POSTPARTUM HAEMORRHAGE

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A 21-year-old nulliparous patient at 41 weeks gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine.What can be done to stanch the ow?

CASE 1 :Third Trimester Bleeding

A 32 yo G2P1 presents at 36 weeks complaining of bright red vaginal bleeding. Upon further questioning she does admit to having had some light bleeding on 1 to 2 occasions last week.

Her previous pregnancy was delivered at term by a Classical Cesarean Section for footling breech presentation.

A 21-year-old nulliparous patient at 41 weeks gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine.What can be done to stanch the ow?

What is the Differential Diagnosis?

Placenta PreviaPlacental AbruptionUterine RuptureVasa PreviaLacerationVaginal mass

Placenta Previa

Painless third-trimester bleedingComplicates 4-6% pregnancies between 10 and 20 wks, 0.5% pregnancies >20 weeksRisk factorsIncreasing parity, maternal age, prior CS, curettages ,myomectomy Types?Complete previa (20-30%)Partial previa (does not completely cover)Marginal (proximate to os)Management: pelvic rest, US, IV, T+S, C/S

Associated ConditionsPlacenta accreta, increta, percretaRisk inc w/ inc no. of prior c/s (50% risk in pt w/ previa and 2 prior c/s)Vasa Previa Vessels traverse the membranes in the lower uterine segment in advance of the fetal head.Rupture can lead to fetal exsanguinationPlacenta accreta, increta, percretaRisk increase w/ inc no. of prior CS PP+unscarred uterus-5 % risk of accretaPP+one previous C/D-24% risk of accretaPP+two previous C/D-47% risk of accretaPP+three previous C/D-50% risk of accretaPP+four previous C/D-67% risk of accreta

Associated ConditionsPlacenta accreta, increta, percretaRisk inc w/ inc no. of prior c/s (50% risk in pt w/ previa and 2 prior c/s)Vasa Previa Vessels traverse the membranes in the lower uterine segment in advance of the fetal head.Rupture can lead to fetal exsanguinationVasa Previa

Vessels traverse the membranes in the lower uterine segment in advance of the fetal head.

Rupture can lead to fetal exsanguination

Placental Abruption

Premature separation of placentaPainful third-trimester bleeding

Risk Factors smoking, trauma, HTN cocaine, pprom, polyhydramnios, multiplesTrauma evaluation bleeding, contractions, abdominal pain and NRFHT in 4hrsU/s misses up to 50% of abruptionsManagement: IV, T+X, Continuous monitoring, C/S vs. vag delivery

Case Contd U/S reveals active, vertex fetus. Placenta anterior and free of os. Pt having contractions q 2-3 minuters. Bleeding increases. BP drops from 110/60 to palpable systolic pressure of 70. FHT drops from 120 to 90 bpm.

What do you do???

Uterine RuptureAssociated with Prior CSRates of uterine rupture?Spontaneous rupture (no C/S history): 1/2000 (0.05%)Low Transverse: 0.5%-1%risk rupture, VBAC 80% success rateClassical C/s: 10% risk rupture, schedule amnio/c/s ~37 weeks.

A 21-year-old nulliparous patient at 41 weeks gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine.What can be done to stanch the ow?

CASE 2 Uterine atony leads to heavy bleeding

A 21-year-old nulliparous patient at 41 weeks gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis.After placental separation, profound uterine atony is noted, and the patient begins to hemorrhage. The atony is unresponsive to bimanual massage, intravenous oxytocin, and intramuscular methylergonovine.

What can be done to stop the ow11/15

A stepwise approach to bleeding caused by persistent uterine atony

A stepwise approach to bleeding caused by persistent uterine atony13/15

A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies. She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandins.

14/15 A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies.

She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandinsCASE3 Postpartum hemorrhage with Hypovolemic shock

The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.

Exploration did not reveal any retained products.

The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.

Exploration did not reveal any retained products.

The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.

Exploration did not reveal any retained products.

The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

She was transferred to a general hospital for further resuscitation but arrived in a moribid state and signs of hyovolemic shock was evident

What should be your first step of management?

