPH•Uterus contractedUterus contracted

Diagnosis off PPHDiagnosis off PPH

Symptoms and sings Symptoms and sings typically presenttypically present

Symptoms and sings Symptoms and sings sometimes presentsometimes present

ProbableProbable diagnosis diagnosis

•Uterine fundus not Uterine fundus not felt on abd.palpationfelt on abd.palpation•Slight or intense Slight or intense painpain

•Inverted uterus Inverted uterus apparent at vulvaapparent at vulva•Primary PPHPrimary PPH

Retained placental Retained placental fragments fragments

•Primary PPHPrimary PPH) ) bleeding bleeding intraabdominal a/o intraabdominal a/o vaginal)vaginal)•Severe abdominal Severe abdominal pain(may decrease pain(may decrease after ruptrureafter ruptrure

•Amount of bleeding Amount of bleeding is not related to the is not related to the degree of shockdegree of shock•Tender abdomenTender abdomen•Rapid maternal Rapid maternal pulsepulse•State of shockState of shock

Rupture uterusRupture uterus

•Bleeding occurs Bleeding occurs more than 24h after more than 24h after deliverydelivery•Uterus softer and Uterus softer and larger than expected larger than expected for time since for time since deliverydelivery

Bleeding is variableBleeding is variable)) light to light to heavy,continuous or heavy,continuous or irregular) and may be irregular) and may be foul-smelligfoul-smellig

Anemia FeverAnemia Fever

Secondary Secondary PPHPPH

ManagementManagement

• Preventive are during the antenatal Preventive are during the antenatal period.period.

• Preventive care during labour and Preventive care during labour and delivery.delivery.

• Emergency rulesEmergency rules• First aid managementFirst aid management• Use of utertonic Use of utertonic

agents :oxytocin,misoprostolagents :oxytocin,misoprostol

Active ManagementActive Management

• Placenta retained: manual removal under Placenta retained: manual removal under adequate anesthesia.adequate anesthesia.

• Uterine inversion reposition of the uterusUterine inversion reposition of the uterus• Placenta delivered: Placenta delivered: -uterus soft use oxytocin-uterus soft use oxytocin -exploration under general anesthesia ,-exploration under general anesthesia , repair any cervical tears.repair any cervical tears. -tear extends beyond the vaginal vault-tear extends beyond the vaginal vault do laparotomy. do laparotomy.

At Lapatotomy :At Lapatotomy :• Surgical compression suture-(Lynch Surgical compression suture-(Lynch

suture)suture)• Balloon tamponadeBalloon tamponade• Surgical repairSurgical repair• Ligation of the uterine ,utero-ovarian or Ligation of the uterine ,utero-ovarian or

hypogastric arteries hypogastric arteries • Subtotal hysterectomySubtotal hysterectomy

Important ConsiderationsImportant Considerations

• Remember that a postpartum women can lose a Remember that a postpartum women can lose a large amount of blood in a very short time.large amount of blood in a very short time.

• You must act promptly and anticipate You must act promptly and anticipate complicationscomplications

• Assure adequate team coverage Assure adequate team coverage • A laparotomy for PPH is an extremely urgent A laparotomy for PPH is an extremely urgent

situation, do not delay while waiting for blood situation, do not delay while waiting for blood transfusion.transfusion.

• Administer prophylactic antibiotics, Ampicillin 2 Administer prophylactic antibiotics, Ampicillin 2 gm IV ,before and after the proceduregm IV ,before and after the procedure

• Do not give oxytocin as an undiluted IV push since Do not give oxytocin as an undiluted IV push since the women may collapse the women may collapse

Thank youThank you