IN THE NAME OF GOD

Post partum hemorrage H.GHASEMI.TEHRANI Associated Professor of ob&gyn departman

Major causes of death for pregnancy women （maternal mortality) Postpartum hemorrhage（28%) heart diseases pregnancy-induced hypertension Amniotic fluid embolism infection

Definition of PPH be defined as a blood loss exceeding 500ml after delivery of the infant PPH: occurs in 24 hour of delivery the late PPH: occurs after 24 hour of delivery to 6 weeks

Major causes Uterine atony (90%) lacerations of the genital tract(6%) retained placenta(3%-4%) coagulation defects (blood dyscrasia) (4T: tone, tissue,trauma,thrombin)

1. Uterine atony Local factors overdistention of the uterine (hydramnios, multiple pregnancy, macrosomia ) condition that interfere with contraction(leiomyomas) complications(PIH,anaemia, placenta praevia

Systemic factors: drugs(magnesium sulfate,sedative) abnormal labor(prolonged,precipitous) History of previous PPH Preeclampsia, abnormal placentation,

Prevention and therapeutic of uterine atony Administration of medicine: promotes contraction of the uterine corpus decreases the likelihood of uterine atony Oxytocin agents Methegine prostaglandin

Oxytocin 40 units in 1 liter of normal saline IV or 10units IM Oxytocin 40 units in 1 liter of normal saline IV or 10units IM. Higher doses of oxytocin (up to 80 units in 1000 mL) Methylergonovine 0.2 mg if no hypertension, Raynaud's phenomenon, or scleroderma. May repeat at two- to four-hour intervals Carboprost tromethamine (15 methyl-PGF2alpha)(Hemabate) 250 mcg IM every 15 to 90 minutes, as needed, to a total dose of 2 mg (8 doses), if no asthma. About 75 percent of patients respond to a single dose

Misoprostol (PGE1) 200 to 1000 mcg via oral, sublingual, and rectal routes or using a combination of routes. The sublingual route has rapid onset of effect, prolonged duration of action, and the greatest total bioavailability Dinoprostone (PGE2) 20 mg vaginal or rectal suppository is an alternative PGE to misoprostol (PGE1). It can be repeated at two-hour intervals

Mechanical stimulation of uterine contraction: Massage of uterus through the abdomen and bimanual compression intrauterine packing

Surgical methods If massage and agents are unsuccessful: Ligation of the uterine arteries ligation of the hypogastric arteries selective arterial embolization hysterectomy taking into account the degree of hemorrhage,the overall status of patient,her future childbearing desires

2. Lacerations of the genital tract Causes: Instrumented delivery (forceps) manipulative delivery(breech extraction,precipitous labor, macrosomia) Types: perineum laceration vaginal laceration cervical laceration

perineum and vaginal laceration The first degree tear: involves only skin and a minor part of the perineal body the second degree tear: involves the perineal body and vagina the third degree tear: involves the anal sphincter and anal canal

management Vaginal examination soon after delivery repair: cervical laceration >2cm in length and be actively bleeding laceration of vaginal and perineum

3. Retained placenta Separation and explosion of placenta is caused by strong uterine contraction Placenta tissue remaining in the uterus prevent adequate contraction and predispose to excessive bleeding

causes: adherence of placenta (previous cesarean delivery,prior uterine curettage) succenturiate placenta placenta accreta (into the decidua) placenta increta(into the myometrium) placenta pericreta(through the myometrium to the peritoneal)

Prevention and treatment The placenta should be examined to see that it is complete or not part of placenta is missing, removed digitally not separated, manual removal of placenta is done hysterectomy is required for placenta increta(percreta,accreta) uterine contraction drugs

4. Coagulation defects Acquired abnormality in blood clotting: abruptio placenta, amniotic fluid embolism severe preclampsia congenital abnormality in blood clotting: thrombocytopenia severe hepatic diseases leukemia

disseminated intravascular coagulopathy(DIC) if bleeding persists in spite of all other treatment described, DIC should be suspected the blood passing from the genital tract is not clotting shock: reduction of effective circulation inadequate perfusion of all tissues oxygen depletion depression of functions

Record: pulse blood pressure maternal heart rate central venous pressure urine output

Lab tests: Hb, BT(bleeding time), CT( clotting time), platelets count fibrinogen prothrombin time and patial thromboplastin time FDP women’s group and cross-matching

Treatment: the key is correcting the coagulation defect resuscitation must be started as soon as possible infusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusion blood transfusion is essential infusion of platelets, fresh frozen plasma, FDP , clotting factors,

Potential complications of PPH: Postpartum infection Anemia Transfusion hepatitis, Sheehan’s syndrome Asherman’s syndrome The best management of PPH is prevention