Postpartum Hemorrhage Flashcards
(11 cards)
Postpartum Haemorrhage
Defined as bleeding in excess of 500ml after vaginal delivery, 1000mls after caesarean section or 1500 mL after
cesarean hysterectomy or any amount sufficient enough to cause cardiovascular compromise
Effect of bld loss is important than amount of bld lost
Clinical definition is; “any amt of bleeding from or into genital tract following delivery up to end of puerperium,
which adversely affects haemodynamic state of the pt evidenced by rise in pulse rate & falling BP.
Types of PPH
a) Primary PPH- Occuring within 24 hours of delivery
There are two types of primary PPH:
i.) Third stage hemorrhage- Bleeding occurs before expulsion of placenta.
ii.) True postpartum hemorrhage- Bleeding occurs subsequent to expulsion of placenta (majority).
b) Secondary PPH- Occurring between 24 hours and 12 weeks post delivery (puerperium)
Also called delayed PPH or late puerperal hemorrhage-
Usually due to; infection, uterine subinvolution, disruption of the placental site “scab” several weeks
postpartum or to the retention of placental fragments that separate several days after delivery
Risk factors for PPH
Matermal factors
a) Maternal age 35 or over
b) Primiparity
c) Grand multiparity
d) Delivery after APH
e) Past history of PPH
f) Uterine fibroids- causes imperfect retraction mechanically
g) Bleeding disorders
h) Obesity
i) Malnutrition and anemia - Even slight amount of blood loss may develop clinical manifestations of PPH
j) Prolonged labor- Poor retraction, infection (amnionitis), dehydration
k) Precipitate labor – in rapid delivery, placental separation occurs after
birth and bleeding continues before onset of uterine retraction
l) Instrumental delivery or cesearian section
m) Pyrexia in labour
Fetal
cause over-distension of the uterus resulting in imperfect retraction and a large placental site
a) Large baby
b) Polyhydramnios
c) Multiple pregnancy
d) Shoulder dystocia
Aetiology of primary PPH
The four Ts
1. Tone- Uterine atony- most common cause
Can be predicted, & so take steps to prevent it, by use of oxytocic infusions & active mgt of 3rd stage of labour.
2. Tissue- Retained placenta and/or membranes. Prevent a uterus from contracting efficiently
3. Trauma- injury of uterus, cervix, vagina, perineum and uterine tears during Caesarean section
4. Thrombus for coagulation defects such as Von Willebrand’s disease, or platelet disorders (DIC)
Commonly arises in those who develop consumptive coagulopathy as an obstetric complication due to
diminished pro-coagulants (washout phenomenon) or increased fibrinolytic activity e.g., massive placental
abruption, an unidentified dead fetus (or IUD), amniotic fluid embolus or massive haemorrhage, jaundice in
preg, thrombocytopenic purpura, HELLP syndrome, etc
5. Others: Inversion of uterus
* Infection (delayed 2
0 PPH)
Clinical Effects of PPH
Vaginal bleeding, as a slow trickle.
Rarely, may be totally concealed either as vulvo-vaginal or broad ligament hematoma.
Effect of blood loss;
Tachycardia- earliest symptom
Hypotension- BP does not fall until massive haemorrhage has occurred (often 1200–1500 mL of blood)
Symptoms of nausea, vomiting and feeling faint, pallor and CRT > 2 sec.
In atonic hemorrhage, uterus is flabby and becomes hard on massaging.
In traumatic haemorrhage, uterus is well contracted
Principles in the management of PPH
Principles in the management are:
1. To empty uterus of its contents and to make it contract.
2. To replace blood and manage shock first.
3. To ensure effective haemostasis in traumatic bleeding
This is a life threatening complication which must be managed promptly and effectively.
General management steps PPH
This is a life threatening complication which must be managed promptly and effectively.
