PPH & COAGULATION DISORDERS SALWA NEYAZI ASSISTANT PROF.& CONSULTANT OBSTETRICIAN GYNECOLOGEST PEDIATRIC & ADOLESCENT GYNECOLOGEST

Postpartum Hemorrhage Definition Loss of 500 ml or more of blood following vaginal delivery. (Hg. may occur before, during or after delivery of the placenta ) Or 1000 ml of blood loss for cesarean section Early PPH Blood lost during the first 24 hrs after delivery Late PPH Blood lost between 24hr—6weeks after delivery

Postpartum Hemorrhage Incidence 5-8% It is the most common cause of excessive blood loss in pregnancy Hemorrhage (including APH, PPH, abortion & ectopic) is the leading obstetric cause of maternal mortality in Saudi Arabia & underdeveloped countries It is the third leading cause of MM in USA

Morbidity & Mortality Women compromised by anemia or intercurrent illness are at increased risk of complications Anemia Morbidity related to blood transfusion hepatitis, HIV, transfusion rection Morbidity related to hypovolemic shock Renal failure (acute tubular necrosis)

Morbidity & Mortality Shehan’s syndrome  postpartum hypotension partial or complete necrosis of the anterior pituitary panhypopituitrism -Characterized by failure to lactate, amenorrhea, hypothyroidism, adrenal insufficiency &  breast size & loss of pubic & axillary hair. -Incidence 1:10000 deliveries Sterility resulting from Hysterectomy performed to control severe Hg

Etiology of PPH 1-Uterine atony With separation of the placenta many uterine blood vessels are severed abruptly the bleeding that results is controlled by contraction & retraction of the myometrium to compress the blood vessels Uterine atony results when there is failure of the myometrium to contract It accounts for 50% of the cases of PPH

1-Uterine Atony Predisposing causes: Uterine over distension twins, polyhydramnious or large infant Grandmultiparity Prolonged labor Dysfunctional labor Oxytocin induction or augmentation of labor

Contd/Uterine Atony Predisposing Causes Instrumental deliveries Uterine infections General anesthesia with halogenated compounds Previous HG or blood transfusion Uterine lieomyoma Intrauterine manipulation Abruptio placenta with couvelaire uterus

Etiology of PPH 2-Obstetric lacerations 20%of PPH It may involve the vagina, vulva, cervix or uterus Predisposing causes : Precipitate delivery, operative delivery & large infant Hematomas  laceration of blood vessels underneath vaginal or vulvar epithelium

Etiology of PPH contd/Obstetric lacerations Excessive bleeding from the episiotomy  if it involves varicosities or arteries, if the episiotomy is large, early episiotomy or delayed repair Rupture uterus  risk factors: CS or uterine surgery, IOL with PG or oxytocin, grandmultiparity & malpresentation

Etiology of PPH 3-Retained placental tissue 5-10% of PPH Predisposing causes: placenta accreta, mismanegement of the 3rd stage of labor, succenturiate placenta U/S or sonohysterography are helpful in the DX of pt. with retained placental tissue

Etiology of PPH 4-Low laying placenta as the lower segment is less contractile  excessive bleeding from the placental site after delivery 5-Inversion of the uterus Due to strong traction on an umbilical cord attached to a fundal placenta 1:2000-6000 deliveries Immediate replacement is mandatory to prevent life threatening Hg

Etiology of PPH 6-Coagulation defects -Consumptive coagulopathy  due to abruptio placenta, retained dead fetus, amniotic fluid embolism, severe PET, septicemia or abortion -Medical causes of coagulation defects  Von Willbrand’s disease, ITP, leukemia, dilutional coagulopathy (when >8 U of blood transfused)

MANAGEMENT 1-Predelivery preparation -Type & screen blood for all Pt in labor -High risk Pt  Cross matching  Large bore IV catheter  Severely anemic Pt transfused

2-Management at delivery Oxytocin IM or IV with the delivery of the anterior shoulder   blood loss at delivery &  PPH by 40% Uterine massage after delivery of the fetus Delivery of the placenta by controlled cord traction Inspection of the placenta for completeness

