Postpartum Hemorrhage Mrs. Mahdia 4/13/2017 Mrs. Mahdia Kony

Definition Total blood loss >500 ml at vaginal delivery and >1000 ml at cesarean delivery suffers from the limitations of clinical estimation of blood loss during delivery. Average blood loss following vaginal delivery, cesarean section, and cesarean hysterectomy was estimated by Pritchard et al .to be approximately 500, 1000, and 1500 ml, respectively. 4/13/2017 Mrs. Mahdia Kony

Types 4/13/2017 Mrs. Mahdia Kony Early or primary PPH: within 24 hours of delivery Late or secondary PPH: if they occur 24 hours after delivery 4/13/2017 Mrs. Mahdia Kony

Retained placental fragments Atony (90% of pts) Genital tract trauma Coagulopathy Retained placental fragments Uterine inversion Uterine rupture Causes of primary PPH 4/13/2017 Mrs. Mahdia Kony

Subinvolution of the placental bed Retained placental fragments Coagulopathy Endomyometritis Subinvolution of the placental bed Retained placental fragments Late PPH 4/13/2017 Mrs. Mahdia Kony

Prevention Avoid genital tract trauma. Prophylactically use oxytocic agents at the onset of the third stage of labor. Actively manage the third stage of labor (with controlled cord traction after signs of placental separation have occurred 4/13/2017 Mrs. Mahdia Kony

Uterine Atony “4 T's”: Causes of Tone Thrombosis Tissue Truma 4/13/2017 Mrs. Mahdia Kony

Diagnosis of Uterine Atony Presence of a soft uterus on abdominal examination Vaginal bleeding. 4/13/2017 Mrs. Mahdia Kony

Risk factors uterine over distention: polyhydramnios, multiple gestation, fetal macrosomia 2. rapid or prolonged labor 3. oxytocin use 4. high parity 5. Chorioamnionitis 6. myometrial relaxing agents (magnesium sulfate, anesthetic agents 7. Nitroglycerine 4/13/2017 Mrs. Mahdia Kony

Prevention of uterine atony Active management of 3rd stage of labor (1) uterotonic administration (oxytocin) immediately upon delivery of the baby (2) Early cord clamping and cutting (3) gentle cord traction with uterine countertraction when the uterus is well contracted 4/13/2017 Mrs. Mahdia Kony

4/13/2017 Mrs. Mahdia Kony

Treatment Massage Bimanual uterine massage and compression between a hand on the abdomen and a hand in the vagina. 4/13/2017 Mrs. Mahdia Kony

Medications Oxytocin intravenously (10 to 40 U per liter up to 500 ml in 10 minutes), intramuscularly, or intramyometrially (10 U). There are no contraindications to the use of oxytocin. Side effects: nausea, vomiting, and water intoxication secondary to its antidiuretic effect are rare. 4/13/2017 Mrs. Mahdia Kony

Medications Methylergonovine ( Methergine) intramuscularly, intravenously, or intramyometrially (0.2 mg every 2 to 4 hours). Methylergonovine is contraindicated in patients with hypertension. Side effects of hypertension, seizures, nausea, vomiting ,and palpitation. 4/13/2017 Mrs. Mahdia Kony

Supportive Measures adequate fluid resuscitation via two large-bore IVs replacement of blood products as needed, anesthesia consultation in the event emergent laparotomy is necessary. 4/13/2017 Mrs. Mahdia Kony

Genital Tract Trauma Genital tract trauma constitutes approximately 7% of postpartum hemorrhages 4/13/2017 Mrs. Mahdia Kony

Clinical manifestations Hemorrhage Bright red bld. Lacerations or hematoma unexplained tachycardia Hypotension Anemia shock 4/13/2017 Mrs. Mahdia Kony

Risk Factors abnormal presentation operative delivery Episiotomy precipitous delivery obstructed labor fetal macrosomia multiple gestation 4/13/2017 Mrs. Mahdia Kony

Bleeding from an episiotomy or perineal laceration is usually obvious and prompt ligature will control the bleeding Persistent bleeding with a contracted uterus especially after oxytocin has been administered is strongly suggestive of genital tract lesion. Exploration is best done under general anaesthesia or continued epidural anaesthesia. 4/13/2017 Mrs. Mahdia Kony

Significant bleeding in the absence of cervical, vaginal or perineal tears is suggestive of uterine rupture even if there is response to oxytocics. Digital exploration of uterus in cases of previous c/s and difficult or complicated deliveries. 4/13/2017 Mrs. Mahdia Kony

Treatment Full-thickness mucosal repair, beginning above the apex because bleeding vessels tend to retract. Continuous interlocking absorbable suture is generally used. When suturing in the proximity of the urethra, insertion of a catheter is advisable to avoid injury of this structure. blood transfusion antibiotics to prevent secondary infection. 4/13/2017 Mrs. Mahdia Kony

Retained Placental Tissue Clinical Manifestations: bleeding persists in the absence of apparent lacerations or atony. The expelled placenta should be carefully inspected for completeness following each delivery. 4/13/2017 Mrs. Mahdia Kony

Early cord traction attempts Risk Factors Early cord traction attempts placenta accreta, increta, and percreta, and succenturiate lobe. Placenta accreta occurs in 1 in approximately 2,500 to 7,000 deliveries and consists of a relatively superficial attachment of the placenta to the myometrium. More invasive attachment (placenta increta or percreta) is less common. 4/13/2017 Mrs. Mahdia Kony

Predisposing factors previous postpartum curettage cesarean delivery Hysterotomy placenta previa high parity. 4/13/2017 Mrs. Mahdia Kony

