Obststric Haemorrhage Obstetric Emergencies Hemorrhage Obstetric Emergencies

Obststric Haemorrhage Hemorrhage Causes of ANTEPARTUM haemorrhage Abruptio Placenta Placenta previa Local causes Unknown origin

ABRUPTIO PLACENTA Underlying pathology Hypertensive Disease Multiple pregnancy Trauma Anemia Polyhydramnios

PLACENTA PREVIA Predisposing factors Previous Caesarean Section Most have no known cause – presumed late implantation

Local & Unknown Causes of APH Rupture of uterus Carcinoma of cervix Trauma Cervical polyp Bilharzia of cervix ? Edge bleed ? Hemorrhoids

Hemorrhage Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar, in comparison with the rate in spontaneously laboring women.

Abruptio Placenta Features Pain and tenderness Often I.U.F.D “Hypotension on hypertension” Clotting defects Renal impairment

Antepartum Hemorrhage Exclude abruption, uterine rupture, placenta previa with labor Is she stable? - ?BP, pulse Check Abdomen - previous C/S scar, fundal height and uterine tenderness Check FH Vaginal examination and ARM

Abruptio placenta APH = ARM

Abruptio Placenta Resuscitate - FDP, whole blood Monitor BP and urine output Give oxytocin infusion or prostaglandin if necessary to induce contractions Avoid Cesarean Section unless salvageable baby, or no progress Watch out for PPH

Placenta Previa Suspicion from low uterine souffle Diagnose by Ultrasound Resuscitate, monitor BP and amount of bleeding Persistent bleeding requires delivery whatever the gestation

Complete Placenta Previa Transfer anterior placenta previa Elective cesarean if  37 weeks Birth through the placenta

Post Partum Hemorrhage Predisposing factors Antepartum hemorrhage Multiple pregnancy Prolonged labour Cesarean Section

Post Partum Hemorrhage Causes Uterine atony Obstetric trauma *Use Large Bore IV Lines*

Post Partum Hemorrhage Atonic uterus (soft uterus) Compression - bimanual is best Oxytocin - 10 units IV or (insert dosage) IM Syntometrine 1 amp IM Misoprostol (Cytotec) 1mg (5 tabs) rectally Trauma (hard uterus) Vaginal tears are most common Cervical tears rare unless instrumental Remember the ruptured uterus Uterine inversion

Post Partum Haemorrhage Other causes Instrumental Delivery Infection - 2° PPH Retained placental fragments

Post Partum Haemorrhage Rub up a contraction Get help Insert two large bore IV lines - Haes-Steril Give an oxytocic Explore digitally for fragments and tears Explore with speculum for tears - especially cervix Evacuate under GA

Rupture of Uterus Two types True rupture Dehiscence of scar

Rupture of Uterus True Rupture Contractions stop Continuous pain Tender abdomen Fundus ill-defined PV Bleeding Fetal heart dips or absent fetal heart Scar Dehiscence Dehiscence may be silent – no bleeding Fetal distress Hematuria Vague uterine outline Failed induction

Rupture of Uterus High Index of suspicion in grande multips and in scarred uteri All cases of Ante and Intra partum haemorrhage must exclude rupture Laparotomy if suspected Repair or Hysterectomy?