POST PARTUM HAEMORRHAGE ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU, MD, PhD

Obstetric hemorrhage POSTPARTUM HAEMORRHAGE First cause of maternal mortality accounting for 25 – 50 % of maternal deaths POSTPARTUM HAEMORRHAGE accounts for the majority of the cases of obstetric hemorrhage the other causes: antepartum hemorrhage, abortion, ectopic pregnancy and ruptured uterus.

POSTPARTUM HAEMORRHAGE . . . the most common and severe type of obstetric haemmorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

MAGNITUDE OF THE PROBLEM PPH - A world of difference Year Developed Developing Countries Countries 1930 1:3000 Births Not Available 1950 1:20,000 Not Available 1980 1:60,000 1:1000 2000 1:100,000 1:5000

POST PARTUM HAEMORRHAGE DEFINITION: Blood loss of > 500-600ml per vaginum during the first 24hrs after the delivery of the baby. Risk of maternal Mortality & Morbidity are 50 times more after PPH

ASSESSMENT OF BLOOD LOSS AFTER DELIVERY Difficult Visual estimation (Subjective & Inaccurate) Underestimation is likely Clinical picture -Misleading Many mothers - Malnourished, Anaemic, Small built, Less blood volume

MECHANISM OF HAEMOSTASIS AFTER DELIVERY Uterine contraction & retraction Platelet aggregation  clot formation

ETIOLOGY of PPH Uterine atony (80%) Retained Placenta Trauma to genital tract Coagulation disorders

MECHANISM OF HAEMOSTASIS AFTER DELIVERY TONUS If the uterus is not contracted, the blood vessels are not compressed.

1. UTERINE ATONY Overdistension of uterus Induction of labour RISK FACTORS Overdistension of uterus Induction of labour Prolonged / precipitate labour Anaesthesia (halogenated) & analgesia Tocolytics Maternal hypotension Grand multiparity Mismanagement of 3rd stage of Labour Full bladder

2. RETAINED PLACENTAL REMNANTS RISK FACTORS Simple adhesion Morbid adhesion → Placenta accreta, increta or percreta

3. TRAUMA TO THE GENITAL TRACT RISK FACTORS Large episiotomy & extensions Tears & lacerations of perineum, vagina or cervix Hematoma cause → delivery before full dilatation of the cervix (by forceps, breach extraction, forcible expulsive efforts, abuse of oxytocin)

4. COAGULATION DISORDERS RISK FACTORS Abruptio placentae Retention of dead fetus Amniotic fluid embolism Severe PE/ Eclampsia Sepsis: PROM Massive blood loss Massive blood transfusion Hepatitis

SYMPTOMS & SIGNS Blood loss Systolic BP Signs & Symptoms 10-15 Normal (% B Vol) Systolic BP ( mm of Hg) Signs & Symptoms 10-15 Normal postural hypotension 15-30 slight fall tachycardia, thirst, weakness 30-40 60-80 pallor, oliguria, confusion 40+ 40-60 anuria, air hunger, coma, death

1. UTERINE ATONY DIAGNOSTIC Hemorrhage “internal” (in the uterus) → the fundus rises, the uterus is soft, no Pinard's globus; external hemorrhage; mixed hemorrhage

2. RETAINED PLACENTAL REMNANTS DIAGNOSTIC inspection of the placenta and membranes → missing placental or membrane fragments

3. TRAUMA TO THE GENITAL TRACT DIAGNOSTIC 1. Perineal and vaginal tears Four degrees of perineal laceration 1-st degree → the skin of the fourchette, the underlying muscle is exposed; 2-nd degree → the posterior vaginal wall and the perineal muscles (anal sphincter - no damage); 3-rd degree → the anal sphincter is torn, the rectal mucosa is intact; 4-th degree → the anal canal is damaged - up to the rectum.

3. TRAUMA TO THE GENITAL TRACT DIAGNOSTIC 2. Vaginal laceration - a difficult delivery (e.g. forceps delivery), inspection → the apex of the tear. 3. Cervical tears bright red bleeding continued when contracted uterus; lithotomy position, a large speculum in the vagina, the anterior and posterior cervical lips are grasped by two forceps. Classification in the vaginal part of the cervix; above the vaginal part of the cervix (can extend to lower segment)

TRAUMA CERVIX TEAR

4. COAGULATION DISORDERS DIAGNOSTIC release of thromboplastine → change in the mechanism of the coagulation continuous hemorrhage with fresh blood that does not coagulate and forms no clots; signs of shock and hypovolemia.

PREVENTION Regular antenatal care Identification of high risk cases Correction of anemia, PE Delivery in hospital with facility for Emergency Obstetric Care. Local / Regional anaesthesia ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR Post partum period - Observation, Oxytocin

ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR (WHO-1989) Oxytocin - Routine use in third stage  blood loss  by 30-40% Oxytocin Ergometrine PG Early cord clamping Controlled cord traction Inspection of placenta & lower genital tract

MANAGEMENT OF PPH TEAM- Obstetrician, Anesthesiologist, Hematologist and Blood Bank Correction of hypovolemia Ascertain origin of bleeding Ensure uterine contraction Surgical management Management of special situation

MANAGEMENT OF PPH ENSURE UTERINE CONTRACTION Palpate fundus Uterine massage Bimanual compression Compression of aorta against sacral promontory

MANAGEMENT OF PPH OXYTOCICS Ergometrine Prostaglandins Oxytocin - Bolus of 10 units IV followed by Continuous Infusion Carbetocine Ergometrine Prostaglandins

MANAGEMENT OF PPH OTHER MODES Anti Shock Treatment UTERINE PACKING UTERINE TAMPONADE Large bulb Foleys

MANAGEMENT OF PPH SURGICAL TREATMENT Depends on Extent & cause of haemorrhage General condition of patient Future reproduction Experience & skill

MANAGEMENT OF PPH SURGICAL TREATMENT Repair of trauma if any Uterine a. ligation + Utero ovarian a. ligation Internal Iliac a. ligation Hysterectomy Angiographic embolisation

RETAINED PLACENTAL FRAGMENTS MANAGEMENT OF PPH RETAINED PLACENTAL FRAGMENTS Examination (under anesthesia) & manual +/- curettage removal If placenta accreta Observation Cytotoxic drugs- Methotrexate Hysterectomy

MANAGEMENT OF DISSEMINATED INTRAVASCULAR COAGULATION MANAGEMENT OF PPH MANAGEMENT OF DISSEMINATED INTRAVASCULAR COAGULATION Fresh blood transfusion Blood products Cryoprecipitate Fresh frozen plasma Platelet concentrate

MORBIDITY & MORTALITY from PPH Shock & DIC Renal Failure Puerperal sepsis Lactation failure Blood transfusion reaction Thromboembolism Sheehan’s syndrome >25% Maternal deaths are due to PPH