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Complications of 3rd stage of labour ?
1- Postpartum Hge
2- Retained Placenta
3- Acute uterine inversion
4- Shock
5- DIC
Postpartum Hge ?
DefinitionIncidenceSignificance
Pre-requisites for Postpartum Hemostasis
Types
* Definition :
- Quantitative Definition :
Excessive Bleeding from or into genital tract after delivery of the fetus with blood loss > 500 cc after vaginal delivery
> 1000 cc after cesarean sectionNot accurate as :- Proper estimation maybe difficult/inaccurate
- General coniditon depend on both amount & rate of bleeding & maternal health prior to delivery "Anemia / HTN / APH etc .."
- Clinical Definition :
Any amount of Bleeding from or into genital tract after delivery of the fetus that affects maternal general condition "Vital signs"* Incidence : 0.5-4% depending on management of labour* Significance :
One of the leading causes of maternal mortality in Egypt " 34% of all deaths"
* Pre-requisites for Postpartum HemostasisBlood flow to placental site is 600 ml/minso excessive blood loss may occur after delivery, postpartum hemostasis depend on :1- Good myometrial contraction & retraction constricting & occluding opened vessels at placental site2- No retained placental parts3- Good coagulation* Types :
1- Primary PPH :- Immediate or within first 24 H after delivery
- Associated with acute blood loss & is life threatening2- Secondary PPH :- After the 1st 24 hours after delivery till end of peurperium " 6 weeks "- Uncommon / Mild / Chronic = gynecological
Aetiology of Primary PPH ?
Due to combined factors as :A) Atonic PPHge "Placental site" 75-80% :Failure of uterine contraction & retractionRisks include :
1- Overdistension : MFP / PHA / Macrosomia2- Prolonged labour : exhaustion+dehydration3- Prolonged Anaethesia or tocolytics
4- APH : PP or Accidental Hge5- Anemia : hypoxia6- Full bladder & Nervous shock : reflex atony
7- Fibroid8- Grand Multipara : lax weak muscles9- Sudden Cessation of uterine stimulants10- Retained seperated placenta : impair uterine contractions
B) Traumatic PPHge "Genital tract lacerations" :As Ruptured uterus or Vaginal / cervical / perineal lacerationsIn difficult or operative VDs
C) DIC & Hypofibrinogenemia :Can occur in Placenta abruptio / Retained IUFD / Amniotic fluid embolism
Diagnosis of Primary PP Hge ?
A) Symptoms : Vaginal bleeding Immediatly or within first 24 H after deliveryB) Signs :- History of : Risk FactorsAtonic : PHA / MFP etcTraumatic : Difficult or instrumental delivery- General Ex : Hypovolemic shock
Pallor & OliguriaLow BP / Rapid weak pulse / subnormal temp
- Abdominal Ex : Uterine size & ConsistencyAtonic Revealed or partially/totally concealed- Uterus : Lax "Soft Doughy"- FL : High above umblicus if concealed Below Umblicus if revealedTraumatic - Uterus : Firm contracted- FL : Below umblicus
- Vaginal Ex : Preferably under anaethesiaDetect bleeding from vaginal / perineal / cervical laceration- Explore uterus digitally for retained parts & exclude ruptured uterus
Complications of PPH ?
1- Maternal Mortality : 34% of MMR in Egypt
2- Hemorrhagic shock : Blood loss + DIC
3- Acute renal failure : 2ry to Hypovolemic S.4- Peurperal sepsis : Low immunity / retained parts / possible manipulations5- Sheehan's syndrome : Hypopituitaris following PPHge = 2ry Amenorrhea
Management of PPH ?
A) Prevention :1- Proper ANC : Identification of risk factorsPrevious PPH - Causes of APH "PP & PA" - Anemia - Overdistended uterus "MFP - PHA " - Grandmultipara.