Call for help
Perform Rapid Evaluation (Vital Signs& cause BP, pulse, RR,
Pallor)
Massage uterus
If shock is present start immediate resuscitation
Start IV Infusion 1 litre/15 min
Give Oxytocin 10units IM to 20u in 1litre NS
Take Blood for Grouping & X/matching & coagulation studies
Give Oxygen
Elevate foot end
IV fluid replacement : in shock
Start resuscitation with crystalloids
Use large bore cannula (16 or bigger)
Aim to give;
* First 1000 ml rapidly 15-20 min
* Give at least 2000 ml in first hour
* Aim to replace at least 2 to 3 times the volume of EBL.
* If condition stabilizes then adjust rate to 1000 mls / 6 hourly
* Monitor BP, pulse every 15 min & urine output hrly (> 30mls /hr)
Catheterize to monitor urine output (<30ml/hr)
Check Placenta for completeness
Examine Birth canal for tears (EUA)
Monitor closely for further bleeding
When client stabilized Check HB
Treat anaemia
Management of atonic uterus
Management of atonic uterus
Uterine Massage- make it hard and express the blood clot
Bimanual compression
Aortic compression
Balloon/ condom tamponade- Foley catheter, Bakri balloon, Condom catheter or Sengstaken-Blakemore
tube is inserted into the uterine cavity & balloon is inflated with normal saline (200–500 mL) & kept for 4–6 hrs.
Uterine tamponade- Intrauterine plugging acts by stimulating uterine contraction and exerts direct
hemostatic pressure (tamponade effect) to open uterine sinuses.
Medical
1. Oxytocin- start a drip (10 units in 500 mL of N/S) at the rate of 40–60 drops per minute
2. Calcium gluconate (1 g IV slowly) if needed in uterine atony
3. Prostaglandinsa) Misoprostol- (PGE1) 1000 µg per rectum is effective
b) Carboprost
4. PPH Prophylaxis protocol in pts at risk- e.g., macrosomia/multipreg, anaemia: give misoprostol 800mcg
rectally, tranexamic acid 1000mg IV stat, oxytocin infusion 20u in 500mls N/S at 40-60 drops/min
Examine expelled placenta and membranes
Surgical management of atonic uterus
Uterine artery ligation of both uterine arteries- ligated at lateral border betwn upper & lower uterine segment
Utero-ovarian artery branch ligation– done just below the ovarian ligament
Hysterectomy- rarely if uterus fails to contract and bleeding continues in spite of the above measures.
Angiographic arterial embolization
B-Lynch compression suture & multiple square sutures
Managing retained placenta
Ensure Bladder is Empty
Apply Controlled Cord Traction: If it fails
Repeat Oxytocin 10u IM: If no success in 30 min
Attempt Manual Removal of Placenta
Give Pethidine and diazepam or Ketamine
Give antibiotics: (Ampicillin 2g + Metronidazole 500mg)
Perform procedure and examine placenta for completeness
Give Oxytocin 20 U/1000 mls NS or RL at 60 dpm
Monitor BP, Pulse, Pad and Urine output closely
Add Ergot or Prostaglandin if bleeding continues
Transfuse PRN and treat for anaemia
Secondary PPH causes
Occurs after 24 hours to 6 weeks postpartum
Causes of late PPH:
1. Retained bits of cotyledon/membranes (common)
2. Infections & separation of slough over a deep cervicovaginal laceration
3. Endometritis & subinvolution of placental site- due to delayed healing process
4. Hemorrhage from C-section wound usually occur betwn 10–14 days.
Mainly due to infection (endometritis)
Look out for RPOC and malignancies such as cancer or cervix and choriocarcinoma
Perform vaginal swabs and scan
Management of secondary of PP
Principles:
1. To assess the amount of blood loss and to replace it (transfusion).
2. To find out the cause and to take appropriate steps to rectify it.
Supportive therapy:
BT, PRN
To administer methergin 0.2 mg IM, if bleeding is uterine in origin
To administer antibiotics as a routine.
Conservative:
If slight bleeding & no detected apparent cause, a carefully hosp observation for 24 hrs or so.
Active treatment:
Most common cause is, retained bits of cotyledon or membranes, so explore uterus urgently UGA.
Products are removed by ovum forceps.
Do gentle curettage by flushing curette.
Methergin 0.2 mg is given IM and curetted materials are sent for histological exam
