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25 Cards in this Set
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Define primary postpartum hemorrhage |
Defined as blood loss of 500 ml or more from the genital tract within the first 24 hours after delivery or 1000mls or more for caesarean section delivery Blood loss from the genital tract causing hemodynamic instability/cardiopulmonary compromise within the first 24 hours after delivery (seen in anaemia, dehydration) |
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Incidence of primary postpartum hemorrhage |
5-15% of all deliveries. Rate is higher in multiple pregnancies (32.4%) compared with singleton (10.6%) |
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Causes of primary postpartum hemorrhage |
Tone (uterine atony) 60-70% Trauma (genital tract laceration) 20% Tissue (retained products) 5-10% Thrombin (coagulopathy/bleeding disorder) 1-2% |
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Predisposing factors to uterine atony |
•uterine overdistension: multiple pregnancy, polyhydramnios, macrosomia •uterine muscle exhaustion: precipitate labour, prolonged labour, IOL or SOL •impaired uterine contractility: grandmultiparity, full bladder, coexisting fibroid, couvelaire uterus/abruptio placenta, placenta praevia, chorioamnionitis |
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Predisposing factors to retained placenta |
Placenta succenturiata, membranes, cotyledons, placenta accreta (resulting from previous scars, repeated uterine curettage, myomectomies) |
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Predisposing factors to trauma |
Perineal tear, episiotomies, ruptured vulvar varicosities, precipitate labour, macrosomic babies, instrumental deliveries, previous scar, obstructed labour |
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Predisposing factors to PPH due to coagulation disorders |
Abruptio, severe pre-eclampsia, amniotic fluid embolism, sepsis, chorioamnionitis, massive blood loss, anticoagulant therapy, hemophilia A |
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Clinical findings in primary PPH |
1. General examination: depends on the amount of blood loss. Low volume and thready pulse, low BP, warm/cool and clammy extremities, normal or increased respiratory rate 2. Abdomen: uterus is soft, doughy & size above the abdomen if due to atony 3. Traumatic PPH: bleeding persists in the presence of contracted uterus; genital tract lacerations 4. Retained tissues: poorly contracted uterus 5. Coagulopathy or DIC: uterus may be contracted; generalized oozing 6. Uterine inversion: fundus of uterus not palpable, beefy mass may protrude through the vagina |
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Management of uterine atony |
Uterine massage Uterotonics (oxytocin, ergometrine) |
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Management of PPH due to trauma |
Surgical repair of lacerations |
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Management of retained tissues |
Blood products like FFP; evacuate RPOC |
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Management of uterine inversion |
Manual/hydrostatic replacement; IV oxytocin |
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Management of primary postpartum hemorrhage can be classified into |
1. Prophylactic management 2. Definitive management |
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Prophylactic management of primary postpartum hemorrhage |
•care provider must be anticipatory •during ANC, identify low risk and high risk paturients based on presence of predisposing factors and institute prophylactic measures •for high risk: -refer to tertiary center with theatre and anaesthetic backup -hospital delivery by experienced skilled birth attendant: establish IV line with a wide bore canula (16G or 18G); blood for grouping and crossmatching; active management of third stage of labour -prophylactic IV oxytocin drip 40 IU for duration 2-4 hours postpartum or 600 microgram of misoprostol per rectum •for low risk: active management of third stage of labour (oxytocin within 1 minute of delivery, CCT, early cord clamping & uterine massage) for all delivery |
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Definitive management of primary postpartum hemorrhage |
Usually start with atony in mind •call for help (senior consultant, obstetrician, anaesthetist, hematologist, theatre staff, nursing staff and support staff including porters •rub up uterine contraction •give IV oxytocics (preferably oxytocin) and start 20-40 IU of oxytocin in 500 ml of normal saline, at rate of 30 drops/min •collect blood samples for urgent PCV/FBC, blood group and cross match 4-6 units of fresh whole blood, bedside clotting/clotting studies •catheterize the bladder and maintain input/output chart hourly until patient is stable •re-examine placenta and membranes for completeness. If there are missing parts carry out manual uterine exploration and evacuation in theatre •if uterus remains atonic, repeat oxytocics (oxytocin, ergometrine, syntometrine, rectal misoprostol 800-1000 micrograms or intramyometrial oxytocin PF2-alpha especially on cases of C/S •if