At ANE: INITIAL ASSESSMENT AND START BASIC TREATMENT17/15

ANE to OT: TEMPORIZING AND TRANSFER INTERVENTIONANE to OT: DRUGS OF CHOICE

If not available or bleeding still continue from previous drugs

ANE to OT: TORRENTIAL BLEEDING

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Uterine packing balloon, tampone, Torpin packer.18

A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies. She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandins.

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A 30 year women in her third pregnancy at 38 weeks of gestation came in labour at a district hospital. Her antenatal period had been uneventful. She delivered vaginally. With active management of 3rd stage and the placenta was delivered by CCT.

CASE 4:

The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.

Exploration did not reveal any retained products.

The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

After the placenta was delivered , there was active bleeding from the vagina. A green cannula was inserted and the on-call doctor was informed.

Over the phone the doctor ordered for uterine massage to be done ,IV ergometrine 0.5mg and IV Pitocin 40 unit in 500mls NS .

The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.

Exploration did not reveal any retained products.

The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

Blood pressure was normal but the pulse rate was 96 b/min.

Abdominal examination done showed that the uterus was contracted. Despite that the patient was still actively bleeding.

Another IV line was inserted and blood was sent for CBC, GXM and PT/PTT. She was given NS running fast.

The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.

Exploration did not reveal any retained products.

The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

Further examination showed a cervical laceration trial to repair was failed. The patient continued to bleed, so vaginal packing was done a planning for transferre to the general hospital.

The placenta was also re-examine for its completeness. By this time, the patients blood loss was about 1 L. the patient was conscious but lethargic, her BP was 90/60mmHg and PR was 110b/min.

23/15While awaiting for arrangements for transfer to the referral center to be made, another 2 iv lines inserted and she was rapidly infused with NS and later transfused with blood.

A Foleys catheter was inserted to monitor urine output and her vital signs was monitored every 15 minutes.

Upon arrival the general hospital the estimated blood loss was about 2L and she had 4 iv lines (all green). 2 unit of blood has already been transfused plus the crystalloids and the 3rd and 4th unit of blood transfusion was still in progress.

Upon arrival the general hospital the estimated blood loss was about 2L .

2 unit of blood has already been transfused plus the crystalloids

Examination upon arrival showed very pale patient, drowsy but still responding to call, the BP was 80/40mmHg ,PR was 130b/min. The uterus was contracted and still actively bleeding from the vagina.

EUA was done and the cervicallaceration was sutured.

Despite that patient continued to bleed.

A laparotomy was done

26/15it showed that there was another cervical laceration which extended up to the lower segment of the uterus.

As it was not able to be repaired, a hysterectomy was performed.

She was managed for 2 days in ICU. The estimated blood loss through out was 5.4L and she was transfused a total of 21 unit of blood and 4 cycles of DIVC regime. She was discharged well on day 6 post delivery.

Post operatively

CASE 5A 37-year-old black female P7 at term admitted in early labor. Her prenatal course was significant for gestational diabetes controlled with diet. her last child weighing 4200KG. Her past medical history was significant only for a strong family history of diabetes mellitus.

On admission, the CX 4cm/VTX/-1/AROM with clear fluid contractions decreased in intensity and frequency after AROM. A Pitocin augmentation was begun and the patient quickly progressed to C/C/VTX/+1.

She delivered a 4300 kg baby with a moderate shoulder dystocia that was treated effectively with the McRoberts maneuver and suprapubic pressure after a left mediolateral episiotomy. The placenta delivered spontaneously without difficulty

29/15She delivered a 4300 kg baby with a moderate shoulder dystocia that was treated effectively with the McRoberts maneuver and suprapubic pressure after a left mediolateral episiotomy.

The placenta delivered spontaneously without difficultyCase cont

She delivered a 4300 kg baby with a moderate shoulder dystocia that was treated effectively with the McRoberts maneuver and suprapubic pressure after a left mediolateral episiotomy. The placenta delivered spontaneously without difficulty

30/15The patient had persistent bleeding after repair of her episiotomy. An immediate re-inspection ofher cervix and vagina revealed no occult lacerations.

