Title: Postpartum hemorrhage for undergraduate
1Dr Manal Behery Assistant professor ,Zagazig
University 2013
2 Definition
- Blood loss gt 500 ml at vaginal delivery
- gt 1000 ml at Cesarean
- ACOG 10 drop in hematocrit
- Need for blood transfusion
- Severe PPH gt 1000 ml loss at vaginal delivery
- Any amount of blood loss causes
- S/O Hypovolemic Hemorrhagic Shock
- - Tachycardia - Hypotension - Reduced urine
out put
3Why it is important?
- PPH remained one of the top 3 causes of direct
maternal deaths. - Incidence 4 after vaginal delivery
- 6,5 after CS delivery
4We have 4 problems
- Problem 1 almost 50 of deliveries lose gt500 ml
of blood. - Problem 2 estimated blood loss is often less
than half the actual blood loss. - Problem 3 Most of the serious causes of PPH
have origins prior to the end of the 3rd Stage of
labor. - Problem 4 PPH, as defined, is technically
misdiagnosed and clinically irrelevant.
5Measuring Blood Loss A key step to EFFECTIVE
TREATMENT..
- Underestimation leads to delayed intervention.
- Visual estimated amounts of blood loss are far
from accurate by as much as 30-50 especially
for very large amounts. - Old methods for estimating blood loss tend to be
complex. - (include weighing soaked clothes and pads,
collection into pans etc., Acid haematin
techniques, Spectrophometric technics and
measuring plasma volume changes) -
6Measuring Blood Loss in PPH THE BRASSS-V
DRAPE
7Advantages of Brasss-V
- Simple and practical
- Low cost ( Plastic)
- Accurate
- Objective
- Can be used in a wide
- range of settings
- Provides a hygienic delivery surface
8CAUSES OF PPHFOUR Ts
- TONE
- TRUAMA
- TISSUE RETENSION
- THROMBIN
- BUT MOST IMPORTANT IS
9ToneUterine Atony90of causes
- - Uterine over distension
- Polyhydramnios, Multiple gestations, Macrosomia
- Prolonged labor uterine fatigue
- Precipitory labor
- High parity
- Chorioamnionitis
- Retained product of conception
- Halogenated anesthetic
10TRUMA Obstetric OR OPERATIVE 7 of causes
- Obstetric Trauma
- - Uterine Rupture
- - Lacerations of the Birth Canal
- - Operative Trauma
- Cesarean sections
- Episiotomies
- Forceps, Vacuums, Rotations
11Tissue retension Abnormal placentaion
- - Placenta Previa
- - Abruptio Placentae
- - Accreta, increta, percreta
- - Vasa previa
12Thrombin Coagulation Defects2-3 of causes
- - Sepsis
- - Amniotic Fluid Embolism
- - Abruptio Placentae associated
- coagulopathy
- - HELLP Syndrome
- - Dilutional Coagulopathy
- - Inherited Clotting Disorders
- - Anticoagulant Therapy
13Prevention of Postpartum Hemorrhage
- Oxytocin
- With or soon after delivery
- Cord traction
- Continues tension
- Gentle pull with contraction
- Uterine massage after placental delivery
14- Goals of Therapy
- Maintain the following
- Systolic pressure gt90mm Hg
- Urine output gt0.5 mL/kg/hr
- Normal mental status
- Eliminate the source of hemorrhage
- Avoid overzealous volume replacement that may
contribute to pulmonary edema
15Management Protocol
- Examine the uterus to rule out atony
- Examine the vagina and cervix to rule out
lacerations repair if present - Explore the uterus and perform curettage to rule
out retained placenta
16On recognition of Hemorrhage
-
- Initiate volume replacement with lactated ringers
or normal saline. - Alert blood bank and surgical team.
- Control the blood loss.
- Initiate decisive therapy.
- Monitor for complications.
17MANAGEMENT of Uterine atony
- Explore uterus for retained placental tissue.
- Uterine massage
- 3Firm bimanual compression
18management of uterine atony Cont
- 4-Ecobolics uterotonic agents
- Oxytocin infusion, 40 units in 1 liter of D5RL
- Methergine 0.2 mg IM
- 15-methyl prostglandin F2a, 0.25 to 0.50 mg
intramuscularly may be repeated - , PGE1 200 mg, or PGE2 20 mg are second line
drugs in appropriate patients
19Vaginal exploration
- General anesthesia usually best
- Uterine cavity manual exploration for retained
placenta / uterine rupture
20Vaginal exploration cont
21Uterine inversion restitution
22Vaginal exploration cont Intrauterine balloon
Cather
23Bakri Balloon is a tamponade technique that can
be used for PPH.
24When medical managament fails
- SURGICAL MANAGEMENT
- Uterus conserving NEED OF TIME
- Definitive - Hysterectomy
25MANAGEMENTcont
- If Hemorrhage is not controlled by medications,
massage, manual uterine exploration, or suturing
lacerations in the birth canal, - then surgical or radiological options must be
considered. At this time, start - Packed red blood cell transfusion
- Foley catheter and monitor urine output
26Selective Artertial Embolization
- If the patient is stable
- and bleeding is not torrential,
- and if interventional radiology is available,
- then pelvic arteriography may show the site of
blood loss and therapeutic arterial embolization
may suffice to stop the bleeding.
