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

2. 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

3. 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

4. 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)

5. 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

6. 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

7. 1-Uterine Atony Predisposing causes:
Uterine over distension twins, polyhydramnious or large infant
Grandmultiparity
Prolonged labor
Dysfunctional labor
Oxytocin induction or augmentation of labor

8. 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

9. 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

10. 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

11. 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

12. 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: deliveries
Immediate replacement is mandatory to prevent life threatening Hg

13. 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)

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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 U/L IV infusion 10-15ml/min
-Methylergonovine 0.2 mg IM (contraindicated in hypertensive Pt)
-PGF2α intramyometrial injection or IM
-Misoprostol rectally

21. 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

22. 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

23. 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

24. 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.

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

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

27. 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

28. 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