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Postpartum Hemorrhage
Dr. Alongkone Phengsavanh
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Objectives Define and discuss risk factors and causes
Describe management and prevention
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Postpartum Hemorrhage
Leading cause of maternal deaths worldwide Responsible for 1/3 of maternal deaths worldwide and 60% in developing countries Majority of deaths within 4 hours of delivery
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Postpartum Hemorrhage (PPH)
Primary (immediate) Hemorrhage in first 24 hours after delivery 70% due to uterine atony Secondary (delayed) Hemorrhage after 24 hours up to 6 weeks postpartum Caused by Retained placental tissue Infection Definitions – Volume loss (Traditional) Spontaneous vaginal delivery >500 cc blood C/Section >1000 cc blood Clinical Any blood loss that has the potential to produce hemodynamic instability
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Clinical Findings & Blood Loss
Mild Hypovolemia Moderate Hypovolemia Severe Hypovolemia Definition (blood volume) <20% % >40% HR Mild tachycardia >110 bpm tachycardia RR Normal >30 rpm tachypnea Clinical Cool extremities, decreased urine output, dizziness, normal neuro status Marked pallor, hypotension with sitting, anxious state Oliguria / anuria, agitation, confusion, loss of consciousness, BP unstable
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PPH Etiology Tone - Uterine tone Tissue - Retained tissue / clots
Trauma - Laceration, rupture, uterine inversion Thrombopathy - Coagulopathy
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PPH Risk Factors - Tone Overdistended uterus Uterine muscle exhaustion
Polyhydramnios Multiple gestation Macrosomia Uterine muscle exhaustion Rapid labor Prolonged labor High parity Intra-amniotic infection Fever Prolonged Rupture of Membranes Uterine abnormalities Fibroid uterus Congenital uterine abnormalities Placenta previa / placental abruption Uterine relaxing agents Magnesium sulfate Halogenated anesthetics Nitroglycerin
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PPH Risk Factors - Tissue
Retained tissue, abnormal placentation (succinuriate lobe, retained cotyledon) Incomplete placental delivery Previous uterine surgery High parity Retained blood clots Atonic uterus
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PPH Risk Factors - Trauma
Lower genital tract lacerations (cervix, vaginal wall, perineum) Precipitous delivery Operative delivery Poorly timed or inappropriate episiotomy Caesarean section – extensions / lacerations Deep engagement of head Malposition Uterine rupture Prior uterine surgery Uterine inversion High parity Fundal placenta
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PPH Risk Factors - Thrombin
Pre-existing states Hereditary conditions History of liver disease Therapeutic anticoagulation History of thrombotic disease Other (DIC, ITP, Pre-eclampsia, placental abruption, severe infection) Intrauterine fetal demise Bruising Elevated blood pressure Fever Elevated WBC Antepartum hemorrhage Sudden collapse
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PPH Prevention Active management of the Third Stage of Labor
Administer oxytocin with delivery of anterior shoulder or immediately after delivery of baby Oxytocin 10 units IM or 5 units IV Clamp and cut cord Palpate uterine fundus & confirm uterus contracting Perform controlled cord traction with suprapubic counter traction with next strong contraction Perform uterine massage after delivery of placenta Examine placenta for completeness
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Controlled Cord Traction
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PPH Management Prevention
Active management of the third stage of labor Identify patients at potential risk of PPH
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PPH Management Primary PPH Active management of third stage of labor
Call for HELP ABC (Airway, Breathing, Circulation) Estimate / measure blood loss Closely monitor vital signs Catheterize bladder (urine volume) Give oxygen Give oxytocin (IV/IM) or misoprostil (PR)
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PPH Management – Tone Determine source of bleeding
Assess the uterine fundus Do Internal Bimanual Massage of uterus
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PPH Management – Tissue
Examine placenta for completeness Examine maternal side of placenta Examine fetal side of placenta
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PPH Management – Tissue
Manual removal of placenta – if incomplete placenta 2 1 4 3
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PPH Management - Trauma
If fundus firm & placenta complete, then examine for trauma Upper vaginal tract - identify and repair tears Lower & external genital tract – apply pressure and repair tears
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PPH Management If bleeding continues consider IV oxytocin Misoprostil
Oxytocin 40 units/1 liter Normal Saline run wide open Misoprostil 800 ug pr (4 tablets per rectum) Correct hypovolemia Normal Saline Ringers Lactate Blood products – RBC transfusion
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PPH Management Consider transfer to center with additional resources
Surgery B-Lynch Stitch Hysterectomy
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PPH Management Consider aortic compression
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Uterine inversion Rare Caused by over vigorous cord traction
More common in grand multiparous women Treatment Replace uterus promptly Replacement is “last out” is “first in” Consider uterine relaxation with nitroglycerin
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Uterine rupture Can occur with: Management
Prolonged or obstructed labor Prior uterine surgery – caesarean section Grand multiparous women being induced or augmented Management Vigorous resuscitation Emergency laparotomy Delivery of fetus / repair of uterus Hysterectomy Prophylactic antibiotics
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Secondary PPH Cause Management Retained tissue Infection
Breakdown of uterine wound following C/S Management ABC – treat for shock Antibiotics Assess patient carefully for source of bleeding
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Secondary PPH After bleeding controlled monitor woman for:
24 – 48 hours for further bleeding Urine output Vital signs Uterine tone CBC Educate patient and family about PPH and when to return to hospital
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Conclusion – Key message
PPH is a serious obstetrical emergency requiring urgent diagnosis and treatment. PPH is prevented with Active Management of the Third Stage of Labor. Patient may need to be transferred to referral hospital if local resources inadequate.
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