She was treated with continued IV Pitocin and given multiple doses of 15-methyl prostaglandin F2-_ as well as a course of rectal misoprostol without responseCase cont

She delivered a 4300 kg baby with a moderate shoulder dystocia that was treated effectively with the McRoberts maneuver and suprapubic pressure after a left mediolateral episiotomy. The placenta delivered spontaneously without difficulty

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Counseling regarding thepossible need for hysterectomy. laparotomy was performed. The uterus was persistently atonic. No evidence of occult lacerations or other cause for the bleeding.

Hemostatic B-Lynch sutures were placed to stop the bleeding. The bleeding markedly decreased with this procedure. She received a total of 8 units of packed red blood cells during and after the surgery. She left the hospital without further incidentCase cont

Remmber : Aetiology of 1ry ppHg32/15

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Principles of managing PPHSpeed Skills Priorities Call For Help (Red Alert System) Assess the patients condition Find the cause of bleeding and stop it Stabilize And Resuscitate The Patient Prevent Further Bleeding

Speed Skills Priorities 1-Call For Help (Red Alert System) 2-Assess the patients condition 3-Find the cause of bleeding and stop it 4-Stabilize And Resuscitate The Patient 5-Prevent Further Bleeding

med-ed-online1- A woman 35 years old /G4 L3 presents with couvelaire uterus in C/S. When is hysterectomy indicated?A-presence of hematoma in the broad ligamentB-presence of hematoma in mesosalpinxC- atony retractable to treatmentD- presence of blood in abdominal cavity

Ans:C

med-ed-online2-Which is wrong about platelet administration?A- Platelet can not be reserved more than 5 days

B-platelets should be administered to patients with hemorrhage and platelet counts less than 50000/ml

C-platelet should be administered after cross-match

D- If there is no hemorrhage, platelets should be administered to patients with platelet counts less than 10000 /mlAns:D

med-ed-online3-which is the most common reason of DIC in Obstetrics?A-IUFDB-abruptionC-AF emboliD- septic shock

Ans:B

med-ed-online4-what is the first step in treating a G2 with late postpartum hemorrhage (after stabilizing her condition)?A-curettageB-uterotonicsC-uterine artery ligationD-hypogastric artery ligation

Ans:B

med-ed-online5-A 16 year-old woman comes to you with heavy bleeding after a two month delay in her periods. Pregnancy test is negative. Ultrasound shows a thin endometrium. There is no coagulation or anatomical problem. Which is the best treatment? A-high dose progesteroneB-curettageC-IV conjugate estrogenD-diagnostic hysteroscopy

Ans:CConjugate estrogen 25-40 mg IV q6h or PO 2.5 mg q6h

med-ed-online6- what is the stage of shock in a woman 70 kg / HR=130 bpm/AP=55mmHg/mod tachycardia/urinary output=10cc in a min A-firstB-secondC-thirdD-fourth

Ans:C

med-ed-online7-Which is true about hemorrhagic shock?A- central venous catheter is not recommendedB-lifting the feet is not recommendedC-colloids are superior to crystalloidsD-excess NS can cause alkalosis

Ans:A

med-ed-online8-A woman suffers intractable heavy vaginal bleeding after C/S. Laparatomy is performed. Retrovesical hematoma is evacuated and the site of bleeding is sutured. The bleeding does not stop. What is the second stage in management? A-total hysterectomyB-bilateral uterine and ovarian arteries ligationC-bilateral hypogastric arteries ligationD-bilateral hypogastric and ovarian arteries ligation

Ans:DOvarian artery is situated in infundibulopelvic and mesosalpinx ligament

med-ed-online9-Which is wrong in abruption?A-It is more likely in heroin addicts than cocaine addictsB-fibroma is one of the causesC-positive past history is a risk factorD-there is no agreement on smoking as a risk factor

