Post Partum Hemorrhage

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Post Partum Hemorrhage PPH
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(No Transcript)
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Definition Blood loss in excess of 500 ml with
vaginal delivery or in excess of 1000 ml
following delivery by caesarian section.
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• Types
• 1- Early PPH more common.
• occurs immediately or slowly over the 1st 24
  hours.
• 2- Late PPH occurs after 24 hours but within 6
  weeks post delivery.

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• Causes
• 1- Uterine atony.
• 2- Genital tract trauma.
• 3- Retained placental tissue.
• 4- Low placental implantation.
• 5- Coagulation disorders.
• 6- Uterine inversion.

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• Uterine atony
• Is the cause of 75 to 80 of PPH.

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• Factors predisposing to uterine atony
• 1- Over distention of the uterus.
• 2- Multiple gestation.
• 3- Polyhydraminos.
• 4- Fetal macrosomia.
• 5- Prolonged labor.
• 6- Grand multiparity.
• 7- Oxytocic augmented labor.
• 8- Preciptious labor.
• 9- MgSo4 ttt of pre eclampsia.
• 10- coriamnionitis.
• 11- Halagenated Anaesthetics.
• 12- Uterine Leiomyoma.

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• Genital tract trauma
• Second most common cause of PPH.
• 1- laceration of the cervix and vagina.
• 2- laceration over the perineal body,
  periurethral area, over the ischeal spines.
• 3- during low transverse c-section.

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• Retained placental tissue
• 1- Incomplete placental seperation.
• 2- Partial placental accreta.
• In ½ the patients with delayed PPH, placental
  reminants are present when uterine curettage is
  performed.

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• Low placental implantation
• This leads to PPH because the lower uterine
  segment has less musculature.

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• Coagulation disorders
• 1- TTP.
• 2- Amniotic fluid embolism.
• 3- Abruptio placentae.
• 4- ITP.
• 5- Von Willebrands disease.

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• Uterine inversion
• The inside out turning of the uterus during the
  3rd stage of labor due to improper management.

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Obstetric History
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Obstetric History

• Personal data name, age.
• Gravidity parity abortion ectopic
  pregnancy.
• Presenting complain.
• History of current pregnancy.
• - was the pregnancy planned?
• - previous booked visit (how many).
• - regularity of menstrual cycle.
• - LMP EDD.
• - GA (40 - present date EDD).

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• Events of pregnancy in 1st, 2nd and 3rd
  trimester
• A) symptoms of pregnancy.
• B) complication of pregnancy.
• C) use of drugs and supplement.
• D) further tests carried out.
• Past obstetric history.
• Past gynecological history
• - menstrual history.
• - contraceptive \ sexual history.
• Gynecological surgical history.
• Past medical history.
• Surgical history.
• Drug history \ allergies.
• Family history.
• Social history.

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Obstetric examination

• General examination.
• Ex. of the chest.
• Ex. of the breast.
• Ex. of the thyroid.
• Abdominal Ex.
• Ex. of the lower limb.
• Special points in the examination fundal height.

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• Pelvic examination
• - inspection.
• - collection of cytologic specimen.
• - palpation.
• - rectal and recto-vaginal examination.

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Examination in active bleeding

• Vital signs.
• Palpation of the fundus.
• Inspection of vagina and cervix.
• Pelvic examination.
• Manual exploration of uterine cavity.

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Initial management of PPH
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• check patient status.
• early recognition of PPH.
• monitor vital signs and oxygen.
• establish IV access, place urinary catheter.
• Baseline lab value.
• Alert anesthesia and blood bank.
• Central hemodynamic monitoring.
• Correct anemia and coagulation disorders and
  blood products.

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Determine underlying cause of PPH

• Examine the uterus, placenta and genital tract.
• Etiology will determine further management.

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Uterine Atony

• By manual massage and/or compression, exclude
  retained placental fragments, uterine rupture.
• Medical Uterotonic therapy
• 1- rapid oxytocin infusion IV, IM or
  intramyometially.
• 2- methylergonovine.
• 3- 15-methyl-prostaglandin F 2 alpha IM or IMM.
• 4- Dinoprostone PEG2 rectally.

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• If no response to above management consider
• 1- uterine packing.
• 2- angiography and embolization.
• 3- explorative laparotomy with surgical options
• - vessel ligation.
• - hysterectomy.

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Lower genital tract laceration

• Cervical, vaginal or perineal tears.
• Determine source of bleeding.
• Establish surgical hemostasis.
• Evacuate hematoma.
• If not responsive to above consider surgical
  options - uterine packing
• - artery ligation.
• - hysterictomy.

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Retained placental fragments

• Manual exploration and removal.
• Curettage.

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Abnormal placentation

• Placenta accreta.
• Conservative surgery curettage, local repair.
• Further surgical management
• - laparotomy.
• - artery ligation.
• - hysterictomy.
• Consider angiography and embolization.

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Uterine inversion

• Immediate intravascular volume expansion with IV
  crystalloids.
• Surgical procedure may be required.
• Uterine rupture
• Laparotomy.
• Repair of scar or hysterectomy.

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Thank you

• Done by.. Group
• E1