2- Proper Mx of 1st & 2nd Stage of labour :
1st Bladder evacuation & Avoid prolonged sedation2nd Avoid difficult prolonged labour & unnecessary instrumental delivery 3- Proper Mx of 3rd Stage of labour :- Delivery of Placenta : Active Mx reduces PPHge by 50%or Wait for signs if placental seperation- Uterine Massage : every 15 mins- Ecbolics : Continue for 1 H after delivery especially in high risk cases- Continous observation : Vital signs + Vaginal bleeding in 1st two hours after delivery
B) Treatment :Support life & arrest bleeding by following successive steps in order1- Anti-Shock Measurments & Blood transfusion whenever necessary.2- Gentle Uterine Massage :By placing thumb abdominally over fundus & other fingers of the same hands behind to stimulate uterine contractions3- Ecbolics : Given with massage
- Oxytocin :- By IV drip not direct IV bolus = serious hypotension & arrhthmia- Increase freq. & strength of contractions - Methyl Ergometrin :- 0.2-0.4 mg IM or IV not more = Coronary spasm- Causes tetanic uterine contractions- Mesoprostol :800-1000 ug rectally or anyroute except IV4- If Retained Placenta :Deliver immediately by controlled cord traction or manual removal5- Vaginal Exploration Under anesthesia :
- Detect & Remove undiagnosed retained placental fragmentes- Detect & Surgically repair any vaginal / cervical lacerations6- Bimanual Compression of uterus :
If bleeding persists = lifesaving till laparotomyBy one hand in vaginal fornix & one hand bending the uterus to kink uterine artery7- Laparotomy : If bleeding persists- Subtotal Hysterectomy :If bleeding is uncontrollable
- Bilateral ligation of Anterior division of internal illiac artery or B-Lynch :If young desiring future fertility but if failed = hysterectomy8- Associated DIC : FFP / FBT / CryoPTT / Fibrinogen / Platelet Concentrate
Secondary PPHge ?Definition
CausesTreatment
Bleeding from or into genital tract after 24 h of delivering the fetus till the end of peurperium
* Causes : RIFL + CP1- Retained placental fragments : MC
Dx : US & Tx : Ecbolics or D&C
2- Infection : Seperation of infected sloughs from lower genital tract laceration = Give AB3- SM Fibroid : Sloughed Necrotic tip4- Local cause : Polyp / erosion / Cancer Cx
5- Choriocarcinoma : Most dangerous
6- Peurperal inversion or UnDx Chronic
* Treatment :Treatment of the cause
Retained Placenta ?DefinitionIncidenceAetiology
* Definition :Failure of expulsion of placenta within 30 mins of delivery of fetus
* Incidence : 0.5% of all deliveries
* Aetiology :1- Retained Seperated Placenta :- Atony : Failure of expulsion of seperated P.
- Contraction ring : Hour glass deformity of uterus = Incarceration of placenta
- Complete Uterine rupture : Passage of placenta to the peritoneal cavity
2- Retained Non-Seperated Placenta :- Atony : No Shearing mechanism needed for seperation- Defective Placentation : - Absent or defective decidual reaction "D.Basalis" = Absence of line of cleavage & MPS layer "Nitabuch's" = CV peneterate uterine muscles.- More common with : PP - CS scar - SM fibroid- Classified as :
Accreta : Directly Attached to superficial myometrium
Increta : Invade myometrium
Percreta : Peneterate through myometrium- May Involve :
All cotyledons = TotalFew to several = Partial
Single Cotyledon = Focal
Clinical Picture ofRetained Placenta ?
* Symptoms :1- Failure of expulsion of placenta within 30 mins of delivery of fetus2- Vaginal Bleeding : if entire or part of placenta is separated
* Signs :- General : ShockHemorrhagic or even in absence of Hge if retained > 2 hrs "Idiopathic Obs. Shock"
- Abdominal : Lax Uterus
- Local : Vaginal examination may reveal
1- Hour glass contraction2- Complete rupture uterus
3- Absent of plane of cleavage
Complications of Retained Placenta ?
1- Shock : Hgic or Idiopathic
2- PP Hge
3- Peurperal Sepsis
4- Subinvolution Due to Congestion
5- Retained Parts : Form Placental Polyp giving rise to Choriocarcinoma
6- Complications of :
Methods to deliver placenta Perforation / Peurperal sepsis / Inversion / PPHge
Anaethesia
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