3-Management in the immediate post partum period Manual removal of the placenta MRP -Timing of MRP  immediately if there is HG Wait for 30 if there is no Hg -Usually performed under GA -Prophylactic antibiotics given

Contd/Management in the immediate post partum period Repair of lacerations -Episiotomy should be repaired immediately -The vagina & cx should be inspected & any lacerations repaired -Lacerations extending into the broad ligament require laparotomy -Large hematomas require operative management

4-Evaluation of persistent bleeding 1-Manually compress the uterus 2-Obtain blood for X-matching if not done 3-Start IV fluids or blood replacement 4-Insert a 2nd IV catheter 5-Cathterize the bladder 6-Start IV oxytocin 7-Inspect the cx & vagina

4-Evaluation of persistent bleeding 8-Manually explore the uterine cavity  in vaginal delivery following CS, when intrauterine manipulation has been performed, when abnormal uterine contour has been noted or preterm delivery Ensure that there are no retained placental tissue & that the uterus is intact  Look for possible structural abnormalities of the uterus

5-Measures to control bleeding 1-Bimanual compression & massage of the uterus 2-Curettage  When manual exploration fails to remove fragments of adherent placenta  It may result in perforation or asherman’s syndrome 3-Utrotonic agents -Oxytocin 20-40 U/L IV infusion 10-15ml/min -Methylergonovine 0.2 mg IM (contraindicated in hypertensive Pt) -PGF2α intramyometrial injection or IM -Misoprostol rectally

5-Measures to control bleeding 4-Radiographic embolization of uterine arteries or internal iliac 5-Operative management a-Pressure occlusion of the aorta to provide time to identify the source of bleeding B-Uterine artery ligation C-Internal iliac ligation D-B-lynch suture E-Hysterectomy 6-uterine packing

Consumptive coagulopathy DIC Pregnancy induces hypercoagulbility  factor I(fibrinogen), VII, VIII, IX, X Plasminogen but  plasmin activity Causes of Obstetric coagulopathy: A-Activation of the extrinsic coagulation pathway through the release of thromboplastin from tissue destruction 1-Abruptio placenta (the most common cause ) 2-Intrauterine fetal death (IUFD) & delayed delivery occurs if the dead fetus is retained for >1 month (25%) Rare before that

Causes of Obstetric coagulopathy: B-Direct activation of factor X by proteases as present in mucin. Amniotic fluid contains abundant mucin from fetal cells rapid DIC with amniotic fluid embolism C-Septicemia release of bacterial endotoxins disruption of vascular endothelium tissue factor is released  activation of the extrinsic coagulation pathway D-Abortion results in coagulopathy when there is prolonged retention of a dead fetus, septic abortion E-HELLP syndrome  Deposition of fibrin in endothelial cells of blood vessels (consumptive coagulopathy) microangiopathic hemolysis

Clinical evidence of defective hemostasis Exessive bleeding at the site of modest trauma Characterizes defective hemostasis eg. Bleeding from venipuncture sites, nicks from shaving, trauma from insertion of a catheter, spontaneous bleeding from nose or gums, continuous oozing from cut surfaces during surgery, petechiae.

Lab. evidence of defective hemostasis 1-Hypofibrinogenemia <100 mg/dl 2-Fibrinogen degradation products 3-Thromboctopenia 4-Prolonged PT & PTT

Amniotic fluid embolism Abrupt onset of hypotension, hypoxia, and cosumptive coagulopathy one of these manifestation may dominate 1:20000 deliveries

Amniotic fluid embolism Clinical presentation In the late stages of labor or immediately postpartum Gasping for air, seizures, cardiorespiratory arrest, DIC, Hg, & death (60-90%) Fetal survival ~70% No data that any type of intervention  improves the prognosis

Treatment of coagulopathy 1-Fresh frozen plasma 2-PLatlets transfusion 3-Cryoprecipitate 4-PRBC 5-Heparin  for IUFD Should not be used in cases of abruptio placenta, septicemia 6-Antibiotics for Pt with septicemia or septic abortion