Ans:A

med-ed-online10-A G2 with GA=14 wks is referred for spotting. Ultrasound imaging shows twin pregnancy with one fetal demise. How the coagulation profile may change?A- The profile is like that of DICB-heavy bleeding will occur during labor because of hypofibrinogenemiaC- repairable transient coagulopathy will occurD-the live infant in the uterine will develop coagulopathy

Ans:C

med-ed-online11-Which is true about uterine inversion?A-BP and MgSO4 can be the reasonB-it is more common in multiparasC-it is never fatalD-hemorrhage occurs with a delay

Ans:A

med-ed-online12-If there is a coagulopathy disorder, which is an indication for Heparin administration provided that circulation is intact?A-IUFDB-AbruptionC-septic abortionD-HELLP syndrome

Ans:AHeparin dose 5000 units TDS for IUFDFFP and platelet for septic abortion

med-ed-online13-Which is wrong about stage II of hypovolemic shock?A-Tachycardia is a constant findingB-blood loss is more than 1000ccC-systolic minus diastolic BP is increasedD-BP at rest is normal

Ans:C

med-ed-online14-Which is true about int iliac artery ligation for controlling pelvic hemorrhage? A-Ext iliac artery should be checked before ligation is attemptedB-ureter should not be locatedC- both sides arteries should not be ligated D-the artery should be ligated proximal to parietal branchAns:A

med-ed-online15-A 40 year old woman is hospitalized for hemorrhagic shock. Her kidney function is normal. What is the most sensitive and reliable clinical criteria for determining severity of volume loss? A- tachycardiaB-tachypneaC-oliguriaD-hypotension

Ans:C

med-ed-online16-An extension of C/S incision causes vaginal artery laceration and heavy bleeding. What should be done for this case?A-uterine artery ligationB-ovarian artery ligationC- hypogastric artery ligationD-hysterectomy

Ans:C

med-ed-online17- How many ml of blood does a soaked lap pad absorbs?A-30 ccB-50 ccC-80 ccD-100 cc

Ans:B

med-ed-online18-What is wrong for blood loss management?A-after an hour in a critical case only 20% of crystalloids remains in circulationB- the volume of crystalloids replacement is three times the volume of blood lossC-in all cases of blood loss a Hb of less than 8 gr/dl mandates whole blood transfusionD-colloids increase mortality rate

Ans:C

med-ed-online19-What is wrong about vaginal hematoma after delivery?A-observation if hematoma is smallB- an incision on the site if pain is severe and hematoma enlargesC-mattress suturing the bed of hematoma D-pressure dressing should be applied on the hematoma bed for 12-24 hours Ans:D

med-ed-online20- A repeat C/S II has hemorrhage of the incisionsite. Which can best control hemorrhage? A-ligation of placental site above and below the incision siteB-ligation of uterine arteryC- ligation of hypogastric arteryD- embolization of uterine artery

Ans:A

med-ed-online21 Which is wrong about fetal complications of abruption?A- 20-25 percent of cases demise perinatallyB-40 % are delivered prematurelyC- 12-15 % are IUFDD-if the fetus doesnt die in uterus, there would be no serious neonatal complication

Ans:D

med-ed-online22A pregnant woman G2 GA=38 wks has the chief complaint of vaginal spotting. There is no sign of abruption or previa by ultrasound. What is the best management?A- observationB-termination of pregnancyC-dischargeD-referring patient to another center

Ans:B

med-ed-online24-Which is true about abruption?A- The chance of repeated abruption is twice B-fetal assessment techniques can predict abruption with good precisionC-there is no means to predict abruptionD-The chance of repeated abruption is not differentAns:C

med-ed-online25-Which is wrong in cases of placenta previa?A-the safest means of diagnosing placenta previa is transabdominal ultrasoundB-false positive results are because of full bladderC-low lying or total previa is best diagnosed by trans vaginal ultrasoundD-NPV of transperineal ultrasound is 70 %Ans: D (its NPV is 100% )

med-ed-online26-What is the first surgical step in a case of retractable uterine atony? A-ligation of uterine and ovarian arteriesB-ligation of hypogastric arteriesC-subtotal hysterectomyD- uterine artery embolization

Ans:A

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