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Postpartum Hemorrhage (PPH)
Family Medicine Specialist CME University of Health Sciences
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Clinical Case 25 year-old G7P2 female presents for delivery, which occurs very rapidly after arriving at the District Hospital. Her baby was delivered without difficulty but then the placenta was retained and she began to hemorrhage. What is your definition of a postpartum hemorrhage? What are the risk factors this patient has for a postpartum hemorrhage? What are you going to do to manage this patient?
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Objectives Define postpartum hemorrhage (PPH)
Discuss the risk factors and possible causes for PPH Describe the preventative measures to take to prevent a PPH Discuss the management of PPH Explain the risks to maternal morbidity and mortality of PPH
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Definitions Primary/immediate PPH Secondary/late PPH
Excessive bleeding during the 24 hours after a delivery Most often due to uterine atony Secondary/late PPH Excessive bleeding between 24 hours and up to 6 weeks after delivery Most often due to retain products of conception, infection or both
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What is excessive bleeding or a PPH?
Vaginal delivery >500 cc of blood loss Cesarean section >1000 cc of blood loss Clinically Any blood loss that causes the patient to be hemodynamically unstable
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Hypovolemia Clinical Presentation
Mild (<20% of blood volume) Heart rate - mild tachycardia Skin – mottled, cool extremities due to increased systemic vascular resistance and prolonged capillary refilling Urinary output - decreased Neurologic status – may report dizziness but usually remains normal Moderate (20–40% of blood volume) Heart rate - >110 bpm Tachycardia - >30 rpm BP – Normal in supine position/significant postural hypotension Skin - marked pallor; conjuntiva, palms and mucous Neurologic status – increasingly anxious Severe (>40% of blood volume) Heart rate - marked tachycardia BP – declines/unstable even in supine position oliguria or anuria Neurologic status – agitation, confusion, possible loss of consciousness
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Estimating blood loss Usually underestimated
Ongoing trickling can cause significant blood loss Underestimation can lead to delayed or inadequate treatment If patient is anemic, then the ability to compensate for blood loss may not be possible and patient cannot tolerate any blood loss
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PPH Etiology Tone – uterine atony Tissue – retained placenta
Trauma – vaginal/cervical lacerations, rupture, inversion of uterus Thrombin - coagulopathy
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Tone: Risk Factors Etiologic process Clinical risk factors
Overdistended uterus Polyhydramnios Multiple gestation Macrosomia Uterine muscle Rapid labour exhaustion Prolonged labour High parity Intraamniotic infection Fever Prolonged rupture of membranes (PROM)
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Tone – Risk Factors (2) Etiologic process Clinical risk factors
Functional or anatomic Fibroid uterus distortion of the uterus Placenta previa or abruptio Uterine anomalies Uterine-relaxing Halogenated medications anesthetics nitroglycerin, magnesium sulphate
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Tissue – Risk Factors Retained Placental tissue
Etiologic process Clinical risk factors Retained products, Incomplete delivery of placenta abnormal placentation, Previous uterine surgery retained cotyledon or High Parity succinuriate lobe Abnormal placenta on ultrasound Retained blood clots Atonic uterus
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Trauma (Genital Tract) – Risk Factors
Etiologic process Clinical risk factors Tears (lacerations) of the Precipitous delivery cervix, vagina, or perineum Operative delivery Ruptured vulvar varicosities Mistimed or inappropriate use of episiotomy Extensions, lacerations Malposition at cesarean section Deep engagement Uterine rupture Previous uterine surgery Uterine inversion High parity Fundal placenta
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Thrombin (Abnormalities of Coagulation) – Risk Factors
Etiologic process Clinical risk factors Pre-existing states History of hereditary coagulopathies History of liver disease Therapeutic History of thrombotic anticoagulation disease
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Thrombin (Abnormalities of Coagulation) – Risk Factors (2)
Etiologic process Clinical risk factors States acquired in pregnancy idiopathic thrombocytopenic bruising purpura elevated blood pressure thrombocytopenia with fetal demise preeclampsia fever disseminated intravascular elevated white blood cells coagulation antepartum hemorrhage preeclampsia sudden collapse dead fetus in utero severe infection/sepsis placental abruption amniotic fluid embolus
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Prevention of PPH – Active Management of the Third Stage of Labor