Treatment manual intrauterine exploration or curettage. Care must be taken to avoid uterine perforation, placenta accreta, increta, or percreta should be suspected. Treatment usually requires hysterectomy for these abnormal placentations. conservative surgical management (with manual removal and packing) can be attempted. Maternal morbidity and mortality are high if surgical therapy is necessary. 4/13/2017 Mrs. Mahdia Kony

THROMBOSIS- COAGULOPATHY Hereditary coagulopathies: Haemophila A Acquired during pregnancy: Thrombocytopenia HELLP syndrome DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism). Anti coagulant therapy: Valve replacement, patients on absolute bed rest. 4/13/2017 Mrs. Mahdia Kony

Uterine Inversion Clinical Manifestations: abdominal examination reveals the uterine fundus to be inverted or missing. Vaginal inspection and examination confirm the diagnosis. 4/13/2017 Mrs. Mahdia Kony

Levels of inversion level I: The fundus may be inverted above the cervix, level II: below the cervix but within the vagina level III: outside the vagina level IV: the uterus and vagina may both be found outside the vulva. 4/13/2017 Mrs. Mahdia Kony

Risk Factors fetal macrosomia fundal placentation use of oxytocin uterine anomalies placenta accreta. Fifty percent of reported cases occur spontaneously in primiparous patients. 4/13/2017 Mrs. Mahdia Kony

Treatment manual replacement intravascular volume replacement. If the placenta has not been removed: replace the uterus by applying pressure to the inverted fundus without removing the placenta and increasing natural oxytocin. If manual replacement succeeds, the placenta can be manually removed uterine contraction assured by massage and oxytocin infusion. If manual replacement fails, When all above measures fail, laparotomy is indicated to correct the inversion 4/13/2017 Mrs. Mahdia Kony

4/13/2017 Mrs. Mahdia Kony

Uterine Rupture Clinical Manifestations Tachycardia Shock fetal distress disappearance of presenting part from the pelvis variable amount of pain and vaginal bleeding. 4/13/2017 Mrs. Mahdia Kony

4/13/2017 Mrs. Mahdia Kony

Classifications of uterine rupture Complete rupture involves rupture of visceral peritoneum and results in intraperitoneal bleeding. Incomplete rupture occurs when the visceral peritoneum remains intact over ruptured myometrium. 4/13/2017 Mrs. Mahdia Kony

Risk Factors obstructed labor multiple gestation abnormal fetal lie high parity. use of oxytocin Prostaglandins spontaneous uterine hyperstimulation internal podalic version breech extraction. 4/13/2017 Mrs. Mahdia Kony

Treatment intravascular volume and blood replacement immediate laparotomy. With spontaneous rupture, 85% of patients require hysterectomy, whereas 65% of ruptured scars can be repaired 4/13/2017 Mrs. Mahdia Kony

Late Postpartum Hemorrhage Late postpartum hemorrhage is defined as any sudden loss of any amount of fresh blood occurring after the first 24 hours of delivery and within 6 weeks postnatally. 4/13/2017 Mrs. Mahdia Kony

Subinvolution of the placental bed Diagnosis Retained placental tissue Subinvolution of the placental bed Endometritis 4/13/2017 Mrs. Mahdia Kony

Treatment Uterotonics curettage antibiotics. If the bleeding is not severe, antibiotics make a good first choice, and if bleeding persists, curettage should be implemented. 4/13/2017 Mrs. Mahdia Kony

Puerperal Infections Puerperal febrile morbidity: a temperature of (38°C), the temperature to occur in any two of the first 10 days post partum, exclusive of the first 24 hr, and to be taken by mouth by a standard technique at least four times daily. The overall rate of postpartum infection is estimated to be 1% to 8%. 4/13/2017 Mrs. Mahdia Kony

Puerperal Infections Transient, low-grade fever is common in the postpartum period and will resolve spontaneously in the majority of patients who delivered vaginally. In patients who undergo cesarean delivery, only 30% of fevers will resolve spontaneously, reflecting the greater risk for development of infection after surgery (26). 4/13/2017 Mrs. Mahdia Kony

Risk factors PROM Anemia Hemorrhage Episiotomy and CS Placenta retain 4/13/2017 Mrs. Mahdia Kony

History and Physical Physical examination focusing on: Lungs Breast uterine fundus abdomen for incision infections Perineum lower extremities 4/13/2017 Mrs. Mahdia Kony

Laboratory Tests Complete blood count with differential. Urinalysis with culture. Blood cultures may be considered. Sputum for Gram's stain and culture if respiratory infection is suspected 4/13/2017 Mrs. Mahdia Kony

Treatment Nutrition: anemia prevention Antimicrobial treatment broad-spectrum, high dose, long time Drainage Treatment of thrombophlebitis 4/13/2017 Mrs. Mahdia Kony

Complications of PPH Immediate complications: Anaemia. HypovolemicShock. Acute renal failure. Acute Liver failure (hepato-renal syndrome) Acute pulmonary oedema, consumption coagulopathy, transfusion reactions, (iatrogenic). 4/13/2017 Mrs. Mahdia Kony

Long term complications: Infections: puerperal infections Sheehan’s syndrome (necrosis of anterior pituitary). Chronic anaemia. Chronic renal failure. 4/13/2017 Mrs. Mahdia Kony

tubal obstruction secondary to infections, post hysterectomy. Infertility: Asherman’s syndrome; a condition characterized by the presence of adhesions and/or fibrosis within the uterine cavity due to scars Sheehan syndrome tubal obstruction secondary to infections, post hysterectomy. 4/13/2017 Mrs. Mahdia Kony