27Uterine artery embolization
- Real time X-Ray (Fluoroscopy)
- Gelatin Sponges are injected
- into the bleeding vessel until
- stasis of flow in target vessel is
- achieved.
- Acess via RTfemorals
- to internal iliac and
- subsequently the uterine arteries
28 Pre embolization vs. .post embolization
Pre Embolization
Post Embolization
29Laparotomy for Obstetric Hemorrhage
-
- - Bleeding at Cesarean section
- - Torrential Hemorrhage
- - Pelvic hematoma (expanding)
- - Bleeding uncontroled by other
- means
30AT laparotomy
- Consider vertical abdominal incision
- General anesthesia usually best
- Get Help!
- Avoid compounding problems by making major
mistakes - Direct manual uterine compression / uterotonics
- Direct aortic compression
- Modified B-Lynch Suture for atony 2 chromic
- Ligation of uterine and utero-ovarian vessels 1
chromic
31B-Lynch suture vs Modified B-Lynch Suture
32Anterior view of uterus showing modified B-Lynch
Technique
posterior view of uterus showing modified B-Lynch
Technique
33OTHER COMPRESSION SUTURES
- Hayman Uterine Compression Suture
- Chos Multiple Square Suture
Global Stitch By Dr. Gunasheela Bangalore
34COMPLICATIONS
NIL - IF DONE PROPERLY TOO TIGHT
COMPRESSION --
CUT THROUGH
STITCH UTERINE NECROSIS
INTRAPERITONEAL BLEED
35Uterine artery ligation
- http//t3.gstatic.com/images?qtbnANd9GcQOaGGcLP1
wYmyIsIQ8fyhFBBwhABO3K3uFHL4V7Dfd51ePIddvGg
36Sutures are placed to ligate the ascending
uterine artery and the anastomotic branch of the
ovarian artery.
37Internal iliac (hypogastric) artery ligation
- 50 success rate
- Desirous of children
- Experience of surgeon
- Steps
- Palpate common iliac
- bifurcation
- Ligate at least 2-3 cm
- from bifurcation
- 1 silk. Do not divide
- vessel
38Repaire of cervical laceration
- Palpate uterine cavity to assure its integrity
- Full thickness mucosal repair above the apex
- Contionous interlocking absorbable sutures
- Hematoma incised,clot removed,bleeding vessels
ligated ,oblitrate defect with interlocking
sutures - Antibiotics vaginal pack for 24 hours .
-
39(No Transcript)
40Uterine Rupture
- Prior Cesarean section 1-2
- Modern obstetrics 1/10,000 to
- 1/20,000 in unscarred uterus
- In Neglected labors, this accounts
- for many maternal deaths where
- modern obstetrical care is not available.
41Classic Symptoms of Uterine Rupture
- Fetal distress
- Vaginal bleeding
- Cessation of labor
- Shock
- Easily palpable fetal parts
- Loss of uterine catheter pressure
42Management of Uterine Rupture
- Laparotomy
- Debride and repair in 2-3 layers of Maxon/PDS
- Subtotal Hysterectomy
- Total Hysterectomy
43Management of Abnormal Placentation
- Diagnosis of exclusion after adressing tone and
truma - Curettage of uterine cavity
- Localized resection and uterine repair
(Vasopressin 1cc/10cc N.S-sub endometrial) - Leave placenta in situ
- If not bleeding Methotrexate
- Uterus will not be normal size by 8 weeks
- Uterine, utero-ovarian, hypogastric artery
ligation - Subtotal/ total abdominal hysterectomy
44Post-Hysterectomy Bleeding
- Patient usually has DIC Rx with whole blood,
FFP, platelets, etc. - Transvaginal or transabdominal
- (pelvic) pressure pack
- Bowel bag with opening pulled through vagina
cuff/ abd. Wall - Stuff with 4 inch gauze tied end-to-end until
pelvis packed tight
45Military Anti-Shock Trousers (MAST)
- Increases pelvic and abdominal pressure to reduce
bleeding - Can use at any point in the procedure
- Used when exploration is to be avoided
46Secondary PPH
- Defined as excessive bleeding 24 hrs to 12 weeks
postpartum. - Incidence is about 1 percent of women.
- Theory is that thought to be atony or
subinvolution of placental site from retained
products or infection.
47Management of Secondary PPH
- Evaluate for underlying disorders
(coagulopathies). - For atony give uterotonics.
- If large amount of bleeding, fever uterine
tenderness, or foul smelling discharge treat for
endometritis. - Consider suction currettage.
48Case 1
- A 22y/o G1P0 was delivered by vaccum assisted
vaginal delivery approximately 2 hours ago. She
was induced for mild preeclampsia at 37 weeks and
required pitocin augmentation for several hours
prior to needing an operative vaginal delivery
for fetal distress. She had a second degree
laceration that was repaired, but she has soaked
a whole pad in the last 15 minutes and the nurse
would like you to evaluate her.
49Case 2
- A 22 yo G4P3 approximately 4 days s/p delivery
presents at OB triage and mentions to you that
she feels lightheaded and has been having
bleeding at about a pad an hour for the last 2
days.
50Case3
- A 34yo G6P6 patient at term has just delivered
a 4000gm infant after second stage of labor
lasting 3 ½ hours. The placenta delivered
spontaneously and the patient is bleeding
briskly. - What is most probable cause?
- What the next step?
51THANK YOU