Rukset Attar, MD, PhD Department of Obstetrics and Gynecology POSTPARTUM BLEEDING Rukset Attar, MD, PhD Department of Obstetrics and Gynecology

POSTPARTUM BLEEDING Postpartum hemorrhage denotes excessive bleeding (> 500 mL in vaginal delivery) following delivery. Hemorrhage may occur before, during, or after delivery of the placenta.

POSTPARTUM BLEEDING Blood lost during the first 24 hours after delivery is early postpartum hemorrhage; Blood lost between 24 hours and 6 weeks after delivery is late postpartum hemorrhage.

POSTPARTUM BLEEDING The incidence of excessive blood loss following vaginal delivery is 5–8%. Postpartum hemorrhage is the most common cause of excessive blood loss in pregnancy, and most transfusions in pregnant women are performed to replace blood lost after delivery

POSTPARTUM BLEEDING Causes of postpartum hemorrhage include uterine atony obstetric lacerations retained placental tissue coagulation defects Atony is the most common cause of postpartum hemorrhage (50% of cases).

Uterine Atony Predisposing causes include excessive manipulation of the uterus, general anesthesia (particularly with halogenated compounds), uterine overdistention (twins or polyhydramnios), prolonged labor, grand multiparity, uterine leiomyomas, operative delivery and intrauterine manipulation, oxytocin induction or augmentation of labor, previous hemorrhage in the third stage, uterine infection, extravasation of blood into the myometrium (Couvelaire uterus), intrinsic myometrial dysfunction.

Obstetric Lacerations Approximately 20% of postpartum hemorrhages. Lacerations can involve the uterus, cervix, vagina, or vulva. They usually result from precipitous or uncontrolled delivery or operative delivery of a large infant; however, they may occur after any delivery. Laceration of blood vessels underneath the vaginal or vulvar epithelium results in hematomas. Bleeding is concealed and can be particularly dangerous because it may go unrecognized for several hours and become apparent only when shock occurs.

Retained Placental Tissue Retained placental tissue and membranes cause 5–10% of postpartum hemorrhages. Retention of placental tissue in the uterine cavity occurs in placenta accreta manual removal of the placenta mismanagement of the third stage of labor unrecognized succenturiate placenta.

Coagulation Defects Coagulopathies in pregnancy may be acquired coagulation defects seen in association with several obstetric disorders, including abruptio placentae, excess thromboplastin from a retained dead fetus, amniotic fluid embolism, severe preeclampsia, eclampsia, and sepsis. Transfusion of more than 8 U of blood in itself may induce a dilutional coagulopathy. Von Willebrand's disease, autoimmune thrombocytopenia, and leukemia may occur in pregnant women.

Coagulation Defects Prevention of hemorrhage is preferable to even the best treatment. Risk factors for hemorrhage include coagulopathy hemorrhage blood transfusion during a previous pregnancy anemia during labor grand multiparity multiple gestation large infant polyhydramnios; dysfunctional labor; oxytocin induction or augmentation of labor; rapid or tumultuous labor; severe preeclampsia or eclampsia; vaginal delivery after previous cesarean birth; general anesthesia for delivery; and forceps delivery.

Delayed Postpartum Hemorrhage Bleeding After 2 Weeeks Retained Placental Fragments Subinvolution Of Placental Bed, Broad Spectrum Antibiotics Oxytocin İnf Ergot Alkaloids

Laboratory evaluation should include blood type and cross-match for 2–6 units, depending on the hemodynamic status, as well as a complete blood count with platelets and baseline coagulation status (prothrombin time and partial thromboplastin time). D-Dimer or fibrin split products are useful when abruptio placentae is suspected Placenta Accreta A layer of decidua normally separates the placental villi and the myometrium at the site of placental implantation. A placenta that directly adheres to the myometrium without an intervening decidual layer is termed placenta accreta.

Placenta Accreta Classification By Degree of Adherence Laboratory evaluation should include blood type and cross-match for 2–6 units, depending on the hemodynamic status, as well as a complete blood count with platelets and baseline coagulation status (prothrombin time and partial thromboplastin time). D-Dimer or fibrin split products are useful when abruptio placentae is suspected Placenta Accreta Classification By Degree of Adherence Placenta Accreta Vera: Villi adhere to the superficial myometrium. Placenta Increta: Villi invade the myometrium. Placenta Percreta: Villi penetrate the full thickness of the myometrium. Classification By Amount of Placental Involvement Focal Adherence: A single cotyledon is involved. Partial Adherence: One or several cotyledons are involved. Total Adherence: The entire placenta is involved.

Laboratory evaluation should include blood type and cross-match for 2–6 units, depending on the hemodynamic status, as well as a complete blood count with platelets and baseline coagulation status (prothrombin time and partial thromboplastin time). D-Dimer or fibrin split products are useful when abruptio placentae is suspected Placenta Accreta Estimates of the incidence of placenta accreta (all forms) vary from 1 in 2000 to 1 in 7000 deliveries. Placenta accreta vera accounts for approximately 80% of abnormally adherent placentas Placenta increta accounts for 15% Placenta percreta accounts for 5%. The rate has risen slightly over the last 2 decades, paralleling the cesarean section rate.

Laboratory evaluation should include blood type and cross-match for 2–6 units, depending on the hemodynamic status, as well as a complete blood count with platelets and baseline coagulation status (prothrombin time and partial thromboplastin time). D-Dimer or fibrin split products are useful when abruptio placentae is suspected Placenta Accreta Although the exact cause is unknown, several clinical situations are associated with placenta accreta, such as previous cesarean section, placenta previa, grand multiparity, previous uterine curettage, and previously treated Asherman's syndrome. These conditions share a common possible defect in formation of the decidua basalis. The incidence of placenta accreta in the presence of placenta previa after 1 prior uterine incision is between 14% and 24%, after 2 is 23–48%, and after 3 is 35–50%. The incidence of placenta accreta after successful treatment of Asherman's syndrome may be as high as 15%.

Uterine Inversion Uterine inversion is prolapse of the fundus to or through the cervix so that the uterus is in effect turned inside out. Almost all cases of uterine inversion occur after delivery and may be worsened by excess traction on the cord before placental separation. Nonpuerperal uterine inversion is rare and usually is associated with tumors (eg, polypoid leiomyomas).

Uterine Inversion Conditions that may predispose women to uterine inversion include fundal implantation of the placenta, abnormal adherence of the placenta (partial placenta accreta), congenital or acquired weakness of the myometrium, uterine anomalies, protracted labor, previous uterine inversion, intrapartum therapy with magnesium sulfate, strong traction exerted on the umbilical cord, and fundal pressure.