prophylactic administration of oxytocin with delivery of anterior shoulder or immediately after delivery 10 U IM OR 5 U IV bolus clamp and cut cord after pulsating has stopped palpate the uterine fundus and confirm the uterus is contracted perform controlled cord traction with suprapubic counter traction with next strong contraction perform uterine massage after delivery of the placenta, as appropriate examine placenta for completeness
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Controlled cord Traction
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Uterotonics - Oxytocin
stimulates smooth muscle tissue of the upper segment of the uterus causing it to contract rhythmically, constricting blood vessels, and decreasing blood safe and effective first choice for prevention and treatment acts almost immediately for IV injections, and within 3 to 5 minutes for IM injections should be stored in a cool, dry place uncommon side effects: nausea, vomiting, and headache
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Uterotonics – Ergot Alkaloids “Ergometrine”
causes the smooth muscle of both the upper and lower uterus to contract tetanically takes 5 to 7 minutes to take effect when given intramuscularly effects last approximately 2 to 4 hours should be stored in a refrigerator between 2°C – 8°C and away from light adverse effects include nausea and vomiting
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Uterotonics – Prostaglandins “Misoprostol”
causes vasoconstriction and enhances contractibility of the uterine muscles administered orally or sublingually (rapid action), or rectally (acts fir greater period of time) for prevention or treatment of PPH relatively inexpensive, easy to store, stable at room temperature side effects: shivering and fever are generally mild
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Management of Postpartum Hemorrhage
Prevention is the key! Identify and manage risk factors identified for potential PPH Active management of the third stage of labor
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Management of Postpartum Hemorrhage
Active management of the Third Stage of Labor REMEMBER the ABCs Call for HELP Estimate blood loss. Ask the woman to urinate or catheterize Put the baby to the breast Give Oxygen Assess the uterus using external or internal bimanual massage Give uterotonic - Oxytocin, Misoprostol, ergotamine Observe the woman, and consider transport if unstable or bleeding continues
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Management of PPH ABC A = airway B = breathing C = circulation
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External Bimanual Uterine Massage
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Internal Bimanual Uterine Massage
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Examine the placenta for completeness
Examination of fetal side Examination of maternal side
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Manual removal of placenta
1. 2. 3. 4.
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Management of Postpartum Hemorrhage
Examine the genitals for trauma and repair as required ie. vulva, vagina, cervix If bleeding continues may require uterine tamponade or aortic compression Ensure no uterine inversion or rupture Manage possible coagulopathy with blood transfusion (if possible) Consider transfer to facility for surgical management of PPH
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Aortic Compression
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Uterine Tamponade
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Management of secondary PPH
Associated with: retained placental fragments or membranes infection shedding of dead tissue following an obstructed labour breakdown of a uterine wound after a cesarean section or ruptured uterus
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Management of secondary PPH (2)
assess the woman’s condition carefully control blood loss treat for shock, if necessary administer antibiotics prophylactically for infection provide anti-tetanus prophylaxis, if necessary if there is no improvement with the above treatments, refer the woman promptly for further assessment and treatment
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Continued care of woman
Once the bleeding is controlled, and the woman is stable, careful monitoring over the next 24–48 hours is required, including: monitoring uterine tone monitoring vital signs estimating ongoing blood loss ensuring adequate fluid intake monitoring blood transfusions monitoring urinary output ensuring the continuous presence of a skilled attendant, who maintains good documentation
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Before discharge from hospital
check hemoglobin, and provide supplements as required examine for hookworm infestation, malaria, HIV/AIDS or other co-existing conditions, provide treatment as required provide the mother and her family with information about her experience of PPH ensure that lactation has been established, and that a well baby care plan is in place
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Conclusion Assess patient for PPH risk factors and manage accordingly
Prevention is the key: Active management of the third stage of labor Management of bleeding is essential for saving a woman’s life Refer to center as required for advanced care
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