bleeding persists due to atony, do -bimanual uterine compression -tight uterine/vaginal packing: intrauterine balloons (Sengstaken-Blakemore tube, Foley catheter balloon, condom ballooned with normal saline) -direct aortic compression on the sacral promontory -uterine artery embolization •if bleeding Persists inspite of well contracted uterus, suspect genital tract trauma/laceration: carry out EUA in theatre; repair tears and lacerations •coagulopathy should be sought and treated: dilutional coagulopathy in pts who have lost large quantities of blood. •laparotomy is indicated if the cardiovascular status is not commensurate with the degree of blood loss. Think of ruptured uterus or supra-levator hematoma •principles of surgery is basically to do the fastest and safest procedure to curtail the impact of PPH ie mortality/morbidity •uterine rupture repair +/- BTL •uterine compression sutures -B-lynch brace sutures -Multiple square sutures (CHO/Hayman) -figure of eight/transverse compression suture of the lower segment placenta praevia •stepwise devascularization procedures -bilateral uterine artery ligation -bilateral utero-ovarian artery anastomosis ligation -bilateral internal artery ligation -UAE •Hysterectomy (last resort) -subtotal (more rapid & easier) -total |
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Differences between subtotal & total hysterectomy |
Uterus alone (subtotal hysterectomy ) Both the uterus and the cervix (total hysterectomy ) |
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Complications of PPH |
1. Immediate •shock •DIC •blood transfusion rxn •embolism •hysterectomy + loss of fertility
2. Late •septicemia •Sheehan's syndrome + failure of lactation •multiple organ failure: ARF (acute renal failure), ARDS (acute respiratory distress syndrome) •maternal death 2-10% |
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Prevention of PPH |
1. Antepartum •commumity awareness and education on PPH, encourage prompt referrals by TBAs & relatives •encourage ANC & hospital deliveries •family planning to increase spacing and iron stores •LLITN & IPT to prevent anaemia and malaria •improve general nutrition •women education and empowerment - better health seeking behaviour •better access to emergency obstetric care •well trained SBA •improved road network, communication facilities and ambulance services •detect and correct anaemia at ANC •detect high risk cases and refer for hospital delivery 2. Intrapartum •avoid prolonged labour - use partograph and judicious use of oxytocin •active management of labour in all cases •proper use of analgesia and anaesthesia •avoid laceration by proper management of second stage of labour & appropriate conduct of instrumental deliveries 3. Postpartum •routine examination of the placenta and membranes for completeness under running water •careful observation of the fourth stage of labour (1-2 hours postpartum) |
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Morality associated with postpartum hemorrhage |
Causes 25-30% of maternal death worldwide 14 million women suffer PPH and 2% die annually. 99% of these deaths occur in low income countries |
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General risk factors for post partum hemorrhage |
•poor nutrition •anaemia •home deliveries •high parity •delay in reaching or receiving prompt healthcare in facilities •lack of blood banks •lack of intensive care units |
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Define secondary PPH |
Fresh/excessive bleeding from the genital tract after the first 24 hours of delivery but before 6 weeks postpartum, irrespective of the quantity of loss. Begins in the second week postpartum. Usually bright red as opposed to the darker colour of lochia |
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Causes of secondary post partum hemorrhage |
1. Retained products of conception (commonest; 5%) •retention of placental fragments, membranes, blood clots •formation of placental polyps 2. Infection/sepsis •infected C/S wounds or breakdown •separation of infected retained products •infected/ separation of slough over a deep genital tract laceration •infected placental site (endometritis) 3.Fibroid polyps: necrosis and slough of its tips 4. Uterus or endometrium •subinvolution of the uterus •puerperal inversion of the uterus 5. Rare (local gynecological lesions/cancers & others) •cervical ectopy/carcinoma •endometrial cancer •choriocarcinoma (rare) •Von Willebrand's disease 6. Early menses |
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Clinical features of secondary PPH |
History: •difficult third stage of labour •primary PPH
Examination: •subinvolution of uterus •cervical os remains open +/- product of conception •foul smelling discharge +/- pelvic collection |
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Investigations done in secondary PPH |
•Ultrasound: confirm diagnosis of RPOC •Urgent PCV/FBC, group & cross match •Clotting profile •Endocervical swab for M/C/S •B-HCG |
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Treatment of secondary PPH |
•Treat underlying cause •for retained products of conception - Evaluation under GA with antibiotics and oxytocics cover |
